手術治療非連續(xù)性脊柱結核的臨床療效

1、The Clinical Outcomes of Surgical Treatment of Noncontiguous Spinal Tuberculosis: A Retrospective Study in 23 CasesPLOS ONEIF 3.234 (2014) Volume 9 , Issue 4 ,April 2014 共三十頁The Clinical Outcomes of Surgical Treatment of Noncontiguous Spinal Tuberculosis: A Retrospective Study in 23 Cases手術治療非連續(xù)性脊柱結

2、核的臨床療效：一項23例患者(hunzh)的回顧性研究Jia HuangHongqi Zhang* Kefeng Zeng Changsha, China，Xiangya Hospital of Central South University共三十頁AbstractStudy design:A retrospective clinical study.Objective:To evaluate the clinical efficacy of the surgical treatment of noncontiguous spinal tuberculosis (NSTB), and to

3、discuss its therapeutic strategies.摘要研究設計：一項回顧性臨床研究。目的:探討手術(shush)治療非連續(xù)脊柱結核(NSTB)的臨床療效，并探討其治療策略。共三十頁Methods: We performed a retrospective review of clinical and radiographic data that were prospectively collected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed

4、and treated as NSTB in our institution from June 2005 to June 2011. Apart from 4 patients being treated conservatively, the remainder received surgery by posterior transforaminal debridement, interbody fusion with instrumentation, posterior instrumentation and anterior debridement with fusion in a s

5、ingle or two-stage operation. The clinical outcomes were evaluated before and after treatment in terms of hematologic and radiographic examinations, bone fusion and neurologic status. The Oswestry Disability Index score was determined before treatment and at the last follow-up visit.方法：我們進行了臨床和影像學資料

6、的回顧性研究，這些資料是在我們單位從2005年6月至2011年6月之間前瞻性收集的550例脊柱結核患者，其中27例患者診斷(zhndun)為非連續(xù)性脊柱結核并行相應治療。除4例患者行保守治療外，其余均接受后路經椎間孔病灶清除椎間融合內固定術，一期或二期行后路內固定聯合前路病灶清除融合術。治療前后通過血液學及影像學檢查、植骨融合及神經功能狀態(tài)等進行臨床療效的評價。ODI指數評分在治療前和最后一次隨訪時確定。共三十頁Results: 23 patients (15 M/8F), averaged 44.614.2 years old (range, 19 to 70 yd), who receiv

7、ed surgical treatment, were followed up after surgery for a mean of 52.519.5 months (range, 24 to 72 months). The kyphotic angle was changed significantly between pre- and postoperation (P0.05). The mean amount of correction was 12.67.2 degrees, with a small loss of correction at last follow-up. All

8、 patients achieved solid bone fusion. No patients with neurological deficit deteriorated postoperatively. Neither mortalities nor any major complications were found. There was a significant difference of Oswestry Disability Index scores between preoperation and the final follow-up.23例患者(15 M/8F)，平均年

9、齡為44.614.2歲（范圍19至70歲），都接受了手術治療，術后平均隨訪時間為52.519.5個月（24至72個月）。手術前、后的后凸角有明顯變化（P0.05），平均矯正率為12.67.2，而最后一次隨訪時有輕微的矯正丟失。所有患者均獲得了堅實的骨性融合(rngh)，既沒有死亡率，也沒有大的并發(fā)癥發(fā)生。 ODI指數評分在術前和末次隨訪時比較差異有統(tǒng)計學意義。共三十頁Conclusion: The outcomes of follow-up showed that posterior and posterior-anterior surgical treatment methods were

10、both viable surgical options for NSTB. Posterior transforaminal debridement, interbody fusion and posterior instrumentation, as a less invasive technique, was feasible and effective to treat specific tubercular foci.結論隨訪結果表明，后路和后前聯合入路手術治療方法都是非連續(xù)性脊柱結核可行的手術方案。后路經椎間孔病灶清除、椎間融合和后路內固定術，作為一種(y zhn)微創(chuàng)技術，是治療

11、特異性結核病灶可行和有效的方法。共三十頁IntroductionTuberculosis has made a dramatic comeback, in part because of the appearance of anti-tuberculosis drug resistance and the acquired immune deficiency syndrome (AIDS) pandemic. As a destructive pattern of tuberculosis, spinal tuberculosis (STB) accounts for 50% of all c

12、ases of musculoskeletal tuberculosis . It is characterized by formation of cold abscess, destruction of the intervertebral disc and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis. Multilevel noncontiguous spinal tuberculosis (NSTB) is an atyp

13、ical form of STB, which leaves not less than two adjacent vertebrae intact between the two foci. The incidence of NSTB is reported as 1.1% to 16.3% .簡介由于抗結核藥物耐藥性的出現和獲得性免疫缺陷綜合癥（艾滋病）的流行導致結核病大量復燃。作為結核病的破壞性形式，脊柱結核（STB）占所有肌肉骨骼結核病的50。它的特點是冷膿腫形成，椎間盤和相鄰椎體的破壞，脊柱附件和前柱的塌陷，從而導致脊柱后凸畸形。多節(jié)段非連續(xù)性脊柱結核（NSTB）是脊柱結核的非典型形

14、式，在兩個病灶之間存留不少于兩個完整的椎體。研究(ynji)報道NSTB的發(fā)病率為1.1% 至 16.3% 。共三十頁Recently, with whole spine magnetic resonance image (MRI) being applied to aid detection of NSTB, its incidence is higher than previously quoted 4. The treatment regimes regarding NSTB vary from purely medicine to a combination of chemothera

15、py and surgery. The pendulum of therapeutic strategies to NSTB has periodically vacillated between non-operative management and radical surgery. In the present study, we seek to discuss the role of surgical treatment method.近年來，隨著全脊柱磁共振成像（MRI）的應用幫助檢測非連續(xù)性脊柱結核（NSTB） ，其發(fā)病率高于先前的報道。關于NSTB的治療方案，從單純的藥物治療到藥

16、物化療與手術相結合等不同。NSTB的治療方案在非手術治療和根治性手術治療之間定期(dngq)波動。在本研究中，我們試圖探討手術治療方法的作用。共三十頁Materials and MethodsPatientsThis study was approved by the Ethic Committee of the Xiangya Hospital of Central South University. We performed a retrospective review of clinical and radiographic data that were prospectively co

17、llected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed and treated as NSTB in our institution from June 2005 to June 2011. Plain radiology, computed tomography and MRI of the spine were performed on all patients admitted with suspected spinal tuberculosis. 資料與

18、方法患者/研究對象：這項研究獲得(hud)了中南大學湘雅醫(yī)院倫理委員會的批準。我們進行了臨床和影像學資料的回顧性研究，這些資料是在我們單位從2005年6月至2011年6月之間前瞻性收集的550例脊柱結核患者，其中27例患者診斷為非連續(xù)性脊柱結核并行相應治療。可疑脊柱結核而收住院的所有患者均完善普通X線片、CT和MRI等檢查。共三十頁Whole spine MRI was performed on patients presenting with multi-level symptomatic vertebral infection. A diagnosis of NSTB was define

19、d as vertebral disease additional to the main lesion identified on MRI separated by at least 2 normal spinal segment (vertebral body/neural arch and/or intervertebral disc). Written informed consent was acquired from each of the patients to authorize treatment, imageology findings, and photographic

20、documentation.多節(jié)段有癥狀的椎體感染患者進行全脊柱MRI檢查，NSTB的診斷(zhndun)被定義為MRI檢出附有椎體病變的主要病灶由至少2個正常脊椎節(jié)段（椎體/神經弓和/或椎間盤）所分開。每個患者均簽署書面知情同意書以知情治療、影像學結果及照相記錄等。共三十頁The cohort comprised 17 males and 10 females, averaged 44.713.2 years old (range, 1970), with a minimum 2-year follow up. Apart from 4 cases treated conservativel

21、y, the remainder 23 patients (15 M/8F), averaged 44.614.2 years old, received surgical treatment . The location of infection varied from cervical spine down to lumbar spine . The clinical outcomes were measured preoperatively, immediately after surgery and at ultimate follow-up visit in term of hema

22、tologic and radiographic examinations and neurologic status.研究對象包括17例男性和10例女性患者，平均年齡為44.713.2歲（19-70歲），至少隨訪2年。除4例患者行保守治療(zhlio)， 其余23例患者(15 M/8F)，平均年齡為44.614.2歲（19至70歲），都接受了手術治療(zhlio)，感染的部位從頸椎到腰椎不同。術前、術后即可及末次隨訪均通過血液和影像學檢查并神經功能狀態(tài)等方面來進行臨床效果的測量。共三十頁Hematologic examination included erythrocyte sediment

23、ation rate (ESR), C-reactive protein (CRP), liver function test and blood count. The neurologic status was graded according to Frankel classification. Kyphotic angel was measured by drawing two linesone was along the top surface of the immediate upper normal vertebral body, and the other was away fr

24、om the diseased segment. The bone fusion was assessed by the Moon standard. Bone fusion was characterized by reappearance of bone trabeculae between the graft bed and graft, along with substantial graft thickness in X ray radiography.血液學檢查包括紅細胞沉降率(ESR)、C反應蛋白(CRP)、肝功能和血細胞計數。神經功能狀態(tài)是根據Frankel分級系統(tǒng)進行分級。后

25、凸角度是通過繪制兩條直線來測量，一條線通過剛剛正常最上椎體的上緣，而另一條線通過正常最下椎體下緣。用Moon標準來評估骨融合(rngh)情況，骨融合(rngh)的特點是在X線片上可見植骨床與植骨塊之間形成骨小梁，也可見植骨塊大量增厚。共三十頁Treatment StrategiesThe diagnosis was established by the presence of typical clinical and radiographic presentations, suggestive of STB in a resident from an endemic area who had

26、an elevated ESR, CRP and a therapeutic response to anti-tubercular therapy. All patients were prescribed isoniazid (INH) (5 mg/kg), rifampicin (10 mg/kg), ethambutol (15 mg/kg) and pyrazinamide (25 mg/kg) for 4 months duration, followed by rifampicin/ INH/pyrazinamide for at least a further nine mon

27、ths, until regression of symptoms, and resolution of laboratory and radiological abnormalities.治療策略根據患者的典型臨床表現和影像學結果做出診斷，來自流行地區(qū)的居民如果有ESR和 CRP 升高，并且抗結核治療有效，則提示為脊柱結核。所有患者均接受4個月的異煙肼（(INH)(5 mg/kg)，利福平(10 mg/kg)，乙胺丁醇(15 mg/kg)和吡嗪酰胺(25 mg/kg)等藥物治療，隨后服用利福平、異煙肼和吡嗪酰胺至少9個月，直到癥狀消失(xiosh)、實驗室和影像學異常均恢復正常。共三十頁Pa

28、tients with progressive neurologic deficit received additional intravenous isoniazid (0.4g/day) for 3 days preoperatively. The basic principles of treatment for spinal tuberculosis that we referred to were as follows: the lesion which was limited vertebral body destruction, small amount of abscess,

29、with neither progressive spinal cord and nerve root compromise, nor drug-resistant TB, could be treated conservatively; and the indications for surgery included the evolving neurological deficit, spinal instability, severe kyphotic deformity, refractory disease, large paravertebral abscesses and epi

30、dural abscess compressing the dural sac.神經功能缺陷逐漸加重的患者術前3天額外靜脈給予異煙肼(0.4g/天)。我們所提出的治療脊柱結核的基本原則如下：局限性椎體破壞、少量膿腫形成、無進行性脊髓和神經根損傷和無耐藥性結核病等病變均可行保守治療；手術適應證包括神經功能缺陷加重、脊柱不穩(wěn)、嚴重后凸畸形、難治性疾病、巨大(jd)椎旁膿腫和硬膜外膿腫壓迫硬膜囊等。共三十頁If the surgical lesion was confined to less than two adjacent segments, mono-stage posterior trans

31、foraminal debridement, interbody fusion and posterior instrumentation could be utilized; if the lesion involved more than 2 adjacent segments or had large paraspinal abscess, anterior debridement and autogenous iliac bone graft or allograft bone could be added after posterior instrumentation. Howeve

32、r, regarding the surgical treatment priority of each skipping lesion, the more serious lesion i.e. the one that resulted in more significant neurological compromise was treated first. If two lesions both caused neurological compromise, the upper lesion was treated first.如果手術病變(bngbin)僅局限于小于兩個相鄰節(jié)段，則采

33、用一期后路經椎間孔病灶清除、椎體間融合和后路內固定術；如果病變(bngbin)涉及到大于兩個相鄰階段或伴有巨大椎旁膿腫，則后路內固定術后再補前路病灶清除、自體髂骨或同種異體骨植骨術。然而，考慮到每一個跳躍性病變(bngbin)的手術治療優(yōu)先性，病變(bngbin)越嚴重、導致患者的神經功能損傷則越明顯，需第一個行手術治療。如果兩處病灶均引起神經功能損害，則上部病變(bngbin)需優(yōu)先治療。共三十頁Operative ProcedureThe surgery was performed under general anaesthesia. During the first stage, pos

34、terior instrumentation was applied. As described previously, if the involvement was confined to mono-segment without mass paravertebral abscess, transforaminal debridement and interbody fusion could be performed. Mild kyphosis could be corrected by postural reduction and the application of compressi

35、ve, or translation correction forces during posterior instrumentation. The instrumentation was always extended 2 levels above and below the focus. Autogenous bone or allograft was selected for posterior fusion at designated segments that underwent decompression and focal debridement.手術流程手術在全身麻醉下進行。第

36、一階段采用后路內固定術，如前所述，如果病變局限于單節(jié)段并無巨大椎旁膿腫，則行經椎間孔病灶清除、椎間融合術。輕度后凸畸形可通過(tnggu)體位復位和使用壓縮物來矯正，或后路內固定時轉化為矯正力。內固定物經常延長到病灶上下兩個節(jié)段，經減壓和病灶清除后，選取自體髂骨或同種異體骨植入到指定的階段中。共三十頁If the focus involved more than 2 adjacent segments or had large paravertebral abscess, anterior focal debridement and bone grafting could be perform

37、ed, via thoracic, thoracolumbar, or peritoneal approaches for different lesions in a single stage or in two stages depending on patients conditions. Additionally, the leaping lesion without mass abscess and severe vertebral body destruction nor neurological compression could be left conservatively.如

38、果病變累及大于兩個相鄰節(jié)段或伴有巨大椎旁膿腫，則采用前路病灶(bngzo)清除植骨融合術，根據患者實際情況選擇經胸段、胸腰段或腹膜后入路行一期或二期手術。此外，無巨大膿腫形成和嚴重椎體破壞及神經功能損害的跳躍性病變可行保守治療。共三十頁Postoperative Procedure and Follow-upThe drainage tube was removed when the drainage flow was less than 50 mL/24 h. The patients were allowed to start walking 2 weeks after surgery b

39、ut the spine was immobilized with an orthosis for 3 months until bony fusion was achieved. Imageological examinations (X-ray) and hematologic parameters (ESR, CRP, liver function test) were performed at one month intervals in the first three months, three month intervals in the next nine months, at

40、six month intervals in the second year and then once a year, along with the assessment of neurologic status, correction of deformity, and success of bone graft fusion. Clinical outcome was assessed preoperatively and at the last follow-up visit using the Oswestry disability index (ODI) questionnaire

41、.術后觀察和隨訪引流量低于50 mL/24 h時拔出引流管，術后2周將允許患者下地行走，但要佩戴矯形器3個月固定脊柱，直至達到骨性融合。頭3個月內每隔1個月復查影像學（X線）和血液學（ESR、CRP和肝功能試驗）等檢查，在接下來的9個月內每隔3個月復查一次，次年隔6個月復查一次，之后隔1年復查一次，每次復查時均進行神經功能狀態(tài)、畸形矯正率和植骨融合成功率等方面的評估。術前和末次隨訪運用ODI指數(zhsh)調查表進行臨床療效的評估。共三十頁DiscussionAs a result of AIDS and new drug-resistant strains, the resurgence o

42、f STB has sparked a flurry of activity toward the prevention and treatment of this condition. Nowadays, management strategies of STB include conservative therapy and various advanced surgical techniques. STB often involves adjacent vertebras and the intervening disc, while leaping and remote lesion

43、is not common and does not characterize the disease. Reviewing the literature, NSTB are mostly reported as episodic case reports in the mainstream academic journals. The incidence of NSTB is reported as 1.1% to 71.4% , and it is 4.3% in our study.討論艾滋病和新發(fā)耐藥菌株導致的脊柱結核再手術率引起了一系列行動以預防和治療這種情況。目前，脊柱結核的手術策

44、略包括保守治療和各種先進的手術技術。脊柱結核往往累及相鄰椎體和椎間盤，而跳躍性和遠端病灶并不常見，也不是本病的特征。通過文獻(wnxin)復習發(fā)現， NSTB大多在主流學術期刊中發(fā)表為偶發(fā)病例報告。文獻(wnxin)報道NSTB的發(fā)病率為1.1至71.4，而在我們的研究中為4.3。共三十頁There is a minority of papers referring to the surgical treatment of NSTB. In 2012, Shi et al. reported the results of 29 cases with NSTB treated with inte

45、rvertebral focal surgery. These investigators obtained a mean correction rate of 59.5% with good bone fusion at the final follow-up. In the same year, Zhang et al. reported the clinical outcomes of posterior transforaminal thoracic debridement, limited decompression, interbody fusion and posterior i

46、nstrumentation for treatment of noncontiguous thoracic tuberculosis, which also achieved good clinical efficacy. So far, however, there is a paucity of information describing the comprehensive therapeutic strategies of NSTB. In this paper, we aim to evaluate the clinical efficacy of the surgical man

47、agements (posterior surgery and a combination of posterior and anterior surgery) for NSTB, and to discuss the relevant therapeutic strategies.報道NSTB手術治療的文獻很少，2012年Shi等人報道29例NSTB患者行椎體(zhu t)間病灶清除術的結果。這些研究人員在末次隨訪中獲得了平均矯正率為59.5，且具有良好的骨性融合。在同一年，Zhang等人報道對非連續(xù)性胸椎結核患者進行后路經椎間孔胸椎病灶清除、局部減壓、椎間融合并后路內固定術，也取得了較好的

48、臨床療效。然而，至今仍缺乏描述NSTB的綜合治療策略的數據。在本研究中，我們探討評估NSTB手術治療（后路手術和后前路聯合手術）的臨床療效，并探討相關的治療策略。共三十頁The treatment principles of NSTB are basically derived from the experience in treating contiguous spinal tuberculosis. Surgery is indicated for patients with severe or evolving neurologic deficit despite antitubercu

49、lous chemotherapy, persistence of symptoms despite adequate antitubercular therapy, spinal instability, and severe spinal deformity. Compare to single focus treatment, there are several noteworthy details in the treatment of NSTB. Multilevel surgical interventions of NSTB result in more surgical tra

50、uma and complications than that of single focus disease.NSTB的治療原則基本上來自于連續(xù)性脊柱結核治療的臨床經驗。手術治療適應證有盡管行抗結核藥治療仍出現嚴重或進行性神經功能缺陷的患者，盡管給予充足的抗結核藥治療癥狀扔持續(xù)存在的患者，脊柱不穩(wěn)、嚴重脊柱畸形的患者。與單純病灶清除治療相比，在NSTB治療過程中有幾個值得注意的細節(jié)。NSTB的多節(jié)段手術干預與單節(jié)段病變相比較，導致(dozh)更多的手術創(chuàng)傷和并發(fā)癥。共三十頁Therefore, surgical indications should be controlled more st

51、rictly for each lesion of patients. Severe surgical trauma and complications caused by multilevel surgical interventions should be reduced as much as possible, by application of minimized invasive surgical techniques and the preference of debridement to radical surgery. In addition, during multileve

52、l surgery, the upper lesion or the one with neurologic compression should be dealt with in priority. Whats more, staged procedures could be performed for patients with physical deterioration.因此，對患者的每個病變應嚴格控制手術指征。應用微創(chuàng)手術技術和徹底病灶清除術，應盡量減少多節(jié)段手術干預導致的嚴重創(chuàng)傷和并發(fā)癥的發(fā)生。此外，在多節(jié)段手術過程中高位病變或神經壓迫性病變應優(yōu)先處理。更重要(zhngyo)的是，

53、對身體狀況惡化的患者進行分期手術治療。共三十頁Diverse surgical techniques, which can be divided into anterior, posterior and combined types, performed either in one or two stages, have been applied in spinal tuberculosis. Radical Hong Kong technique is the standard for anterior radical debridement with strut graft fusion.

54、 Sufficient experience has demonstrated this procedure could gain good clinical efficacy in STB treatment. Nonetheless, after radical and extended Hong Kong procedure, the incidence of spinal instability is very high. Therefore, a combination with a posterior instrumentation for full stabilisation a

55、ppears crucial. Likewise, in cases with posterior instrumentation, when an anterior approach is needed for extended focus debridement, anterior instrumentation can be accomplished at the same time.多種手術技術，即可分為前路、后路和前后聯合等類型(lixng)，無論在一期或二期手術中執(zhí)行，已應用于脊柱結核的治療。根治性的“香港”術式是前路徹底病灶清除與支撐植骨融合的標準，豐富的經驗已證明這種術式在脊柱

56、結核的治療中能夠獲得良好的臨床療效。盡管如此，經過根治性和擴大的港式術后，脊柱不穩(wěn)的發(fā)生率很高。因此，聯合后路內固定術以獲得充分的穩(wěn)定性顯得至關重要。同樣地，在后路內固定術的病例中，當需行前路手術以徹底病灶清除時，也可以同時完成前路內固定術。共三十頁Previously, the posterior approach was primarily indicated in cases with destruction of posterior structures of spine accompanied by an epidural abscess, or the involvement of

57、 neural arch, causing posterior spinal cord compression. However, in recent years, as transforaminal thoracic or lumbar interbody fusion (TTIF or TLIF) has become widely applied as minimally invasive surgical intervention in various etiologies, these techniques have been modified to treat spinal tub

58、erculosis, which were performed by a single-stage posterior transforaminal debridement, interbody fusion plus posterior instrumentation. 以前，后路手術主要用于脊柱后部結構破壞并伴有硬膜外膿腫的患者，或神經弓破壞并引起后部脊髓受壓迫的患者。然而，近年來經椎間孔胸椎或腰椎椎間融合術(TTIF or TLIF) 作為微創(chuàng)手術干預措施廣泛應用于各種( zhn)病因引起的疾病中，這些技術已改用于治療脊柱結核一期后路經椎間孔病灶清除、椎間融合并后路內固定術中。共三十頁T

59、hey have the advantages of minor surgical invasion and minimal hazard of focal neurological injury due to easy access to the spinal canal, obviating the need for anterior exposure and its associated complications. In 2009, Gautam et al employed TLIF to treat lumbar tuberculosis which was associated

60、with disease resolution, and no recurrence at final follow-up, in all patients. In this study, 17 patients were treated with transforaminal debridement, interbody fusion and posterior instrumentation, and achieved bone fusion without recurrence at last follow-up.這些技術的手術(shush)創(chuàng)傷很輕微，局部神經功能損傷的風險也很小，因為