单纯后路手术治疗儿童脊柱结核后凸脓肿
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摘要
[目的]评估单纯经后路病灶清除植骨融合内固定术治疗合并椎旁脓肿的儿童脊柱结核胸腰椎后凸畸形的治疗效果。[方法] 2014年1月～2018年2月本院收治合并椎旁脓肿的儿童脊柱结核后凸患儿16例,其中男6例,女10例,年龄3～14岁,平均(7.40±3.67)岁。均采用单纯后路病灶清除矫形植骨融合内固定术治疗,观察比较术前术后及末次随访的局部后凸Cobb角,血沉、C反应蛋白、神经功能评级等指标的变化情况。[结果]所有患儿手术顺利,围手术期无神经损伤或术后瘫痪加重等表现,术后切口均一期愈合。所有病例均获得随访,随访时间12～36个月,平均(21.25±7.65)个月。随访中,ASIA分级由术前B级2例,C级2例,D级12例,改进为未次随访时1例患儿从B级恢复至D级,其余15例患儿恢复至E级,差异有统计学意义(P<0.05)。辅助检查术后3个月ESR和CRP较术前显著降低,差异有统计学意义(P<0.05)。末次随访时影像测量Cobb角较术前显著减少,差异有统计学意义(P<0.05)。至末次随访,未见内固定松动、断裂、脱出等发生,骨性融合良好。[结论]一期后路病灶清除矫形植骨融合内固定术治疗合并椎旁脓肿的小儿胸腰段结核后凸疗效可靠。
[Objective] To explore the efficacy and feasibility of one-stage posterior debridement combined with instrumented fusion for thoracolumbar tuberculosis accompanied with kyphosis in children. [Methods] From January 2014 to February 2018, a total of 16 children who suffered from thoracolumbar tuberculosis accompanied with abscess and kyphosis, including 6 males and 10 females, aged from 3 to 14 years old with an average age of(7.40±3.67) years, were surgically treated with one-stage posterior debridement combined with instrumented fusion. The neurological function, erythrocyte sedimentation rate(ESR), C-reaction protein(CRP), and local kyphotic Cobbs angle measured on X-rays before and after operation were evaluated. [Result] All the children had surgical procedures performed smoothly without nerve injuries or paralysis deterioration in anyone of them, while with primary incision healing in all of them. The children were followed up for 12 to 36 months with an average of(21.25±7.65) months. In term of neurological function, the ASIA grades significantly improved from Grade B in 2, Grade C in 2 and Grade D in 12 cases preoperatively to Grade E in all patients at the latest follow up expect one child who recovered from Grade B to Grade D, which proved statistically significant(P<0.05). The ESR and CRP significantly decreased at 3 months after operation compared with those before operation(P<0.05). In addition, the Cobb angle of kyphosis significantly reduced at the latest follow up compared with that preoperatively(P<0.05). To the latest follow up no loosening or breaking of internal implants was noticed in anyone of them, whereas bony fusion was achieved in all the children. [Conclusion] This one-stage posterior debridement combined with instrumented fusion is effective and reliable for thoracolumbar tuberculosis accompanied with abscess and kyphosis in children.
[Objective] To explore the efficacy and feasibility of one-stage posterior debridement combined with instrumented fusion for thoracolumbar tuberculosis accompanied with kyphosis in children. [Methods] From January 2014 to February 2018, a total of 16 children who suffered from thoracolumbar tuberculosis accompanied with abscess and kyphosis, including 6 males and 10 females, aged from 3 to 14 years old with an average age of(7.40±3.67) years, were surgically treated with one-stage posterior debridement combined with instrumented fusion. The neurological function, erythrocyte sedimentation rate(ESR), C-reaction protein(CRP), and local kyphotic Cobbs angle measured on X-rays before and after operation were evaluated. [Result] All the children had surgical procedures performed smoothly without nerve injuries or paralysis deterioration in anyone of them, while with primary incision healing in all of them. The children were followed up for 12 to 36 months with an average of(21.25±7.65) months. In term of neurological function, the ASIA grades significantly improved from Grade B in 2, Grade C in 2 and Grade D in 12 cases preoperatively to Grade E in all patients at the latest follow up expect one child who recovered from Grade B to Grade D, which proved statistically significant(P<0.05). The ESR and CRP significantly decreased at 3 months after operation compared with those before operation(P<0.05). In addition, the Cobb angle of kyphosis significantly reduced at the latest follow up compared with that preoperatively(P<0.05). To the latest follow up no loosening or breaking of internal implants was noticed in anyone of them, whereas bony fusion was achieved in all the children. [Conclusion] This one-stage posterior debridement combined with instrumented fusion is effective and reliable for thoracolumbar tuberculosis accompanied with abscess and kyphosis in children.
引文
[1]张宏其,刘少华.儿童脊柱结核的治疗[J].中华骨科杂志,2014,34(2):240-246.
[2]Willems KF,Slot GH,Anderson PG,et al.Spinal osteotomy in patients with ankylosing spondylitis:complications during first postoperative year[J].Spine(Phila Pa 1976),2005,30(1):101-107.
[3]周春光,宋跃明,刘立岷,等.前后路手术治疗儿童静止期脊柱结核后凸畸形[J].中国骨与关节外科杂志,2009,2(5):357-361.
[4]张宏其,陈勇,郭超峰,等.改良型经椎弓根截骨治疗小儿胸腰段治愈型结核伴后凸畸形[J].中国矫形外科杂志,2015,23(11):961-966.
[5]徐韬,买尔旦·买买提,盛伟斌,等.一期后路截骨矫形治疗儿童静止期脊柱结核性后凸(侧后凸)畸形[J].中华骨科杂志,2014,34(2):183-188.
[6]余希临,沈先涛,桂彤,等.一期前路病灶清除植骨融合治疗儿童颈椎结核[J].中国脊柱脊髓杂志,2006,16(4):313-314.
[7]张宏其,肖力戈.后路短节段融合固定合并二期前路病灶清除治疗幼儿腰椎结核[J].中国矫形外科杂志,2018,26(2):117-121.
[8]张宏其,王昱翔,郭超峰,等.分期后路融合内固定前路病灶清除椎间植骨治疗儿童腰椎结核伴后凸畸形[J].中国脊柱脊髓杂志,2010,20(10):820-824.
[9]张宏其,唐明星,王昱翔,等.多枚分网异形钛网技术在单纯一期后路脊柱结核手术中的应用[J].中国矫形外科杂志,2014,22(15):1353-1358.
[10]Jain AK.Tuberculosis of the spine:a fresh look at an old disease[J].J Bone Joint Surg Br,2010,92(7):905-913.
[11]Rajasekaran S,Shanmugasundaram TK,Prabhakar R,et al.Tuberculous lesions of the lumbosacralregion.A 15-year follow-up of patients treated by ambulant chemotherapy[J].Spine(Phila Pa1976),1998,23(10):1163-1167.
[12]Rajasekaran S.The problem of deformity in spinal tuberculosis[J].Clin Orthop,2002,(398):85-92.
[13]Schulitz KP,Kothe R,Leong JC,et al.Growthchangesofsolidlyfusedkyphoticblocafter surgery for tuberculosis.Comparison of four procedures[J].Spine(Phila Pa 1976),1997,22(10):1150-1155.
[14]Hassan K,Elmorshidy E.Anterior versus posterior approach in surgical treatment of tuberculous spondylodiscitis of thoracic and lumbar spine[J].Eur Spine J,2016,25(4):1056-1063.
[15]Fukata S,Miyamoto K,Masuda T,et al.Two stage(posterior and anterior)surgical treatment using posterior spinal instrumentation for pyogenic and tuberculous spondylitis[J].Spine(Phila Pa1976),2003,28:E302-E308
[16]张宏其,郭超峰,唐明星,等.一期后路病灶清除、异形钛网椎间植骨融合治疗胸、腰椎结核[J].中华骨科杂志,2014,34(2):102-108.
[17]Zhang H,Zeng K,Yin X,et al.Debridement,internal fixation,and reconstruction using titanium mesh for the surgical treatment of thoracic and lumbar spinal tuberculosis via a posterior-only approach:a 4-year follow-up of 28 patients[J].J Orthop Surg Res,2015,10:150.2019-04-16 2019-04-24
[2]Willems KF,Slot GH,Anderson PG,et al.Spinal osteotomy in patients with ankylosing spondylitis:complications during first postoperative year[J].Spine(Phila Pa 1976),2005,30(1):101-107.
[3]周春光,宋跃明,刘立岷,等.前后路手术治疗儿童静止期脊柱结核后凸畸形[J].中国骨与关节外科杂志,2009,2(5):357-361.
[4]张宏其,陈勇,郭超峰,等.改良型经椎弓根截骨治疗小儿胸腰段治愈型结核伴后凸畸形[J].中国矫形外科杂志,2015,23(11):961-966.
[5]徐韬,买尔旦·买买提,盛伟斌,等.一期后路截骨矫形治疗儿童静止期脊柱结核性后凸(侧后凸)畸形[J].中华骨科杂志,2014,34(2):183-188.
[6]余希临,沈先涛,桂彤,等.一期前路病灶清除植骨融合治疗儿童颈椎结核[J].中国脊柱脊髓杂志,2006,16(4):313-314.
[7]张宏其,肖力戈.后路短节段融合固定合并二期前路病灶清除治疗幼儿腰椎结核[J].中国矫形外科杂志,2018,26(2):117-121.
[8]张宏其,王昱翔,郭超峰,等.分期后路融合内固定前路病灶清除椎间植骨治疗儿童腰椎结核伴后凸畸形[J].中国脊柱脊髓杂志,2010,20(10):820-824.
[9]张宏其,唐明星,王昱翔,等.多枚分网异形钛网技术在单纯一期后路脊柱结核手术中的应用[J].中国矫形外科杂志,2014,22(15):1353-1358.
[10]Jain AK.Tuberculosis of the spine:a fresh look at an old disease[J].J Bone Joint Surg Br,2010,92(7):905-913.
[11]Rajasekaran S,Shanmugasundaram TK,Prabhakar R,et al.Tuberculous lesions of the lumbosacralregion.A 15-year follow-up of patients treated by ambulant chemotherapy[J].Spine(Phila Pa1976),1998,23(10):1163-1167.
[12]Rajasekaran S.The problem of deformity in spinal tuberculosis[J].Clin Orthop,2002,(398):85-92.
[13]Schulitz KP,Kothe R,Leong JC,et al.Growthchangesofsolidlyfusedkyphoticblocafter surgery for tuberculosis.Comparison of four procedures[J].Spine(Phila Pa 1976),1997,22(10):1150-1155.
[14]Hassan K,Elmorshidy E.Anterior versus posterior approach in surgical treatment of tuberculous spondylodiscitis of thoracic and lumbar spine[J].Eur Spine J,2016,25(4):1056-1063.
[15]Fukata S,Miyamoto K,Masuda T,et al.Two stage(posterior and anterior)surgical treatment using posterior spinal instrumentation for pyogenic and tuberculous spondylitis[J].Spine(Phila Pa1976),2003,28:E302-E308
[16]张宏其,郭超峰,唐明星,等.一期后路病灶清除、异形钛网椎间植骨融合治疗胸、腰椎结核[J].中华骨科杂志,2014,34(2):102-108.
[17]Zhang H,Zeng K,Yin X,et al.Debridement,internal fixation,and reconstruction using titanium mesh for the surgical treatment of thoracic and lumbar spinal tuberculosis via a posterior-only approach:a 4-year follow-up of 28 patients[J].J Orthop Surg Res,2015,10:150.2019-04-16 2019-04-24