后路矫形联合前路支撑植骨治疗非治愈性重度结核性胸腰椎后凸畸形

摘要

目的 探讨后路畸形矫正联合前路病灶清除、支撑植骨治疗非治愈性重度结核性胸腰椎后凸畸形的临床疗效.方法 回顾性分析2013年1月至2017年7月采用后路畸形矫正联合一期或二期前路病灶清除、支撑植骨治疗非治愈性重度结核性胸腰椎后凸畸形患者27例,男10例,女17例;年龄2~38岁,平均(17.3±9.9)岁.后凸畸形矫正均采用后柱截骨、脊髓减压、悬臂梁压棒技术+术中纵向牵引;联合一期或二期.后凸畸形矫正评价指标包括后凸Cobb角及矫正率、脊柱矢状面偏移(sagittal vertical axis,SVA)、手术前后身高差,采用Eck融合分级标准评价植骨融合程度.临床功能评价指标包括视觉疼痛模拟评分(visual analogue scale,VAS)、美国脊柱损伤协会(American Spinal Injury Association,ASIA)脊髓损伤分级、Oswestry能障碍指数(Oswestry dysfunction index,ODI)及Kirkaldy?Willis功能评价标准.结果 27例患者均顺利完成手术治疗,手术时间210~530min,平均(343.0±71.5)min;术中出血量300~2 600 ml,平均(1 168.5±606.7)ml.术前后凸Cobb角81°~144°,平均105.2°±17.7°;术后后凸Cobb角5°~47°,平均28.2°±10.3°,平均矫正率为72.9%±9.8%;术前SVA为-96.66~78.76 mm,平均(40.5±20.4)mm;术后为-33.61~44.96 mm,平均(26.6±12.6)mm.手术前后身高差26.8~172.7 mm,平均(67.5±37.8)mm.术后随访12~36个月,平均(19.3±6.7)个月.末次随访后凸Cobb角丢失1°~8°,平均4.3°± 1.8°.所有患者术后结核中毒及营养状况均明显好转.术后3个月时VAS评分平均为(1.1±0.6)分,改善率平均为47.5%,与术前比较差异有统计学意义(t=6.31,P＜0.05).术后3个月时ODI平均为6.5%±4.1%,改善率平均为68.1%,与术前比较差异有统计学意义(t=8.41,P＜0.05).末次随访时除1例术前ASIA分级B级改善至D级、1例E级无变化外,其余患者均改善至E级.按Kirkaldy?Willis功能评分标准:优24例、良2例、中1例,总优良率为88.9%.末次随访时27例患者根据Eck融合分级标准植骨区均达到Ⅰ级.术后3例患者出现脑脊液漏及4例患者出现胸腔积液,均经积极对症治疗后痊愈.随访期间均未发现结核复发,内固定松动、断裂及明显矫正度丢失.结论 对多节段椎体破坏的非治愈性重度结核性胸腰椎后凸畸形,通过后路截骨结合悬臂梁技术+术中纵向牵引可达到良好畸形矫正和适当恢复椎体高度的目的,联合前路病灶清除、植骨融合是安全、可靠的治疗方法.%Objective To explore the clinical effect of posterior deformity correction combined with anterior lesion re?moval and bone graft in the treatment of non?curable severe tuberculous thoracolumbar kyphosis. Methods All of 27 patients with non?curable severe tuberculous thoracolumbar kyphosis treated by posterior deformity correction combined with primary or secondary anterior debridement and bone grafting from January 2013 to July 2017 were retrospective analyzed, including 10 males and 17 females. The age ranged from 2 to 38 years with an average of 17.3±9.9 years. Posterior column osteotomy, spinal cord de?compression, cantilever bar pressing technique and intraoperative longitudinal traction were used to correct kyphosis. According to clinical symptoms, Cobb angle correction rate of kyphosis deformity, sagittal SVA of spine, height difference before and after opera?tion, operation time, intraoperative bleeding volume, complications, and the effect of the operation was evaluated. Symptoms and functional evaluation indicators included visual analogue scale (VAS), American Spinal Injury Association (ASIA) spinal cord inju?ry classification, Oswestry dysfunction index (ODI), and Kirkaldy?Willis functional score. Laboratory tests included erythrocyte sedimentation rate (ESR) and C?reactive protein (CRP). Eck fusion grading standard was used to evaluate the degree of bone graft fusion. Results All the 27 patients successfully underwent the operation. The operation time was 210-530 minutes, with an aver?age of 343.0±71.5 minutes, while the bleeding volume was 300-2 600 ml, with an average of 1 168.5±606.7 ml. The preoperative Cobb angle ranged from 81 to 144 degrees, with an average of 105.2±17.7 degrees; the postoperative Cobb angle ranged from 5 to 47 degrees, with an average of 28.2±0.3 degrees, and the average correction rate was 72.9%±9.8%; the preoperative sagittal SVA ranged from 96.66 mm to 78.76 mm, with an average of 40.5±20.4 mm; and the postoperative sagittal SVA ranged from 33.61 mm to 44.96 mm, with an average of 26.6±12.6 mm. The height difference before and after operation was 26.8-172.7 mm, with an aver?age of 67.5±37.8 mm. The follow?up period ranged from 12 to 36 months, with an average of 19.3±6.7 months. At the last follow?up, the loss of Cobb angle ranged from 1 degree to 8 degree, with an average of 4.3°±1.8°degree. The postoperative nutritional sta?tus of all patients was significantly improved. At 3 months after operation, the average VAS score was 1.1±0.6 and the improve?ment rate was 47.5%. The difference was statistically significant (t=6.31, P<0.05). At 3 months after operation, the average ODI was 6.5%±4.1%, and the improvement rate was 68.1%. The difference was statistically significant (t=8.41, P<0.05). At the last fol?low?up, all the patients were improved to grade E in ASIA except one patient from grade B to grade D, and one stayed at grade E. Kirkaldy?willis functional score: excellent in 24 cases, good in 2 cases, and good in 1 case, with a total good/good rate of 88.9%. Cerebrospinal fluid leakage occurred in 3 patients after surgery, and pleural effusion occurred in 4 patients after surgery. No recur?rence of tuberculosis, loosening of internal fixation, fracture or loss of obvious correction were found during the follow?up. Accord?ing to the Eck fusion classification standard, at the time of the last follow?up bone graft area of all 27 cases reached I level fusion. Conclusion For non?curable severe tuberculous thoracolumbar kyphosis with multi?segment vertebral body loss, good deformity correction and proper recovery of vertebral height can be achieved by posterior osteotomy combined with cantilever beam tech?nique and intraoperative longitudinal traction. The combination of anterior debridement and bone graft fusion is a safe and reliable method.