手术治疗非连续性脊柱结核的临床疗效

手术治疗非连续性脊柱结核的临床疗效第1页，课件共26页，创作于2023年2月TheClinicalOutcomesofSurgicalTreatmentofNoncontiguousSpinalTuberculosis:ARetrospectiveStudyin23Cases手术治疗非连续性脊柱结核的临床疗效：一项23例患者的回顾性研究JiaHuangHongqiZhang*KefengZeng

Changsha,China，XiangyaHospitalofCentralSouthUniversity第2页，课件共26页，创作于2023年2月AbstractStudydesign:Aretrospectiveclinicalstudy.Objective:Toevaluatetheclinicalefficacyofthesurgicaltreatmentofnoncontiguousspinaltuberculosis(NSTB),andtodiscussitstherapeuticstrategies.摘要研究设计：一项回顾性临床研究。目的:探讨手术治疗非连续脊柱结核(NSTB)的临床疗效，并探讨其治疗策略。第3页，课件共26页，创作于2023年2月Methods:Weperformedaretrospectivereviewofclinicalandradiographicdatathatwereprospectivelycollectedon550consecutivespinaltubercularpatientsincluding27patientswhowerediagnosedandtreatedasNSTBinourinstitutionfromJune2005toJune2011.Apartfrom4patientsbeingtreatedconservatively,theremainderreceivedsurgerybyposteriortransforaminaldebridement,interbodyfusionwithinstrumentation,posteriorinstrumentationandanteriordebridementwithfusioninasingleortwo-stageoperation.Theclinicaloutcomeswereevaluatedbeforeandaftertreatmentintermsofhematologicandradiographicexaminations,bonefusionandneurologicstatus.TheOswestryDisabilityIndexscorewasdeterminedbeforetreatmentandatthelastfollow-upvisit.方法：我们进行了临床和影像学资料的回顾性研究，这些资料是在我们单位从2005年6月至2011年6月之间前瞻性收集的550例脊柱结核患者，其中27例患者诊断为非连续性脊柱结核并行相应治疗。除4例患者行保守治疗外，其余均接受后路经椎间孔病灶清除椎间融合内固定术，一期或二期行后路内固定联合前路病灶清除融合术。治疗前后通过血液学及影像学检查、植骨融合及神经功能状态等进行临床疗效的评价。ODI指数评分在治疗前和最后一次随访时确定。第4页，课件共26页，创作于2023年2月Results:23patients(15M/8F),averaged44.6±14.2yearsold(range,19to70yd),whoreceivedsurgicaltreatment,werefollowedupaftersurgeryforameanof52.5±19.5months(range,24to72months).Thekyphoticanglewaschangedsignificantlybetweenpre-andpostoperation(P＜0.05).Themeanamountofcorrectionwas12.6±7.2degrees,withasmalllossofcorrectionatlastfollow-up.Allpatientsachievedsolidbonefusion.Nopatientswithneurologicaldeficitdeterioratedpostoperatively.Neithermortalitiesnoranymajorcomplicationswerefound.TherewasasignificantdifferenceofOswestryDisabilityIndexscoresbetweenpreoperationandthefinalfollow-up.23例患者(15M/8F)，平均年龄为44.6±14.2岁（范围19至70岁），都接受了手术治疗，术后平均随访时间为52.5±19.5个月（24至72个月）。手术前、后的后凸角有明显变化（P＜0.05），平均矫正率为12.6±7.2°，而最后一次随访时有轻微的矫正丢失。所有患者均获得了坚实的骨性融合，既没有死亡率，也没有大的并发症发生。ODI指数评分在术前和末次随访时比较差异有统计学意义。第5页，课件共26页，创作于2023年2月Conclusion:Theoutcomesoffollow-upshowedthatposteriorandposterior-anteriorsurgicaltreatmentmethodswerebothviablesurgicaloptionsforNSTB.Posteriortransforaminaldebridement,interbodyfusionandposteriorinstrumentation,asalessinvasivetechnique,wasfeasibleandeffectivetotreatspecifictubercularfoci.结论随访结果表明，后路和后前联合入路手术治疗方法都是非连续性脊柱结核可行的手术方案。后路经椎间孔病灶清除、椎间融合和后路内固定术，作为一种微创技术，是治疗特异性结核病灶可行和有效的方法。第6页，课件共26页，创作于2023年2月IntroductionTuberculosishasmadeadramaticcomeback,inpartbecauseoftheappearanceofanti-tuberculosisdrugresistanceandtheacquiredimmunedeficiencysyndrome(AIDS)pandemic.Asadestructivepatternoftuberculosis,spinaltuberculosis(STB)accountsfor50%ofallcasesofmusculoskeletaltuberculosis.Itischaracterizedbyformationofcoldabscess,destructionoftheintervertebraldiscandtheadjacentvertebralbodies,collapseofthespinalelements,andanteriorwedgingleadingtokyphosis.Multilevelnoncontiguousspinaltuberculosis(NSTB)isanatypicalformofSTB,whichleavesnotlessthantwoadjacentvertebraeintactbetweenthetwofoci.TheincidenceofNSTBisreportedas1.1%to16.3%.简介由于抗结核药物耐药性的出现和获得性免疫缺陷综合症（艾滋病）的流行导致结核病大量复燃。作为结核病的破坏性形式，脊柱结核（STB）占所有肌肉骨骼结核病的50％。它的特点是冷脓肿形成，椎间盘和相邻椎体的破坏，脊柱附件和前柱的塌陷，从而导致脊柱后凸畸形。多节段非连续性脊柱结核（NSTB）是脊柱结核的非典型形式，在两个病灶之间存留不少于两个完整的椎体。研究报道NSTB的发病率为1.1%至16.3%。第7页，课件共26页，创作于2023年2月Recently,withwholespinemagneticresonanceimage(MRI)beingappliedtoaiddetectionofNSTB,itsincidenceishigherthanpreviouslyquoted[4].ThetreatmentregimesregardingNSTBvaryfrompurelymedicinetoacombinationofchemotherapyandsurgery.ThependulumoftherapeuticstrategiestoNSTBhasperiodicallyvacillatedbetweennon-operativemanagementandradicalsurgery.Inthepresentstudy,weseektodiscusstheroleofsurgicaltreatmentmethod.近年来，随着全脊柱磁共振成像（MRI）的应用帮助检测非连续性脊柱结核（NSTB），其发病率高于先前的报道。关于NSTB的治疗方案，从单纯的药物治疗到药物化疗与手术相结合等不同。NSTB的治疗方案在非手术治疗和根治性手术治疗之间定期波动。在本研究中，我们试图探讨手术治疗方法的作用。第8页，课件共26页，创作于2023年2月MaterialsandMethodsPatientsThisstudywasapprovedbytheEthicCommitteeoftheXiangyaHospitalofCentralSouthUniversity.Weperformedaretrospectivereviewofclinicalandradiographicdatathatwereprospectivelycollectedon550consecutivespinaltubercularpatientsincluding27patientswhowerediagnosedandtreatedasNSTBinourinstitutionfromJune2005toJune2011.Plainradiology,computedtomographyandMRIofthespinewereperformedonallpatientsadmittedwithsuspectedspinaltuberculosis.资料与方法患者/研究对象：这项研究获得了中南大学湘雅医院伦理委员会的批准。我们进行了临床和影像学资料的回顾性研究，这些资料是在我们单位从2005年6月至2011年6月之间前瞻性收集的550例脊柱结核患者，其中27例患者诊断为非连续性脊柱结核并行相应治疗。可疑脊柱结核而收住院的所有患者均完善普通X线片、CT和MRI等检查。第9页，课件共26页，创作于2023年2月WholespineMRIwasperformedonpatientspresentingwithmulti-levelsymptomaticvertebralinfection.AdiagnosisofNSTBwasdefinedasvertebraldiseaseadditionaltothemainlesionidentifiedonMRIseparatedbyatleast2normalspinalsegment(vertebralbody/neuralarchand/orintervertebraldisc).Writteninformedconsentwasacquiredfromeachofthepatientstoauthorizetreatment,imageologyfindings,andphotographicdocumentation.多节段有症状的椎体感染患者进行全脊柱MRI检查，NSTB的诊断被定义为MRI检出附有椎体病变的主要病灶由至少2个正常脊椎节段（椎体/神经弓和/或椎间盘）所分开。每个患者均签署书面知情同意书以知情治疗、影像学结果及照相记录等。第10页，课件共26页，创作于2023年2月Thecohortcomprised17malesand10females,averaged44.7±13.2yearsold(range,19–70),withaminimum2-yearfollowup.Apartfrom4casestreatedconservatively,theremainder23patients(15M/8F),averaged44.6±14.2yearsold,receivedsurgicaltreatment.Thelocationofinfectionvariedfromcervicalspinedowntolumbarspine.Theclinicaloutcomesweremeasuredpreoperatively,immediatelyaftersurgeryandatultimatefollow-upvisitintermofhematologicandradiographicexaminationsandneurologicstatus.研究对象包括17例男性和10例女性患者，平均年龄为44.7±13.2岁（19-70岁），至少随访2年。除4例患者行保守治疗，其余23例患者(15M/8F)，平均年龄为44.6±14.2岁（19至70岁），都接受了手术治疗，感染的部位从颈椎到腰椎不同。术前、术后即可及末次随访均通过血液和影像学检查并神经功能状态等方面来进行临床效果的测量。第11页，课件共26页，创作于2023年2月Hematologicexaminationincludederythrocytesedimentationrate(ESR),C-reactiveprotein(CRP),liverfunctiontestandbloodcount.TheneurologicstatuswasgradedaccordingtoFrankelclassification.Kyphoticangelwasmeasuredbydrawingtwolines–onewasalongthetopsurfaceoftheimmediateuppernormalvertebralbody,andtheotherwasawayfromthediseasedsegment.ThebonefusionwasassessedbytheMoonstandard.Bonefusionwascharacterizedbyreappearanceofbonetrabeculaebetweenthegraftbedandgraft,alongwithsubstantialgraftthicknessinXrayradiography.血液学检查包括红细胞沉降率(ESR)、C反应蛋白(CRP)、肝功能和血细胞计数。神经功能状态是根据Frankel分级系统进行分级。后凸角度是通过绘制两条直线来测量，一条线通过刚刚正常最上椎体的上缘，而另一条线通过正常最下椎体下缘。用Moon标准来评估骨融合情况，骨融合的特点是在X线片上可见植骨床与植骨块之间形成骨小梁，也可见植骨块大量增厚。第12页，课件共26页，创作于2023年2月TreatmentStrategiesThediagnosiswasestablishedbythepresenceoftypicalclinicalandradiographicpresentations,suggestiveofSTBinaresidentfromanendemicareawhohadanelevatedESR,CRPandatherapeuticresponsetoanti-tuberculartherapy.Allpatientswereprescribedisoniazid(INH)(5mg/kg),rifampicin(10mg/kg),ethambutol(15mg/kg)andpyrazinamide(25mg/kg)for4monthsduration,followedbyrifampicin/INH/pyrazinamideforatleastafurtherninemonths,untilregressionofsymptoms,andresolutionoflaboratoryandradiologicalabnormalities.治疗策略根据患者的典型临床表现和影像学结果做出诊断，来自流行地区的居民如果有ESR和CRP升高，并且抗结核治疗有效，则提示为脊柱结核。所有患者均接受4个月的异烟肼（(INH)(5mg/kg)，利福平(10mg/kg)，乙胺丁醇(15mg/kg)和吡嗪酰胺(25mg/kg)等药物治疗，随后服用利福平、异烟肼和吡嗪酰胺至少9个月，直到症状消失、实验室和影像学异常均恢复正常。第13页，课件共26页，创作于2023年2月Patientswithprogressiveneurologicdeficitreceivedadditionalintravenousisoniazid(0.4g/day)for3dayspreoperatively.Thebasicprinciplesoftreatmentforspinaltuberculosisthatwereferredtowereasfollows:thelesionwhichwaslimitedvertebralbodydestruction,smallamountofabscess,withneitherprogressivespinalcordandnerverootcompromise,nordrug-resistantTB,couldbetreatedconservatively;andtheindicationsforsurgeryincludedtheevolvingneurologicaldeficit,spinalinstability,severekyphoticdeformity,refractorydisease,largeparavertebralabscessesandepiduralabscesscompressingtheduralsac.神经功能缺陷逐渐加重的患者术前3天额外静脉给予异烟肼(0.4g/天)。我们所提出的治疗脊柱结核的基本原则如下：局限性椎体破坏、少量脓肿形成、无进行性脊髓和神经根损伤和无耐药性结核病等病变均可行保守治疗；手术适应证包括神经功能缺陷加重、脊柱不稳、严重后凸畸形、难治性疾病、巨大椎旁脓肿和硬膜外脓肿压迫硬膜囊等。第14页，课件共26页，创作于2023年2月Ifthesurgicallesionwasconfinedtolessthantwoadjacentsegments,mono-stageposteriortransforaminaldebridement,interbodyfusionandposteriorinstrumentationcouldbeutilized;ifthelesioninvolvedmorethan2adjacentsegmentsorhadlargeparaspinalabscess,anteriordebridementandautogenousiliacbonegraftorallograftbonecouldbeaddedafterposteriorinstrumentation.However,regardingthesurgicaltreatmentpriorityofeachskippinglesion,themoreseriouslesioni.e.theonethatresultedinmoresignificantneurologicalcompromisewastreatedfirst.Iftwolesionsbothcausedneurologicalcompromise,theupperlesionwastreatedfirst.如果手术病变仅局限于小于两个相邻节段，则采用一期后路经椎间孔病灶清除、椎体间融合和后路内固定术；如果病变涉及到大于两个相邻阶段或伴有巨大椎旁脓肿，则后路内固定术后再补前路病灶清除、自体髂骨或同种异体骨植骨术。然而，考虑到每一个跳跃性病变的手术治疗优先性，病变越严重、导致患者的神经功能损伤则越明显，需第一个行手术治疗。如果两处病灶均引起神经功能损害，则上部病变需优先治疗。第15页，课件共26页，创作于2023年2月OperativeProcedureThesurgerywasperformedundergeneralanaesthesia.Duringthefirststage,posteriorinstrumentationwasapplied.Asdescribedpreviously,iftheinvolvementwasconfinedtomono-segmentwithoutmassparavertebralabscess,transforaminaldebridementandinterbodyfusioncouldbeperformed.Mildkyphosiscouldbecorrectedbyposturalreductionandtheapplicationofcompressive,ortranslationcorrectionforcesduringposteriorinstrumentation.Theinstrumentationwasalwaysextended2levelsaboveandbelowthefocus.Autogenousboneorallograftwasselectedforposteriorfusionatdesignatedsegmentsthatunderwentdecompressionandfocaldebridement.手术流程手术在全身麻醉下进行。第一阶段采用后路内固定术，如前所述，如果病变局限于单节段并无巨大椎旁脓肿，则行经椎间孔病灶清除、椎间融合术。轻度后凸畸形可通过体位复位和使用压缩物来矫正，或后路内固定时转化为矫正力。内固定物经常延长到病灶上下两个节段，经减压和病灶清除后，选取自体髂骨或同种异体骨植入到指定的阶段中。第16页，课件共26页，创作于2023年2月Ifthefocusinvolvedmorethan2adjacentsegmentsorhadlargeparavertebralabscess,anteriorfocaldebridementandbonegraftingcouldbeperformed,viathoracic,thoracolumbar,orperitonealapproachesfordifferentlesionsinasinglestageorintwostagesdependingonpatients’conditions.Additionally,theleapinglesionwithoutmassabscessandseverevertebralbodydestructionnorneurologicalcompressioncouldbeleftconservatively.如果病变累及大于两个相邻节段或伴有巨大椎旁脓肿，则采用前路病灶清除植骨融合术，根据患者实际情况选择经胸段、胸腰段或腹膜后入路行一期或二期手术。此外，无巨大脓肿形成和严重椎体破坏及神经功能损害的跳跃性病变可行保守治疗。第17页，课件共26页，创作于2023年2月PostoperativeProcedureandFollow-upThedrainagetubewasremovedwhenthedrainageflowwaslessthan50mL/24h.Thepatientswereallowedtostartwalking2weeksaftersurgerybutthespinewasimmobilizedwithanorthosisfor3monthsuntilbonyfusionwasachieved.Imageologicalexaminations(X-ray)andhematologicparameters(ESR,CRP,liverfunctiontest)wereperformedatonemonthintervalsinthefirstthreemonths,threemonthintervalsinthenextninemonths,atsixmonthintervalsinthesecondyearandthenonceayear,alongwiththeassessmentofneurologicstatus,correctionofdeformity,andsuccessofbonegraftfusion.Clinicaloutcomewasassessedpreoperativelyandatthelastfollow-upvisitusingtheOswestrydisabilityindex(ODI)questionnaire.术后观察和随访引流量低于50mL/24h时拔出引流管，术后2周将允许患者下地行走，但要佩戴矫形器3个月固定脊柱，直至达到骨性融合。头3个月内每隔1个月复查影像学（X线）和血液学（ESR、CRP和肝功能试验）等检查，在接下来的9个月内每隔3个月复查一次，次年隔6个月复查一次，之后隔1年复查一次，每次复查时均进行神经功能状态、畸形矫正率和植骨融合成功率等方面的评估。术前和末次随访运用ODI指数调查表进行临床疗效的评估。第18页，课件共26页，创作于2023年2月DiscussionAsaresultofAIDSandnewdrug-resistantstrains,theresurgenceofSTBhassparkedaflurryofactivitytowardthepreventionandtreatmentofthiscondition.Nowadays,managementstrategiesofSTBincludeconservativetherapyandvariousadvancedsurgicaltechniques.STBofteninvolvesadjacentvertebrasandtheinterveningdisc,whileleapingandremotelesionisnotcommonanddoesnotcharacterizethedisease.Reviewingtheliterature,NSTBaremostlyreportedasepisodiccasereportsinthemainstreamacademicjournals.TheincidenceofNSTBisreportedas1.1%to71.4%,anditis4.3%inourstudy.讨论艾滋病和新发耐药菌株导致的脊柱结核再手术率引起了一系列行动以预防和治疗这种情况。目前，脊柱结核的手术策略包括保守治疗和各种先进的手术技术。脊柱结核往往累及相邻椎体和椎间盘，而跳跃性和远端病灶并不常见，也不是本病的特征。通过文献复习发现，NSTB大多在主流学术期刊中发表为偶发病例报告。文献报道NSTB的发病率为1.1％至71.4％，而在我们的研究中为4.3％。第19页，课件共26页，创作于2023年2月ThereisaminorityofpapersreferringtothesurgicaltreatmentofNSTB.In2012,Shietal.reportedtheresultsof29caseswithNSTBtreatedwithintervertebralfocalsurgery.Theseinvestigatorsobtainedameancorrectionrateof59.5%withgoodbonefusionatthefinalfollow-up.Inthesameyear,Zhangetal.reportedtheclinicaloutcomesofposteriortransforaminalthoracicdebridement,limiteddecompression,interbodyfusionandposteriorinstrumentationfortreatmentofnoncontiguousthoracictuberculosis,whichalsoachievedgoodclinicalefficacy.Sofar,however,thereisapaucityofinformationdescribingthecomprehensivetherapeuticstrategiesofNSTB.Inthispaper,weaimtoevaluatetheclinicalefficacyofthesurgicalmanagements(posteriorsurgeryandacombinationofposteriorandanteriorsurgery)forNSTB,andtodiscusstherelevanttherapeuticstrategies.报道NSTB手术治疗的文献很少，2012年Shi等人报道29例NSTB患者行椎体间病灶清除术的结果。这些研究人员在末次随访中获得了平均矫正率为59.5％，且具有良好的骨性融合。在同一年，Zhang等人报道对非连续性胸椎结核患者进行后路经椎间孔胸椎病灶清除、局部减压、椎间融合并后路内固定术，也取得了较好的临床疗效。然而，至今仍缺乏描述NSTB的综合治疗策略的数据。在本研究中，我们探讨评估NSTB手术治疗（后路手术和后前路联合手术）的临床疗效，并探讨相关的治疗策略。第20页，课件共26页，创作于2023年2月ThetreatmentprinciplesofNSTBarebasicallyderivedfromtheexperienceintreatingcontiguousspinaltuberculosis.Surgeryisindicatedforpatientswithsevereorevolvingneurologicdeficitdespiteantituberculouschemotherapy,persistenceofsymptomsdespiteadequateantituberculartherapy,spinalinstability,andseverespinaldeformity.Comparetosinglefocustreatment,thereareseveralnoteworthydetailsinthetreatmentofNSTB.MultilevelsurgicalinterventionsofNSTBresultinmoresurgicaltraumaandcomplicationsthanthatofsinglefocusdisease.NSTB的治疗原则基本上来自于连续性脊柱结核治疗的临床经验。手术治疗适应证有尽管行抗结核药治疗仍出现严重或进行性神经功能缺陷的患者，尽管给予充足的抗结核药治疗症状扔持续存在的患者，脊柱不稳、严重脊柱畸形的患者。与单纯病灶清除治疗相比，在NSTB治疗过程中有几个值得注意的细节。NSTB的多节段手术干预与单节段病变相比较，导致更多的手术创伤和并发症。第21页，课件共26页，创作于2023年2月Therefore,surgicalindicationsshouldbecontrolledmorestrictlyforeachlesionofpatients.Severesurgicaltraumaandcomplicationscausedbymultilevelsurgicalinterventionsshouldbereducedasmuchaspossible,byapplicationofminimizedinvasivesurgicaltechniquesandthepreferenceofdebridementtoradicalsurgery.Inaddition,duringmultilevelsurgery,theupperlesionortheonewithneurologiccompressionshouldbedealtwithinpriority.What’smore,stagedprocedurescouldbeperformedforpatientswithphysicaldeterioration.因此，对患者的每个病变应严格控制手术指征。应用微创手术技术和彻底病灶清除术，应尽量减少多节段手术干预导致的严重创伤和并发症的发生。此外，在多节段手术过程中高位病变或神经压迫性病变应优先处理。更重要的是，对身体状况恶化的患者进行分期手术治疗。第22页，课件共26页，创作于2023年2月Diversesurgicaltechniques,whichcanbedividedintoanterior,posteriorandcombinedtypes,performedeitherinoneortwostages,havebeenappliedinspinaltuberculosis.RadicalHongKongtechniqueisthestandardforanteriorradicaldebridementwithstrutgraftfusion.SufficientexperiencehasdemonstratedthisprocedurecouldgaingoodclinicalefficacyinSTBtreatment.Nonetheless,afterradicalandextendedHongKongprocedure,theincidenceofspinalinstabilityisveryhigh.Therefore,acombinationwithaposteriorinstrumentationforfullstabilisationappearscrucial.Likewise,incaseswithposteriorinstrumentation,whenananteriorapproachisneededforextendedfocusdebridement,anteriorinstrumentationcanbeaccomplishedatthesametime.多种手术技术，即可分为前路、后路和前后联合等类型，无论在一期或二期手术中执行，已应用于脊柱结核的治疗。根治性的“香港”术式是前路彻底病灶清除与支撑植骨融合的标准，丰富的经验已证明这种术式在脊柱结核的治疗中能够获得良好的临床疗效。尽管如此，经过根治性和扩大的港式术后，脊柱不稳的发生率很高。因此，联合后路内固定术以获得充分的稳定性显得至关重要。同样地，在后路内固定术的病例中，当需行前路手术以彻底病灶清除时，也可以同时完成前路内固定术。第23页，课件共26页，创作于2023年2月Previously,theposteriorapproachwasprimarilyindicatedincaseswithdestructionofposteriorstructuresofspineaccompaniedbyanepiduralabscess,ortheinvolvementofneuralarch,causingposteriorspinalcordcompression.However,inrecentyears,astransforaminalthoracicorlumbarinterbodyfusion(TTIForTLIF)hasbecomewidelyappliedasminimallyinvasivesurgicalinterventioninvariousetiologies,thesetechniqueshavebeenmodifiedtotreatspinaltuberculosis,whichwereperformedbyasingle-stageposteriortransforaminaldebridement,interbodyfusionplusposteriorinstrumentation.以前，后路手术主要用于脊柱后部结构破坏并伴有硬膜外脓肿的患者，或神经弓破坏并引起后部脊髓受压迫的患者。然而，近年来经椎间孔胸椎或腰椎椎间融合术(TTIForTLIF)作为微创手术干预措施广泛应用于各种病因引起的疾病中，这些技术已改用于治疗脊柱结核一期后路经椎间孔病灶清除、椎间融合并后路内固定术中。第24页，课件共26页，创作于2023年2月Theyhavetheadvantagesofminorsurgicalinvasionandmini