胸腰段脊柱结核术后未愈及术后复发原因的探讨

【目的】探讨胸腰段脊柱结核术后未愈及术后复发的原因。【方法】回顾性分析2006年1月至2009年8月本院收住的经本科手术治疗术后未愈及术后复发的胸腰段脊柱结核患者16例，男性7例，女性9例，初次入院时均表现为不同程度的椎体骨质破坏、后凸畸形及椎旁脓肿形成；16例采用一期后路内固定、经椎弓根或肋一横突入路病灶清除、椎间自体肋骨植骨术。行后正中入路术患者术后均未行规律抗结核、严格制动及佩戴支具治疗；术后规律抗结核大于8个月者7例，但其中2例耐药，不规律者5例。【结果】4例行后正中入路手术患者于术后第18～22个月再次出现椎旁大量脓肿并伴有25％～35％矫正角度（Cobb角）丢失；12例行肋一横突入路手术患者，术后规律抗结核大于8个月者于术后第24~32个月均出现椎弓根螺钉松动及脊柱后凸畸形，其中2例耐药者还伴有椎旁大量脓肿形成；术后抗结核不规律或周期少于4个月者于术后第20~26个月再次形成大量椎旁脓肿、中、重度后凸畸形并伴有不同程度的内固定松动或断裂。【结论】手术时机选择不当、病灶清除不彻底、内固定方式选择不理想、植骨材料或植骨位置选择欠佳、抗结核化疗不正规、结核杆菌耐药、制动不严格及术后未行佩戴支具治疗是胸腰段脊柱结核手术未愈或复发的主要原因。

Discussion of the Reason of Un-healing and Recurrence after Operation of Thoracolumbar Spinal Tuberculosis

Objective] To explore the reason of un-healing and recurrence after operation of thoracolumbar spinal tuberculosis. Methods] Sixteen cases（7 males and 9 females） of postoperative un healing and recurrent thoracolumbar spinal tuberculosis patients were analyzed retrospectively from Jan. 2006 to Aug. 2009. The manifestations of all patients were different level of vertebral destruction, spine kyphosis and paravertebral abscess at first admission. All 16 patients underwent one-stage posterior internal fixation, debridement by vertebral arch or rib-transverse process approach and intervertebral rib bone autograft. The patients undergoing posterior midline approach operation were not treated with regular antitu- berculosis therapy, firmly local braking and orthosis therapy. Seven patients were given regular antituberculosis therapy, in which 2 patients had drug resistance and 5 patients received irregular antituberculosis therapy. Results] Paravertebral abscess and 25 %- 35% right angle（cobb＇s angle） loss was found in 4 cases who underwent posterior midline approach operation at 18~22 months after operation. Pedical screw loosing and spine kyphosis was found in 12 patients at 24~32 months after operation who underwent rib-transverse process operation and received regular antituberculosis therapy for more than 8 months. Large paravertebral abscess was found in 2 cases with drug resistance. Large paravertebral abscess, spine kyphosis and internal fixation loosing or fracture were also appeared in the cases at 20~ 26 months after operation who received irregular antituberculosis therapy for less than 4 months. Conclusion]Improper operation time, incomplete debridement, unsatisfactory internal fixation, poor bone graft material, wrong bone graft position, irregular antbtuberculosis treatment, antituberculosis drug resistance, and without strictly local braking and orthosis treatment is the main important reason of un-healing and recurrence after operation of thoracolumbar spinal tuberculosis.