Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation
Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation
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DOI：
10.1016/j.spinee.2013.07.466
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发表时间：
2014-06-01
期刊：
影响因子：
4.5
通讯作者：
Geng, Guangqi
中科院分区：
文献类型：
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作者：
Jin, Weidong;Wang, Qian;Geng, Guangqi
背景：传统的病灶清理术包括清除冷性脓肿、干酪样坏死、残留的椎间盘组织、窦道、骨隔离和炎性肉芽。有报道表明，大约13%至26%的患者在传统的病灶清除后没有好转或复发；这些患者需要再次手术或延长抗结核治疗时间。需要切除的残留和病变的局灶性组织的存在仍然知之甚少。重点讨论保留结核病灶的内容、改进手术策略、提高脊柱结核的成功率。前言：解释病灶内容，探讨完全清除的手术方法和疗效。研究设计：完全清除治疗胸腰椎结核的疗效的回顾性研究。研究样本：共289例患者。按Moon标准评定前路融合情况。根据C-反应蛋白和血沉判断感染是否消失。方法：289例脊柱结核患者，男150例，女139例，年龄18~82岁，平均年龄41.0±1.4岁。椎体损伤情况：胸椎损伤86例，胸腰椎损伤49例，腰椎损伤125例，腰椎损伤47例。抗结核治疗2~4周后，所有患者均行前路清除、畸形矫正、植骨融合、内固定。在这项研究中，完全清创被定义为清除任何损伤或疾病，包括腰肌脓肿、肉芽肿、残留的椎间盘组织、窦道、骨隔离和炎性肉芽组织。没有支撑和被病灶侵蚀的结核空洞、硬化壁和骨桥也被移除。采用Zephir系统(美敦力Sofamor-Danek，明尼阿波利斯，美国)、Z钢板(美敦力Sofamor-Danek，美敦力)或Ventrifix(中国长城公司，北京，中国)进行前路内固定。181例患者接受了固定、后路矫正和1~2次前路清创植骨融合术。后路内固定包括美敦力Sofamor-Danek(美敦力Sofamor-Danek)、Cotrell-Dubousset(Medtronic Sofamor-Danek)、普通脊柱系统(威高矫形器械公司，中国)或UPASS(威高矫形器械公司，中国)。结果：289例患者随访72.0+-2.8个月，治愈265例(91.69%)，不完全治愈24例(91.69%)，其中3例因肝肾衰竭暂停化疗。清创失败21例(7.27%)，其中骨清除不全16例，二次手术6例，保守治疗10例，其中5例不完全清除脓肿，3例二次手术，2例CT引导下脓肿穿刺术，二次手术率为3.81%。22例患者有手术并发症，包括3例移植物移位，5例伤口感染和脂肪液化，4例胸腔积液，6例移植物取材部位疼痛，4例切口疝。术后植骨愈合时间为4.3±1.2个月。术后Cobb角为22.16+/-11.51°，术后为8.11+/-4.83°，末次随访为9.96+/-3.49°，术后平均矫正63.40%，末次随访时丢失1.85+/-1.34°，丢失率为8.35%。清除结节、硬化骨、多发性空洞、骨桥是提高疗效的有效方法。(C)2014 Elsevier Inc.保留所有权利。
BACKGROUND CONTEXT: Traditional focal debridement involves clearing of cold abscesses, caseous necrosis, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Reports have demonstrated that approximately 13% to 26% of patients were not better or relapsed after traditional focal debridement; these patients required a second surgery or prolonged antituberculous therapy. The presence of retained and diseased focal tissues requiring removal remains poorly understood. The contents of these retained tuberculous foci, improvement of surgical strategies, and improvement in spinal tuberculosis success rate are key subjects for discussion.PURPOSE: To explain the contents of foci and explore the surgical methods and curative effect of complete debridement.STUDY DESIGN: Retrospective study of the curative effect of treatment of thoracolumbar spinal tuberculosis by using complete debridement.PATIENT SAMPLE: A total of 289 patients were included.OUTCOME MEASUREMENT: The outcomes were evaluated clinically by Frankel grading. The status of the anterior fusion was assessed according to the Moon standard. Eradication of infection was determined by the level of C-reactive protein and erythrocyte sedimentation rate. X-ray, computed tomography, and magnetic resonance imaging were used to evaluate disease localization and morphology.METHODS: A total of 289 patients with spinal tuberculosis (150 male and 139 female patients, aged 18-82; average age, 41.0 +/- 1.4 years) were included in this study. Damage to the vertebrae was as follows: 86 patients had thoracic damage, 49 had thoracolumbar damage, 125 had lumbar damage, and 47 had lumbosacral segment damage. After 2 to 4 weeks of antituberculous therapy, all patients underwent anterior debridement, deformity correction, graft fusion, and internal fixation. In this study, complete debridement was defined as the clearing of any damage or disease, including psoas abscesses, granulomas, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Tuberculosis cavities, sclerotic walls, and bony bridges that had no support and that were eroded by the foci were also removed. Atotal of 108 patients underwent anterior fixation with the Zephir system(Medtronic Sofamor-Danek, Minneapolis, MN, USA), Z plates (Medtronic Sofamor-Danek), or Ventrifix (China Great Wall Corporation, Beijing, China). Atotal of 181 patients underwent fixation, posterior correction, and one or two second anterior debridements and graft fusions. Posterior fixation, including TSRH (Medtronic Sofamor-Danek), Cotrell-Dubousset (Medtronic Sofamor-Danek), General Spinal System (WeiGao Orthopaedic Devices Company, Weihai City, China), or UPASS (WeiGao Orthopaedic Devices Company), was performed. All patients underwent structural bone grafting, including autologous iliac bone (251 patients), titanium mesh (32 patients), and rib (6 patients).RESULTS: The 289 patients were followed for 72.0 +/- 2.8 months, with 265 patients (91.69%) completely treated and 24 incompletely treated, including 3 who suspended chemotherapy because of liver or renal failure. Twenty-one patients (7.27%) failed to have a complete debridement, including 16 with incomplete bone debridement, 6 of whom underwent a second surgery, and 10 who received conservative therapy; 5 of this group had incomplete abscess debridement, 3 underwent a second surgery, and 2 received puncture aspiration of abscess under computed tomographic guidance; the second surgery rate was 3.81%. Twenty-two patients had surgery complications, including three with graft displacement, five with wound infection and fat liquefaction, four with pleural effusion, six with pain at the graft harvesting site, and four with incisional hernia. Bone graft healing was observed 4.3 +/- 1.2 months after surgery. The Cobb angle before and after surgery and at the final follow-up was 22.16 +/- 11.51 degrees, 8.11 +/- 4.83 degrees, and 9.96 +/- 3.49 degrees, respectively, with a mean correction of 63.40% after surgery; however, a 1.85 +/- 1.34 degrees loss was observed at the final follow-up with loss rate of 8.35%.CONCLUSIONS: Sclerotic bone, multiple cavities, and bony bridges are foci in spinal tuberculosis. Clearing tuberculous foci, sclerotic bone, multiple cavities, and bony bridges to increase the curative effect is an effective treatment method. (C) 2014 Elsevier Inc. All rights reserved.