脊柱结核手术指征再认识

OrthopedicDepartment脊柱结核手术指征再认识杭州市红十字会医院骨科费骏OrthopedicDepartment随着抗结核药物的发现、外科技术的进步、围手术期处理的完善、内植物的快速发展，脊柱结核的疗效获得极大进步（治愈率95%）OrthopedicDepartment3中国结核病数仅次于印度，是27个M/XDR-TB高负担国家之一[1]耐药结核的流行加剧了结核病的全球疫情[1]WHOreport2012:Globaltuberculosiscontrol.WorldHealthOrganization,2012.脊柱结核发病率增高，其诊治尚面临诸多挑战OrthopedicDepartment脊柱结核治疗策略英国医学研究会(BMRC)曾开展两个多中心前瞻性临床对照研究，拟解决该通过化疗联合手术还是单纯化疗治疗脊柱结核的分歧Anonymous.Acontrolledtrialofdebridementandambulatorytreatmentinthemanagementoftuberculosisofthespineinpatientsonstandardchemotherapy.AstudyinBulawayo,Rhodesia[J].JournalofTropicalMedicineandHygeine1974,77(4):72-92.MRC.Acontrolledtrialofanteriorspinalfusionanddebridementinthesurgicalmanagementoftuberculosisofthespineinpatientsonstandardchemotherapy:astudyinHongKong[J].BrJSurg1974,61:853-66.MRC.5yearassessmentsofcontrolledtrialsofambulatorytreatment,debridementandanteriorspinalfusioninthemanagementoftuberculosisofthespine.StudiesinBulawayo(Rhodesia)andinHongKong.SixthreportoftheMedicalResearchCouncilWorkingPartyonTuberculosisoftheSpine[J].JBoneJointSurgBr1978,60B(2):163-177.MRC.Aten-yearassessmentofacontrolledtrialcomparingdebridementandanteriorspinalfusioninthemanagementoftuberculosisofthespineinpatientsonstandardchemotherapyinHongKong[J].JBoneJointSurg[Br]1982,64-B:393-8.ICMR/MRC.Acontrolledtrialofshort-courseregimensofchemotherapyinpatientsreceivingambulatorytreatmentorundergoingradicalsurgeryfortuberculosisofthespine[J].IndJTub1989,36:Suppl1-21.结论：脊柱结核更倾向于内科疾病，基本治疗手段应为化疗、休息及制动；对不伴严重并发症的患者，单行化疗即能取得良好疗效；香港术式只用于获得早期骨融合或防止后凸畸形OrthopedicDepartment学术共识营养支持治疗是基础抗结核药物治疗是治疗的根本手术只是预防、治疗严重并发症的辅助手段界定其手术指征并制定个体化手术方案非常重要1.许建中.脊柱结核的治疗方案存在仁智之争.中华骨科杂志.2011.4：394-399.2.许建中.规范脊柱结核治疗，为我国结核病防治做出更大贡献.中华骨科杂志,2014,34(2):97-1013.许建中.脊柱结核治疗中面临的几个问题.第三军医大学学报.2009，20（3）：1923-1925.OrthopedicDepartment手术指征①死骨、脓肿和窦道形成②结核病灶压迫脊髓出现神经症状③晚期结核引起迟发型瘫痪*陈孝平.外科学(8年制及7年制临床专业用)[J].2010.邱贵兴OrthopedicDepartment手术指征①穿刺活检不能确诊，不能除外肿瘤者②一线药物治疗失败后，耐药者特别耐多药者③较大的寒性脓肿、经久不愈的窦道及较大的死骨或空洞存在者④脊髓或马尾神经，神经根受压，椎管内，硬膜内外有结核肉芽肿者⑤严重的椎体破坏或塌陷⑥严重的骨破坏致腰背痛⑦脊柱畸形或不稳⑧脊柱结核未治愈或复发*张光铂,吴启秋,关骅,等.脊柱结核病学[M].北京:人民军医出版社,2007：223.王自立OrthopedicDepartment手术指征①严重的或渐进加重的后凸畸形②椎体破坏继发脊柱不稳③脊柱结核合并截瘫Frankel分级A或B级④不全截瘫Frankel分级C或D级，致压物为死骨或椎间盘，尽早手术；致压物为脓肿，抗结核治疗1月无效，手术治疗⑤局部疼痛剧烈，不能下地行走，常规止痛药物无效⑥脓肿不作为手术绝对指征，绝大多数脓肿可通过抗结核药物治疗吸收，除非引起剧烈疼痛或髋关节屈曲，可CT引导下置管引流⑦抗结核治疗效果差，需手术切除病灶，或通过手术获取标本辅助诊断*马远征,王自立，金大地等.脊柱结核[M].人民卫生出版社,2013.OrthopedicDepartmentLargecervicalabscessesinapatientinwhomrespiratoryobstructionhasdevelopedMarkedneurologicdeficitrelatedtoseverekyphosis,retropulsedboneorretropulseddiscProgressionofkyphosisorinstabilitydespiteadequatechemotherapyProgressionofneurologicdeficitdespiteadequatechemotherapyAbsoluteindicationsWattsHG,LifesoRMCurrentConceptsReview;TBofBonesandJoints.JBJS78-ANo2288-295.Feb1996OrthopedicDepartmentInabilitytoobtainmaterialforculturebyothermeansNeurologicdeficitsinpatientsforwhomprolongedbedrestmaygiverisetootherproblemsPersistentpainorspasticityPainrelatedtospinalinstabilitywherespontaneousfusionhasnotoccurredRelativeindicationsOrthopedicDepartmentKCMak,KMCheung.SurgicaltreatmentofacuteTBspondylitis:indicationsandoutcomes.EurSpineJ(2013)22(Suppl4):S603–S611.OrthopedicDepartment达成的共识OrthopedicDepartment13重要脏器受压神经功能障碍绝对手术指征脊柱后凸畸形脊柱明显不稳OrthopedicDepartment14典型病例OrthopedicDepartment15男，4岁,颈1、2、3椎体结核伴咽后脓肿指征1重要脏器受压术前正侧位片、MROrthopedicDepartment16术前CTOrthopedicDepartment17前方入路病灶清除术术后12月随访OrthopedicDepartment18男，2岁，T12L1结核伴椎旁冷脓肿形成ASIA分级B级术前X正侧位、3D-CT维重建指征2神经功能障碍OrthopedicDepartment19术后X正侧位术后1个月术后3个月术后半年OrthopedicDepartment20术前正侧位术后1年OrthopedicDepartment21100°女，48岁，胸椎结核伴后凸畸形,行2次病灶清除术指征3脊柱后凸畸形OrthopedicDepartment22行病灶清除、后路截骨植骨融合，根据药敏试验调整化疗方案OrthopedicDepartment23术后18月40°OrthopedicDepartment28岁女性，诊断T7-9结核伴椎旁脓肿平片、MRI示T7-9椎体骨质破坏，椎旁脓肿，脊髓受压指征4脊柱明显不稳OrthopedicDepartmentCT示T7-9椎体骨质破坏，脊柱失稳OrthopedicDepartment术后12月CT示融合节段有连续性骨痂生长，骨性融合OrthopedicDepartment存在的争议OrthopedicDepartment28相对手术指征较大的死骨、较大的脓肿、经久不愈的窦道诊断不明确、标准化疗效果欠佳1.LiL,XuJ,MaY,TangD,ChenY,LuoF,LiD,HouT,ZhouQ,DaiF,HeQ,ZhangZ.SurgicalStrategyandManagementOutcomesforAdjacentMultisegmentalSpinalTuberculosis:ARetrospectiveStudyofForty-eightPatients.Spine.2014.39（1）：40-48.2.PuX,ZhouQ,HeQ,DaiF,XuJ,ZhangZ,BrankoK.Aposteriorversusanteriorsurgicalapproachincombinationwithdebridement,interbodyautograftingandinstrumentationforthoracicandlumbartuberculosis.InternationalOrthopaedics.2012.36（2）:307-3133.QingyiHe,XuJ.Comparisonbetweentheantero-posteriorandanteriorapproacherfortreatingL5-S1vertebraltuberculosis.InternationalOrthopaedics.2012.36:345-351.4.HeQ,XuJ.Transpedicularclosingwedgeosteotomyinthetreatmentofthoracicandlumbarkyphoticdeformitywithdifferentetiologies.EurJOrthopSurgTraumatol.2012.OrthopedicDepartment29C7T15岁女性，颈、腰、背痛活动受限10月，全身乏力1月余血沉84mm/h，CRP41.3mg/LOrthopedicDepartment30T8-10L4胸8-10、腰4椎结核伴椎旁脓肿，右侧髂骨、粗隆间结核L4T8T3C2OrthopedicDepartmentECT：上述部位骨代谢异常活跃伴减低CT介导穿刺活检：确诊多发性结核保守治疗？手术治疗？OrthopedicDepartment3年随访OrthopedicDepartmentOrthopedicDepartment女，57岁，腰1、2椎体结核，慢性腰痛相对手术指征1椎体破坏OrthopedicDepartment抗结核治疗18月，腰部症状缓解OrthopedicDepartment36男，34岁，腰骶椎结核伴骶前脓肿2005年，严格标准化疗18月相对手术指征2脓