手术治疗非连续性脊柱结核的临床疗效ppt课件

The Clinical Outcomes of Surgical Treatment of Noncontiguous Spinal Tuberculosis: A Retrospective Study in 23 Cases PLOS ONE IF 3.234 (2014) Volume 9 , Issue 4 ,April 2014,The Clinical Outcomes of Surgical Treatment of Noncontiguous Spinal Tuberculosis: A Retrospective Study in 23 Cases 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 Jia Huang Hongqi Zhang* Kefeng Zeng Changsha, China，Xiangya Hospital of Central South University,Abstract Study design:A retrospective clinical study. Objective:To evaluate the clinical efficacy of the surgical treatment of noncontiguous spinal tuberculosis (NSTB), and to discuss its therapeutic strategies. 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。,Methods: We performed a retrospective review of clinical and radiographic data that were prospectively collected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed and treated as NSTB in our institution from June 2005 to June 2011. Apart from 4 patients being treated conservatively, the remainder received surgery by posterior transforaminal debridement, interbody fusion with instrumentation, posterior instrumentation and anterior debridement with fusion in a single or two-stage operation. The clinical outcomes were evaluated before and after treatment in terms of hematologic and radiographic examinations, bone fusion and neurologic status. The Oswestry Disability Index score was determined before treatment and at the last follow-up visit. 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。,Results: 23 patients (15 M/8F), averaged 44.614.2 years old (range, 19 to 70 yd), who received surgical treatment, were followed up after surgery for a mean of 52.519.5 months (range, 24 to 72 months). The kyphotic angle was changed significantly between pre- and postoperation (P0.05). The mean amount of correction was 12.67.2 degrees, with a small loss of correction at last follow-up. All patients achieved solid bone fusion. No patients with neurological deficit deteriorated postoperatively. Neither mortalities nor any major complications were found. There was a significant difference of Oswestry Disability Index scores between preoperation and the final follow-up. 23例患者(15 M/8F)，平均年龄为44.614.2岁（范围19至70岁），都接受了手术治疗，术后平均随访时间为52.519.5个月（24至72个月）。手术前、后的后凸角有明显变化（P0.05），平均矫正率为12.67.2，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。,Introduction Tuberculosis has made a dramatic comeback, in part because of the appearance of anti-tuberculosis drug resistance and the acquired immune deficiency syndrome (AIDS) pandemic. As a destructive pattern of tuberculosis, spinal tuberculosis (STB) accounts for 50% of all cases of musculoskeletal tuberculosis . It is characterized by formation of cold abscess, destruction of the intervertebral disc and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis. Multilevel noncontiguous spinal tuberculosis (NSTB) is an atypical form of STB, which leaves not less than two adjacent vertebrae intact between the two foci. The incidence of NSTB is reported as 1.1% to 16.3% . 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% 。,Recently, with whole spine magnetic resonance image (MRI) being applied to aid detection of NSTB, its incidence is higher than previously quoted 4. The treatment regimes regarding NSTB vary from purely medicine to a combination of chemotherapy and surgery. The pendulum of therapeutic strategies to NSTB has periodically vacillated between non-operative management and radical surgery. In the present study, we seek to discuss the role of surgical treatment method. 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。,Materials and Methods Patients This study was approved by the Ethic Committee of the Xiangya Hospital of Central South University. We performed a retrospective review of clinical and radiographic data that were prospectively collected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed and treated as NSTB in our institution from June 2005 to June 2011. Plain radiology, computed tomography and MRI of the spine were performed on all patients admitted with suspected spinal tuberculosis. 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。,Whole spine MRI was performed on patients presenting with multi-level symptomatic vertebral infection. A diagnosis of NSTB was defined as vertebral disease additional to the main lesion identified on MRI separated by at least 2 normal spinal segment (vertebral body/neural arch and/or intervertebral disc). Written informed consent was acquired from each of the patients to authorize treatment, imageology findings, and photographic documentation. 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。,The cohort comprised 17 males and 10 females, averaged 44.713.2 years old (range, 1970), with a minimum 2-year follow up. Apart from 4 cases treated conservatively, the remainder 23 patients (15 M/8F), averaged 44.614.2 years old, received surgical treatment . The location of infection varied from cervical spine down to lumbar spine . The clinical outcomes were measured preoperatively, immediately after surgery and at ultimate follow-up visit in term of hematologic and radiographic examinations and neurologic status. 研究对象包括17例男性和10例女性患者，平均年龄为44.713.2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(15 M/8F)，平均年龄为44.614.2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。,Hematologic examination included erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver function test and blood count. The neurologic status was graded according to Frankel classification. Kyphotic angel was measured by drawing two linesone was along the top surface of the immediate upper normal vertebral body, and the other was away from the diseased segment. The bone fusion was assessed by the Moon standard. Bone fusion was characterized by reappearance of bone trabeculae between the graft bed and graft, along with substantial graft thickness in X ray radiography. 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。,Treatment Strategies The diagnosis was established by the presence of typical clinical and radiographic presentations, suggestive of STB in a resident from an endemic area who had an elevated ESR, CRP and a therapeutic response to anti-tubercular therapy. All patients were prescribed isoniazid (INH) (5 mg/kg), rifampicin (10 mg/kg), ethambutol (15 mg/kg) and pyrazinamide (25 mg/kg) for 4 months duration, followed by rifampicin/ INH/pyrazinamide for at least a further nine months, until regression of symptoms, and resolution of laboratory and radiological abnormalities. 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)(5 mg/kg)，利福平(10 mg/kg)，乙胺丁醇(15 mg/kg)和吡嗪酰胺(25 mg/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。,Patients with progressive neurologic deficit received additional intravenous isoniazid (0.4g/day) for 3 days preoperatively. The basic principles of treatment for spinal tuberculosis that we referred to were as follows: the lesion which was limited vertebral body destruction, small amount of abscess, with neither progressive spinal cord and nerve root compromise, nor drug-resistant TB, could be treated conservatively; and the indications for surgery included the evolving neurological deficit, spinal instability, severe kyphotic deformity, refractory disease, large paravertebral abscesses and epidural abscess compressing the dural sac. 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。,If the surgical lesion was confined to less than two adjacent segments, mono-stage posterior transforaminal debridement, interbody fusion and posterior instrumentation could be utilized; if the lesion involved more than 2 adjacent segments or had large paraspinal abscess, anterior debridement and autogenous iliac bone graft or allograft bone could be added after posterior instrumentation. However, regarding the surgical treatment priority of each skipping lesion, the more serious lesion i.e. the one that resulted in more significant neurological compromise was treated first. If two lesions both caused neurological compromise, the upper lesion was treated first. 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。,Operative Procedure The surgery was performed under general anaesthesia. During the first stage, posterior instrumentation was applied. As described previously, if the involvement was confined to mono-segment without mass paravertebral abscess, transforaminal debridement and interbody fusion could be performed. Mild kyphosis could be corrected by postural reduction and the application of compressive, or translation correction forces during posterior instrumentation. The instrumentation was always extended 2 levels above and below the focus. Autogenous bone or allograft was selected for posterior fusion at designated segments that underwent decompression and focal debridement. 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。,If the focus involved more than 2 adjacent segments or had large paravertebral abscess, anterior focal debridement and bone grafting could be performed, via thoracic, thoracolumbar, or peritoneal approaches for different lesions in a single stage or in two stages depending on patients conditions. Additionally, the leaping lesion without mass abscess and severe vertebral body destruction nor neurological compression could be left conservatively. 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。,Postoperative Procedure and Follow-up The drainage tube was removed when the drainage flow was less than 50 mL/24 h. The patients were allowed to start walking 2 weeks after surgery but the spine was immobilized with an orthosis for 3 months until bony fusion was achieved. Imageological examinations (X-ray) and hematologic parameters (ESR, CRP, liver function test) were performed at one month intervals in the first three months, three month intervals in the next nine months, at six month intervals in the second year and then once a year, along with the assessment of neurologic status, correction of deformity, and success of bone graft fusion. Clinical outcome was assessed preoperatively and at the last follow-up visit using the Oswestry disability index (ODI) questionnaire. 术后观察和随访 引流量低于50 mL/24 h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。,Discussion As a result of AIDS and new drug-resistant strains, the resurgence of STB has sparked a flurry of activity toward the prevention and treatment of this condition. Nowadays, management strategies of STB include conservative therapy and various advanced surgical techniques. STB often involves adjacent vertebras and the intervening disc, while leaping and remote lesion is not common and does not characterize the disease. Reviewing the literature, NSTB are mostly reported as episodic case reports in the mainstream academic journals. The incidence of NSTB is reported as 1.1% to 71.4% , and it is 4.3% in our study. 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。,There is a minority of papers referring to the surgical treatment of NSTB. In 2012, Shi et al. reported the results of 29 cases with NSTB treated with intervertebral focal surgery. These investigators obtained a mean correction rate of 59.5% with good bone fusion at the final follow-up. In the same year, Zhang et al. reported the clinical outcomes of posterior transforaminal thoracic debridement, limited decompression, interbody fusion and posterior instrumentation for treatment of noncontiguous thoracic tuberculosis, which also achieved good clinical efficacy. So far, however, there is a paucity of information describing the comprehensive therapeutic strategies of NSTB. In this paper, we aim to evaluate the clinical efficacy of the surgical managements (posterior surgery and a combination of posterior and anterior surgery) for NSTB, and to discuss the relevant therapeutic strategies. 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。,The treatment principles of NSTB are basically derived from the experience in treating contiguous spinal tuberculosis. Surgery is indicated for patients with severe or evolving neurologic deficit despite antituberculous chemotherapy, persistence of symptoms despite adequate antitubercular therapy, spinal instability, and severe spinal deformity. Compare to single focus treatment, there are several noteworthy details in the treatment of NSTB. Multilevel surgical interventions of NSTB result in more surgical trauma and complications than that of single focus disease. 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。,Therefore, surgical indications should be controlled more strictly for each lesion of patients. Severe surgical trauma and complications caused by multilevel surgical interventions should be reduced as much as possible, by application of minimized invasive surgical techniques and the preference of debridement to radical surgery. In addition, during multilevel surgery, the upper lesion or the one with neurologic compression should be dealt with in priority. Whats more, staged procedures could be performed for patients with physical deterioration. 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。,Diverse surgical techniques, which can be divided into anterior, posterior and combined types, performed either in one or two stages, have been applied in spinal tuberculosis. Radical Hong Kong technique is the standard for anterior radical debridement with strut graft fusion. Sufficient experience has demonstrated this procedure could gain good clinical efficacy in STB treatment. Nonetheless, after radical and extended Hong Kong procedure, the incidence of spinal instability is very high. Therefore, a combination with a posterior instrumentation for full stabilisation appears crucial. Likewise, in cases with posterior instrumentation, when an anterior approach is needed for extended focus debridement, anterior instrumentation can be accomplished at the same time. 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。,Previously, the posterior approach was primarily indicated in cases with destruction of posterior structures of spine accompanied by an epidural abscess, or the involvement of neural arch, causing posterior spinal cord compression. However, in recent years, as transforaminal thoracic or lumbar interbody fusion (TTIF or TLIF) has become widely applied as minimally invasive surgical intervention in various etiologies, these techniques have been modified to treat spinal tuberculosis, which were performed by a single-stage posterior transforaminal debridement, interbody fusion plus posterior instrumentation. 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(TTIF or TLIF) 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。,They have the advantages of minor surgical invasion and minimal hazard of focal neurological injury due to easy access to the spinal canal, obviating the need for anterior exposure and its associated complications. In 2009, Gautam et al employed TLIF to treat lumbar tuberculosis which was associated with disease resolution, and no recurrence at final follow-up, in all patients. In this study, 17 patients were treated with transforaminal debridement, interbody fusion and posterior instrumentation, and achieved bone fusion without recurrence at last follow-up. 这些技术的手术创伤很轻微，局部神经功能损伤的风险也很小，因为术中易暴露椎管，避免前路暴露及其相关并发症。2009年， Gautam等人采用TLIF术式治疗腰椎结核并获得疾病治愈 ，在末次随访中所有患者均无复发。在这项研究中，17例患者行经椎间孔病灶清除、椎间植骨融合及后路内固定术治疗，并在最后一次随访中获得骨性融合且无复发。,Many studies have shown a direct correlation between sagittal spine imbalance and severity of back pain. Hirakawa et al. showed that good restoration and maintenance of spinal alignment was obtained by 2-staged posterior (first) and anterior fusion for spinal tuberculosis. They also pointed out that pain level decreased significantly after posterior instrumentation. It is well known that posterior transpedicular instrumentation could provide sufficient spinal stability and obviate the evolution of late angu