脊柱结核手术指征再认识

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/11/3,*,Orthopedic Department,Orthopedic Department,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/11/3,Orthopedic Department,58,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/11/3,*,Orthopedic Department,28,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/11/3,*,Orthopedic Department,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/11/3,*,脊柱结核手术指征再认识,杭州市红十字会医院骨科 费骏,2020/11/3,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%,）,2020/11/3,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,1WHO report 2012: Global tuberculosis control.World Health Organization, 2012.,脊柱结核发病率增高，其诊治尚面临诸多挑战,2020/11/3,3,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. A controlled trial of debridement and ambulatory treatment in the management of tuberculosis of the spine in patients on standard chemotherapy. A study in Bulawayo, Rhodesia J. Journal of Tropical Medicine and Hygeine 1974, 77(4): 72-92.,MRC. A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy: a study in Hong Kong J. Br J Surg 1974, 61: 853-66.,MRC. 5 year assessments of controlled trials of ambulatory treatment, debridement and anterior spinal fusion in the management of tuberculosis of the spine. Studies in Bulawayo (Rhodesia) and in Hong Kong. Sixth report of the Medical Research Council Working Party on Tuberculosis of the Spine J. J Bone Joint Surg Br 1978, 60B (2): 163-177.,MRC. A ten-year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong J. J Bone Joint Surg Br 1982, 64-B: 393-8.,ICMR/MRC. A controlled trial of short-course regimens of chemotherapy in patients receiving ambulatory treatment or undergoing radical surgery for tuberculosis of the spine J.Ind J Tub 1989, 36: Suppl 1-21.,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,2020/11/3,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,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.,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): 97-101,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.,2020/11/3,手 术 指 征,死骨、脓肿和窦道形成,结核病灶压迫脊髓出现神经症状,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,2020/11/3,手 术 指 征,穿刺活检不能确诊，不能除外肿瘤者,一线药物治疗失败后，耐药者特别耐多药者,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,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,严重的椎体破坏或塌陷,严重的骨破坏致腰背痛,脊柱畸形或不稳,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,2020/11/3,手 术 指 征,严重的或渐进加重的后凸畸形,椎体破坏继发脊柱不稳,脊柱结核合并截瘫,Frankel,分级,A,或,B,级,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,局部疼痛剧烈，不能下地行走，常规止痛药物无效,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,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.,2020/11/3,Large cervical abscesses in a patient in whom respiratory,obstruction has developed,Markedneurologicdeficit related to severekyphosis,retropulsed bone orretropulseddisc,Progression ofkyphosisor instability despite adequate chemotherapy,Progression ofneurologicdeficit despite adequate chemotherapy,Absolute indications,WattsHG,LifesoRM Current Concepts Review; TB of Bones and Joints. 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Eur Spine J (2013) 22 (Suppl 4):S603S611.,2020/11/3,达成的共识,2020/11/3,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,2020/11/3,13,典型病例,2020/11/3,14,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、,MR,2020/11/3,15,术前,CT,2020/11/3,16,前方入路病灶清除术,术后,12,月随访,2020/11/3,17,男，,2,岁，,T,12L1,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,2020/11/3,18,术后,X,正侧位,术后,1,个月,术后,3,个月,术后半年,2020/11/3,19,术前正侧位,术后,1,年,2020/11/3,20,100,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,2020/11/3,21,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,2020/11/3,22,术后,18,月,40,2020/11/3,23,28,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,2020/11/3,24,CT,示,T7-9,椎体骨质破坏，,脊柱失稳,2020/11/3,25,术后,12,月,CT,示融合节段有连续性骨痂,生长,，骨性融合,2020/11/3,26,存在的争议,2020/11/3,27,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,Li L,Xu J,Ma Y,Tang D,Chen Y,Luo F,Li D,Hou T,Zhou Q,Dai F,He Q,Zhang Z.Surgical Strategy and Management Outcomes for Adjacent Multisegmental Spinal Tuberculosis: A Retrospective Study of Forty-eight Patients.Spine.2014.39,（,1,）：,40-48.,Pu X, Zhou Q, He Q, Dai F, Xu J, Zhang Z, Branko K. A posterior versus anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis. International Orthopaedics.2012.36,（,2,）,:307-313,Qingyi He, Xu J.Comparison between the antero-posterior and anterior approacher for treating L5-S1 vertebral tuberculosis. International Orthopaedics.2012.36:345-351.,HeQ,XuJ.Transpedicularclosingwedgeosteotomyin thetreatmentofthoracicandlumbarkyphoticdeformitywithdifferentetiologies.Eur J Orthop Surg Traumatol.2012.,2020/11/3,28,C7T1,5,岁女性，,颈,、腰、背痛,活动受限,10,月，全身乏力,1,月余,血沉,84mm/h,，,CRP 41.3mg/L,2020/11/3,29,T8-10,L4,胸,8-10,、腰,4,椎结核伴椎旁脓肿，右侧髂骨、粗隆间结核,L4,T8,T3,C2,2020/11/3,30,ECT,：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？,2020/11/3,3,年 随 访,2020/11/3,2020/11/3,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,2020/11/3,抗,结核治疗,18,月,，腰部症状缓解,2020/11/3,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,脓肿形成,2020/11/3,36,5,年随访,2020/11/3,37,CT,引导下穿刺置管引流、局部化疗的微创治疗脊柱结核脓肿（,N=67,）,适合脓肿为主的脊柱结核，不伴严重并发症者,如骨质破坏不明显，以冷脓肿为主的腰大肌脓肿、韧带下型脊柱结核,1g,利福霉素钠或,0.6g,异烟肼加入,500ml,生理盐水，,24h,维持灌注,张西峰，王岩，刘郑生,等,.,局部持续化疗和持续引流治疗脊柱结核，中国脊柱脊髓杂志，,2003,，,13,：,656,659.,2020/11/3,早期获得标本，及时行耐药检测,提高了病灶内药物浓度,特别适用于对低浓度耐药、高浓度敏,单独应用或作为后路手术的补充，一定程度可代替,病灶清除术,优点,Li, Litao; Zhang, Zehua; Luo, Fei;Xu, Jianzhong; Cheng, Peng; Wu, Zheng;Zhou, Qiang; He, Qingyi; Dai, Fei; Wang, Jian; Zhang, Jinsong; Management of Drug-resistant Spinal Tuberculosis with a Combination of Surgery and Individualized Chemotherapy:A Retrospective Analysis of 35 Patients. 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BMC INFECT DIS. 2012;12:303,2020/11/3,39,荧光扫描仪采集各阵列荧光点的位置、获取,样品分子序列信息，传至计算机分析,Journal of Clinical Microbiology, 2010.48(10):3654,International Journal of Tuberculosis and Lung Disease, 2009.13(7): 914,Diagnostic Microbiology and Infectious Disease, 2007, 59:149,芯片制备,样本处理,杂交反应,信号检测和结果分析,根据结核耐药基因设计探针,提取样本中的,DNA,，,PCR,扩增，并荧光标记,探针与样品中互补序列进行杂交,图,1,晶芯,DNA,微阵列芯片试剂盒,图,3,芯片杂交仪,图,2,核酸快速提取仪,图,4,芯片扫描仪,基因芯片法检测结核耐药,（晶芯，博奥）,2020/11/3,40,菌种鉴定,鉴定为结核分枝杆菌（,MTB,）,鉴定结果为未发现分枝杆菌,2020/11/3,41,技术优势,平均耗时,5.8,(4-9),小时,检出阳性率为,74.18%,RMP,耐药检测敏感度为,88.9%,，特异度为,90.7%,INH,耐药检测敏感度为,80.0%,，特异度为,91.0%,耗时显著缩短、阳性率明显提高，敏感度、特异度高,BMC INFECT DIS. 2012;12:303,耐药检测,N=153,2020/11/3,42,21,岁男性，腰,1-5,椎体结核伴脓肿,2020/11/3,43,3,月随访，拔管,15,月随访,2020/11/3,44,女性，,40,岁，,L5/S1,椎体结核伴骶前脓肿、右腹股沟窦道形成，行前路,L5/S1,病灶清除、椎间植骨融合内固定术,术前,X,、,CT,、,MR,相对手术指征,3,窦道形成,2020/11/3,45,术后,2,月原窦道皮肤破溃伴渗出，血沉为,71mm/h,，,MRI,见,L5S1,椎旁及骶前脓肿,2020/11/3,46,术后,57,天时,药敏试验示,INH,、,RFP,、,SM,、,Pasiniazid,、,RPT,、,LOFLX,共,6,种药物耐药,。遂调整化疗方案为,EMB/ PZA/ KM/ Pasiniazid/ LOFLX,2020/11/3,47,术后,5,月血沉,19mm/h,，窦道愈合，,MRI,示脓肿吸收,术后,7,月血沉为,2mm/h,，,CT,示椎间骨性融合,2020/11/3,48,男，,21,岁,腰,4,椎体病变,相对手术指征,4,诊断欠明确,2020/11/3,49,诊断性抗结核治疗,随访,1,年,2020/11/3,50,手术治疗：,彻底清除病灶、解除神经压迫、纠正脊柱畸形、缩短疗程,非手术治疗：,节约医疗费用、减少不必要的医源性损伤,如何确定手术指征,脊柱结核临床分型,2020/11/3,经典的病理分型（边缘型、中心型、韧带下型、附件型）过于简单，难以指导手术方式的选择,Kumar,（,1985,）根据病灶解剖位置、结核活动程度、是否伴椎管内病灶及神经功能障碍等对脊柱附件结核进行分型,Mehta,和,Bhojraj,（,2001,）,基于,MRI,表现将胸椎结核分为四型，并针对不同分型推荐手术方案,Kush Kumar.A clinical study and classification of posterior spinal tuberculosis,Int Orthop. 1985,9(3):147-152.,Mehta JS, Bhojraj SY.Tuberculosis of the thoracic spine. A classification based on the selection of surgical strategies. J Bone Joint Surg Br. 2001,3(6):859-863.,脊 柱 结 核 分 型,2020/11/3,Oguz,（,2008,）结合患者是否伴有脓肿、神经障碍、椎体塌陷、后凸畸形、脊柱失稳及椎间盘退变等指标，提出分型标准,Oguz E,，,Sehirliaglu A,，,Altinmakas M,，,et a1,A new classification and guide for surgical treatment of spinal tuberculosis,Int Orthop.,，,2008,，,32(1),：,127-133,2020/11/3,信号改变型,型,脓肿形成型,型,椎体破坏型,型,椎管占位型,型,后凸畸形型,型,*张忠民等,.,脊柱结核的,MRI,分型系统,J.,中华骨科杂志, 2011, 31(5): 418-423.,张忠民（,2011,）等考虑到脓肿、神经障碍、椎体塌陷、后凸畸形、脊柱失稳等因素，但其仅为基于,MR,的影像学分型,2020/11/3,张泽华、许建中等,轻型脊柱结核,处于活动期的脊柱结核,单椎体中央型结核、双椎体边缘型结核或附件结核无椎管侵犯,骨质破坏较轻（,1/3,椎体高度）,椎旁脓肿较小，无咽后壁脓肿、腰大肌脓肿等流注脓肿,无神经功能障碍,无明显后凸畸形,(,30),无明显椎间失稳,*张泽华等,.,轻型脊柱结核的早期诊断及非手术治疗,J.,中华骨科杂志, 2014, 34(2): 177-182.,2020/11/3,标准化疗方案,18,月,*张泽华等,.,轻型脊柱结核的早期诊断及非手术治疗,J.,中华骨科杂志, 2014, 34(2),临床治愈率,95.51%(85/89),；,4,例药敏试验提示耐药，手术治疗联合化疗后治愈,非手术治疗对轻型脊柱结核疗效确切,未出现后凸畸形、椎间失稳、神经功能障碍，避免手术,2020/11/3,男，,77,岁，胸,12,腰,1,椎体结核,2020/11/3,57,抗结核药物治疗,1,年,2020/11/3,58,脊柱结核绝对手术指征：,重要脏器受压、神经功能障碍、脊柱后凸畸形、脊柱明显不稳,对于脓肿、死骨、窦道、诊断不明确、治疗效果欠佳者应根据病情选择手术或非手术,绝大多数轻型脊柱结核采用保守治疗均可获得满意疗效,结 论,大样本、多中心随机对照研究,2020/11/3,规范绝对手术指征,活动期脊柱结核导致的神经功能障碍，应在积极抗结核药物治疗的前提下，尽早手术减压,彻底清除病灶的同时，行椎间植骨融合内固定，重建节段稳定性,手术矫形，以恢复脊柱矢状面平衡，预防畸形进一步加重，防止迟发型截瘫,Li L,Xu J,Ma Y,Tang D,Chen Y,Luo F,Li D,Hou T,Zhou Q,Dai F,He Q,Zhang Z.Surgical Strategy and Management Outcomes for Adjacent Multisegmental Spinal Tuberculosis: A Retrospective Study of Forty-eight Patients.Spine.2014.39,（,1,）：,40-48.,Pu X, Zhou Q, He Q, Dai F, Xu J, Zhang Z, Branko K. A posterior versus anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis. International Orthopaedics.2012.36,（,2,）,:307-313,Qingyi He, Xu J.Comparison between the antero-posterior and anterior approacher for treating L5-S1 vertebral tuberculosis. International Orthopaedics.2012.36:345-351.,HeQ,XuJ.Transpedicularclosingwedgeosteotomyin thetreatmentofthoracicandlumbarkyphoticdeformitywithdifferentetiologies.Eur J Orthop Surg Traumatol.2012.,2020/11/3,谢谢！,2020/11/3,