脊柱结核的手术指征与内固定选择

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,*,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,*,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,*,脊柱结核的手术指征与内固定选择,2013-1-22,1779,年，,Percival Pott,首次报道，因此，脊柱结核又称为,Pott,病。,每年新增,80,万活动性脊柱结核病例（,WHO,）,超过,80,的脊柱结核患者伴有脊柱畸形,近,3,-5%,患者死于严重的后凸畸形（,60,度）相关并发症。,Background,Background,骨结核占所有,HIV,阴性结核病患者的,3-5%,脊柱结核占骨结核的,50,以上,如果及时、充分抗痨，缺血、坏死的骨结核病灶最终可以重建，尤其在骨组织形态完整的,“,破坏前期,”,Jain AK. Tuberculosis of the Spine: Editorial Comment. CORR, 2007; 460: 23,Jain AK. Treatment of tuberculosis of the spine with neurologic complications. CORR,，,2002;398:7584.,好发于,负重大,活动多,积累性劳损,肌肉附着少处,脊柱,50,膝,12,髋,10,肘,5,骨与关节结核,好 发 部 位,好 发 部 位,腰椎最高,胸椎,颈椎,骶尾椎最少,Background,在发展中国家，脊柱结核患者首诊时即有严重畸形、神经功能障碍的比例远高于发达国家,Data collected by PubMed search in the last five years,Data from India, Turkey and other developing countries,按发病部位可分为椎体结核和附件结核两类，椎体结核又分为中心型、边缘型及骨膜下型（韧带下型）三种,中心型多见于,10,岁以下的儿童，以胸椎多见，病灶起始于椎体前方，以骨质破坏为主。,边缘型最常见以腰椎最常见。多见于成年人，病灶多在椎体前缘、骨膜下或前纵韧带下的椎间盘开始，常累及相邻两个椎体。,骨膜下型主要累及椎旁韧带，常有椎旁脓肿形成，椎体及椎间盘改变很少，当大量脓液积聚于前纵韧带下时可使椎体前缘凹陷性骨侵蚀。,1,、,椎体骨质破坏；,2,、椎间隙变窄或消失；,3,、椎体变形；,4,、骨质密度增高；,5,、骨质增生及骨桥形成；,6,、脓肿形成及钙化。,影像学表现,T,1,及,T,2,显示椎体破坏和椎间隙消失、脓肿形成，硬膜囊及脊髓受压,X,线平片显示各椎体未见明显异常,CT,显示椎体右侧缘骨质致密及右侧腰大肌脓肿,核素扫描显示,L4,椎体右上缘摄取增加。,T,1,显示右侧腰大肌脓肿,L,4,、,5,椎体右侧缘破坏；增强后脓肿呈环形强化，中心为坏死液化区,枢椎椎体及齿状突骨质破坏变形，,T,1,为低信号；,T,2,为混杂信号,同上病例脂肪抑制像病灶呈混杂信号，椎体前缘可见局限脓肿；增强扫描显示破坏的椎体不规则强化，椎前脓肿呈高信号,多发性脊柱结核,T,1,显示,L,1,、,2,、,4,、,5,椎体及椎间盘呈低信号；,T,2,呈混杂信号，脊髓受压,脂肪抑制像病灶显示更加清楚；同上患者,T,1,显示胸,8,、,9,椎体呈低信号,同上病例,T,2,及脂肪抑制像显示胸,8,、,9,腰,1,、,2,椎间盘呈混杂信号,外科治疗,脊柱结核患者需要解决的常见问题,病灶清除,畸形矫正,稳定性重建,神经组织减压,Historical review of operative treatments,1910s,Hibbs,后路融合术,手术部位远离病灶，在无抗痨药物时代相对安全,提高病变节段稳定性,Hibbs RA. An operation for Potts disease of spine. JAMA,1912,59:433-6,Historical review of operative treatments,1950s,方先之 病灶清除术,需充分抗痨化疗,直接清除病变组织，提高了疗效,方先之,.,骨关节结核病灶清除疗法（,941,例临床报告）,.,中华外科杂志,1957,5(1):90-92,Historical review of operative treatments,1960s,MRC Working Party on Tuberculosis of the Spine,Hodgson,“,香港术式,”,前路病灶清除、结构性植骨,进一步提高了病变节段的稳定性,Hodgson AR, Stock FE. Anterior fusion for the treatment of tuberculosis of the spine:,the operative findings and results of treatment in the first one hundred cases. JBJS,1960,42A:295-310,Historical review of operative treatments,1990s,病灶清除 内固定辅助融合,内固定提供术后即刻稳定性,改善康复期间生活质量,1. Oga M, Arizono T, Takasita M, et al. Evaluation of the risk of instrumention as a foreign body in spinal tuberculosis: clinical and biological study. Spine, 1993,18(13):1890-4,2.,Sundararaj GD,，,Behera S,，,Ravi V, et al.,Role of posterior stabilization in the management of tuberculosis of the dorsal and lumbar spine. JBJS,2003,85B(1):100-6,3.,金大地，陈建庭，张浩，等,.,一期前路椎间植骨并内固定治疗胸腰椎结核,.,中华外科杂志，,2000,，,38,（,12,）：,900-2,目前常用术式,前路病灶清除、植骨融合、内固定术,目前常用术式,前后路后前路联合手术,Question?,单纯后入路手术能完成胸椎、胸腰段椎体结核的所有治疗步骤吗？,病灶清除,畸形矫正,稳定性重建,神经组织减压,本组病例,男性,11,例，女性,5,例,10,60,岁，平均,21.5,岁,T5,T10 9,例，,T11,L2 7,例,2,例单椎体破坏，,8,例,2,椎体破坏，,5,例,3,个以上椎体破坏（其中,2,例有非连续性脊柱结核病灶）,节段性后凸角度为,11,55,平均,31,轻度后凸,9,例，中度后凸,7,例,神经功能,Frankel B,级,1,例，,C,级,3,例，,D,级,7,例，,E,级,5,例,Yilmaz,脊柱后凸分度标准：, 60,重度,手术步骤,后正中入路,邻近健康椎体椎弓根钉植入，一侧临时固定,病灶清除、局部,ATT,药物植入,椎弓根入路单纯椎体病灶,关节突关节切除后椎间隙周围病灶,全椎切除多节段病灶,矫正畸形：中后柱短缩,后外侧植骨融合,Case show,M,16yrs,T9-11&L3 TB, Frankel B E,Cobb 55, 25,15mths,Case show,Case show,M,27yrs, L1-2 TB, Frankel E, Cobb 42,18,Case show,F,21yrs, L1-2 TB, Frankel D E, Cobb 25,5,Case show,M,60yrs, T7-8 TB, Frankel B C,Discussion-,病灶清除,前路,经胸膜腔入路：肺功能损失,10,经胸膜腔外入路,后路,经肋横突关节入路,经椎弓根入路,经关节突关节入路,Discussion-,后凸,胸椎和胸腰段结核非手术治疗治愈后,33% (52 /160),后凸增加,11,30,17% (27 /160),后凸增加,30,50,6% (9/160),后凸增加,50,70,Ninth Report of the Medical Research Council Working Party on Tuberculosis of the Spine. A 10-year assessment of controlled trials of inpatient and outpatient treatment and of plaster-of-paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. J Bone Joint Surg Br. Jan 1985;67(1):103-110,Smith-Petersen osteotomy,10,-12/segment,Smith-Petersen MN, Larson CB, Aufranc OE. Osteotomy of the spine,for correction for flexion deformity in rheumatoid arthritis.,JBJS(Br),1945;27:1,Ponte osteotomy,Multilevel S-P osteotomy,Ponte A, Sicciard GL. Surgical treatment of Scheuermanns hyperkyphosis.,Orthop Trans,1985;9:127,Pedicle subtraction osteotomy,25,/T-segment, 35/L-segment,Heinig CF, Boyd BM. One stage vertebrectomy or eggshell procedure.Orthop Trans, 1985, 9( 11) : 130-5.,Bridwell KH, Lewis SJ, Lenke LG, et al. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance.,JBJS,2003;85A:45463,Vertebral column resection,Bradford DS, Tribus DB. Vertebral column resection for the treatment,of rigid coronal decompensation.,Spine,1997; 22: 15909,神经功能恢复,严重后凸畸形者神经功能恢复差于中度和轻度畸形者,静止期结核出现神经功能障碍者恢复差于活动期结核,儿童预后优于成人,截瘫超过,6,月者一般无恢复,Moon MS, Moon JL, Moon YW. Potts paraplegia in patients with severely deformed dorsal or dorsolumbar spines: treatment and prognosis. Spinal Cord,2003;41(3):164-71,Conclusion,血沉并不是脊柱结核手术的唯一指征；,化疗辅助下，脊柱结核骨质破坏时，应选用相应内固定；,伴有后突畸形时，应进行截骨矫形术。,