脊柱结核的手术指征与内固定选择许国华.ppt
脊柱结核的手术指征与内固定选择,第二军医大学长征医院骨科许国华,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;460:23Jain 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 yearsData 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,T1及T2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。,T1显示右侧腰大肌脓肿L4、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，T1为低信号；T2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,T1显示L1、2、4、5椎体及椎间盘呈低信号；T2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T1显示胸8、9椎体呈低信号,同上病例T2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 SpineHodgson“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):100-63.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1060岁，平均21.5岁T5T10 9例，T11L2 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1155,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 4218,Case show,F,21yrs,L1-2 TB,Frankel D E,Cobb 255,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 osteotomy10-12/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 osteotomyMultilevel 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。,
