一期前后路联合手术治疗儿童活动性胸腰椎结核的中长期临床疗效（临床论著）

张  毅，王孝宾，吕国华，李  晶

（中南大学湘雅二医院脊柱外科 410011 长沙市）

第一作者简介：男（1990-），硕士研究生在读，研究方向：脊柱脊髓损伤

电话：（0731）85295124  E-mail：ZYspine@126.com

通讯作者：李晶  E-mail：jingli1969@126.com

【摘要】 目的：探讨应用一期后路椎弓根螺钉内固定融合联合前路病灶清除、同种异体骨重建术治疗儿童活动性脊柱结核的中、长期效果。方法：回顾性分析我院2008年1月~2013年1月共19例采用一期后路椎弓根螺钉内固定融合联合前路病灶清除、同种异体骨支撑重建的术式治疗胸、腰椎结核感染导致至少连续两个椎体破坏的患儿资料，年龄3～10岁，平均6.3±2.1岁，随访时间5～11年，平均7.5±2.0年，受累椎体2～4个。所有患儿分别于术后1周、3、6、12个月行X线检查，随后每年行X线检查一次，测量后凸Cobb角，同时观察有无植骨块移位、松动、塌陷以及有无后凸畸形发生，记录患儿术前、术后1周及每次复查时的Frankel分级、后凸角、红细胞沉降率（ESR）、C-反应蛋白（CRP），对于随访超过5年的患儿（19例）行高分辨率三维CT扫描通过Bridwell分级评估植骨块融合情况。结果：随访期间均未发现结核复发，未发现钉棒松动、断裂，术后6个月ESR、CRP与术前相比均有明显统计学差异（P＜0.05）。术前Frankel神经功能分级：B级2例，C级5例，D级9例，E级3例，术后1周时Frankel分级：B级1例，C级3例，D级1例，E级14例，末次随访时D级1例（术前B级），E级18例，术后1周及末次随访与术前相比有统计学差异（P＜0.05）。术前后凸角平均41.32°±13.19°，术后即刻后凸角度平均9.74°±5.80°，即刻矫正率76.4%，末次随访后凸角平均12.32°±6.40°，平均丢失2.58°±0.60°，末次随访时矫正度数为29.0°±8.9°，矫正率为70.1%，术后即刻后凸角与术前相比有统计学差异（P<0.05），末次随访后凸角与术后即刻相比，无统计学差异（P>0.05）。19例患儿植入的同种异体骨的上下两端及后方的附件均与周围骨形成骨性连接，Bridwell分级1级融合；2例发生骨块下端轻度塌陷但形成骨痂且有骨小梁通过植骨接触面并且无明显植骨块松动及移位，1例出现局部轻度后凸畸形，但无神经损害及局部疼痛。结论：一期后路椎弓根螺钉内固定融合联合前路病灶清除、同种异体骨重建的方法治疗儿童胸腰椎结核导致的椎体破坏是一种安全可行的术式，中、远期随访观察获得了满意的临床结果。

【关键词】 活动性胸腰椎结核；儿童；椎体破坏；椎弓根螺钉；同种异体大块骨块；中长期随访

doi：10.3969/j.issn.1004-406X.2019.08.01

中图分类号：R529.2，R687.3    文献标识码：A   文章编号：1004-406X（2019）-08-0676-08

Mid-term and long-term follow-up ofone-stage combined anterior-posterior approach in the treatment of pediatricactive thoracic and lumbar tuberculosis/ZHANG Yi, WANG Xiaobin, L?譈 Guohua, et al//Chinese Journal of Spineand Spinal Cord, 2019, 29(8): 676-683

【Abstract】 Objectives: To observe the mid-or long-term efficacy of posteriorpedicle-screw fixation and fusion combined with anterior debridement andreconstruction with allograft bone strut in the treatment of pediatric activethoracic and lumbar tuberculosis. Methods: Retrospectively reviewed data of 19pediatric patients (aged 3-10 years, mean age 6.3±2.1 years) with spinal activetuberculosis infection which resulted in at least two consecutive vertebraldestruction treated in our hospital from January 2008 to January 2013. Allpatients underwent one-stage posterior pedicle-screw fixation and fusioncombined with anterior debridement and reconstruction of spinal stability with allograftbone strut. The duration of follow-up ranged from 5 to 11 years, averaged7.5±2.0 years, and the affected vertebral bodies ranged from 2 to 4. Allpatients were examined clinically and radiologically at 1 week, 3, 6 and 12months after surgery and received X-ray examination once per 12 months tomeasure the Cobb angle and  observedisplacement, loosening, collapse of allograft bone, and any kyphoticdeformity. The Cobb angle, Frankel grade, ESR and CRP before and one-week aftersurgery and at every reexamination of each patient were also collected andcompared. All 19 patients were followed up more than 5 years, and underwenthigh resolution 3-D CT scan to evaluate the fusion of bone grafts. Results:During the following up, no recurrence of tuberculosis or instrumentationfailure occurred. ESR and CRP at 6 months after operation were significantlydifferent from those before surgery (P<0.05). The Frankel classificationgrading before surgery was: 2 cases of Grade B, 5 cases of Grade C, 9 cases ofGrade D and 3 cases of Grade E; 1-week after: 1 case of Grade B, 3 cases ofGrade C, 1 cases of Grade D and 14 cases of Grade E; and at final follow-up: 1cases of Grade D (of Grade B before surgery) and 18 cases of Grade E. Accordingto the Frankel motor score system, neurological deficits were improved at oneweek after surgery (an average improvement of 0.80 grades) and at finalfollow-up (an average improvement of 1.26 grades) than before surgery, and thedifferences were of statistical significance(P<0.05). The average kyphoticangle was changed significantly from a preoperative value of 41.32°±13.19° to a immediate postoperative value of 9.74°±5.80° and, with an average correction rate of 76.4%(P＜0.05). The average kyphotic angle atfinal follow-up was 12.32°±6.40°, with an average loss of 2.58°±0.60°. The stable kyphosis correction was 29.0°±8.9°, with an correctionrate of 70.1%, and there was no significant difference in the Cobb anglebetween final follow-up and immediate postoperative values(P>0.05). All 19patients gained solid fusion at both upper and lower ends of allograft bonestrut, achieving Bridwell grade 1 fusion. The lower end of grafts of 2 casesout of the 19 slightly subsided, but osteophyte formed  and there were trabeculae through the contactsurface with no obvious loosening and dislocation of bone grafts; 1 caseexhibited slight local kyphosis, with no neurological deficit and clinicalsymptoms. Conclusions: It is effective, practical and safe to treat vertebraldestruction caused by pediatric thoracic and lumbar spinal active tuberculosisby posterior pedicle-screw fixation and fusion combined with anteriordebridement and spinal stability reconstruction with allograft bone strut, andin our study, satisfactory clinical results were obtained after mid-term andlong-term follow-up.

【Key words】 Active pediatric spinal tuberculosis; Vertebral body destruction;Pedicle-screw fixation; Allograft bone strut; Mid- or long-term follow up

【Author′s address】 Department of Spine Surgery, the Second Xiangya Hospital of CentralSouth University, Changsha, 410011, China

图1  患儿女性，6岁  a 同种异体大块骨实物图 b、c 术前胸椎正侧位X线片，侧位片示T7、8椎体大量骨质破坏，局部形成约60°后凸角，正位片示椎体有明显脱位 d、e 胸椎MRI冠状面显示有弥漫的椎旁脓肿，矢状面显示脓肿及死骨突入椎管，压迫脊髓 f 病椎横断位的CT及MRI，CT显示大量死骨形成，MRI可见椎前及椎旁大量脓肿形成 g、h 术后3个月的胸椎X线片，显示后凸角纠正为19° i 术后5年CT示大块骨与椎体上下两端均融合 j 术后8年时患者的全脊柱侧位X线片示局部后凸角约20°，全脊柱矢状面整体序列良好，无明显后凸畸形

Figure 1 A six-year-old girl  a A largeallograft bone b, c Pre-operative X-ray demonstrated destruction of T7 and T8,with a 60° kyphosis measured between T6 and T9, the AP X-ray showed anobviouscoronal dislocation d, e MRI reveals protrusion of dead bone fragments andgranulation tissue into the canal, leading to compression of the dural sac,Pronounced paravertebral abscesses f A cross-sectional CT scan showed motheatenbone destruction g A cross-sectional MRI scan showed huge abscecess around thevertebrae h, i At the three-month follow up, AP and lateral X-ray wasperformed, the lateral X-ray indicates that kyphosis was corrected to 19° j Atthe 5-year follow-up, a CT scan showed successful fusion at thegrafted site kAt the 8-year follow-up, a global spine lateral X-ray showed good sagittalplane alignment without kyphosis

图2  患儿女性，3岁  a、b 术前正侧位X线片示L1~L3椎体被结核病灶严重破坏，大部分骨质消失 c、d 双侧腰大肌巨大脓肿形成、脓肿进入椎管，神经严重受压 e、f 行后路T11~L5椎弓根螺钉内固定、L1~4椎板间植骨融合及前路病灶清除大块异体骨支撑植骨融合，术后1周X线片可见植骨块较大超出椎体前缘 g 术后2年侧位X线片示植骨块良好塑形，超出椎体前缘的骨质被完全吸收，已完全融合 h、i 术后5年脊柱全长正侧位X线片示没有明显后凸及侧弯畸形 j 术后5年CT示植骨处上下两端融合良好

Figure 2 A three-year-old girl  a, bPre-operative X-ray indicating complete disappearance of L2 vertebra c, d MRIdemonstrates a huge abscess around the psoas and thespinal cord was compressedby the dead bone fragments and granulation tissue e, f Posterior T11-L5 pediclescrew fixation, L1-4 interlaminar bone graft fusion combined with anterior debridementand reconstruction with allograft bone strut. At 1 week follow-up, X-ray showedcomplete correction of kyphosis, but the edge of the bone graft exceeds thefront edge of the T12 vertebral body g At the 24-month follow-up, the lateralX-ray showed that the bone graft fused well, with the protruding bone at T12vertebral body being absorbed completely h, i At the 5-year follow-up, the global anterposterior and lateral X-rayshowed no obvious kyphosis and lateral deformity j At the 5-year follow-up, aCT scan showed successful fusion at thegrafted site

本文为删节版，原文见《中国脊柱脊髓杂志》2019年8月刊