腰骶段结核术后复治的原因分析与应对策略

doi:10.3969/j.issn.1000-6621.2019.04.008

摘要/Abstract

摘要：

目的探讨腰骶段脊柱结核术后复治的相关原因及临床应对策略。方法搜集2013年6月至2016年6月河北省胸科医院骨科收治的84例腰骶段结核患者,将15例复治患者作为观察组,初治术后未复发的69例患者作为对照组,通过单因素和多因素logistic回归分析影响腰骶段结核术后复发的相关因素。对观察组患者制定并实施个体化的手术治疗方案,术后联合应用抗结核药物治疗18~24个月,随访观察病灶愈合及植骨融合情况,并评估治疗效果。结果观察组术前血白蛋白水平、植骨融合率、术后规范抗结核药物治疗比率、手术彻底清除病灶比率分别为(35.56±6.04)g/L、53.3%(8/15)、60.0%(9/15)、46.7%(7/15),均明显低于对照组[分别为(38.71±5.25)g/L、85.5%(59/69)、89.9%(62/69)、87.0%(60/69)];观察组结核分枝杆菌耐药率、其他部位并发结核的发生率分别为33.3%(5/15)和60.0%(9/15),均明显高于对照组[分别为11.6%(8/69)和29.0%(20/69)];上述各项指标两组间比较差异均有统计学意义(t=2.05、χ ²=7.90、χ ²=21.84、χ ²=12.39、χ ²=4.45、χ ²=5.24,P值分别为0.043、0.010、0.000、0.000、0.035、0.022)。多因素logistic回归分析结果表明,术前血白蛋白水平<35g/L(OR=7.32,95%CI:1.04~51.28)、手术病灶清除不彻底(OR=25.17,95%CI:3.06~207.29)、未行植骨融合(OR=9.38,95%CI:1.13~77.90)、术后应用抗结核药物不规范(OR=20.44,95%CI:1.23~339.25)、结核分枝杆菌耐药(OR=18.57,95%CI:1.61~213.77)、并发其他部位结核(OR=13.91,95%CI:1.64~117.87)均是腰骶段结核术后复发的危险因素。84例患者随访28~62个月,平均随访(36.5±11.2)个月;15例复治患者经调整治疗方案并再次行手术后均达到临床治愈标准,且术后植骨顺利愈合,随访期内未见复发患者。结论术前积极行营养支持治疗,规范施行抗结核药物治疗,参考结核分枝杆菌药物敏感性试验结果选用有效的治疗药物,依据影像学表现制定个体化的手术治疗方案是减少腰骶段结核复发的关键。

关键词: 结核, 脊柱, 腰骶部, 复发, 外科手术, 因素分析, 统计学

Abstract:

Objective To summarize the reasons and clinical treatments of postoperative recurrence of spinal tuberculosis in lumbosacral portion. Methods Eighty-four patients with spinal tuberculosis in lumbosacral portion admitted to the Department of Orthopedics, the Chest Hospital of Hebei Province from June 2013 to June 2016 were retrospectively studied, including 15 patients with postoperative recurrence of spinal tuberculosis as observation group and 69 patients without recurrence of spinal tuberculosis as control group. Risk factors for postoperative recurrence of spinal tuberculosis in lumbosacral portion were determined by univariate and multivariate logistic regression analysis. Individual operation was performed for the patients in the observation group. All patients were treated by anti-tuberculosis chemotherapy for 18-24 months. To evaluate the therapeutic effects, lesion healing and bone graft fusion were observed during follow-up period. Results The preoperative blood albumin level, bone graft fusion rate, postoperative standard anti-tuberculosis treatment rate and degree of debridement of the observation group were (35.56±6.04)g/L, 53.3% (8/15), 60.0% (9/15) and 46.7% (7/15), which were significantly lower than those of the control group ((38.71±5.25)g/L, 85.5% (59/69), 89.9% (62/69) and 87.0% (60/69)). The incidence of drug resistance and concurrent tuberculosis at other parts of the observation group were 33.3% (5/15) and 60.0% (9/15), which were significantly higher than those of the control group (11.6% (8/69) and 29.0% (20/69)). There were significant differences between the two groups (t=2.05, χ ²=7.90, χ ²=21.84, χ ²=12.39, χ ²=4.45, χ ²=5.24; P values were 0.043, 0.010, 0.000, 0.000, 0.035 and 0.022). Multivariate logistic regression analysis showed that albumin level <35g/L (OR=7.32, 95%CI: 1.04-51.28), without complete debridement (OR=25.17, 95%CI: 3.06-207.29), without graft bone fusion (OR=9.38, 95%CI: 1.13-77.90), postoperative irregular chemotherapy (OR=20.44, 95%CI: 1.23-339.25), drug resistance (OR=18.57, 95%CI: 1.61-213.77) and concurrent tuberculosis at other parts (OR=13.91, 95%CI: 1.64-117.87) were the risk factors for postoperative recurrence of spinal tuberculosis in lumbosacral portion. The follow-up period ranged from 28-62 months (average (36.5±11.2)months). All 15 cases were recovered by adjusting therapeutic scheme and reoperation, the bone graft was successfully fused, and there was no recurrence during the follow-up period. Conclusion The early and positive therapies such as nutritional support, standard and effective anti-tuberculosis chemotherapy according to hypersensitive test and reoperation based on imaging manifestation were the keys to improve the curative effect.

Key words: Tuberculosis, spinal, Lumbosacral region, Recurrence, Surgical procedures, operative, Factor analysis, statistical

姚黎明,贾晨光,李卓,董昭良,王连波,刘丰胜. 腰骶段结核术后复治的原因分析与应对策略[J]. 中国防痨杂志, 2019, 41(4): 405-413. doi: 10.3969/j.issn.1000-6621.2019.04.008

Li-ming YAO,Chen-guang JIA,Zhuo LI,Zhao-liang DONG,lian-bo WANG,Feng-sheng LIU. Clinical study on the reasons and therapeutic scheme of postoperative recurrence of spinal tuberculosis in lumbosacral portion[J]. Chinese Journal of Antituberculosis, 2019, 41(4): 405-413. doi: 10.3969/j.issn.1000-6621.2019.04.008

图/表 5

表2

两组患者临床资料的比较

临床资料	观察组(15例)	对照组(69例)	统计检验值	P值
病变受累节段[例(构成比,%)]			χ²=1.80	0.242
2个椎体	7(46.7)	45(65.2)
≥3个椎体	8(53.3)	24(34.8)
并发其他部位结核[例(构成比,%)]			χ²=5.24	0.022
是	9(60.0)	20(29.0)
否	6(40.0)	49(71.0)
白蛋白(g/L, $x ˉ$ ±s)	35.56±6.04	38.71±5.25	t=2.05	0.043
红细胞沉降率[mm/1h,M(Q₁,Q₃)]	56.0(33.0,80.0)	43.0(28.5,73.5)	U=430.50	0.309
血红蛋白(g/L, $x ˉ$ ±s)	114.13±20.27	121.33±22.90	t=1.12	0.264
术前抗结核治疗时间[周,M(Q₁,Q₃)]	2.0(2.0,5.5)	2.0(1.0,4.0)	U=408.0	0.189
手术入路[例(构成比,%)]			χ²=3.66	0.160
单纯前路	9(60.0)	36(52.2)
单纯后路	3(20.0)	5(7.2)
前后路联合	3(20.0)	28(40.6)
手术彻底清除病灶[例(构成比,%)]			χ²=12.39	0.000
是	7(46.7)	60(87.0)
否	8(53.3)	9(13.0)
植骨融合[例(构成比,%)]			χ²=7.90	0.010
是	8(53.3)	59(85.5)
否	7(46.7)	10(14.5)
内固定[例(构成比,%)]			χ²=1.46	0.242
是	8(53.3)	48(69.6)
否	7(46.7)	21(30.4)
术后规范抗结核治疗[例(构成比,%)]			χ²=21.84	0.000
是	9(60.0)	62(89.9)
否	6(40.0)	7(10.1)
耐药[例(构成比,%)]			χ²=4.45	0.035
是	5(33.3)	8(11.6)
否	10(66.7)	61(88.4)

表2

表3

表4

影响腰骶段结核术后复发的多因素logistic回归分析

因素	β值	s $x ˉ$ 值	Wald χ² 值	P值	OR(95%CI)值
术前白蛋白水平<35g/L	1.99	0.99	4.01	0.045	7.32(1.04~51.28)
手术病灶清除不彻底	3.23	1.08	8.99	0.003	25.17(3.06~207.29)
未行植骨融合	2.24	1.08	4.30	0.038	9.38(1.13~77.90)
术后应用抗结核药物不规范	3.02	1.43	4.43	0.035	20.44(1.23~339.25)
结核分枝杆菌耐药	2.92	1.25	5.49	0.019	18.57(1.61~213.77)
并发其他部位结核	2.63	1.09	5.83	0.016	13.91(1.64~117.87)

表4

图1~12

图13~20

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变量	观察指标	赋值
X1	术前白蛋白水平	≥35g/L=0;<35g/L=1
X2	手术彻底清除病灶	是=0;否=1
X3	植骨融合	是=0;否=1
X4	术后规范抗结核药物治疗	是=0;否=1
X5	结核分枝杆菌不耐药	是=0;否=1
X6	其他部位未并发结核	是=0;否=1
Y	复发	是=0;否=1