经皮椎弓根螺钉内固定联合腹部小切口病灶清除治疗老年腰椎结核的效果分析

doi:10.3969/j.issn.1000-6621.2019.06.011

摘要/Abstract

摘要：

目的探讨采用经皮椎弓根螺钉内固定联合腹部小切口病灶清除治疗老年腰椎结核的临床疗效。方法 2014年3月至 2017年3月浙江省中西医结合医院收治的符合纳入标准的老年腰椎结核患者56例,年龄65~85岁,平均(74.37±8.13)岁,采用信封法将患者随机分为 A、B 两组,各28例,所有患者均给予标准抗结核治疗,A组采用经皮椎弓根螺钉内固定联合腹部小切口前路病灶清除植骨融合术;B组行切开后路椎弓根螺钉固定前路病灶清除植骨融合术。对比分析两组患者术中出血量、手术时间、血红细胞沉降率(ESR)、C-反应蛋白(CRP)变化、手术节段后凸Cobb角测量、置钉准确性和腰椎功能情况。结果 56例患者均获得随访,时间12~20个月,平均(16.00±4.51)个月。至末次随访,均未见混合感染、结核复发及椎弓根螺钉松动、退钉发生。术中平均出血量 A 组为(154.37±11.28)ml,B 组为(297.28±30.73)ml,差异有统计学意义(t=6.412,P=0.000);平均手术时间 A 组为(193.56±15.72)min,B 组为(205.07±19.80)min,差异有统计学意义(t=3.937,P=0.000)。椎弓根置钉准确性,A组置钉准确率为85.80%(151/176),B组置钉准确率为84.18%(149/177),组间比较差异无统计学意义(χ ²=0.359, P=0.549)。术后A组出现并发症16例(57.14%), B组出现并发症17例(60.71%),两组间差异无统计学意义(χ ²=0.074,P=0.786)。日本骨科协会脊椎功能评分(Japanese Orthopaedic Association scores,JOA),术前分别为A组(6.37±0.51)分、B组(6.41±0.61)分,组间比较差异无统计学意义(t=0.060,P=0.952);术后1个月分别为A组(16.82±2.75)分、B组(19.03±3.57)分,组间比较差异有统计学意义(t=0.128, P=0.036);末次随访分别为A组(26.71±3.91)分、B组(27.23±5.23)分,组间比较差异无统计学意义(t=0.279, P=0.782)。结论 A组与B组手术方式比较早期疗效均比较满意,前者较后者具有创伤小、手术时间短、出血少的优点。

关键词: 结核, 脊柱, 老年人, 外科手术, 微创性, 脊柱融合术, 疗效比较研究

Abstract:

Objective To evaluate the curative effect of percutaneous pedicle screw internal fixation combined with small abdominal incision debridement for lumbar tuberculosis in old patients.Methods From March 2014 to March 2017, 56 old patients with lumbar tuberculosis in Zhejiang Integrated Traditional and Western Medicine Hospital met the inclusion criteria were divided into group A and group B. All patients were received the standard anti-tuberculosis chemotherapy. Patients in group A were underwent percutaneous pedicle screw internal fixation combined with small abdominal incision debridement and interbody fusion with bone grafting. Patients in group B were underwent pedicle screw internal fixation and anterior debridement and interbody fusion with bone grafting. The volume of surgical bleeding, operation time, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), segment kyphotic Cobb angle, accuracy of nailing and lumbar function were compared and analyzed between the two groups. SPSS 17.0 statistical software was used for data analysis, t test and χ ² test were used, and P<0.05 was the significant difference.Results Fifty-six patients were followed up for an average of 16.00±4.51 months ranged from 12 to 20 months. No mixed infection, relapse of tuberculosis, pedicle screw loosening and retreating were found. The bleeding volume in the group A was (154.37±11.28) ml and the group B was (297.28±30.73) ml. The operation time was (193.56±15.72) min in the group A and (205.07±19.80) min in the group B. The mean operation time and bleeding volume in group A were less than those in group B with significant difference (t=6.412,t=3.937,P=0.000). The accuracy of pedicle screw placement was 85.80% (151/176) in group A and 84.18% (149/177) in group A. There was no significant difference in the accuracy of pedicle screw placement between the two groups (χ ²=0.359, P=0.549). Postoperative complications occurred 16 cases (57.14%) in group A and 17 cases (60.71%) in group B without significant statistically difference between the two groups (χ ²=0.074,P=0.786). Japanese Orthopaedic Association Scores (JOA) score of lumbar function, preoperative follow-up was (6.37±0.51) scores in group A and (6.41±0.61) scores in group B, 1 month after operation was (16.82±2.75) scores in group A and (19.03±3.57) scores in group B. There was significant difference between the two groups (t=0.128, P=0.036), the last follow-up was (26.71±3.91) scores in group A and (27.23±5.23) scores in group B, there was no significant difference between the two groups (t=0.279, P=0.782).Conclusion The early curative effect of group A and group B was satisfactory,but the former had the advantages of less trauma, shorter operation time and less bleeding than the latter.

Key words: Tuberculosis, spinal, Aged, Surgical procedures, minimally invasive, Spinal fusion, Comparative effectiveness research

石仕元,赖震,费骏,韩贵和,胡胜平. 经皮椎弓根螺钉内固定联合腹部小切口病灶清除治疗老年腰椎结核的效果分析[J]. 中国防痨杂志, 2019, 41(6): 650-656. doi: 10.3969/j.issn.1000-6621.2019.06.011

Shi-yuan SHI,Zhen LAI,Jun FEI,Gui-he HAN,Sheng-ping HU. Curative effect of percutaneous pedicle screw internal fixation combined with small abdominal incision debridement for lumbar tuberculosis in old patients[J]. Chinese Journal of Antituberculosis, 2019, 41(6): 650-656. doi: 10.3969/j.issn.1000-6621.2019.06.011

图/表 9

表1

两组患者术前一般资料比较

组别	例数	性别(例)		年龄 (岁, $x ˉ$ ±s)	ESR (mm/1h, $x ˉ$ ±s)	CRP (mg/L, $x ˉ$ ±s)	节段后凸Cobb角 (°, $x ˉ$ ±s)	JOA评分 (分, $x ˉ$ ±s)
组别	例数	男	女	年龄 (岁, $x ˉ$ ±s)	ESR (mm/1h, $x ˉ$ ±s)	CRP (mg/L, $x ˉ$ ±s)	节段后凸Cobb角 (°, $x ˉ$ ±s)	JOA评分 (分, $x ˉ$ ±s)
A组	28	15	13	73.15±9.02	70.53±6.21	87.42±6.77	18.35±4.26	6.37±0.51
B组	28	14	14	73.24±9.08	69.86±5.85	89.35±6.43	18.51±5.73	6.41±0.61
检验值		χ²=0.091		t=1.402	t=1.409	t=0.345	t=0.267	t=0.06
P值		0.725		0.156	0.167	0.732	0.519	0.952

表1

图1,2

图3,4

表2

两组各28例患者手术出血量、手术时间的比较

组别	例数	出血量 (ml, $x ˉ$ ±s)	手术时间 (min, $x ˉ$ ±s)
A组	28	154.37±11.28	193.56±15.72
B组	28	297.28±30.73	205.07±19.80
t值		6.412	3.937
P值		0.000	0.000

表2

表3

两组28例患者术后不同时期血ESR及CRP值的比较

组别	ESR(mm/1h, $x ˉ$ ±s)			CRP(mg/L, $x ˉ$ ±s)
组别	术后2周	术后1个月	术后6个月	术后2周	术后1个月	术后6个月
A组	37.21±3.23	29.47±0.82	9.98±0.19	70.86±7.96	15.67±2.81	3.17±0.52
B组	39.56±5.09	28.50±0.74	10.16±0.91	74.12±8.37	16.12±3.20	2.84±0.76
t值	1.957	1.841	0.911	1.861	1.233	1.125
P值	0.057	0.073	0.368	0.070	0.852	0.267

表3

图5~9

图10~14

图15

图16

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