脊柱结核术后未愈的影响因素分析

摘要/Abstract

摘要：

目的探讨脊柱结核患者术后未愈的影响因素。方法收集2012年1月至2016年12月成都市公共卫生临床医疗中心收治的312例脊柱结核患者作为研究对象,其中,经手术治疗未愈者24例,治愈者288例。收集研究对象性别、年龄、营养状况、发病至就诊间隔时间、手术入路、抗结核药物治疗方案、患者依从性、脊柱病变节段、是否并发其他部位结核、耐药情况、病灶清除情况、内固定稳定性、术前规范抗结核时间、全程随访情况、抗结核药物治疗效果评定等信息,分析导致患者术后未愈的影响因素。结果未愈组不规范抗结核药物治疗者、脊柱病变>2个节段者、耐药结核病者、病灶清除不彻底者、全程未进行规律随访者、抗结核药物治疗效果评定为无效者、发病至就诊间隔时间>12个月者、行后路手术者分别占75.0%(18/24)、66.7%(16/24)、41.7%(10/24)、66.7%(16/24)、58.3%(14/24)、58.3%(14/24)、41.7%(10/24)、66.6%(16/24),均明显高于治愈组[分别占27.4%(79/288)、35.8%(103/288)、12.1%(35/288)、35.8%(103/288)、26.4%(76/288)、29.2%(84/288)、4.9%(14/288)、17.7%(51/288)],差异均有统计学意义(χ ²值分别为10.11、7.19、15.64、8.97、11.01、8.75、12.14、12.29,P值均＜0.05)。多因素logistic回归分析显示,不规范抗结核药物治疗[OR(95%CI)=3.15(1.03~9.64)]、脊柱病变>2个节段[OR(95%CI)=2.52(1.29~4.94)]、耐药结核病[OR(95%CI)=4.31(1.25~14.88)]、病灶清除不彻底[OR(95%CI)=4.90(1.39~17.27)]、全程未规律随访[OR(95%CI)=3.99(1.39~17.27)]、抗结核药物治疗效果评定为无效[OR(95%CI)=4.46(1.34~11.84)]、发病至就诊间隔时间>12个月[OR(95%CI)=12.30(2.20~68.80)]及行后路手术方式[OR(95%CI)=6.51(1.77~23.91)]是脊柱结核患者术后不愈的危险因素。结论脊柱结核诊治过程中要早期就诊,采用规范的抗结核药物方案治疗,避免适应性耐药,手术尽量选择前路手术方式,术中尽可能彻底清除病灶,术后注重全程随访,及时调整不合理抗结核药物方案。

关键词: 结核, 脊柱, 外科手术, 治疗失败, 因素分析, 统计学

Abstract:

Objective To explore the influencing factors of postoperative non-healing of patients with spinal tuberculosis.Methods A total of 312 patients with spinal tuberculosis admitted to the Chengdu Public Health Clinical Medical Center from January 2012 to December 2016 were included in the study. Among them, 24 were unhealed by surgery and 288 were cured. Data on gender, age, nutritional status, time from onset to visit, surgical approach, anti-tuberculosis drug treatment plan, patient compliance, spinal lesion segment, whether concurrent with other parts of the tuberculosis, drug resistance, lesion removal, internal fixed stability, duration of preoperative standard anti-tuberculosis treatment, follow-up of the whole process, assessment of anti-tuberculosis efficacy were collected. The factors that led to the non-healing after surgery were analyzed.Results In the unhealed group, patients with nonstandard anti-tuberculosis drugs, spinal lesions more than two segments, drug-resistant tuberculosis, incomplete removal of lesions, irregular follow-up of the whole process, invalid efficacy of anti-tuberculosis therapy, interval from onset to visit of longer than 12months, and posterior surgery accounted for 75.0% (18/24), 66.7% (16/24), 41.7% (10/24), 66.7% (16/24), 58.3% (14/24), 58.3% (14/24), 41.7% (10/24), and 66.6% (16/24), which were higher than those of the patients in the cured group (27.4% (79/288), 35.8% (103/288), 12.1% (35/288), 35.8% (103/288), 26.4% (76/288), 29.2% (84/288), 4.9% (14/288), and 17.7% (51/288)); the differences were statistically significant (χ ² values were 10.11, 7.19, 15.64, 8.97, 11.01, 8.75, 12.14, 12.29, all P values ＜0.05). Multivariate logistic regression analysis showed that irregular antituberculous drugs (OR (95%CI)=3.15 (1.03-9.64)), spinal lesions more than two segments (OR (95%CI)=2.52 (1.29-4.94)), drug-resistant tuberculosis (OR (95%CI)=4.31 (1.25-14.88)), incomplete removal of the lesion (OR (95%CI)=4.90 (1.39-17.27)), irregular follow-up throughout the course (OR (95%CI)=3.99 (1.39-17.27)), invalid efficacy of anti-tuberculosis therapy (OR (95%CI)=4.46 (1.34-11.84)), onset to visit interval >12months (OR (95%CI)=12.30 (2.20-68.80)), and posterior approach (OR (95%CI)=6.51 (1.77-23.91)) were the risk factors for postoperative non-healing of spinal tuberculosis patients. Conclusion Early diagnosis and treatment, standardized anti-tuberculosis program, avoiding adaptive drug resistance, choosing anterior approach as much as possible, removing the lesion thoroughly, paying attention to regular follow-up after surgery, and adjusting irrational anti-tuberculosis drug program can reduce the rate of postoperative non-healing of tuberculosis.

Key words: Tuberculosis, spinal, Surgical procedures, operative, Treatment failure, Factor analysis, statistical

李邦银,蒲育,何敏,蒋曦,李海,刘林,何磊,环明苍,蔡玉郭,刘勇. 脊柱结核术后未愈的影响因素分析[J]. 中国防痨杂志, 2019, 41(5): 510-514.

Bang-yin LI,Yu PU,Min HE,Xi JIANG,Hai LI,Lin LIU,Lei HE,Ming-cang HUAN,Yu-guo CAI,Yong LIU. Analysis of risk factors of postoperative non-healing of spinal tuberculosis patients[J]. Chinese Journal of Antituberculosis, 2019, 41(5): 510-514.

图/表 2

表1

表2

脊柱结核术后未愈影响因素多因素logistic回归分析

变量	β值	s $x ˉ$ 值	Wald χ²值	P值	OR(95%CI)值
常量	-5.25	1.25	17.57	0.000
不规范抗结核	1.15	0.57	4.03	0.045	3.15(1.03~9.64)
病变>2个节段	0.93	0.34	7.25	0.007	2.52(1.29~4.94)
耐药结核病	1.46	0.63	5.32	0.021	4.31(1.25~14.88)
病灶清除不彻底	1.59	0.64	6.10	0.014	4.90(1.39~17.27)
全程未进行规律随访	1.38	0.56	6.21	0.013	3.99(1.39~17.27)
抗结核药物治疗效果评定为无效	1.50	0.60	6.23	0.013	4.46(1.34~11.84)
发病至就诊间隔时间(月;以<3个月为参照)
3~	1.65	0.62	6.99	0.008	5.12(1.53~17.62)
>12	2.51	0.88	8.17	0.004	12.30(2.20~68.80)
手术入路(以前路为参照)
前后路	1.77	0.79	5.08	0.024	5.87(1.26~27.40)
后路	1.87	0.67	7.96	0.005	6.51(1.77~23.91)

表2

参考文献 18

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临床特征	未愈组(24例)	治愈组(288例)	χ²值	P值
年龄组(岁)			0.01	0.916
<30	2(8.3)	31(10.8)
30~	15(62.5)	162(56.3)
>60	7(29.2)	95(32.9)
性别			0.28	0.600
男	14(58.3)	152(52.8)
女	10(41.7)	136(47.2)
不规范抗结核药物治疗	18(75.0)	79(27.4)	10.11	0.001
脊柱病变>2个节段	16(66.7)	103(35.8)	7.19	0.007
耐药结核病	10(41.7)	35(12.1)	15.64	0.000
病灶清除不彻底	16(66.7)	103(35.8)	8.97	0.003
全程未进行规律随访	14(58.3)	76(26.4)	11.01	0.001
抗结核药物治疗效果评定为无效	14(58.3)	84(29.2)	8.75	0.003
营养状况			6.37	0.012
差	10(41.7)	53(18.4)
一般	12(50.0)	184(63.9)
良好	2(8.3)	51(17.7)
发病至就诊间隔时间(月)			12.14	0.000
<3	3(12.5)	83(28.8)
3~	11(45.8)	191(66.3)
>12	10(41.7)	14(4.9)
手术入路			12.29	0.000
后路	16(66.6)	51(17.7)
前后路	4(16.7)	12(4.2)
前路	4(16.7)	225(78.1)
患者依从性差	15(62.5)	199(69.1)	0.45	0.504
其他部位活动性结核	19(79.2)	206(71.5)	0.64	0.423
内固定松动	1(4.2)	18(6.3)	0.08	0.781
术前规范抗结核药物治疗时间(周)			0.17	0.684
2~	21(87.5)	243(84.4)
>4	3(12.5)	45(15.6)