Anterior plate internal fixation and autologous iliac bone graft fusion in the repair of thoracic spinal tuberculosis: bone healing

doi:10.3969/j.issn.2095-4344.2014.40.011

Abstract

Abstract:

BACKGROUND: Thoracic vertebrae connected with the ribs of corresponding segments constitute the thorax. Because of thoracic vertebrae deeply and complicated structure, it is difficult to operate or to expose thoracic vertebrae completely. The traditional anterior ways can thoroughly remove the focus and achieve a good internal fixation, but this treatment needs to cut the rid. The surgeon discovered in years of clinical practice that distraction of intercostal space without cutting off the ribs could completely remove the focus and achieve fixation and fusion.

OBJECTIVE: To explore the feasibility, advantages and disadvantages of anterior plate fixation and autologous bone graft fusion in the repair of thoracic spinal tuberculosis.

METHODS: A total of 30 cases of thoracic spinal tuberculosis were enrolled. On the base of traditional thoracic spinal anterior surgical approach, the rib was reserved. Anterior distraction device was used to open the ribs for clearance and to move the focus of thoracic spinal tuberculosis. Autologous ilium was obtained and subjected to fusion and anterior plate fixation. Visual Analog Scale, Oswestry Disability Index, Frankel grade and Bridwell bone healing rating were used before and after treatment.

RESULTS AND CONCLUSION: A total of 30 patients were followed up for 3-60 months. The bone healing (class A) was seen, but no fistula formation was visible. Nerve compression symptoms were improved, without aggravating cases. Postoperatively, the average Cobb angle correction was 10.32°. After 6 months, imaging revealed bone fusion of affected vertebral body. After 18 months, the vertebral height was not lost obviously, no recurrence of vertebral tuberculosis. These results indicated that anterior intercostal space without cutting ribs exposed clearly, showing a large space, where can meet the requirement of first-stage debridement fixation and fusion in the repair of thoracic tuberculosis. The pathological changes were visibly clear; the focus was thoroughly removed, and the ribs were reserved. The outcomes are identical to rib resection. Simultaneously, autogenous iliac trilateral cortex has good supporting effects. Loose cancellous bone mesh has good osteogenesis and is helpful to bone healing.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: thoracic vertebrae, tuberculosis, internal fixators, bone transplantation, ilium

CLC Number:

R318

Huang Jiang, Li Xiao-feng, Yang Yuan. Anterior plate internal fixation and autologous iliac bone graft fusion in the repair of thoracic spinal tuberculosis: bone healing[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(40): 6459-6463.

Figures/Tables 1

2.1 参与者数量分析本组病例共30例，男19例，女11例。病例来源于不同的医疗机构，但具体的诊疗方案及手术计划均有通讯作者完成，第二作者参与统计。所有病例资料均符合临床研究纳入标准，无死亡病例。全部采用一期经肋间隙操作，完成胸椎结核一期病灶清除、植骨融合、前路钢板内固定，治疗后植骨均骨性融合、病灶无复发，所有患者内固定无折断、松动及脱落。病例跟踪随访到位。 2.2 随访结果 30例患者术后均获随访，时间为3-60个月。治疗后患者的疼痛明显缓解，采用目测类比评分法，改善率为(83.6±0.3)%。ODI改善率为(84.6±3.0)%。Cobb角明显改善，改善率为(73.6±3.0)%，平均改善10.32°。治疗前1周与治疗后3个月症状改善明显，患者基本恢复正常生活，见表1。 2.3 影像学结果治疗后平均6个月影像学显示病变椎体间骨性融合，治疗后18个月复查影像学显示椎体高度未丢失，无椎体结核复发患者。按照骨愈合的Bridwell判定标准，Ⅰ级愈合29例，Ⅱ级愈合1例。骨愈合率为100%。 2.4 治疗前、治疗后Frankel分级本组末次随访时Frankel C级2例，D级8例，E级20例，见表2。 2.5 不良事件 30例患者伤口均甲级愈合，无窦道形成；神经压迫症状得到改善，无加重病例。术中2例行肋间隙撑开时出现肋骨骨折，经缝合内固定2个月后骨折愈合，胸廓外观无畸形，胸腹壁皮肤感觉无异常。建议对于50岁以上骨质疏松明显的女性患者行肋骨撑开时需缓慢操作，切忌强行撑开造成肋骨骨折。 2.6 典型病例男性患者，42岁，胸背疼痛2年，四肢麻木、无力2个月。于2011年9月入院，治疗前诊断为：T9椎体结核伴椎旁脓肿形成、脊髓压迫症。给予三联抗结核治疗3周，血沉、C-反应蛋白均基本恢复正常。入院时目测类比评分8分，ODI为28.9%，Cobb角约20°，Frankel 分级C级。在插管全麻下行经肋间隙入路胸椎结核一期病灶清除、植骨融合、前路钢板内固定，治疗后1周神经功能有部分改善。6个月后Frankel 分级E级；椎间植骨块按Bridwell标准达Ⅰ级骨性愈合；Cobb角恢复，内固定无松动；戴胸腰椎支具下地活动未见明显异常(图1)。"

References

[1] 刘志辉,罗一鲁.结核病实验诊断现状及展望[J].中国防痨杂志, 2003, 25(1): 38.
[2] Garg RK, Somvantion DS. Spinal tuberculosis：a review. Spinal Cord Med. 2011;34(5): 440-454.
[3] 吴兴彪,张曦,吕正祥,等.经胸一期病灶清除植骨融合内固定术治疗胸椎结核并截瘫[J].临床骨科杂志,2011,14(6):613-616.
[4] Jain AK. Tubeerculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010;92(7):905-913.
[5] 金大地.脊柱结核治疗若干问题探讨[J].脊柱外科杂志,2005,6(3): 186.
[6] 李承球.脊柱结核的诊断和治疗进展[J].颈腰痛杂志,1999,20(3): 161-163.
[7] 金大地,陈建庭,张浩,等.一期前路椎体间植骨并内固定治疗胸腰椎结核[J].中华外科杂志,2000,38(12):900-902.
[8] 谢富荣,林春博,杨渊,等.不断肋并保留肋骨经肋间隙入路治疗胸椎疾患的体会[J].广西医科大学学报,2010,27(2):303-304.
[9] 李树林,李章红,江柏青,等.改良胸后外侧切口在胸外科的应用[J].微创医学,2006,1(4):250-252.
[10] 刘茂林,杨勇.腋下不中断肋骨小切口在胸外手术中的应用[J].中华临床医药,2004,5(2):3.
[11] 余雨,王群波,邵高海.前路钉棒系统在多发下胸椎结核手术中的应用[J].中国矫形外科杂志,2010,18(19):1595-1598.
[12] 候树勋,邱贵兴,金大地,等.脊柱外科学[M].北京:人民军医出版社,2005:1151-1182.
[13] 张巍巍,张怀学,余华伟,等.前路钉-棒系统在手术治疗胸椎结核中的应用[J].脊柱外科杂志,2006,4(1):46-47.
[14] 瞿东滨,金大地,陈建庭,等.脊柱结核的一期手术治疗[J].中华医学杂志,2003,83(2):110-113.
[15] 张宏其,龙文荣,邓展生,等.影响一期手术治疗脊柱结核并截瘫患者疗效的相关因素[J].中国脊柱脊髓杂志,2004,14(12): 720-723.
[16] 余雨,李波,邵高海.侧前路单钉棒系统内固定治疗多发胸椎结核[J].四川医学,2008,29(12):1641-1643.
[17] 林宏,李康宁,向勇.胸腰椎结核伴截瘫的前路手术治疗[J].中国矫形外科杂志,2006,14(1):23-24.
[18] 李涛,杨述华,刘国辉,等.钛网植骨侧前路钉棒系统内固定治疗脊柱结核伴截瘫[J].中国矫形外科杂志, 2007, 15(5): 274-276.
[19] 陈云生,游辉,陈荣春. 胸腔镜辅助下前路病灶清除植骨内固定治疗胸椎结核[J].中国矫形外科杂志,2011,19(3):184-186.
[20] 张忠民,付忠泉,尹刚辉,等.胸椎结核外科治疗的长期临床随访[J].脊柱外科杂志,2014,10(4):198-201.
[21] 范俊,秦世炳,董伟杰.胸椎结核术后常见并发症的临床分析[J].北京医学,2014,36(3):184-187.
[22] 朱定川,高峰,曾建成.胸椎结核经前路病灶清除融合单钉棒固定术的疗效观察[J].华西医学,2014, 29(1):26-29.