【摘要】  　　目的 探讨重症脊柱结核手术治疗的方法和临床效果。方法 110 例病变累及1～3个椎节的胸腰椎结核患者，伴有不同程度结核中毒症状，32例患者有不同程度后凸畸形。一期行前路病灶切除减压，自体髂骨肋骨和同种异体骨椎体间植骨，“K”钢板内固定重建脊柱稳定性，术后给予12～18个月抗痨治疗，观察术后腰背部疼痛缓解、脊髓神经功能恢复、植骨融合及内固定稳定情况。结果 术后患者腰背部疼痛缓解，下肢疼痛麻木消失，术前伴有脊髓功能障碍的27例患者术后神经功能均有不同程度恢复。术后影像学检查示植骨块及内固定钢板位置良好，椎体序列及高度恢复良好。随访1～7年，平均4.2年，复发8例，经处理后痊愈。结论 采用前路一期病变椎体切除椎体间植骨钢板内固定的手术方式有利于病变切除彻底，椎管减压彻底，脊柱稳定性重建可靠。

【关键词】  脊柱结核 植骨 内固定

　　Surgical Treatment for Severe Spinal Tuberculosis

　　Deng Shaolin, Pan Xianming, Yan Zhenwei, Qu Bo, Fan Ling, Jiang Kai, Li Wei, Quan Yi, Chengdu Military General Hospital, Chengdu, Sichuan Province 610083

　　Abstract  Objective  To discuss the surgical treatment for severe spinal tuberculosis and the clinical curative effect.Methods  110 cases with thoraco-lumbar spinal tuberculosis on 1 to 3 vertebra segments suffered from different degrees of tuberculous symptoms, out of the 110 cases, 32 cases had different degrees of kyphosis malformation; one-stage anterior resection of the lesion was performed for decompression and intervertebral body bone graft with autogenous iliac and ribs was made as well as allogenic bone graft, internal fixation with K steel plate reconstructed the stability of the spine; after operation, antituberculous therapy kept on for 12 to 18 months; observation was made after operation on the relief of low back pain, recovery of spinal cord function, bone graft fusion and stability of internal fixation.Results  The low back pain of the patients was relieved and the lower extremity pain and numbness disappeared; 27 cases with spinal cord dysfunction before operation had certain recovery of neural function; X-ray after operation showed right location of grafted bones and steel plates for internal fixation, good recovery of spine sequence and height; follow-up lasted from 1 to 7 years with the average of 4.2 years, and 8 cases with reoccurrence recovered after certain treatment.Conclusions  One-stage anterior resection with intervertebral body bone grafting and steel-plate internal fixation is favorable to total remove of the lesion and complete decompression of spinal canal, and it is reliable in reconstructing the stability of the spine.

　　KEYWORDS  spinal tuberculosis      bone graft      internal fixation

　　胸腰椎是脊柱结核的好发部位，占全身骨关节结核约50%，其中99%为椎体结核，主要破坏脊柱前中柱，累及椎间盘，常出现椎旁脓肿或腰大肌脓肿，脊柱后凸畸形，脊髓受压。近年来脊柱结核发病率呈明显上升趋势。我们从2001～2008年应用前路一期病变椎体切除植骨内固定治疗胸腰椎结核110例，取得满意疗效，报告如下。

　　1  资料和方法

　　1.1  一般资料  110例患者依据临床表现、查体、常规化验检查、X线摄片、CT及MRI检查，诊断为胸腰椎结核并经病理检查证实。男性75例，女性35例，年龄19～63岁，平均35.38岁，病史3月～5年。病变部位：T7～L5胸椎40例,腰椎70例。结核累及范围：单椎44例，双椎49例，三椎17例（其中5例为跳跃性）。无窦道形成病例。所有病例均有不同程度结核中毒症状和胸腰部疼痛及椎旁脓肿。27例有不同程度的脊髓或神经根受压症状，神经功能按Frankel分级，B级2例，C级10例，D级15例。27例MRI显示椎管内脓肿，死骨占位压迫脊髓。术前后凸成角13°～45°，平均30°。术前绝对卧床抗痨2周以上，待一般情况较好，结核中毒症状减轻时手术。

　　1.2  手术方法  腰椎常规采用侧卧位左侧腹膜后入路，腰部置于腰桥上；胸腰段采用11、12肋缘下切口，必要时切除肋骨，肋膈角胸膜返折处注意小心分离，避免损伤胸膜，若胸膜破裂，修补后仍需安置胸腔闭式引流；胸椎一般采用右侧入路，以避开心脏大血管。通过肋骨定位病椎及固定钢板的上下椎体，注意先处理胸椎的肋间动脉和腰椎的腰横动脉，这两根知名动脉均从椎体侧方正中凹陷处通过。彻底