长节段皮质骨轨迹螺钉固定胸腰椎结核临床疗效分析：2年随访比较

doi:10.3877/cma.j.issn.2096-0263.2023.02.003

目的

探究长节段皮质骨轨迹螺钉固定胸腰椎结核的长期临床疗效。

方法

回顾性收集2015年6月至2019年6月接受后路受累椎体固定联合前路清创术和植骨治疗的76例胸腰椎结核患者资料，根据手术方式不同分为CBT组及PS组（CBT组42例，PS组34例）。观察并比较两组术中出血量、手术时间、切口疼痛和腿部疼痛的视觉模拟评分（VAS）、植骨融合和并发症、术前、术后矢状位Cobb角度、术后日本骨科协会（JOA）评分的各项指标。

结果

76例患者全部获得随访，CBT组随访时间（31.8±7.8）月，PS组（30.5±7.3）月。CBT组男23例，女19例，平均年龄（39.8±12.2）岁；PS组男19例，女15例，平均年龄（43.5±11.3）岁。CBT组出血量为（172.0±70.7）ml，少于PS组的（243.0±75.4）ml，住院时间为（8.9±2.9）d，少于PS组的[（11.4±1.7）d]（均P<0.05）。两组术前及术后3 d、7 d、3个月及末次随访时的腰痛VAS评分显著优于术前（P<0.01），术后3 d、7 d CBT组明显优于PS组（P<0.05），术后3个月及末次随访时差异无统计学意义。两组术前及术后1、3、6个月及末次随访时JOA评分均明显优于术前（P<0.01），组间比较差异无统计学意义，术后及末次随访时矢状位Cobb角度CBT组优于PS组（术后：F=3.541，P=0.041；末次随访：F=2.341，P=0.046），骨融合时间组间比较差异无统计学意义。

结论

两组术后均达到矫正后凸畸形的效果及明显提高患者生活质量，CBT螺钉有保留脊柱的运动单元的优势。

关键词: 骨结核, 胸腰椎, 皮质骨螺钉, 椎弓根螺钉

Objective

To investigate the long-term clinical effect of long segment cortical bone track screw fixation for thoracolumbar tuberculosis.

Methods

The data of 76 patients with thoracolumbar tuberculosis who received posterior vertebral body fixation combined with anterior debridement and bone grafting from June 2015 to June 2019 were retrospectively collected. They were divided into CBT group and PS group according to different surgical methods (42 cases in CBT group and 34 cases in PS group). The intraoperative bleeding volume, operation time, visual analogue score (VAS) of incision pain and leg pain, bone graft fusion and complications, preoperative and postoperative Cobb angle in sagittal position, and postoperative JOA score of the two groups were observed and compared.

Results

All 76 patients were followed up for (31.8±7.8) months in CBT group and (30.5±7.3) months in PS group. In CBT group, there were 23 males and 19 females, with an average age of (39.8±12.2) years; There were 19 males and 15 females in PS group, with an average age of (43.5±11.3). The bleeding volume (172.0±70.7 ml), fixed segment (243.0±75.4 ml) and hospital stay (8.9±2.9 days) in CBT group were significantly lower than those in PS group (11.4±1.7 days) (all P<0.05). The VAS score of low back pain in the two groups was significantly better than that before operation and at the 3rd, 7th, 3rd and last follow-up. The JOA scores of the two groups were significantly better than those before operation and 1, 3, 6 months after operation and at the last follow-up. The sagittal Cobb angle in the CBT group was better than that in the PS group at postoperative and final follow-up (postoperative: F=3.541, P=0.041; final follow-up: F=2.341, P=0.046).

Conclusion

Both groups have achieved the effect of correcting kyphosis deformity and significantly improve the quality of life of patients after operation. CBT screw has the advantage of preserving the motor unit of the spine.

Key words: Tuberculosis, Thoracolumbar spine, Cortical bone trajectory screw, Pedicle screws

表1 两组胸腰椎结核患者术前一般资料比较

组别	例数	受累椎体（个）					BMI（kg/m²，±s）	年龄（岁，±s）
组别	例数	3	4	5	6	7	BMI（kg/m²，±s）	年龄（岁，±s）
CBT组	42	19	12	7	3	1	19.2±5.3	39.8±12.2
PS组	34	15	12	5	3	1	20.1±6.1	43.5±11.3
χ²/t值		χ²=2.178					t=1.373	t=2.934
P值		0.118					0.578	0.663

表1 两组胸腰椎结核患者术前一般资料比较

组别	例数	受累椎体（个）					BMI（kg/m²，±s）	年龄（岁，±s）
组别	例数	3	4	5	6	7	BMI（kg/m²，±s）	年龄（岁，±s）
CBT组	42	19	12	7	3	1	19.2±5.3	39.8±12.2
PS组	34	15	12	5	3	1	20.1±6.1	43.5±11.3
χ²/t值		χ²=2.178					t=1.373	t=2.934
P值		0.118					0.578	0.663

图5 矢状位螺钉示意图

表2 两组胸腰椎结核患者术中出血量、手术时间、固定节段选择、住院时间、随访时间、内固定松动、骨融合时间的相关指标比较（±s）

组别	例数	术中出血量（ml）	手术时间（min）	固定节段选择（个）	住院时间（d）	随访时间（月）	内固定松动（例）	骨融合时间（月）
CBT组	42	172±70.7	222.7±26.3	5.2±2.3	8.9±2.9	31.8±7.8	1.1±0.8	8.2±1.4
PS组	34	243.0±75.4	237.5±36.2	6.3±3.7	11.4±1.7	30.5±7.3	1.9±0.9	7.9±1.8
t值		-3.312	-0.976	-0.959	-2.853	-0.859	-0.861	-1.118
P值		0.006	0.253	0.421	0.048	0.338	0.372	0.057

表2 两组胸腰椎结核患者术中出血量、手术时间、固定节段选择、住院时间、随访时间、内固定松动、骨融合时间的相关指标比较（±s）

组别	例数	术中出血量（ml）	手术时间（min）	固定节段选择（个）	住院时间（d）	随访时间（月）	内固定松动（例）	骨融合时间（月）
CBT组	42	172±70.7	222.7±26.3	5.2±2.3	8.9±2.9	31.8±7.8	1.1±0.8	8.2±1.4
PS组	34	243.0±75.4	237.5±36.2	6.3±3.7	11.4±1.7	30.5±7.3	1.9±0.9	7.9±1.8
t值		-3.312	-0.976	-0.959	-2.853	-0.859	-0.861	-1.118
P值		0.006	0.253	0.421	0.048	0.338	0.372	0.057

表3 两组胸腰椎结核患者Cobb角度比较的相关指标比较（°，±s）

组别	例数	术前	术后	末次随访	F值	P值
CBT组	42	24.7±1.9	5.1±0.4	6.5±0.6	127.323	0.04
PS组	34	29.3±1.1	7.1±1.9	7.6±1.4	118.218	0.03
F值		0.366	3.541	2.341
P值		0.173	0.041	0.046

表3 两组胸腰椎结核患者Cobb角度比较的相关指标比较（°，±s）

组别	例数	术前	术后	末次随访	F值	P值
CBT组	42	24.7±1.9	5.1±0.4	6.5±0.6	127.323	0.04
PS组	34	29.3±1.1	7.1±1.9	7.6±1.4	118.218	0.03
F值		0.366	3.541	2.341
P值		0.173	0.041	0.046

表4 两组VAS评分比较的相关指标比较（±s）

组别	例数	术前	术后3 d	术后7 d	术后3月	末次随访	F值	P值
CBT组	42	7.2±0.8	3.3±0.8	2.7±0.6	1.1±0.4	0.9±0.6	120.257	0.03
PS组	34	7.6±1.1	4.4±0.7	3.1±0.8	1.6±1.9	0.8±1.7	115.371	0.02
F值		0.446	2.978	1.166	0.541	0.643
P值		0.269	0.018	0.033	0.741	0.846

表4 两组VAS评分比较的相关指标比较（±s）

组别	例数	术前	术后3 d	术后7 d	术后3月	末次随访	F值	P值
CBT组	42	7.2±0.8	3.3±0.8	2.7±0.6	1.1±0.4	0.9±0.6	120.257	0.03
PS组	34	7.6±1.1	4.4±0.7	3.1±0.8	1.6±1.9	0.8±1.7	115.371	0.02
F值		0.446	2.978	1.166	0.541	0.643
P值		0.269	0.018	0.033	0.741	0.846

图6~15 长节段CBT组经典病例：患者37岁，男性，图6~8为术前CT提示脊柱结核骨质破坏累计多椎体；图9~11为术前MRI提示脊柱结核骨质破坏累及多椎体；图12~13为术后X线CBT内固定；图14~15为术后2年随访CT影像达到骨质融合标准

图16~23 长节段PS组病例：患者46岁，女性，图16~17为术前CT提示脊柱结核骨质破坏累及多椎体；图18~19为术前MRI提示脊柱结核骨质破坏累及多椎体；图20~21为术6月X线PS内固定，右侧远端PS螺钉可见退钉现象；图22~23为术后2年随访计算机CT体层影像达到骨质融合标准，右侧远端PS螺钉可见退钉现象较前无明显进展

表5 两组JOA评分比较的相关指标比较（±s）

组别	例数	术前	术后1月	术后3月	术后6月	术后24月	F值	P值
CBT组	42	13.67±4.9	20.4± 2.4	21.7± 1.9	22.1± 0.4	22.5± 0.6	167.671	0.04
PS组	34	14.81±4.2	19.1± 1.1	19.3± 1.1	21.1± 1.9	22.6± 1.4	159.493	0.03
F值		0.379	3.171	1.457	1.843	0.997
P值		0.183	0.043	0.347	0.065	0.146

表5 两组JOA评分比较的相关指标比较（±s）

组别	例数	术前	术后1月	术后3月	术后6月	术后24月	F值	P值
CBT组	42	13.67±4.9	20.4± 2.4	21.7± 1.9	22.1± 0.4	22.5± 0.6	167.671	0.04
PS组	34	14.81±4.2	19.1± 1.1	19.3± 1.1	21.1± 1.9	22.6± 1.4	159.493	0.03
F值		0.379	3.171	1.457	1.843	0.997
P值		0.183	0.043	0.347	0.065	0.146

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Clinical analysis of long-term cortical bone track screw fixation for thoracolumbar tuberculosis: a 2-year follow-up comparison

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Clinical analysis of long-term cortical bone track screw fixation for thoracolumbar tuberculosis: a 2-year follow-up comparison