目的:探讨和分析应用不同术式治疗下腰椎结核的适应证和临床效果.方法:回顾总结2001年6月至2008年10月行手术治疗的下腰椎结核72例,男38例,女34例;年龄16～70岁,平均38.5岁;病程4个月～2年,平均6.8个月.其中单椎体受累10例,2个椎体受累50例,3个椎体12例.下腰椎前凸角度(L4-S1)33.0°～5.0°,平均13.1°.手术方式包括:①28例行经后路病灶清除、椎弓根系统内固定后外侧植骨融合术;②32例行经前路病灶清除、椎间植骨后路椎弓根系统内固定术;③12例行经皮穿刺置管脓肿引流术(PCD).疗效评价根据治愈率、植骨融合率、下腰椎曲度矫正状况及临床症状恢复情况(JOA评分)评定.结果:所有患者获得随访,时间1.5～8年,平均3.6年.PCD组首次置管治愈10例,2例重新置管引流后治愈;其中1例半年后因复发行病灶清除融合术.切开病灶清除融合组术后1年植骨融合率95.0%(57/60).患者皆治愈,手术并发症主要包括髂总静脉损伤3例,硬膜撕裂2例,经术中、术后处理,未造成机体残余损害.下腰椎前凸角度35.0°～16.0°,平均27.3°,最终随访时为33.0°～15.0°,平均25.6°.依照JOA腰腿痛疗效标准(29分法),术前为(15.2±3.4)分,术后最终随访时为(25.6±2_4)分,与术前比较均有统计学差异(P<0.01).结论:下腰椎结核应根据病变特点的不同选择不同的术式治疗,手术治疗能促进下腰椎结核病灶愈合,缓解临床症状,矫正畸形,避免远期并发症.%Objective:To evaluate the surgical indications and clinical effectiveness of different operative procedures in the treatment of lower lumbar tuberculosis. Methods:From June 2001 to Oct 2008,72 patients with lower lumbar tuberculosis were treated by different operative procedures. Including 38 males and 34 females,with an average age of 38.5 years old ranging from 16 to 70 years. The average duration of symptom was 6.8 months (ranging from 4 months to 2 years). A single vertebrae was involved in 10 patients,two contiguous vertebrae in 50 cases and three vertebrae in 12 cases. The average preoperative lordotic angle was 13.1 degree (ranging from -5.0° to 34.0° ). Three different operative procedures included: ( 1 ) posterior debridement and posterolateral fusion and posterior instrumentation in 28 patients; (2)anterior radical debridement and anterior fusion and anterior instrumentation in 32 patients; (3) image-guided percutaneous drainage (PCD) of tuberculous abscesses in 12 patients. The selection of the procedure was made according to the degree of the lesions. The resolution of inflammatory process ,bony fusion ,correction of sagittal angles and JOA scores were used for evaluating the result of the surgery and the complications were analyzed. Results:All patients were followed up from 1.5 to 8.0 years (means 3.6 years). PCD was an effective treatment in 11 out of the 12 patients, one required surgical debridement and fusion. Among them, 57 (95％,57/60)patients were treated by open operation showed successful bony fusion. The complications maily included common iliac vein jnjury in 3 patients ,dural tear in 2 patients ,they were all cuerd by intro-or postoprative treatment. The average immediate postoperative lordotic angle was 27.3 degree (35.0° to 16.0° ) ,the average lordotic angle was 25.6 degree (33.0° to 15.0° ) at final follow-up. Preoperatively and at final follow-up,JOA scores were respectively ( 15.2±3.4), (25.6±2.4) (P＜0.01). Conclusion:Different operative procedures should be selected to treat lower lumbar tuberculosis according to the degree of lesions. Aggressive surgical treatment was found helpful in the resolution of inflammatory process and correcting the loss of lordosis, preventing progression of kyphosis.
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