摘要：
目的 探讨脊柱结核死骨范围和抗结核药物治疗效果的相关性.方法 选择相邻双椎体脊柱结核患者96例,进行前瞻性队列研究.采用东芝Aquillon one 320排螺旋CT对病灶区进行层厚0.5 mm的连续扫描,并进行二维重建,分别选取病灶区横断面、冠状面和矢状面死骨范围最大的层面,用320排螺旋CT的面积测量工具测量该层面死骨面积.横断面的死骨面积与相邻正常椎体横断面积比值的百分数为横断面死骨范围,冠状面的死骨面积与相邻正常椎体最大冠状面积比值的百分数为冠状面死骨范围,矢状面的死骨面积与相邻正常椎体正中矢状面积比值的百分数为矢状面死骨范围;横断面、冠状面和矢状面死骨范围之和的平均值为综合死骨范围.对96例患者采用标准抗结核化疗方案进行治疗,将治疗过程中结核中毒症状减轻、局部疼痛缓解、死骨脓肿范围缩小、血沉和C反应蛋白下降的病例判为治疗有效者,继续保守治疗至疗程满12个月;将治疗过程中死骨、脓肿范围增大,或者达到手术指征,停止保守治疗改为手术治疗的患者判为治疗无效者.对影响抗结核药物治疗效果的危险因素,包括性别、年龄、病程、死骨范围,进行Logistic回归单因素及多因素分析,判断各因素的相对危险性.利用受试者工作特征曲线(ROC)确定合适的死骨范围阳性参考值(即最适合进行抗结核药物治疗的死骨范围),此范围以上就是达到手术指征的死骨范围.结果 治疗过程中1例寰枢椎结核患者因无法按照其他部位脊柱结核的测量方法测量死骨范围而被排除出组,4例因耐药排除出组(其中1例脓液穿刺培养显示耐药,1例穿刺活检耐药基因检测显示耐药,2例抗结核治疗、术后病理组织培养显示耐药),2例不具备手术指征但患者强烈要求手术而被排除出组.最终入组的89例患者中,58例抗结核药物治疗有效,31例抗结核治疗失败而采取手术治疗.89例患者年龄15～80岁(平均41.2岁),男57例、女32例,病程0.5～72个月,横断面死骨范围平均值为5.8％,冠状面死骨范围平均值为4.6％,矢状面死骨范围平均值为4.9％,综合死骨范围平均值为5.1％.Logistic逐步回归分析显示横断面死骨范围、综合死骨范围和抗结核药物治疗效果相关(P均<0.01).以横断面死骨范围作为诊断指标,适合抗结核治疗或手术治疗的最佳临界值为1.9％,其预测敏感度和特异度分别达96.77％、65.52％,横断面死骨范围超过1.9％更需要手术治疗.以综合死骨范围作为诊断指标,适合抗结核治疗或手术治疗的最佳临界值为2.6％,其预测敏感度和特异度分别为93.55％、68.97％,综合死骨范围超过2.6％更需要手术治疗.结论 脊柱结核死骨范围与抗结核药物治疗效果具有相关性,横断面死骨范围超过1.9％需要手术治疗的可能性大,综合死骨范围超过2.6％需要手术治疗的可能性大.%Objective To investigate the correlation between the range of dead bone of the patients,with spinal tuber-culosis and the therapeutic effect of antituberculosis drugs. Methods Ninety-six patients with spinal tuberculosis of adja-cent double vertebral bodies were enrolled in the prospective cohort study. The lesions were scanned continuously with a thickness of 0. 5mm by 320 slice spiral CT. The largest extent of the dead bone on the axial section,the coronal section and the sagittal section were calculated respectively. The patients were treated by standard antituberculosis chemotherapy regi-men. The patients whose symptoms of tuberculosis poisoning and range of dead bone and abscesses were reduced,local pain were relieved,ESR and C reactive protein decreased,were included in the effective group and were conservatively treated for 12 months. The patients with increased range of dead bone and abscesses,or achieved the indication of operation were included in the invalid group. Risk factors affecting the effectiveness of antituberculosis drugs,such as sex,age, course of disease,and range of dead bone were analyzed by univariate and multivariate logistic regression. The ROC curve was used to determine the appropriate positive reference value. Results One case of atlantoaxial tuberculosis was excluded because the dead bone of whom couldn't be measured according to the method of measurement of spinal tuberculosis in other places. Four cases of drug-resistant tuberculosis were excluded,in which one case showed resistance by abscess puncture and culture,one by puncture biopsy and resistance gene detection,2 by postoperative pathological tissue culture. Two ca-ses strongly required surgery because of worrying about the effectiveness of conservative treatment and then were excluded. Fifty eight patients of 89 patients enrolled in the study at last were successfully treated with antituberculosis drugs and the others undertook operation. The effective rate of conservative treatment with antituberculosis drugs was 65. 2％ . The 89 pa-tients aged 15-80 years,with an average age of 41. 2 years. There were 57 males and 32 females. The course of disease ranged from 0. 5 months to 72 months,with an average of 7. 6 months. The average range of dead bone was 5. 8％ in trans-verse section,4. 6％ in coronal section,4. 9％ in sagittal section,5. 1％ of composite range. When transverse sectional dead bone range exceeded 1. 9％,surgical treatment was needed probably by the result of the ROC curve. When composite dead bone range exceeded 2. 6％,surgical treatment was needed probably. Conclusions The range of dead bone of the patients with spinal tuberculosis has the correlation with the therapeutic effect of antituberculosis drugs,whereas sex,age and the course of disease do not. When transverse sectional dead bone range exceeds 1. 9％,surgical treatment is needed probably by the result of the ROC curve. When composite dead bone range exceeds 2. 6％,surgical treatment is needed probably.
