脊柱结核的外科治疗研究进展

doi:10.3969/j.issn.1000-8535.2024.09.001

广州医药 ›› 2024, Vol. 55 ›› Issue (9): 963-973.DOI: 10.3969/j.issn.1000-8535.2024.09.001

• 专家述评 • 下一篇

脊柱结核的外科治疗研究进展

高博¹, 陈家楠¹, 丘金城², 黄东生¹

1 中山大学孙逸仙纪念医院（南院区）脊柱外科（广东广州 510000）;
2 广州市番禺区中医院骨伤二科（脊柱微创专科）（广东广州 510000）

收稿日期:2024-06-28 出版日期:2024-09-20 发布日期:2024-10-22
通讯作者: 黄东生,E-mail：hdongsh@mail.sysu.edu.cn
作者简介:黄东生中山大学二级教授,一级主任医师,医学博士,博士生导师。历任中山大学孙逸仙纪念医院骨科主任,脊柱外科主任。担任中国康复医学会骨与关节康复专业委员会副主任委员,广东省康复医学会骨科分会主任委员,广东省医学会脊柱外科学分会第二届主任委员,中华医学会骨科学分会脊柱学组第七、八、九届委员,国际内固定学会AO脊柱培训中心主任,“第九届吴阶平医学研究奖暨保罗·杨森药学研究奖”获得者。以第一完成人获广东省科技进步二等奖1项,广东省自然科学奖二等奖1项,中华医学科技奖三等奖1项。主攻方向为脊柱畸形的手术矫正及基础研究、颈腰椎间盘退变性疾病的手术治疗、原发性及转移性脊柱肿瘤的外科手术治疗等。曾作为访问学者赴美国斯坦福大学和澳大利亚悉尼大学医学院从事脊柱外科和人工关节置换术的临床及实验研究。共承担国家自然科学基金7项,已完成国家自然科学基金5项,已完成广东省自然科学基金重点项目及其他基金多项,主编专著《脊柱退变性疾病》《腰椎间盘突出症》,参编医学专著5本,为国家自然科学基金评审专家和国内外多家杂志编委及审稿专家,并在国内外主要杂志发表论文100多篇,其中SCI论文50多篇,影响因子10以上10篇。

The progress in surgical treatment research for spinal tuberculosis

GAO Bo¹, CHEN Jianan¹, QIU Jincheng², HUANG Dongsheng¹

1 Department of Spinal surgery,Sun Yat-sen Memorial Hospital,Sun Yat-sen University,Guangzhou 510000,China;
2 Department of Specialized in Minimally Invasive Spinal Surgery,Panyu District Traditional Chinese Medicine Hospital,Guangzhou 510000,China

Received:2024-06-28 Online:2024-09-20 Published:2024-10-22

摘要/Abstract

摘要： 脊柱结核是脊柱感染性疾病中最为常见的类型。本文综述了脊柱结核外科治疗的现状及最新进展。在早期治疗阶段,规范化的抗结核药物治疗能够有效缓解疼痛,改善患者生活质量。但对于中后期,特别是椎旁脓肿较大,椎体骨质破坏较大而导致脊柱不稳定的患者,手术治疗往往是必要且必需的辅助手段,手术可以最大限度清除病变的椎间盘、椎体和脓肿,也应该最大限度保留健康的骨质。其主要原则包括病灶彻底清除、脊髓充分减压、脊柱稳定性重建等步骤。在手术治疗中,一期前路手术作为经典入路已经得到广泛应用,而单纯后路手术治疗也逐渐受到重视。近年来,随着微创手术技术的发展,其在脊柱结核治疗中的应用越来越广泛。微创手术的优势在于术中创伤更小、恢复更快,为患者带来了更好的治疗体验和临床效果。然而,对于手术的选择,临床医师需要综合考虑患者的个体差异性、临床表现及特征、影像学资料和手术适应证等多种因素,以确定最合适的治疗方案。只有充分考虑各种治疗手段的优劣,采取个性化、综合性的治疗方案,才能更好地提高患者的生活质量和治疗效果。

关键词: 脊柱结核, 手术治疗, 开放手术, 微创手术

Abstract: Spinal tuberculosis is the most common types of infectious diseases affecting the spine．This article reviews the current status and progress of surgical treatment for spinal tuberculosis．In the early and initial stages,standardized anti-tuberculosis drug therapy can effectively alleviate pain and improve patients' quality of life．However,for more complex cases in the middle and late stages,surgical treatment is needed,including thorough lesion clearance,adequate spinal cord decompression,and reconstruction of spinal stability．In surgical treatment,anterior approach surgery,as a classical method,has been widely applied,and posterior approach surgery alone has gradually gained attention．In recent years,with the development of minimally invasive surgical techniques,their application in the treatment of spinal tuberculosis has become increasingly widespread．The advantages of minimally invasive surgery lie in smaller intraoperative trauma and faster recovery,providing patients with better treatment experience and clinical outcomes．However,for the selection of surgery,clinicians need to consider multiple factors such as individual differences,clinical manifestations and characteristics,imaging data and surgical indications to determine the most suitable treatment plan．Only by fully considering the advantages and disadvantages of various treatment modalities and adopting personalized,comprehensive treatment plans can the quality of life and treatment outcomes of patients be effectively improved．

Key words: spinal tuberculosis, surgical treatment, open surgery, minimally invasive surgery

高博, 陈家楠, 丘金城, 黄东生. 脊柱结核的外科治疗研究进展[J]. 广州医药, 2024, 55(9): 963-973.

GAO Bo, CHEN Jianan, QIU Jincheng, HUANG Dongsheng. The progress in surgical treatment research for spinal tuberculosis[J]. Guangzhou Medical Journal, 2024, 55(9): 963-973.

参考文献

[1] 梁健,康文婷,冯晶,等.中国脊柱结核外科治疗现状及进展[J].生物骨科材料与临床研究,2023,20(3):84-88.
[2] 吕贵何,宗治贤,陈祝明,等.脊柱结核的发病机制、诊断及治疗相关进展[J].系统医学,2019,4(2):174-177.
[3] KUMAR V,NERADI D,SHERRY B,et al.Tuberculosis of the spine and drug resistance:A review article[J].Neurosurg Rev,2022,45(1):217-229.
[4] 王传庆. 脊柱结核外科治疗的现状与进展[J].结核病与肺部健康杂志,2013,2(1):64-68.
[5] MERINO P,CANDEL F J,GESTOSO I,et al.Microbiological diagnosis of spinal tuberculosis[J].Int Orthop,2012,36(2):233-238.
[6] WANG M S,HAN C,WANG J L,et al.The prevalence,diagnosis and surgical risk factors of spinal tuberculosis in children[J].Trop Med Int Health,2020,25(7):834-838.
[7] DIAN S,GANIEM A R,TE BRAKE L H M,et al.Current insights into diagnosing and treating neurotuberculosis in adults[J].CNS Drugs,2023,37(11):957-972.
[8] 金阳辉,石仕元,郑琦,等.Xpert MTB/RIF在脊柱结核诊断及利福平耐药检测中的应用价值[J].中国骨伤,2017,30(9):787-791.
[9] 张宏其,李亮,许建中,等.中国脊柱结核外科治疗指南(2022年版)[J].中国矫形外科杂志,2022,30(17):1537-1548.
[10] WANG B,GAO W,HAO D.Current study of the detection and treatment targets of spinal tuberculosis[J].Curr Drug Targets,2020,21(4):320-327.
[11] 郭路明,于龙,李力韬,等.宏基因组二代测序技术对结核性与非结核性脊柱感染疾病的诊断价值研究[J].解放军医学院学报,2024,45(5):457-462,480.
[12] LI Y,YAO X W,TANG L,et al.Diagnostic efficiency of metagenomic next-generation sequencing for suspected spinal tuberculosis in China:A multicenter prospective study[J].Front Microbiol,2022(13):1018938.
[13] LI C,XIAO N S,KE B Y,et al.Application of metagenomic next-generation sequencing in suspected spinal Ⅱnfectious diseases[J].World Neurosurg,2024(185):e542-e548.
[14] PENG J,SONG J,WANG F,et al.Harnessing big data to optimize an algorithm for rapid diagnosis of pulmonary tuberculosis in a real-world setting[J].Front Cell Infect Microbiol,2021(11):650163.
[15] HORNE D J,KOHLI M,ZIFODYA J S,et al.Xpert MTB/RIF and Xpert MTB/RIF Ultra for pulmonary tuberculosis and rifampicin resistance in adults[J].Cochrane Database Syst Rev,2019,6(6):CD009593.
[16] 胡潮兴,梁秋冬.基因诊断技术在脊柱结核诊断中的应用现状[J].新乡医学院学报,2023,40(1):93-96.
[17] 王志永,王立,张志飞,等.血清Hsp10联合CT诊断脊柱结核的价值[J].海南医学,2023,34(22):3301-3304.
[18] 郁雯,胡晶晶,黄碧红,等.热激蛋白10联合MRI对胸腰椎体结核的诊断价值[J].中华医院感染学杂志,2024(12):1836-1840.
[19] 李健,武太勇,付海军,等.脊柱结核外科治疗进展[J].国际骨科学杂志,2021,42(1):18-21.
[20] LIU Y,LIU Q,DUAN X,et al.One-stage posterior transpedicular debridement,hemi-interbody and unilateral-posterior bone grafting,and instrumentation for the treatment of thoracic spinal tuberculosis:A retrospective study[J].Acta Neurochirurgica,2024,166(1):65.
[21] JAIN A K,KUMAR J.Tuberculosis of spine:Neurological deficit[J].Eur Spine J,2013,22(Suppl 4):624-633.
[22] PANG X,WU P,SHEN X,et al.One-stage posterior transforaminal lumbar debridement,360° interbody fusion,and posterior instrumentation in treating lumbosacral spinal tuberculosis[J].Arch Orthop Trauma Surg,2013,133(8):1033-1039.
[23] ZHANG H Q,LI J S,ZHAO S S,et al.Surgical management for thoracic spinal tuberculosis in the elderly:Posterior only versus combined posterior and anterior approaches[J].Arch Orthop Trauma Surg,2012,132(12):1717-1723.
[24] HE B,HU Z,HAO J,et al.Posterior transpedicular debridement,decompression and instrumentation for thoracic tuberculosis in patients over the age of 60[J].Arch Orthop Trauma Surg,2012,132(10):1407-1414.
[25] ZHANG P,SHEN Y,DING W Y,et al.The role of surgical timing in the treatment of thoracic and lumbar spinal tuberculosis[J].Arch Orthop Trauma Surg,2014,134(2):167-172.
[26] 金阳辉,石仕元,郑琦,等.脊柱结核手术时机选择的初步研究[J].中国骨伤,2021,34(8):717-724.
[27] WANG Z,GE Z,JIN W,et al.Treatment of spinal tuberculosis with ultrashort-course chemotherapy in conjunction with partial excision of pathologic vertebrae[J].Spine J,2007,7(6):671-681.
[28] HE Z,TANG K,GUI F,et al.Comparative analysis of the efficacy of a transverse process bone graft with other bone grafts in the treatment of single-segment thoracic spinal tuberculosis[J].J Orthop Surg Res,2019,14(1):288.
[29] LEE T C,LU K,YANG L C,et al.Transpedicular instrumentation as an adjunct in the treatment of thoracolumbar and lumbar spine tuberculosis with early stage bone destruction[J].J Neurosurg,1999,91(2 Suppl):163-169.
[30] LI H,WU Y,XU C,et al.Early ultrasound-guided percutaneous catheter drainage in the treatment of severe acute pancreatitis with acute fluid accumulation[J].Exp Ther Med,2018,16(3):1753-1757.
[31] ZHANG W,SUN J,SHEN X,et al.Percutaneous catheter drainage combined with peritoneal dialysis for treating acute severe pancreatitis:A single-center prospective study[J].Minerva Chir,2019,74(3):207-212.
[32] ZHANG T,MA L,LAN X,et al.One-stage anterolateral debridement,bone grafting,and Ⅱnternal fixation for treating lumbosacral tuberculosis[J].Asian Spine J,2017,11(2):305-313.
[33] LAI Z,SHI S,FEI J,et al.A comparative study to evaluate the feasibility of preoperative percutaneous catheter drainage for the treatment of lumbar spinal tuberculosis with psoas abscess[J].J Orthop Surg Res,2018,13(1):290.
[34] BENLI I T,ACAROĞLU E,AKALIN S,et al.Anterior radical debridement and anterior instrumentation in tuberculosis spondylitis[J].Eur Spine J,2003,12(2):224-234.
[35] HASSAN K,ELMORSHIDY E.Anterior versus posterior approach in surgical treatment of tuberculous spondylodiscitis of thoracic and lumbar spine[J].Eur Spine J,2016,25(4):1056-1063.
[36] JIN D,QU D,CHEN J,et al.One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis[J].Eur Spine J,2004,13(2):114-121.
[37] TANG Y,WU W J,YANG S,et al.Surgical treatment of thoracolumbar spinal tuberculosis-a multicentre,retrospective,case-control study[J].J Orthop Surg Res,2019,14(1):233.
[38] DAI L Y,JIANG L S,WANG W,et al.Single-stage anterior autogenous bone grafting and Ⅱnstrumentation in the surgical management of spinal tuberculosis[J].Spine,2005,30(20):2342-2349.
[39] LI W,LIU Z,XIAO X,et al.Comparison of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic spinal tuberculosis in adults[J].BMC Musculoskelet Disord,2019,20(1):570.
[40] QIU J,PENG Y,QIU X,et al.Comparison of anterior or posterior approach in surgical treatment of thoracic and lumbar tuberculosis:A retrospective case-control study[J].BMC Surg,2022,22(1):161.
[41] HEE H T,MAJD M E,HOLT R T,et al.Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages[J].J Spinal Disord Tech,2002,15(2):149-156;discussion 156.
[42] RUPAREL S,TANAKA M,MEHTA R,et al.Surgical management of spinal tuberculosis-the past,present,and future[J].Diagnostics ,2022,12(6):1307.
[43] ZHAO C,PU X,ZHOU Q,et al.Can a posterior approach effectively heal thoracic and lumbar tuberculosis?Microbiology outcomes of the operative area[J].J Orthop Surg Res,2019,14(1):24.
[44] PU X,ZHOU Q,HE Q,et al.A posterior versus anterior surgical approach in combination with debridement,interbody autografting and instrumentation for thoracic and lumbar tuberculosis[J].Int Orthop,2012,36(2):307-313.
[45] 胡永胜,张晓璇,宋兴华,等.胸腰椎结核前路与后路病灶清除融合固定比较[J].中国矫形外科杂志,2024,32(1):24-30.
[46] ZHAN Y,KANG X,GAO W,et al.Efficacy analysis of one-stage posterior-only surgical treatment for thoracic spinal tuberculosis in the T4-6 segments with minimum 5-year follow-up[J].Sci Rep,2022,12(1):149.
[47] WU W,LYU J,LIU X,et al.Surgical treatment of thoracic spinal tuberculosis:A multicenter retrospective study[J].World Neurosurg,2018(110):e842-e850.
[48] WANG K,WANG N,WANG Y,et al.Anterior versus posterior instrumentation for treatment of thoracolumbar tuberculosis :A meta-analysis[J].Orthopade,2019,48(3):207-212.
[49] KHANNA K,SABHARWAL S.Spinal tuberculosis:A comprehensive review for the modern spine surgeon[J].Spine J,2019,19(11):1858-1870.
[50] LIU J,WAN L,LONG X,et al.Efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal tuberculosis:A meta-analysis[J].World Neurosurg,2015,83(6):1157-1165.
[51] WANG B,SHANG R,YANG T,et al.Evaluation of clinical outcomes of one-stage anterior and posterior surgical treatment for atlantoaxial tuberculosis complicated with neurological damage[J].BMC Musculoskelet Disord,2019,20(1):148.
[52] ZHANG H Q,HU X,YIN X,et al.One-stage combined anterior-posterior approach treatment of multiple cervicothoracic spinal tuberculosis with kyphosis[J].Int Orthop,2015,39(8):1605-1610.
[53] ZHOU Y,LI W,LIU J,et al.Comparison of single posterior debridement,bone grafting and instrumentation with single-stage anterior debridement,bone grafting and posterior instrumentation in the treatment of thoracic and thoracolumbar spinal tuberculosis[J].BMC Surg,2018,18(1):71.
[54] WANG T,MA Z,LEI W,et al.Clinical efficacy of different open approaches in the surgical treatment of thoracolumbar tuberculosis:A single-center retrospective comparative study[J].J Orthop Surg Res,2023,18(1):352.
[55] ZHONG Y,YANG K,YE Y,et al.Single posterior approach versus combined anterior and posterior approach in the treatment of spinal tuberculosis:A meta-analysis[J].World Neurosurg,2021(147):115-124.
[56] 王国良,刘湘泽,刘泽众.不同手术方式治疗老年胸腰椎结核疗效对比[J].潍坊医学院学报,2024,46(2):111-113.
[57] WONG Y W,SAMARTZIS D,CHEUNG K M C,et al.Tuberculosis of the spine with severe angular kyphosis:Mean 34-year post-operative follow-up shows that prevention is better than salvage[J].Bone Joint J,2017,99-B(10):1381-1388.
[58] SCHWAB F,BLONDEL B,CHAY E,et al.The comprehensive anatomical spinal osteotomy classification[J].Neurosurgery,2015,74(Suppl 1):S33-S41;discussion S41.
[59] YANG H,SONG F,ZHANG L,et al.Management of spine tuberculosis with chemotherapy and percutaneous pedicle screws in adjacent vertebrae:A retrospective study of 34 cases[J].Spine ,2016,41(23):E1415-E1420.
[60] GOLDSTEIN C L,MACWAN K,SUNDARARAJAN K,et al.Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion:Meta-analysis and systematic review[J].J Neurosurg Spine,2016,24(3):416-427.
[61] GARG N,VOHRA R.Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine[J].Clin Orthop Relat Res,2014,472(6):1855-1867.
[62] GUO S,ZHU K,ZHANG S,et al.Percutaneous pedicle screw fixation alone versus debridement and fusion surgery for the treatment of early spinal tuberculosis:A retrospective cohort study[J].Med Sci Monit,2019,25:1549-1557.
[63] 陈品奇,杨杰,陈朝奎,等.微创术与传统病灶清除术在脊柱结核治疗中的疗效对比[J].中国实用医药,2021,16(20):66-69.
[64] IFTHEKAR S,AHUJA K,MITTAL S,et al.Outcomes of Dorsolumbar and Lumbar Spinal Tuberculosis Treated by Minimally Invasive and Open Techniques:A Prospective Comparative Study[J].Indian J Orthop,2024,58(5):558-66.
[65] JIANG J,GAN F,TAN H,et al.Effect of computer navigation-assisted minimally invasive direct lateral interbody fusion in the treatment of patients with lumbar tuberculosis:A retrospective study[J].Medicine,2018,97(48):e13484.
[66] LI W,LIU Z,XIAO X,et al.Early surgical intervention for active thoracic spinal tuberculosis patients with paraparesis and paraplegia[J].BMC Musculoskelet Disord,2021,22(1):213.

脊柱结核的外科治疗研究进展

The progress in surgical treatment research for spinal tuberculosis

PDF

可视化

摘要/Abstract

引用本文

使用本文

参考文献

相关文章 5

编辑推荐

Metrics

本文评价

[1]	黄庆, 索彩霞, 何凤, 罗青青, 李旺林, 曹杰. 结直肠癌的早期诊断策略和治疗进展[J]. 广州医药, 2024, 55(1): 1-8.
[2]	霍亮. 脊柱微创手术治疗腰椎间盘突出症的临床价值[J]. 广州医药, 2023, 54(4): 91-95.
[3]	莫称龙, 赖海岸, 胡桂和, 莫泽珣, 黄晓梅, 侯乐, 魏树全. 三重多原发恶性肿瘤病例分析[J]. 广州医药, 2023, 54(1): 34-38.
[4]	聂力, 罗俊男, 温世锋. 手术与保守治疗无骨折脱位型颈脊髓损伤的Meta分析[J]. 广州医药, 2020, 51(4): 119-123.
[5]	胡趣儿, 何结叶, 冯露露. 6例阴茎折断术后患者的护理干预[J]. 广州医药, 2015, 46(2): 57-58.