Anshori Fahmi, Priyamurti Heka, Rahyussalim Ahmad Jabir
Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
Department of Orthopaedics and Traumatology FKUI-RSCM, Department of Orthopaedics and Traumatology Koja County Hospital, North Jakarta, Indonesia.
Int J Surg Case Rep. 2020;77:191-197. doi: 10.1016/j.ijscr.2020.10.126. Epub 2020 Nov 2.
There is a controversy in the recent literature regarding the most appropriate approach to treat spondylitis tuberculosis, whether to choose anterior, posterior, and combined approach as well as one-stage versus two-stage approach. Mesh cage has potential advantages, including inhibition of infection by fusion and reconstruction technique combined with corpectomy. Anterior surgery has advantage as it allows direct access to the diseased vertebral bodies and intervertebral disc.
We present a case of spondylitis tuberculosis of lower lumbar vertebrae (L5) and L4-L5 intervertebral disc causing paraparese treated with anterior debridement and fusion with expendable mesh cage. Patient presented with weakness of lower limb and back pain, with history of anti-tuberculosis drugs. Patient was diagnosed with paraparesis due to spondylitis Tb of L4-S1 with paravertebral abscess at L4-S1 Frankle D.
The patient was treated with anterior debridement and fusion using expendable mesh cage. Immediate postoperative radiograph showed restoration of vertebral height. This case showed that paraparesis can occur in lower lumbar vertebrae with distinct clinical appearance to that of lower thoracal or upper lumbar spondylitis tuberculosis, and that anterior approach for debridement and fusion using expendable mesh is a logical and direct means of addressing a tuberculous spine lesion, which predominantly affects anterior elements.
The anterior approach has the advantage of leading the surgeon directly into the lesion and allowing a good visualization. Instrumentation after debridement and bone graft can provide instant stability for the spinal column, which can lead patients to resume activities.
近期文献中对于治疗脊柱结核的最佳方法存在争议，即选择前路、后路还是联合入路，以及一期手术还是二期手术。椎间融合器具有潜在优势，包括通过融合和重建技术结合椎体切除来抑制感染。前路手术具有优势，因为它能直接到达病变椎体和椎间盘。
我们报告一例下腰椎（L5）及L4-L5椎间盘结核导致截瘫的病例，采用前路清创并使用可扩张椎间融合器进行融合治疗。患者因下肢无力和背痛就诊，有抗结核药物治疗史。患者被诊断为L4-S1脊柱结核伴L4-S1椎旁脓肿导致的截瘫（Frankle D级）。
该患者采用前路清创并使用可扩张椎间融合器进行融合治疗。术后即刻X线片显示椎体高度恢复。该病例表明，下腰椎结核可导致截瘫，其临床表现与下胸椎或上腰椎脊柱结核不同，并且前路清创并使用可扩张椎间融合器进行融合是处理主要累及前部结构的结核性脊柱病变的合理且直接的方法。
前路手术的优点是能使外科医生直接进入病变部位并获得良好的视野。清创和植骨后进行内固定可为脊柱提供即时稳定性，这可使患者恢复活动。
