Nussbaum E S, Rockswold G L, Bergman T A, Erickson D L, Seljeskog E L
Department of Neurological Surgery, University of Minnesota Hospital and Clinic, Minneapolis, USA.
J Neurosurg. 1995 Aug;83(2):243-7. doi: 10.3171/jns.1995.83.2.0243.
The authors reviewed 29 cases of spinal tuberculosis treated from 1973 to 1993 with an average follow-up time of 7.4 years. Clinical findings included back pain, paraparesis, kyphosis, fever, sensory disturbance, and bowel and bladder dysfunction. Twenty-two patients (76%) presented with neurological deficit; 12 (41%) were initially misdiagnosed. Sixteen patients (55%) had predominant vertebral body involvement; nine had marked bone collapse with neurological compromise. Eleven individuals (39%) had intraspinal granulomatous tissue causing neurological dysfunction in the absence of bone destruction, and two (7%) had intramedullary tuberculomas. All patients received antituberculous medications: 13 were initially treated with bracing alone, eight underwent laminectomy and debridement of extra- or intradural granulomatous tissue, and eight underwent anterior, posterior, or combined fusion procedures. No patient with neurological deficit recovered or stabilized with nonoperative management. Thirteen patients were readmitted with progression of inadequately treated osteomyelitis; 12 (92%) of these required new or more radical fusion procedures. Anterior fusion failure was associated with marked preoperative kyphosis and multilevel disease requiring a graft that spanned more than two disc spaces. Courses of antibiotic medications shorter than 6 months were invariably associated with disease recurrence. It was concluded that 1) patients should receive at least 12 months of appropriate antituberculous therapy; 2) individuals with neurological deficit should undergo surgical decompression; 3) laminectomy and debridement are adequate for intraspinal granulomatous tissue in the absence of significant bone destruction; 4) when vertebral body involvement has produced wedging and kyphosis, aggressive debridement and fusion are indicated to prevent delayed instability and progression of disease.
作者回顾了1973年至1993年期间治疗的29例脊柱结核病例，平均随访时间为7.4年。临床表现包括背痛、下肢轻瘫、脊柱后凸、发热、感觉障碍以及肠道和膀胱功能障碍。22例患者（76%）出现神经功能缺损；12例（41%）最初被误诊。16例患者（55%）主要累及椎体；9例有明显的骨质塌陷并伴有神经功能损害。11例患者（39%）在无骨质破坏的情况下有椎管内肉芽肿组织导致神经功能障碍，2例（7%）有脊髓内结核瘤。所有患者均接受抗结核药物治疗：13例最初仅接受支具治疗，8例接受椎板切除术及硬膜外或硬膜内肉芽肿组织清除术，8例接受前路、后路或联合融合手术。没有神经功能缺损的患者通过非手术治疗恢复或病情稳定。13例患者因治疗不充分的骨髓炎进展而再次入院；其中12例（92%）需要进行新的或更彻底的融合手术。前路融合失败与术前明显的脊柱后凸和需要跨越两个以上椎间盘间隙的移植物的多节段疾病有关。抗生素疗程短于6个月总是与疾病复发相关。得出的结论是：1）患者应接受至少12个月的适当抗结核治疗；2）有神经功能缺损的患者应接受手术减压；3）在无明显骨质破坏的情况下，椎板切除术和清创术适用于椎管内肉芽肿组织；4）当椎体受累导致楔形变和脊柱后凸时，应积极清创和融合以防止延迟性不稳定和疾病进展。
