Vidyasagar C, Murthy H K
Department of Neurosurgery, Sanjay Gandhi Accident and Rehabilitation Centre, Bangalore, Karnataka.
Natl Med J India. 1996 Jan-Feb;9(1):25-7.
Two hundred patients suffering from tuberculosis (TB) of the spine with neurological complications were the subjects of this review. They were graded according to the Frankel system into--A: complete neurological deficit; B: sparing of some sensation; C: sparing of sensation but no useful motor function; D: sparing of sensation and useful motor function; and E: no deficits. Investigations carried out included detailed neurological assessment, radiography, contrast myelography and, in the later stages of the study, spinal computerized tomography (CT) scan. The authors believe that contrast myelography provides the best indication of spinal compression in TB spine. Treatment was by surgical decompression followed by chemotherapy. The surgical approach for thoracic spine disease was by the anterior transthoracic route. Cervical lesions were also approached by the anterior route, lateral to the carotid vessels. Unexpected findings during operation included lymphoma, plasmacytoma, non-tuberculous granulation tissue, salmonella osteomyelitis and tumour metastasis. Ten patients died during the postoperative period, all of whom had extensive systemic TB. When indicated, antituberculous drugs were administered postoperatively for two years and immobilization was done in a plaster cast for 3 months. Only 30 patients showed partial recovery. Improvement was found to be related to the grade of deficit; thoracic lesions with severe neurological deficits showed the least improvement while lumbar disease had the best outcome. The study recommended a combination of surgery and chemotherapy for all cases of TB spine with neurological deficits after a short delay during which respiratory function should be improved. The surgery should aim at decompression of the cord by removal of pus, granulation tissue and sequestra, with internal splintage with bone grafts to reduce the hospital stay. Conservative treatment is unwise because it is not always possible to distinguish between TB and neoplastic lesions.
本综述的研究对象为200例患有脊柱结核（TB）并伴有神经并发症的患者。根据Frankel系统，他们被分为以下等级：A：完全神经功能缺损；B：保留部分感觉；C：保留感觉但无有用的运动功能；D：保留感觉且有有用的运动功能；E：无功能缺损。进行的检查包括详细的神经学评估、放射学检查、脊髓造影，在研究后期还包括脊柱计算机断层扫描（CT）。作者认为脊髓造影能最好地显示脊柱结核中脊髓受压的情况。治疗方法是手术减压后进行化疗。胸椎疾病的手术入路是经胸前路。颈椎病变也采用前路，位于颈动脉外侧。手术中意外发现包括淋巴瘤、浆细胞瘤、非结核性肉芽组织、沙门氏菌骨髓炎和肿瘤转移。10例患者在术后死亡，他们均患有广泛的全身性结核。如有指征，术后给予抗结核药物治疗两年，并使用石膏固定3个月。只有30例患者有部分恢复。发现改善情况与缺损等级有关；伴有严重神经功能缺损的胸椎病变改善最少，而腰椎疾病的预后最好。该研究建议，对于所有伴有神经功能缺损的脊柱结核病例，在短暂延迟以改善呼吸功能后，应采用手术和化疗相结合的方法。手术应旨在通过清除脓液、肉芽组织和死骨来减压脊髓，并进行骨移植内固定以缩短住院时间。保守治疗是不明智的，因为往往无法区分结核和肿瘤性病变。
