1、脊柱结核：诊断与治疗,医学院 周云飞,脊柱结核,Spinal Tuberculosis,全世界现有结核病患者 2000万，每年新增 800-1000万，每年因结核病死亡人数约 300万。我国是全球22个结核病高负担国家之一，我国结核病患者数量居世界第二位，其中75在农村，目前有结核菌感染者5.5亿人，结核病患者500万人，每年死于结核病的约13万人。脊柱结核患者虽只占结核患者总数的1%，但是由于其致残率高，对患者的生活质量影响大，需引起人们的重视。,Introduction,Introduction,脊柱结核的临床表现：背痛 导致椎体塌陷及脊柱后凸的骨破坏 冷脓肿 (感染扩散至相邻的韧带及软组
2、织) 脊髓压迫症状和神经损伤：脓肿, 肉芽组织或直接压迫,Introduction,并发症：脊柱结核十分危险，因为其时常伴有神经结构的破坏，以及脊柱畸形。,Spinal Tuberculosis,Diagnosis,结核病病史, 结核菌素皮肤试验阳性, 红细胞沉降率, 活检, DNA扩增技术, CT 和MRI 均有助于脊柱结核的诊断,Diagnosis(CT),CT appearance,1) 骨质破坏 Bone destruction 2) 骨密度增高 Bone density increase 3) 椎间盘破坏或退变 Destruction or degeneration of inter
3、vertebral disc 4) 椎旁软组织肿胀及腰大肌脓肿 Tumefaction of paravertebral soft tissue and psoas abscess 5) 附属组织受累 Involvement in the annex 6) 死骨形成 Bone sequestration 7) 椎管狭窄 Spinal stenosis,Diagnosis(CT),CT provides bony detail 平片或者CT上可以看见明显的骨质破坏。 脊柱结核与化脓性椎间盘炎相比，最大的区别在于脊柱结核的骨质破坏保留有相对完整的椎间盘轮廓和不均匀强化影。在化脓性椎间盘炎中，骨质破
4、坏和均匀强化影是十分常见的。 88.5%至96.4%的病例诊断中，CT/荧光引导的细针穿刺活检是十分常见和常用的。,Diagnosis(MRI),MRI appearance,1) 椎体骨质破坏 Destruction of vertebral bodies 2) 椎间隙变窄 Narrowing of intervertebral space 3) 椎旁肿胀形成 Paravertebral abscess 5) 脊髓及硬膜囊受压 Compression of the thecal sac and spinal cord,Diagnosis(MRI),The eight point MRI cr
5、iteria, T1 加权像高信号 T2 加权像高信号 侵及椎间盘 侵及骨骺 侵及椎弓根 前纵韧带拉伸 椎旁肌群拉伸 无棘突受累 Each of the variables were given 1 point when present and zero when absent. The score in the non tubercular patients is ranging from one to a maximum of four. The score in tubercular patients is ranging from six to seven,Yandrapati Bal
6、a Venkata Krishna Chandrasekhar, Alugolu Rajesh, Anirrudh Kumar Purohit. Novel magnetic resonance imaging scoring system for diagnosis of spinal tuberculosis: A preliminary report.Journal of Neurosciences in Rural Practice. April - June 2013,Diagnosis(MRI),MRI findings,Diagnosis(MRI),Non tubercular
7、patients,Diagnosis(MRI),Tubercular patients,Spinal Tuberculosis,Classification of Spinal TB,1985年, Kumar 通过结核的侵及范围和病变程度，为后路脊柱结核规定了一种4-point分类方法。但是由于这种分类方法最大的缺陷就是只对后路脊柱结核进行了分类，使得这种分类方法有很大的局限性。Kumar K. A clinical study and classification of posterior spinal tuberculosis. Int Orthop 1985;9:147-52.,Clas
8、sification of Spinal TB,2001年, Mehta and Bhojraj 通过对MRI表现的观察，介绍了一种新的脊柱结核分类方法。他们通过需采取的不同的手术方法，将患者分为4类。Mehta JS, Bhojraj SY. Tuberculosis of the thoracic spine. A classification based on the selection of surgical strategies. J Bone Joint Surg Br 2001;83:859-63.,Classification of Spinal TB,Group A 病变局限
9、于脊柱前柱， MRI上无明显表现， 无畸形. 病灶呈中央型或周围型.,Classification of Spinal TB,Group B GroupB患者病变广泛， 伴有畸形和不稳定性。 病变累及同一水平的前柱与后柱。,Classification of Spinal TB,Group C 这类患者可以是广泛病变（如group B），也可以使局限于前柱的病变（如group A），但是这一类患者的基本情况较差，体弱或者年纪较大。这类患者开胸手术的麻醉风险很大，并且易出现术后并发症。,Classification of Spinal TB,Group D 这类患者病变累及后柱，但是不伴有不稳定
10、性和畸形。一般采取经后路的有限减压术，减压程度由局部破坏程度决定。病变无融合。一些病灶呈干燥、颗粒状，并在韧带周边形成一层厚厚的袖套状组织。,Classification of Spinal TB,Disadvantage这一分类方法的最大缺陷在于只对胸椎病变进行了分类。,Classification of Spinal TB,Oguz developed a new classification system in 2008.,Classification of Spinal TB,Disadvantage这一分类方法最大的缺陷在于只对前柱的脊柱结核进行了分类，忽视了后柱的脊柱结核。Oguz
11、 E, Sehirlioglu A, Altinmakas M, et al. A new classification and guide for surgical treatment of spinal tuberculosis. Int Orthop 2008;32:127-33.,Spinal Tuberculosis,Management,Management,Management Selection,Medical Therapy,Most frequentprotocol,利福平、异烟肼、乙胺丁醇和吡嗪酰胺联合用药两个月后联合利福平和异烟肼，总疗程 6, 9, 12或者18个月,
12、WHO,总疗程6个月，包括异烟肼、利福平、吡嗪酰胺和乙胺丁醇联合用药2个月后辅以4个月的利福平与异烟肼.,American Thoracic Society,总疗程9个月，首次药物2个月+异烟肼和利福平联合用药7个月,Canadian Thoracic Society,912个月的联合治疗,通常来说，手术治疗并不是脊柱结核的首选治疗方式,Indications of Surgical Intervention,椎旁脓肿,Surgical Techniques,1) 后路减压植骨融合术2) 前路减压植骨融合术3) 联合前后路的减压植骨融合术,The following techniques ar
13、e currently used for the treatment of TB spondylitis,Surgical Techniques,The posterolateral or transpedicular approach,Surgical Techniques,Surgical Techniques,From a biomechanical view point, neither anterior nor posterior approaches alone can stabilize the spinal column as well as combined approach
14、es in cases of spinal TB. Therefore, several reports have suggested that the combined approach may yield better outcomes and prevent future kyphosis more efficiently.,Surgical Techniques,Combined approache,Advantage:1)缩短外固定周期，住院时间2)良好和持久的后凸畸形矫正3)防止进一步的破坏和植骨失败Disadvantage:对于后凸畸形的矫正有一定的局限性,Surgical Te
15、chniques,1-年龄 2-并发症 3-骨质破坏部位 (anterior, posterior or both) 4-压缩损伤部位 (anterior, posterior or both) 5-压缩损伤部位的密度 (pus or solid extradural lesion) 6-患者病变部位残余骨量 7-受累节段数量 8-后凸畸形程度 9-受累区域 (craniovertebral junction, cervical, cervicothoracic junction, thoracic, thoracolumbar junction, upper lumbar, cauda equina),To achieve the best results, the surgical treatment of choice for each patient should be individualized. According to different reports, considering the following factors could be helpful in order to select the approach,Thank You !,
