1. Li L, Xu J, Ma Y, Tang D, Chen Y, Luo F, Li D, Hou T, Zhou Q, Dai F, He Q, Zhang Z.Surgical Strategy and Management Outcomes for Adjacent Multisegmental Spinal
ICMR/MRC. A controlled trial of short-course regimens of chemotherapy in patients receiving ambulatory treatment or undergoing radical surgery for tOubrertchuloopsies dofitcheDspeipneartment
除非引起剧烈疼痛或髋关节屈曲，可CT引导下置管引流 ⑦ 抗结核治疗效果差，需手术切除病灶，或通过手术获取标本辅助诊断
*马远征,王自立，金大地等.脊柱结核[M]. 人民卫生出版社, 2013.
Orthopedic Department
Absolute indications
➢ Large cervical abscesses in a patient in whom respiratory obstruction has developed ➢ Marked neurologic deficit related to severe kyphosis, retropulsed bone or retropulsed disc ➢ Progression of kyphosis or instability despite adequate chemotherapy ➢ Progression of neurologic deficit despite adequate chemotherapy
Watts HG, Lifeso RM Current Concepts Review; TB of Bones and Joints. JBJS 78-A No 2 288-295. Feb 1996 Orthopedic Department
Relative indications
➢ Inability to obtain material for culture by other means ➢ Neurologic deficits in patients for whom prolonged
脊柱结核治疗策略
英国医学研究会(BMRC)曾开展两个多中心前瞻性临床对
照研究，拟解决该通过化疗联合手术还是单纯化疗治疗脊
柱结核的分歧
结论：脊柱结核更倾向于内科疾病，基本治疗手段应为
化疗、休息及制动；对不伴严重并发症的患者，单行化
疗即能取得良好疗效；香港术式只用于获得早期骨融合
或防止后凸畸形
Anonymous. A controlled trial of debridement and ambulatory treatment in the management of tuberculosis of the spine in patients on standard chemotherapy. A study in Bulawayo, Rhodesia [J]. Journal of Tropical Medicine and Hygeine 1974, 77(4): 72-92. MRC. A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy: a study in Hong Kong [J]. Br J Surg 1974, 61: 853-66. MRC. 5 year assessments of controlled trials of ambulatory treatment, debridement and anterior spinal fusion in the management of tuberculosis of the spine. Studies in Bulawayo (Rhodesia) and in Hong Kong. Sixth report of the Medical Research Council Working Party on Tuberculosis of the Spine [J]. J Bone Joint Surg Br 1978, 60B (2): 163-177. MRC. A ten-year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong [J]. J Bone Joint Surg [Br] 1982, 64-B: 393-8.
达成的共识
Orthopedic Department
绝对手术指征
➢ 重要脏器受压 ➢ 神经功能障碍
➢ 脊柱后凸畸形 ➢ 脊柱明显不稳
Orthopedic Departme1n3t
典型病例
Orthopedic Departme1n4t
指征1 重要脏器受压
男，4岁, 颈1、2、3椎体结核伴咽后脓肿
Orthopedic Departme1n8t
术后X正侧位
术后1个月
术后3个月
术后半年
Orthopedic Departme1n9t
术前正侧位
术后1年
Orthopedic Departme2n0t
指征3 脊柱后凸畸形
女，48岁，胸椎结核伴后凸畸形, 行2次病灶清除术
100°
Orthopedic Departme2n1t
instrumentation for thoracic and lumbar tuberculosis. International Orthopaedics.2012.36（2）:307-313
Orthopedic Departme2n8t
3. Qingyi He, Xu parison between the antero-posterior and anterior approacher for treating L5-S1 vertebral tuberculosis. International Orthopaedics.2012.36:345-351.
Tuberculosis: A Retrospective Study of Forty-eight Patients.Spine.2014.39（1）：40-48.
2. Pu X, Zhou Q, He Q, Dai F, Xu J, Zhang Z, Branko K. A posterior versus anterior surgical approach in combination with debridement, interbody autografting and
5岁女性，颈、腰、背痛活动受限10月，全身乏力1月余
手术指征
① 严重的或渐进加重的后凸畸形 ② 椎体破坏继发脊柱不稳 ③ 脊柱结核合并截瘫Frankel分级A或B级 ④ 不全截瘫Frankel分级C或D级，致压物为死骨或
椎间盘，尽早手术；致压物为脓肿，抗结核治疗1月无效，手术治疗 ⑤ 局部疼痛剧烈，不能下地行走，常规止痛药物无效 ⑥ 脓肿不作为手术绝对指征，绝大多数脓肿可通过抗结核药物治疗吸收，
[J].Ind J Tub 1989, 36: Suppl 1-21.
学术共识
➢ 营养支持治疗是基础 ➢ 抗结核药物治疗是治疗的根本 ➢ 手术只是预防、治疗严重并发症的辅助手段
界定其手术指征并制定个体化手术方案非常重要
1. 许建中. 脊柱结核的治疗方案存在仁智之争.中华骨科杂志.2011.4：394-399. 2. 许建中.规范脊柱结核治疗，为我国结核病防治做出更大贡献.中华骨科杂志, 2014, 34(2): 97-101 3. 许建中.脊柱结核治疗中面临的几个问题.第三军医大学学报. 2009， 20（3）：1923-1925.
bed rest may give rise to other problems ➢ Persistent pain or spasticity ➢ Pain related to spinal instability where spontaneous
fusion has not occurred
➢ 中国结核病数仅次于印度，是27个M/XDR-TB高负担国 家之一[1]
➢ 耐药结核的流行加剧了结核病的全球疫情
[1]WHO report 2012: Global tuberculosis control.World Health Organization, 2012.
Orthopedic Departmen3t
脊柱结核手术指征再认识
杭州市红十字会医院骨科 费骏
Orthopedic Department
随着抗结核药物的发现、外科技术的进步、 围手术期处理的完善、内植物的快速发展，脊柱 结核的疗效获得极大进步（治愈率95%）
Orthopedic Department
脊柱结核发病率增高，其诊治尚面临诸多挑战
Orthopedic Department
KC Mak , KM Cheung. Surgical treatment of acute TB spondylitis: indications and outcomes. Eur Spine J (20O1r3t)h2o2p(eSduicppDlepartment 4):S603–S611.