孤立性脊柱椎弓结核的临床特点及诊断治疗

　　【摘要】　目的　探讨脊柱椎弓结核的临床特点及诊断与治疗。方法　对1956～1996年收治的3 825例脊椎结核中的17例椎弓结核的临床表现及治疗进行回顾性分析。结果　17例椎弓结核中除1例为2岁儿童外，余均为青壮年，早期症状不典型，仅有局部固定性疼痛和压痛，以后有脓肿瘘管和神经系统症状出现。均经病史、体征、影像学检查及细菌学检查综合诊断，其中仅1例误诊。17例中1例行抗结核药物化疗，16例在抗结核药物化疗下行椎弓病灶清除术，其中4例伴有神经系统症状者同期作了椎板切除减压治疗。结果全部治愈，经随访无1例复发。结论　椎弓结核早期症状较隐匿不易诊断，但限局性疼痛及X线、CT、磁共振(MRI)等检查对该症的早期诊断极有帮助，脓肿穿刺、抗酸染色涂片检查常能明确诊断。手术是椎弓结核治疗的重要手段。

　　Clinical features, diagnosis and treatment of solitary vertebral arch tuberculosis　　Lin Yu, Wu Qiqiu, Xu Shuangzheng, et al. Beijing Tuberculosis and Thoracic Tumour Institute, Beijing 101149

　　【Abstract】　Objective　To explore clinical features of vertebral arch tuberculosis, and to discuss the diagnosis and treatment of this illness.Method　Seventeen of 3 825 cases of spinal tuberculosis who were hospitalized and treated from 1956 to 1996 were reviewed, and their clinical features, diagnosis and treatment were analysed and reported.Result　Sixteen cases of vertebral arch tuberculosis were in adolescence and prime of life, and another one was a 2-year-old child. Their symptoms in early stages were untypical, including local fixed pain and tenderness, and later, abscess, fistula and symptoms of nerve system appeared. All the cases were diagnosed through summarizing of their history, signs, imaging examination and bacteriology tests, and only one case was misdiagnosed. In one of 17 cases, antituberculosis chemotherapy was conducted alone and non-operation was performed. In the other 16 cases, focal debridement of vertebral arch was performed on the basis of antituberculous chemotherapy, and in 4 cases of them with symptoms of nerve system, laminectomy and spinal decompression was performed homochronously. All the cases were healed and no relapse occured during follow-up.Conclusion　It is difficult to diagnose vertebral arch tuberculosis in early stages due to its occult symptoms, but the symptom of confined pain and manifestation in X-ray, CT and MRI are much useful for early diagnosis. Abscess puncture and acid-fast staining smear microscopy can usually be used to confirm diagnosis. And surgical intervention is an important measure for its treatment.

　　【Key words】　Tuberculosis, osteoarticular　　Vertebral arch　　Diagnosis　　Surgery, operative

　　孤立性脊柱椎弓结核临床上较罕见。我院1956～1996年，共收治脊柱结核3 825例，其中椎弓结核仅17例，占0.44％。现将我们诊断治疗中的一些体会报告如下。

临床资料

　　本组17例椎弓结核中男9例，女8例，年龄除1例2岁外，余16例均16～57岁，平均31岁。其中脊柱胸段4例，腰段13例（占76％）。脊柱椎弓各部位受累情况见附表。17例中共受累22处，2处同时发病者5例（胸椎椎弓1例，腰椎椎弓4例）。

　　本组病例发病至确诊时间最短1月，最长2年，平均9个月。最初症状多为局部一般性疼痛，本组17例中有13例，占76％。体温多数在38℃以下，仅有2例脓肿较大和1例瘘管者体温在38℃以上。血沉多在正常范围内，20 mm/1h以上者有5例。X线大多显示为骨质疏松，或呈溶骨性改变，甚至骨质缺损。个别病例可出现病灶局部呈膨胀性改变，本组1例腰椎横突结核即呈膨胀性改变。本组17例中有脓肿者14例，占82％，其中合并瘘管者3例；伴有神经系统症状者4例，占24％，其中腰椎椎弓结核3例，胸椎椎弓结核1例（合并完全截瘫）。本组17例椎弓结核均通过病史、体征结合X线、CT、磁共振（MRI）等影像学检查和脓肿穿刺涂片和细菌培养作出诊断，除1例误诊为腰椎横突肿瘤外，余16例均经手术后病理或细菌学检查证实。

　　17例中除1例行单纯抗结核药物保守治疗治愈外，余16例均在抗结核药物治疗支持下行椎弓病灶清除术，其中4例伴有神经系统症状者同期作了椎板切除减压术。病灶清除中见椎弓结核的病变物质为结核性肉芽组织14例次，脓肿者9例次，干酪者7例次，小死骨者3例次。术后伤口除2例合并瘘管者Ⅱ期愈合外，余均I期愈合。4例合并有神经系统症状者，术后症状完全消失，截瘫完全恢复。全部17例均得到随访，随访期1～10年不等，全部患者均恢复正常生活与工作，无复发或死亡。

讨论

　　椎弓结核即脊柱椎体后方的棘突、椎板、上下关节突、横突和椎弓根部位的结核病变。临床上亦称为后部脊椎结核或椎体附件结核。

　　临床所见椎弓结核有3种：(1)继发于同一水平椎体或肋骨（特别是肋骨小头）的结核病变，因脓肿向侧后方蔓延侵袭椎弓所致；(2)因结核分支杆菌栓子经血液传播同时侵犯同一水平椎体和椎弓，引起椎体和椎弓同时发病；(3)与椎体及附近骨无关，结核分支杆菌经淋巴或血液直接侵入椎弓而未感染椎体，仅引起局限于椎弓的结核病变，即孤立性椎弓结核。临床上前两种椎弓结核较多见，特别是在椎体结核手术中时有发现，而孤立性椎弓结核却不多见，国内外文献报道亦较少［1～4］。据文献记载其发病仅占脊椎结核的0.4%～2％［3］，本组17例及本组中所讨论的均属这种孤立性椎弓结核。