评价有限病灶清除后路内固定联合个体化药物治疗布鲁杆菌病性脊柱炎(BS)的临床疗效。

选取2014年6月至2019年1月河北北方学院附属第一医院骨科收治且符合纳入标准的BS患者44例，男26例，女18例。病变部位：T₁₁/T₁₂ 2例，T₁₂/L₁ 8例，L₃/L₄ 6例，L₄/L₅ 20例，L₅/S₁ 8例。术前行腰背疼痛视觉模拟评分(VAS)，C反应蛋白(CRP)、红细胞沉降率(ESR)检查，虎红平板凝集试验、血清试管凝集试验均阳性。术前16例患者伴有神经症状，其中按照美国脊柱损伤协会(ASIA)神经功能分级为C级者6例，D级者10例。有6例患者对一线抗布鲁杆菌药物过敏。术前规范化药物治疗，依据个体体质、营养状态、肝肾功能情况制定个体化服药剂量及频次，实施有限病灶清除后路内固定手术。术后继续实施个体化治疗方案或根据药物敏感试验结果调整抗生素应用。观察并记录所有患者的手术时间、手术出血量及是否有相关并发症发生。术前及术后3、6、12个月随访，对患者行VAS、CRP、ESR、虎红平板凝集试验、血清试管凝集试验实验室检查和X线检查；术后6、12个月随访，行MRI检查；并且末次随访时行ASIA神经功能分级评估。对数据行重复测量方差分析与配对t检验。

所有患者手术过程顺利，平均手术时间、出血量分别为(2.2±0.2) h、(360±50) mL。本组44例患者术后伤口愈合良好，无手术并发症发生，末次随访肝肾功能无损害，均达到临床治愈标准。44例患者术前，术后3、6、12个月VAS分别为(6.3±1.3)、(2.3±0.8)、0、0分，比较差异有统计学意义(F＝64.26, P<0.05)；44例患者术前，术后3、6、12个月CRP分别为(65.31±4.01)、(4.31±0.12)、(3.05±0.01)、(1.33±0.12) mg/L，比较差异有统计学意义(F＝226.13, P<0.05)；44例患者术前，术后3、6、12个月ESR分别为(54.78±3.12)、(13.08±1.01)、(6.21±1.32)、(2.32±0.38) mm/h，比较差异有统计学意义(F＝182.38, P<0.05)。患者术前与术后3个月VAS、CRP及ESR比较，差异均有统计学意义(t＝1.749、5.763、4.219，P值均小于0.05)。虎红平板凝集试验、血清试管凝集试验术后3个月复查均阴性。术后6、12个月X线显示椎弓根钉着力牢固、脊柱稳定，椎间隙植骨融合；术后6、12个月MRI显示椎体及椎旁组织炎症吸收，椎管内脊髓无受压。术前ASIA神经功能C级6例，术后改善为D级2例，E级4例；术前ASIA神经功能D级患者10例，术后均改善为E级。

有限病灶清除后路内固定联合个体化药物治疗对于BS控制感染、合理用药、消除炎症、缓解疼痛、解除脊髓神经受压、促进快速康复是安全可行的且临床疗效满意。

To evaluate the clinical efficacy of patients with brucellar spondylitis(BS), who were treated with limited lesion clearance posterior internal fixation combined with individualized medication therapy.

From June 2014 to January 2019, 44 patients with BS who were admitted to the First Affiliated Hospital of Hebei North University and met the inclusion criteria were selected, including 26 males and 18 females. Pathological entity: T₁₁/T₁₂ 2 cases; T₁₂/L₁ 8 cases; L₃/L₄ 6 cases; L₄/L₅ 20 cases; L₅/S₁ 8 cases.Visual alnalogue scale (VAS) of waist and back, C-Reactive protein(CRP), erythrocyte sdimentation rate(ESR) were checked before surgery, and the bengal plate agglutination text and serum tube agglutination test were positive. Before surgery, 16 patients were associated with neurological symptoms, including 6 patients with grade C and 10 patients with grade D according to American spinal injury association (ASIA). Six patients were allergic to the first-line anti-brucella drug. Preoperative standardized drug therapy was performed. The dosage and frequency of the individualized drug were determined according to the individual′s physical condition, nutritional status and liver and kidney function, and the operation of posterior internal fixation was performed after limited lesion removal. After the operation, the patient continued to receive individualized treatment or adjusted the sensitive antibiotics according to the results of drug sensitivity test. The operation time, bleeding volume and related complications of all patients were observed and recorded. VAS, CRP, ESR, bengal plate agglutination text, serum tube agglutination test, X-ray examination were performed before surgery and after 3, 6 and 12 months of follow-up. MRI examination were performed after 6 and 12 months of follow-up. ASIA nerve functional rating evaluation was performed at the last follow-up. Data were processed with repeated measures analysis of variance and paired t test.

The operation process of all patients was smooth, the average operation time and bleeding volume were (2.2±0.2) h, (360±50) mL. Forty-four patients had good postoperative wound closure, no surgical complications occurred, and liver and kidney functions were not damaged at the last follow-up, all of which reached clinical cure. The VAS of 44 patients were (6.3±1.3), (2.3±0.8), 0, and 0 points at the time of before surgery and 3, 6, 12 months after surgery, respectively, the difference was statistically significant (F=64.26, P<0.05). CRP of 44 patients were (65.31±4.01), (4.31±0.12), (3.05±0.01), (1.33±0.12) mg/L at the time of before surgery and 3, 6, 12 months after surgery, respectively, the difference was statistically significant (F=226.13, P<0.05). The ESR of 44 patients were (54.78±3.12), (13.08±1.01), (6.21±1.32), (2.32±0.38) mm/h at the time of before surgery and 3, 6, 12 months after surgery, respectively, the difference was statistically significant (F=182.38, P<0.05). Comparison of VAS, CRP and ESR before surgery and 3 months after surgery, the differences were statistically significant (t=1.749, 5.763, 4.219; with P values below 0.05). Bengal plate agglutination text and serum tube agglutination test were negative at 3 months after surgery. The results of X-ray at 6 and 12 months after surgery showed that pedicle screws were strong, the spine was stable, and intervertebral bone grafting was performed. At the 6 and 12 months after surgery, MRI showed that the vertebral body and paravertebral tissue showed inflammatory absorption, and the spinal cord in the spinal canal showed no compression. Preoperative ASIA neurological function grading was grade C in 6 cases, and postoperative improvement was grade D in 2 cases, and grade E in 4 cases. There were 10 patients with grade D before surgery and all were improved to grade E after surgery.

Limited lesion clearance posterior internal fixation combined with individualized medication therapy is safe and feasible for BS to control infection, rational medication, eliminate inflammation, relieve pain, relieve spinal nerve compression, and promote rapid recovery. The clinical effect is satisfactory.