脊柱感染.ppt

*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,脊 柱 感 染,SPINE infections and related,概 念,累及椎间盘,椎体,附件感染,可并发硬膜外脓肿,分 类,Pyogenic Infections,Fungal Infections,TB Infections,化脓性感染,Incidence,Nagel et al.(2)8%of all osteomyelitis.,52%of the patients were older than age 50,intravenous(IV)drug use(4).,病理基础,干骺部,丰富静脉丛,终末动脉分支,椎体和椎间盘延续发展,椎间盘分解,-,狭窄间隙,细菌学,单一细菌,金葡菌,50%,G-,老年人,伴泌尿系感染,IV drug abusers,慢性低毒性感染,凝血酶阴性,Staphylococcus,类白喉菌,10 days,培养期,临床表现,90%,疼痛,压痛,肌痉挛,50%;,发热,with 20%,小于,3 weeks,30%3 weeks to 3 months,and 50%,超过,3 months duration,腰,48%,胸,35%,颈,6.5%,胸,腰骶段,Rest.,跳跃性,4%to 5%,部分诊断困难,不发热,血沉,病程指标,白细胞正常,病程和诊断时间长,最终活检确诊,出现瘫痪危险因素,老年,平面高,糖尿病,类风关,激素使用,影 像,X-RAY NEGATIVE-,间隙狭窄,软组织阴影,晚期两侧椎体破坏,CT:,溶骨,椎旁软组织肿胀,产气,核素,:,并不优于,MR;,儿童,老年人局部缺血灶,MR:,椎体,椎间盘低,T1,T2,裂隙消失,;,增强的椎体和间盘,脓肿不增强,影 像,Biopsy Techniques,除了明确影像学,临床,血培养阳性,.,血培养,25%,阳性,非手术治疗,针对性抗生素,培养阴性,=,广谱抗生素,6-8,周,万古,替考拉宁,庆大,妥布,克林可到达,头孢,青霉素类浓度低,手术治疗,活检阴性,体温高呈感染性临床表现,;,保守治疗失败血沉快,;,持续剧烈疼痛,畸形骨破坏影像学进展,;,神经症状,临床病例,椎管外脓肿,the titanium mesh cages,e titanium cages and PEEK cages were efficient in providing anterior fusion of the infected spine.,the rate of subsidence was higher,and the interval until subsidence was shorter in the strut group than in the cage group.,Fungal Infections,少见,临床症状隐匿,开放检出率高,TB INFECTIONS,3%to 4%of all tuberculous skeletal system,50%involve the spine,病源学,椎体前部,85%to 90%,终板,椎间盘,-,椎体,胸腰段,腰段,不同临床类型,晚期残留畸形,自然病史,畸形进展,活动期,静止期,成人,儿童差异,儿童结核自然病史,Causes of neurologic deficit in active and healed disease,Paraplegia of active disease(occurring however late),Compressive pathology caused byInflammatory edemaGranulation tissueCaseous tissue and abscessSequestrated bone and disc materialInfective vasculitisSpinal tumor syndromePathologic dislocation of the spineDirect infiltration of the cord,Paraplegia of healed disease,Stretching of the cord over the apex during progressive deformity(internal gibbous)Progressive extradural fibrosis,影像学,椎体疏松,终板模糊毛燥,椎间隙狭窄,早期,/,晚期椎体破坏后凸,影像学,化脓菌感染,:,感染症状明显,血培养和穿刺证实,.,布氏菌感染,:,地域特点,波状热,椎体破坏少,新骨形成明显,明显硬化,血清学反应阳性。,转移瘤,:,椎间盘完好,骨破坏,椎弓侵犯,.,*,椎旁脓肿,CT,发现死骨,边缘强化支持,TB,鉴别诊断,药物治疗,300 mg of isoniazid(INH),600 mg of rifampicin,20 to 30 mg/kg of body weight pyrazinamide,ethambutol(or streptomycin),when:(a)the severity of the lesion is extensive,(b)the patient population has a high primary resistance to INH,(c)there is a suspicion of drug resistance,4,药强化,2,月,2,药,9-12,月维持,手术治疗,明确诊断,引流脓肿,清创融合,同时行后路或,2,期后路融合,6 to 10,周临床治疗无改善,复发,耐药或者不规则药物治疗,防止畸形,窦道,大的脓肿,颈部脓肿导致呼吸,吞咽困难,无神经症状结核手术指征,畸形进展危险因素,10,岁伴有影像学不稳,初发后凸,30 degrees,椎体高度丢失大于,1.5,累及大于,3,个椎体,CT,提示牵后柱累及,儿童在发育高峰前局部有未融合残余椎体,术后预后危险因素,营养状态差,没有进行药物治疗,交界性病变,明显后凸,使用跨两节段病变,脊柱影像学不稳定,伴有神经症状,活动期结核,保守治疗和药物治疗有效,.,手术治疗更好的恢复及全身情况改善及减少,20%,需要外科手术,前路彻底减压,清创植骨融合,后路手术限于后方结构受累及椎弓根病灶为主,后路手术对于前路病灶并不是首选,稳定期治疗,更难,需要在后凸基础上进行减压,手术难度及风险大,.,THANKS !,