The common form of extrapulmonary tuberculosis is spinal tuberculosis (TB). Spinal TB can lead to vertebral damage, resulting in kyphosis and neurological impairment. Debridement, bone grafting, and reconstruction are common surgical treatments for spinal TB. Spinal TB patients with anterior-middle spinal column destruction are more likely to experience loosening of internal fixation. Cortical bone trajectory (CBT) screw fixation reduces this complication probability because the entrance trajectory of CBT screws in the sagittal and axial planes substantially interacts with the cortical bone and boosts the screw-bone contact strength interface. The CBT screw insertion path is closer to the spinous process and involves less dissection of the paraspinal muscles; this approach appears to reduce intrinsic injury and postoperative pain. CBT screw is a safe and effective internal fixation method for spinal TB because it can effectively reduce the number of fixed segments, maximize spinal mobility, reduce tissue damage, and alleviate postoperative pain at the surgical site.

Abstract Objective: This study aimed to compare bundled multifracture rib implants and titanium mesh implants for thoracic spinal tuberculosis using the transverse costal approach. Methods: Patients with thoracic spinal tuberculosis were divided into two groups. Both groups underwent surgery via the transverse costal approach. After removal of the necrotic tissue from the tuberculosis lesion, group A received titanium mesh bone grafts and group B received bundled rib bone grafts. Bone grafting time, blood loss during surgery, Cobb angle correction after surgery, loss of Cobb angle after the last follow-up, and bone graft fusion time were compared between the two groups. Results: Thirty-eight patients (n = 19 per group) were included in this study. The follow-up duration was 24–42 months. The mean operative time was significantly longer in group A than in group B (154.63 ± 15.48 min vs. 130.95 ± 25.51 min, t = 3.460, P = 0.001). Implant fusion time, intraoperative bleeding volume, and preoperative Cobb angle were not significantly different between the two groups (7.11 ± 0.46 months vs. 7.16 ± 0.60 months, P > 0.05; 556.68 ± 116.76 ml vs. 518.63 ± 108.48 ml, P > 0.05; 36.47° ± 7.57° and 37.63° ± 6.45°, P > 0.05, respectively). After treatment, spinal nerve function recovered at least partially in both groups. The Oswestry dysfunction indices were not significantly different between the two groups (P > 0.05). Conclusion: Compared with the titanium mesh implant, the bundled rib implant is more convenient, has easy bone block implantation procedure, and requires shorter time for bone grafting. No differences in intraoperative blood loss, postoperative bone graft fusion time, and spinal nerve function recovery were detected. Furthermore, stabilization function is achieved earlier with the bundled rip implant after thoracic spinal tuberculosis lesion removal, supporting the use of this implant.

目的 观察生脉饮在骨关节结核患者抗痨过程中增效减毒的作用.方法 选取2017年1月至2019年12月于浙江省中西医结合医院骨科住院诊治,诊断为骨关节结核患者66例,依照3HRZE/15HRE抗结核方案进行治疗的患者分为治疗组和对照组.治疗组患者予以生脉饮汤剂口服,对照组患者予以利可君片口服.分别观察、记录患者2周的外周血白细胞计数、IFN-γ、淋巴细胞亚群占比、中医证候疗效及不良事件.结果 治疗1周及2周后,治疗组患者外周血白细胞计数分别为(3.73±0.87)×109/L、(4.38±1.14)×109/L,高于对照组患者的(3.30±0.68)×109/L、(3.86±0.79)×109/L(P<0.05);治疗2周后,治疗组患者血清IFN-γ为(38.88±11.74)pg/ml,低于对照组的(45.85±13.37)pg/ml(P<0.05);治疗组患者CD3+、CD4+、CD4+/CD8+占比分别为(79.21±9.25)％、(47.52±9.80)％、(2.01±0.63),高于对照组的(73.73±11.13)％、(41.95±8.04)％、(1.72±0.47)(P<0.05);治疗组患者中医证候疗效总有效率为87.9％,高于对照组的51.5％(P<0.05).研究期间,两组患者各有1例中止研究,无恶心呕吐、肝肾功能不全等不良事件.结论 生脉饮可以对抗骨关节结核治疗过程中白细胞减少、乏力、食欲不振、低热盗汗等毒副反应,增强机体免疫力,起到增效减毒的作用.

结核病至今仍然是全球十大死因之一,也是单一传染源的主要死因(居HIV/AIDS之上).WHO《2020年全球结核病报告》指出[1],2019年估计有1000万人(范围:890～1100万)罹患结核病,其中90％的新发结核病患者来自30个全球结核病高负担国家,排名前三位的依次是:印度(26％)、印度尼西亚(8.5％)、中国(8.4％).受新型冠状病毒(COVID-19)疫情影响,2020～2025年间每年罹患结核病的人数可能增加100多万.

Purpose:This study is aimed at comparing the clinical efficacy of cortical bone trajectory (CBT) screw fixation and pedicle screw (PS) fixation of the affected vertebrae in lumbar tuberculosis.Methods:We retrospectively analyzed the outcomes in 52 patients (27 cases in the CBT group, 25 cases in the PS group) with lumbar TB who underwent posterior affected-vertebra fixation combined with anterior debridement and bone grafting. The intraoperative blood loss, operative time, visual analog scale (VAS) scores for incision pain and leg pain, Japanese Orthopedic Association (JOA) score, bone grafting fusion, and complications were recorded.Results:All patients were followed up for 35-52 months and achieved good clinical outcomes. There were no differences between the two groups in the operative time, intraoperative blood loss, JOA score, bone grafting fusion, and complications. However, there was a significant difference between the two groups in VAS scores for incision pain on the 1st day and 3rd day after surgery. At the last follow-up, JOA scores were significantly improved in both groups compared to the preoperation.Conclusion:This retrospective study confirmed that both the affected-vertebra CBT screw fixation and PS fixation for lumbar TB via posterior and anterior approaches could achieve satisfactory outcomes, while the former resulted in better improvement for postoperative VAS scores.

Disturbance of bone homeostasis caused by Mycobacterium tuberculosis (Mtb) is a key clinical manifestation in spinal tuberculosis (TB). However, the complete mechanism of this process has not been established, and an effective treatment target does not exist. Increasing evidence shows that abnormal osteoclastogenesis triggered by an imbalance of the receptor activator of NF-κB ligand (RANKL)/osteoprotegerin (OPG) axis may play a key role in the disturbance of bone homeostasis. Previous studies reported that RANKL is strongly activated in patients with spinal TB; however, the OPG levels in these patients were not investigated in previous studies. In this study, we investigated the OPG levels in patients with spinal TB and the dysregulation of osteoblasts caused by Mtb infection. Inhibition of the Mce4a gene of Mtb by an antisense locked nucleic acid (LNA) gapmer (Mce4a-ASO) was also investigated. Analysis of the serum OPG levels in clinical samples showed that the OPG levels were significantly decreased in patients with spinal TB compared to those in the group of non-TB patients. The internalization of Mtb in osteoblasts, the known major source of OPG, was investigated using the green fluorescent protein (GFP)-labeled Mycobacterium strain H37Ra (H37RaGFP). The cell-associated fluorescence measurements showed that Mtb can efficiently enter osteoblast cells. In addition, Mtb infection caused a dose-dependent increase of the CD40 mRNA expression and cytokine (interleukin 6, IL-6) secretion in osteoblast cells. Ligation of CD40 by soluble CD154 reversed the increased secretion of IL-6. This means that the induced CD40 is functional. Considering that the interaction between CD154-expressing T lymphocytes and bone-forming osteoblast cells plays a pivotal role in bone homeostasis, the CD40 molecule might be a strong candidate for mediating the target for treatment of bone destruction in spinal TB. Additionally, we also found that Mce4a-ASO could dose-dependently inhibit the Mce4a gene of Mtb and reverse the decreased secretion of IL-6 and the impaired secretion of OPG caused by Mtb infection of osteoblast cells. Taken together, the current finding provides breakthrough ideas for the development of therapeutic agents for spinal TB.

脊柱结核是肺外结核,约占骨结核的 70％."HRZE"[异烟肼(H)、利福平(R)、乙胺丁醇(E)、丙嗪酰胺(Z)]化疗方案是治疗脊柱结核最重要的治疗方法,副反应白细胞减少发生率约为11％,利福平引起的占其87％[1].近期文献数据表明,长期及联用抗结核药物是加剧白细胞减少的重要因素[2-3].脊柱结核化疗后白细胞减少症常予骨髓生长因子 [(常为粒细胞集落刺激因子(G-CSF)],伴有肌痛、关节痛不良反应[4],且此法诱导增殖的白细胞其免疫力多低于正常白细胞[5].中医治疗脊柱结核化疗后白细胞减少症,侧重调补营卫,益气养血,疗效确切,且不良反应小,费用低,作用持久[6]."气为血之帅"包括气能生血、气能行血、气能摄血.秉承"气为血之帅"理论,目前多种中医药疗法在脊柱结核化疗后白细胞减少症中发挥治疗优势.

Objective:To investigate the application value of metagenomic next generation sequencing (mNGS) in the diagnosis of spinal infectious diseases except tuberculosis and non-tuberculous mycobacterium infection.Methods:According to the inclusion and exclusion criteria, the clinical data of 171 patients with suspected non-tuberculous infectious diseases of spine from January 2019 to November 2020 were analyzed retrospectively. All patients underwent puncture biopsy of spine or surgery to obtain tissue specimens, then tissue biopsy were measured, and Foci purulent blood or lavage fluid was obtained for routine bacterial and mNGS. The differences of reporting time, sensitivity (positive rate) and specificity (true negative rate) were compared between the two methods. The pathogenic microorganism spectrum of spinal infection was analyzed. The effects of specimen collection method, preoperative antibiotic use and specimen type on the detection of pathogenic microorganisms were analyzed.Results:According to the diagnostic criteria of non-tuberculous infectious diseases of the spine, there were 136 cases of infection, among which 111 cases had specific pathogenic microorganism. The average reporting time of traditional culture and mNGS were 81.67+15.52 h and 36.33+11.92 h. There were 43 positive cases and 5 false positive cases in traditional culture, the sensitivity was 31.62%, and the specificity was 85.71%; There were 76 positive cases and 19 false positive cases in mNGS, the sensitivity was 55.88%, and the specificity was 45.71%. There were significant statistical differences in the sensitivity, specificity and reporting time for detection of pathogenic microorganisms by mNGS. The top 3 pathogens of non-specific infection were Staphylococcus aureus and Staphylococcus, Escherichia coli and Streptococcus. Eleven patients with non-tuberculous specific infection were confirmed, including 2 positive cases with traditional culture, 11 positive cases with mNGS. A higher detection rate for rare specific infections were expressed in mNGS. Logistic regression analysis indicated that the standard antibiotic use 4 weeks before surgery and specimen acquisition methods had significant effects on the traditional culture results, while the specimen acquisition methods had no statistically significant effects on the mNGS.Conclusion:Metagenomic next generation sequencing has a higher sensitivity to the detection of pathogenic microorganisms in the diagnosis of non-tuberculous spinal infectious diseases, especially for the detection of rare pathogenic microorganisms, which has a high diagnostic value.

脊柱结核约占骨关节结核的50％,80％以上脊柱结核由于血行播散继发于肺结核[1].并且其耐药程度高,总耐药率高达66.7％[2].近年发现,脊柱结核若失治误治,椎间盘及椎体受累加重,可导致脊椎骨塌陷、结核脓液聚集于椎管引起神经系统并发症或截瘫[3].目前临床研究发现,单一抗结核药物治疗效果不佳,且病程迁延,容易久治不愈[4].联合使用抗结核药物又易造成肝、肾及周围神经等损害.本研究对阳和汤联合抗结核西药治疗阳虚寒凝型脊柱结核的短期临床疗效进行观察,现报道如下.

目的:观察pRNA-3WJ-siLNA gapmer(Mce4)-aptamer(CD40)纳米微粒(简称pRNA纳米微粒)在脊柱结核细胞模型中对结核分枝杆菌生长的影响.方法:利用荧光结核分枝杆菌感染人成骨细胞建立脊柱结核细胞模型.先培养及准备人成骨细胞,人成骨细胞培养至第三代;然后构建培养荧光结核分枝杆菌;将培养良好的人成骨细胞用lxTrypsin-EDTA胰蛋白酶消化之后以70％密度在100mm细胞培养皿种植细胞,经24h培养使细胞稳定之后,将1麦氏比浊管的对数生长中期荧光结核分枝杆菌以感染复数(multiplicity of infection,MOI)1:10感染培养的人成骨细胞6h,用不加血清培养液清洗3次,在培养箱中培养24h;然后将感染成功的人成骨细胞随机分为A组(空白对照组)及B、C、D组(三个实验组),三个实验组分别置人本研究团队构建的 0.1μ M.1μ M、l0 μM浓度的脊柱结核靶向治疗pRNA纳米微粒溶液,共培养36h之后,加入细胞裂解液裂解细胞,裂解产物用Middlebrook 7H9培养液稀释20倍,之后均匀涂抹到琼脂平板,放入到370C,5％C02细胞培养箱中培养21d,使用Gel Doc XR+system凝胶成像系统观察菌落影像,使用Bio-Rad Discovery Quantity One?1-D analysis软件对四组的所有菌落进行了测定,统计分析各组人成骨细胞中结核分枝杆菌菌落形成单位(colony forming unit,CFU).结果:人成骨细胞培养良好;成功构建荧光结核分枝杆菌(H37Ra-GFP);荧光结核分枝杆菌结合并进入人成骨细胞.经统计分析A、B、C、D四组菌落形成单位(272.67±67.06、183.33±8.74、154.33±25.72、76.67±11.02)的差异存在统计学意义(F=14.68,P＜0.05);且B、C、D三组的菌落形成单位分别与A组相比时,均明显低于A组(P＜0.05),B、C、D三组菌落形成单位依次下调,三组菌落形成单位两两比较存在差异,并且有统计学意义(P＜0.05).结论:pRNA纳米微粒以浓度梯度的方式抑制结核分枝杆菌在人成骨细胞中的生长存活,甚至低浓度也具备抑制结核分枝杆菌生长的能力.

Due to the complexity of the anatomical structure and the difficulty of exposing the surgical area, the surgery for spinal tuberculosis in the upper thoracic vertebra (above T6–T7) is complicated and the prognosis is not good. This study aimed to investigate the clinical effects of posterolateral costotransversectomy using an extrapleural approach in patients with upper thoracic spinal tuberculosis. This was a retrospective analysis of 132 patients (including 78 males and 54 females) with upper thoracic spinal tuberculosis who underwent one-stage internal fixation and debridement followed by combined interbody and posterior fusion via posterolateral costotransversectomy using an extrapleural approach. The age ranged from 23 to 82 years (54.5 ± 13.2 years). Lesion segments were distributed from T2 to T7. According to Frankel’s spinal cord function evaluation, there were 2 cases of grade A, 6 of grade B, 6 of grade C, 12 of grade D, and 106 of grade E. The preoperative Cobb angle was 16–40° (29.1° ± 6.5°). Operation time, bleeding volume, incision healing, bone graft fusion, deformity correction, and improvement of nerve function were analyzed. The operation time ranged from 2.8 to 4.1 h (3.4 ± 0.3 h), and blood loss ranged from 350 to 550 mL (460 ± 47 mL). All incisions healed in the first stage. The bone graft fusion time was 3–6 months (median of 4 months). There was no loosening or broken of the internal fixation. The C-reactive protein and erythrocyte sedimentation rate were significantly improved at the end of follow-up in comparison with before surgery. The Cobb angle of the fusion segment was corrected and ranged from 5° to 17° (average of 10.7° ± 3.3°) at the end of follow-up. The nerve function of all patients improved at different degrees by the time of the last follow-up. In the last follow-up, the Frankel grade distribution was 1 case in B grade, 2 cases in grade C, 6 cases in grade D, and 123 cases in grade E. Posterolateral costotransversectomy using an extrapleural approach is a safe and effective surgical method that can expose the upper thoracic spine lesions and reduce trauma.

OBJECTIVE:To compare the clinical effects of three different methods of binding multi-fold rib graft, iliac bone graft and titanium mesh graft in tuberculosis of thoracic vertebra by approach of transverse rib process.METHODS:A hundred and seven patients with tuberculosis of thoracic vertebra received surgical treatment from January 2010 to December 2016 were retrospectively analyzed. The patients were divided into three groups according different methods of bone graft. The surgical approach of the transverse rib process was used in all 107 patients, after thoroughly remove the necrotic tissue of tuberculosis, three different bone grafts were used respectively including iliac bone graft (36 cases, group A), binding multi-fold rib graft (35 cases, group B), titanium mesh bone graft (36 cases, group C). Perioperative indexes, the time required for bone graft during operation, intraoperation blood loss, the loss rate of the anterior edge of the lesion, Cobb angle, postoperative bone graft fusion time, spinal nerve recovery and Oswestry Disability Index were compared among three groups.RESULTS:All the patients were followed up for 13 to 24 months, and the operation time required for bone graft was (23.2±4.1) min in group A, (23.8± 4.4)min in group B, and (25.5±4.2) min in group C, with no statistically significant difference among three groups (P>0.05). Intraoperative blood loss was (541.6±35.3) ml in group A, (546.8±27.8) ml in group B, and (540.1±34.5) ml in group C, withno statistically significant difference among three groups(P>0.05). Preoperative anterior vertebral height loss rate was (46.0± 3.1)% in group A, (46.4±3.3)% in group B, and (45.3±3.6)% in group B;at the final follow up, the loss rate of anterior vertebral height among three groups was (8.6±5.0)%, (8.1±4.2)%, (9.4±4.3)%, respectively. There were no statistically significant differences before operation and final follow-up among three groups (P>0.05). Preoperative Cobb angle was (35.1±4.8)° in group A, (35.2±4.5)° in group B and (35.2±4.5)° in group C, with no statistically significant difference among three groups (P>0.05);postoperative at 3 days, Cobb angle in three groups was (15.1±3.6)°, (15.3±3.1)° and (15.2±3.4)°, respectively, there was no statistically significant difference among three groups (P>0.05);at the final follow-up, the Cobb angle among three groups was (17.7±3.3)°, (17.9±3.9)°, (18.6±3.6)°, respectively, with no statistically significant difference among three groups (P>0.05). The time of bone graft fusion was (5.6±0.5) months in group A, (5.6±0.6) months in group B and (5.8±0.6)months in group C, with no statistically significant difference among three groups (P>0.05). Frankel classification at the final follow up, 4 cases were grade B, 7 cases were grade C, 10 cases were grade D, and 86 cases were grade E. Spinal nerve function in all three groups recovered to a certain extent after treatment, with no statistically significant difference among three groups (P> 0.05). Oswestry Disability Index at the final follow-up showed no statistically significant difference among three groups (P> 0.05).CONCLUSION:The approach of transverse rib process for debridement of lesions can effectively treat tuberculosis of thoracic vertebra by binding multi-fold rib graft, iliac bone graft and titanium mesh graft, but binding multi-fold rib graft can effectively avoid iliac bone donor complications, and is an effective alternative to iliac bone graft, which is worth popularizing.

OBJECTIVE:To observe the changes of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and nerve function in patients with spinal tuberculosis before and after surgery, explore the timing of surgical intervention, and evaluate its influence on surgical safety. METHODS:A retrospective analysis was conducted on 387 patients with spinal tuberculosis who received surgical treatment from March 2012 to March 2017, including 278 males and 109 females, aged 12 to 86 years old with an average of (49.9±19.1) years. There were 64 cases of cervical tuberculosis, 86 cases of thoracic tuberculosis, 76 cases of thoracolumbar tuberculosis and 161 cases of lumbar tuberculosis. There were 297 patients with single segmental involvementand 90 patients with multiple segmental involvement. Among them, 62 cases presented neurological damage, and preoperative spinal cord neurological function depended on ASIA grade, 5 cases of grade A, 8 cases of grade B, 39 cases of grade C, and 10 cases of grade D. According to the duration of preoperative antituberculosis treatment, the patients were divided into group A (256 cases, receiving conventional quadruple antituberculosis treatment for 2-4 weeks before surgery) and group B (131 cases, receiving conventional quadruple antituberculosis treatment for more than 4 weeks before surgery). The two groups were compared in terms of gender, age, preoperative complicated pulmonary tuberculosis, lesion site, lesion scope, surgical approach, drug resistance and other general clinical characteristics. ESR, CRP, visual analogue scale(VAS), Oswestry Disability Index (ODI), Frankel grade and postoperative complications were observed. RESULTS:All 387 patients were followed up for 12 to 36 (18.3±4.5) months. There were no significant differences in gender, age, preoperative pulmonary tuberculosis, lesion site, lesion range, surgical approach, preoperative drug resistance and other characteristics between two groups. A total of 32 patients in two groups did not heal after surgery, with an incidence rate of 8.27%. The VAS and spinal cord dysfunction index of the two groups were significantly improved after surgery (P<0.05), but there was no significant difference between two groups at the same time point (P>0.05) . From 1 to 14 days after operation, the neurological function began to gradually recover, and the neurological function grade was increased by 1 to 3 grades. From 3 months after operation to the final follow up, 52 cases recovered completely, 8 cases partially recovered, and 2 cases did not improve. There was no significant difference in ESR and CRP between two groups before admission, 1 month after surgery, and final follow-up (P>0.05). CONCLUSION:After 2-4 weeks of anti tuberculosis treatment before operation, patients with spinal tuberculosis could be operated upon with ESR and CRP in a descending or stable period. In principle, patients with spinal tuberculosis and paraplegia should be treated as soon as possible after active preoperative management of the complication without emergency surgery.

Objective To explore the value of multi‐mode neuroelectrophysiological monitoring (MIOM) in evaluating spinal cord and nerve root function in the treatment of thoracic tuberculosis via costal transverse process approach. Methods From December 2017 to September 2019, a retrospective study of thoracic tuberculosis patients in our hospital was conducted. This study included 25 patients (14 men and 11 women). The average age of patients at the time of surgery was 63.3 years (range, 20–83 years). All patients (three cases with the destruction of a single vertebral body, 13 cases with the destruction of two vertebral bodies, and nine cases with the destruction of three or more vertebral bodies) underwent costal transverse process approach with debridement and bone grafting and internal fixation combined with intraoperative multimodal neuroelectrophysiological monitoring. During the operation, somatosensory evoked potential (SEP), transcranial electrical stimulation motor evoked potential (TES‐MEP), and spontaneous electromyography (EMG) were used to monitor progress. ESR, visual analogue scale (VAS), Cobb angle, and Oswestry disability index (ODI) were statistically analyzed to evaluate the treatment effects and patient satisfaction. Results All 25 patients were successfully monitored. The follow‐up time ranged from 12 to 21 months, with an average of 15.3 months. SEP waveform abnormalities occurred in five patients during the operation, the incidence rate was 28%. Of these five patients, three patients changed their instruments and postures, and adjusted the flushing water flow in time; one patient received pressure therapy in time; the operation was suspended for 10 min for one patient. There were seven cases with abnormal TES‐MEP waveform, the incidence rate was 28%. Among these seven cases, five cases adjusted the nail path during the operation and adjusted the nail position in time. One case adjusted the inclination angle of the operating table in time; one case completed the contralateral nail stick correction in time; five of them had abnormal TES‐MEP waveforms, and EMG burst potential was also detected, the incidence rate was 20%. After prompt treatment, the abnormal waveforms of all patients returned to normal; no abnormal waveforms, recurrence of tuberculosis, loosening of internal fixation, nerve and spinal cord dysfunction, etc. The VAS score, erythrocyte sedimentation rate (ESR), Cobb angle, and ODI scores of the patients 1 year after operation were significantly improved compared with 1 week after operation (P < 0.05). Conclusion Multi‐mode intraoperative electrophysiological detection combined with costal transverse process approach for the treatment of thoracic tuberculosis could avoid intraoperative nerve and blood vessel damage, reduce surgical risk, improve surgical efficiency, and ensure curative effect.

OBJECTIVE:To explore the value of multimodal neuroelectrophysiological monitoring technology in the evaluation of spinal cord and nerve root function for the treatment of thoracic tuberculosis with debridement and bone grafting and posterior internal fixation by transcostal transverse process approach.METHODS:The clinical data of 25 patients with thoracic tuberculosis underwent debridement and bone grafting and posterior vertebral arch internal fixation by transcostal transverse process approach from December 2018 to September 2019 was retrospectively analyzed. Among these 25 patients, including 14 males and 11 females;aged from 20 to 83 years old, with a mean of (63.45±9.65) years;there were 3 cases of single vertebral body destruction, 13 cases of 2 vertebral bodies destruction, and 9 cases of 3 or more vertebral bodies destruction. All surgical patients underwent intraoperative detection of somatosensory evoked potential(SEP) and transcranial electric stimulation-motor evoked potential(TES-MEP);and electromyography (EMG) was used to monitor the pedicle screw placement and lesion removal. The erythrocyte sedimentation rate(ESR) was used to evaluate the decline of inflammatory indexes, the visual analogue scale (VAS) was used to evaluate the thoracic spine pain, and the Cobb angle and Oswestry Disability Index(ODI) were used to evaluate the improvement of function.RESULTS:All 25 patients were successfully monitored. Five patients had abnormal SEP waveforms during operation, 3 cases were caused by intraoperative clearing of lesions and spinal cord compression during irrigation, timely replacement of instruments and gestures, and adjustment of irrigation water flow rate returned the waveform to normal; one case was caused by a decrease in systolic blood pressure, and the waveform returned to normal after timely treatment of increased blood pressure;after 1 case of SEP waveform abnormality, the operation was suspended for 10 minutes and recovered spontaneously, and the waveform abnormality did not reappear until the end of the operation. Seven patients had abnormal TES-MEP waveforms, 5 cases occurred when the pedicle screw was inserted, the nail path was adjusted in time, and the waveform recovered after nail repositioning;one case was caused by tilting the operation bed during operation, and the waveform gradually recovered after adjusting the tilt angle of operation bed; one case occurred during the correction of the pedicle screw and rod system, and the waveform gradually returned to normal after the contralateral screw and rod correction were completed during operation. In 5 cases, the EMG burst potential was detected at the same time when the TES-MEP waveform was abnormal. After adjustment, the EMG burst potential disappeared. There was no abnormality in the TES-MEP and SEP waveforms at the same time. Postoperative VAS, ESR, Cobb angle, and ODI were improved compared with preoperatively (P<0.05).CONCLUSION:In patients with thoracic tuberculosis, the use of debridement and bone grafting and posterior internal fixation by transcostal transverse process approach combined with intraoperative SEP, TES-MEP and EMG monitoring can timely reflect the spinal cord and nerve root function, avoid intraoperative injuries while achieving good fixation and lesion removal.

Abstract Background: To explore the accuracy and security of 3-dimensional (3D) printing technology combined with guide plates in the preoperative planning of thoracic tuberculosis and the auxiliary placement of pedicle screws during the operation. Methods: Retrospective analysis was performed on the data of 60 cases of thoracic tuberculosis patients treated with 1-stage posterior debridement, bone graft fusion, and pedicle screw internal fixation in the Department of Orthopedics, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital from March 2017 to February 2019. There were 31 males and 29 females; age: 41 to 52 years old, with an average of (46.6 ± 2.0) years old. According to whether 3D printing personalized external guide plates are used or not, they are divided into 2 groups: 30 cases in 3D printing group (observation group), and 30 cases in pedicle screw placement group (control group). A 1:1 solid model of thoracic spinal tuberculosis and personalized pedicle guide plates was created using the 3D printing technology combined with guide plates in the observation group. Stability and accuracy tests were carried out in vitro and in vivo. 30 patients in the control group used conventional nail placement with bare hands. The amount of blood loss, the number of fluoroscopy, the operation time, and the occurrence of adverse reactions related to nail placement were recorded. After the operation, the patients were scanned by computed tomography to observe the screw position and grade the screw position to evaluate the accuracy of the navigation template. All patients were followed up for more than 1 year. Visual Analogue Scale scores, erythrocyte sedimentation rate, and C-reactive protein were evaluated before surgery, 6 months after surgery, and 12 months after surgery. Results: Sixty patients were followed up for 6 to 12 months after surgery. One hundred seventy-five and 177 screws were placed in the 3D printing group and the free-hand placement group, respectively. The rate of screw penetration was only 1.14% in the 3D-printed group (all 3 screws were grade 1) and 6.78% in the free-hand nail placement group (12 screws, 9 screws were grade 1 and 3 screws were grade 2). The difference was statistically significant (P = .047). The operation time of the 3D printing group ([137.67 ± 9.39] minutes), the cumulative number of intraoperative fluoroscopy ([4.67 ± 1.03] times), and the amount of intraoperative blood loss ([599.33 ± 83.37] mL) were significantly less than those in the manual nail placement group ([170.00 ± 20.48] minutes, [9.38 ± 1.76] times, [674.6 ± 83.61] mL). The differences were statistically significant (P < .05). There was no significant difference in VAS score and Oswestry disability index score between the 2 groups of patients before operation, 3 and 6 months after operation (P > .05). Conclusion: The 3D printing technology combined with guide plate is used in thoracic spinal tuberculosis surgery to effectively reduce the amount of bleeding, shorten the operation time, and increase the safety and accuracy of nail placement.

BackgroundWe aimed to explore the biomechanical stability and advantages of cortical bone trajectory (CBT) screws in the treatment of lumbar spine tuberculosis and provide biomechanical basis for the choice of clinical fixation methods. Methods16 pig spine specimens (T12-L5) were selected to simulate the lumbar spine(L2-L3) tuberculosis bone destruction model in vitro. The 16 specimens were randomly divided into 4 groups, and short segments (pedicle screws of the diseased vertebrae) were assigned respectively. Fixation (group A), short-segment fixation (group B), fixation with pedicle screw (group C), fixation with CBT screw (group D), 4 specimens in each group , Each specimen in each group was subjected to biomechanical testing in the state of complete specimen (state 1) and L2-3 spinal tuberculosis model bone graft fusion and internal fixation (state 2). Load each specimen on the spine 3D exercise machine, respectively apply moments of 2N·m, 2.5N·m, 1N·m, 3N·m, meanwhile record the movement of the specimens in the four directions of flexion，extension，lateral bending and torsion ROM, compare Simultaneously analyze each group of ROM. ResultsThe ROMs of flexion, extension, lateral bending, and torsion in group A in state 1 and state 3 modes were （8.47±1.76）°、 （7.01±1.10）°、 （5.03±0.92）°、 （4.48±0.41）°and （4.78±0.07）°、 （2.91±0.16）°、 （2.66±0.09）°、 （2.23±0.05）°; the ROMs of flexion, extension, lateral bending and torsion in group B in state 1 and state 3 modes were （7.32±0.75）°、 （5.35±0.69）°、 （3.44±0.51）°、 （3.36±1.02）°and（3.51±0.29）°、 （1.74±0.04）°、 （1.53±0.31）°、 （1.23±0.08）°; The ROMs of flexion, extension, lateral bending, and torsion in group C in state 1 and state 3 modes were （10.01±0.39）°、 （9.05±0.25）°、 （7.42±1.06）°、 （6.92±1.15）°and （7.21±0.17）°、 （5.07±0.02）°、 （5.12±0.74）°、 （4.58±0.01）°; The ROMs of flexion, extension, lateral bending, and torsion in group D in state 1 and state 3 modes were （9.20±1.37）°、 （7.38±0.88）°、 （6.89±1.22）°、 （6.00±0.52）°and （6.06±0.16）°、 （3.99±0.02）°、 （3.85±0.08）°、 （3.47±0.10）°. The ROM value of each fixed mode group under the state of bone graft fusion and internal fixation was lower than that of the intact state, and the difference was statistically significant ( P <0.05)，The t values are 4.531, 5.346, 6.008, 4.149; 9.481, 16.181, 11.814, 4.769; 4.349, 8.002, 4.473, 4.800; 5.041, 4.146, 12.232, 10.58. ConclusionCBT screw disease intervertebral fixation can not only provide sufficient mechanical stability, but also provide stronger stability when using the same fixed segment, and The fixed segments are minimized.

目的:观察1,25(OH)2 D3在脊柱结核治疗中对患者免疫功能的调节作用.方法:2016年1月至2019年12月在浙江省中西医结合医院骨科就诊,诊断为脊柱结核,按照3HRZE/15HRE方案抗结核治疗的患者随机分为治疗组和对照组.对照组常规抗结核治疗,治疗组在此基础上加用1,25(OH)2 D3软胶囊.分别观察治疗后4周、8周两组患者血清1,25(OH)2 D3、人γ干扰素(IFN-γ)、白介素(IL)-10含量和血T淋巴细胞亚群占比的变化;分析治疗组1,25(OH)2 D3与各指标之间相关性.结果:治疗后4周、8周,治疗组血清1,25(OH)2 D3含量分别为(31.08±10.30)、(26.12±6.66)pg/mL,高于对照组的(26.50±8.70)、(21.29±6.82)pg/mL;治疗组血清IFN-γ含量分别为(19.85±5.12)、(22.14±6.83)pg/mL,高于对照组的(16.08±5.16)、(17.03±5.34)pg/mL;治疗后8周,治疗组血清IL-10含量为(19.18±5.46)pg/mL,低于对照组(21.92±6.03)pg/mL;治疗组血CD4+、CD4+/CD8+水平分别为(43.48±9.39)％、(1.88±0.57),高于对照组(39.05±8.71)％、(1.58±0.46);治疗组1,25(OH)2D3水平与CD4+、CD4+/CD8+、IFN-γ水平呈正相关,与CD8+、IL-10水平呈负相关.结论:脊柱结核患者在治疗中补充1,25(OH)2 D3是有必要的,可以提高患者血1,25(OH)2 D3的含量,改善免疫功能,增强抗结核的能力.

目的 探讨皮质骨轨迹螺钉(cortical bone trajectory,CBT)内固定对老年腰椎结核患者加速康复外科(enhanced recovery after surgery,ERAS)的影响.方法 选取2019年1月至2020年1月浙江大学医学院附属杭州市胸科医院收治的78例手术治疗的老年腰椎结核患者,根据内固定不同分为CBT组和传统组,所有患者均按照ERAS管理.其中2019年7月至2020年1月患者为CBT组,共38例,男21例,女17例,平均年龄(73.95±5.30)岁;平均骨密度T值(2.34±0.46);单节段椎体破坏30例,两节段椎体破坏8例;并发糖尿病12例,并发高血压16例,并发肺结核27例.2019年1-6月为传统组,共40例,男23例,女17例,平均年龄(73.75±5.02)岁;平均骨密度T值(2.22±0.40);单节段椎体破坏34例,两节段椎体破坏6例;并发糖尿病13例,并发高血压15例,并发肺结核30例.比较两组患者手术时间、术中出血量、术后24 h VAS评分、术后卧床时间、住院时间及术后并发症发生率.结果 CBT组手术时间[(231.34±8.57) min]、术中出血量[(483.34±58.90) ml]、术后24 hVAS评分[(4.11±0.83)分]、术后卧床时间[(7.32±1.85)d]、住院时间[(21.82±4.57)d]均低于传统组[(246.98±11.81) min]、[(517.48±37.16) ml]、[(5.10±1.06)分]、[(8.33±1.62)d]、[(24.38±3.25)d],差异均有统计学意义(t值分别为 6.664、 3.077、 4.601、 2.567、 2.863,P值分别为0.000、0.003、0.000、0.012、0.005).CBT组并发症发生率为2.6％(1/38),传统组并发症发生率为7.5％(3/40)(x2=0.949,P=0.330).结论 CBT螺钉内固定对老年腰椎结核患者ERAS产生了积极影响,能明显减少手术出血量及手术时间,加速患者康复并缩短住院时间.

全髋关节置换术是多种骨性疾病的主要治疗方法,包括髋臼破坏重、股骨颈骨折、股骨头坏死、塌陷和继发髋关节骨性关节炎等疾病,可以帮助重建髋关节,有助于患者恢复日常生活[1].常规入路全髋关节置换术创口大,但手术视野清晰,操作空间较大,同时常规术式容易造成机体创伤,恢复时间长,不利于改善预后等缺点[2].与常规入路相比,SuperPATH入路经臀小肌和梨状肌间隙开放手术创口,无需切断臀部外旋肌群,可以保留完整的髋关节囊,造成的手术创伤小,有利于恢复[3].但其操作难度大,花费高,并未完全普及.本文通过Meta分析的方法评价两种手术入路的临床治疗效果.