1.1 Inclusion criteria
①Patients with lumbar single-stage brucellosisspondylitis who have previously received 1 course of regular anti-tuberculosis medication and have no remission of infectious spondylitis;②Patients with intervertebral disc destruction causing intractable spinal pain;③Patients with significant psoas abscess or spinal canal inflammatory granuloma or spinal abscess non-absorption;④Spinal cord, Cauda equina, or nerve root compression;⑤Spinal stability affected by posterior vertebral column destruction;⑥follow-up data before and after surgery are complete and not less than 1 year.
1.2 Exclusion criteria
①Immature bone development;②Immunosuppressants have been used recently;③Presence of other spinal infections other than brucellosis;④The symptoms of brucellosis are mainly systemic, and the local symptoms of the spine are mild;⑤The infection only affects the vertebral body and does not involve the intervertebral space;⑥Large bone destruction at the anterior vertebral column;⑦Incomplete or lost follow-up.
1.3 General information
44 patients with brucellosis spondylitis treated in the Department of Orthopaedics, the First Affiliated Hospital of Hebei North University from January 2014 to January 2019 were selected. These cases were diagnosed as confirmed cases[4]. After epidemiological history, clinical manifestations, imaging, and laboratory serology-specific tests (RBPT,SAT) before admission. There were 26 males and 18 females, aged 32 to 65 years, with an average age of (42.51 ± 1.92) years. The onset time was 3 to 7 months, with an average of (4.12 ± 0.23) months. Lesions were located in the thoracolumbar segment in 2 cases, lumbar spine in 32 cases, and lumbosacral segment in 10 cases. All patients had a history of fever before surgery, showing an undulant fever of 37.9 to 38.8 ° C, with an average of (38.4 ± 0.4) ° C. Patients have varying degrees of lower back pain, muscle stiffness, restricted rotation or flexion and extension, the preoperative VAS was 5-8, with an average (6.56 ± 1.33), and the ODI was 51.15-84.36%, with an average (68.84 ± 4.55)%. 32 patients with mild to moderate malnutrition, anemia, and hypoproteinemia, BMI was 16.2 to 17.5, average (16.82 ± 0.24). 16 cases had symptoms of nerve injury, 6 cases of ASIA neurological grade C, 10 cases of D grade. MRI showed 44 cases of intervertebral disc destruction, including 16 cases of dural sac compression. RBPT and SAT were positive in 44 patients. The preoperative ESR was 31 to 105 mm / h, with an average of (55.42 ± 11.42) mm / h; the CRP was 22 to 89 mg / L, with an average of (55.40 ± 17.56) mg / L. 4 patients were allergic to 2 kinds of first-line anti brucellosis drugs, and 2 patients were intolerant to 1 kind of drugs after operation. Last follow-up for at least 12 months. At the request of the patients, 32 patients underwent secondary surgery to remove spinal internal fixation at an average of (24.02 ± 1.22) months after surgery.
This clinical study was authorized and approved by the Ethics Committee of the First Affiliated Hospital of Hebei North University (batch number: 2013-10), and informed the patients and their families of the clinical diagnosis and treatment plan, and signed the informed consent of the treatment plan.
1.4 Treatment method
1.4.1 Preoperative preparation and personalized medication plan After admission, patients are encouraged to rest in bed and implement health education about brucellosis spondylitis to improve medication compliance. X-ray, Computed Tomography (CT), and MRI examinations are performed to determine the degree of destruction of the
disc, whether there are inflammatory granulomas or abscesses in the spinal canal, whether there is compression in the spinal cord, horsetail, or nerve roots, whether the pedicle bone structure is intact, and whether the soft tissue around the spine is involved. Perfect T-SOPT. According to individual needs, patients need to strengthen systemic nutritional support before surgery, correct malnutrition indicators such as low body weight, hypoalbuminemia, and anemia, and effectively control internal medical diseases such as heart, lung, brain, liver, kidney, endocrine, and blood. Before the operation, individualized anti-brucellosis medications were administered, using a combination, appropriate amount, regular and full-course administration. For confirmed cases, doxycycline + rifampicin + sulfamethoxazole is the first choice[7]. The dose of the drug is based on the weight, liver and kidney function of the patient. Doxycycline (2.2mg/kg once daily, maximum dose 0.2g/kg once daily, for 56 days continuously); Rifampicin (10mg/kg once daily, maximum dose 0.6mg/kg once daily, for 56 days continuously); Sulfamethoxazole composite (1.0g doubled for the first time, twice a day, for 56 days continuously). T-SPOT was used to detect rifampicin resistance. For those who were allergic or intolerant to a rifampicin drug, it could be changed to doxycycline + sulfamethoxazole + streptomycin according to individual allergies and physical conditions, Streptomycin (20 mg / kg, maximum dose 1.0 g / kg, intramuscular injection, once a day for 21 days). For those who were allergic or intolerant to the two drugs of doxycycline and streptomycin, they can be changed to rifampicin + fluoroquinolones + tobramycin according to the "Brucellosis Diagnosis and Treatment Guide" [8], Tobramycin (1mg / kg per day, once per 8 hours, the maximum dose is 5mg / kg per day, 1 course of treatment on 10-14 days); Patient's liver and kidney function and drug side effects were regularly monitored during medication. Through individualized drug treatment, surgery could be performed only when nutrition was improved, various indicators were stable, and ESR was decreasing, and no higher than 40mm / h. [9 10]
1.4.2 One-stage posterior approach for limited lesion removal and internal fixation The patient was given general anesthesia, prone position, and a midline incision was taken from the back of the spine. Expose the spinous process, lamina, articular process of the diseased vertebra and one vertebra adjacent to the diseased vertebra, and accurately insert pedicle screws under C-arm. According to the preoperative imaging evaluation, if the pedicle and the upper part of the vertebral body are intact, the lower part of the vertebral body is slightly damaged and the sclerotic bone is less, the pedicle screw can be inserted into the diseased vertebral body after applying streptomycin; If the vertebral body is severely damaged or unstable, the adjacent vertebral body can be selected for pedicle screw fixation across the diseased vertebral body. According to the location of the lesion, part of the facet joints on one or both sides of the diseased intervertebral space were excised, and the dural capsule and the nerve roots of the diseased segment were exposed and separated. Abscesses and granulomas in the spinal canal were removed, and the bone destruction area behind the vertebral body and the infected intervertebral disc tissue were thoroughly scraped until the normal vertebral bone surface leaked. After repeated rinsing, an appropriate amount of the autologous sacrum, the previously cut articular process and a little bite of the lamina were added to 1 g of streptomycin powder for intervertebral bone grafting. The gelatin sponge was filled behind the bone grafting gap to prevent Bone fragments fall into the spinal canal. According to the preoperative imaging location, if there was a large paravertebral abscess, the abscess could be removed through the transverse process of the diseased vertebra, and then the streptomycin powder could be placed after repeated washing with gentamicin saline. The fixation rod was placed, the screws were pressed and fixed, the scoliosis deformity was corrected, the drainage tube was placed and sutured layer by layer. The operation time was 70 to 120 min, with an average of (80.15 ± 9.51) min, and the bleeding volume was 200 to 400 mL, with an average of (250.24 ± 20.12) mL. Bacterial culture, drug sensitivity and pathological examination were carried out on the diseased tissue or pus removed by operation to provide basis for pathological diagnosis and further development of sensitive chemotherapy plan.
1.4.3 Postoperative management and individualized medication plan After the operation, we continued to carry out health education and medication compliance guidance, continued to give nutritional support therapy, corrected anemia and hypoproteinemia, stabilized internal diseases, and regularly reexamined blood routine and related biochemical indicators. The drainage tube was removed 48 hours later. The next day, the patient was asked to gradually get out of bed and move with spinal brace. The wearing time was at least 3 months. According to the individualized anti brucellosis medication plan before operation, the anti-brucellosis drugs should be taken on the second day after operation. According to the results of bacterial culture and drug sensitivity, sensitive and non-allergic anti- brucellosis drugs were used, and three sensitive drugs were combined for two courses. If there are less than 3 first-line sensitive drugs in the Brucellosis Treatment Guideline, use quinolones or aminoglycosides until the RBPT turns negative, and continue to take the medicine for 2 weeks. During the treatment period, check the liver and kidney functions monthly and find out if there is any abnormal response treatment. When there are less than 3 first-line sensitive drugs in the Brucellosis Treatment Guidelines, use quinolone or aminoglycoside drugs, until RBPT becomes negative for 2 weeks. During the period of medication, the liver and kidney functions were rechecked every month, and the corresponding treatment was carried out in time if any abnormality was found.
1.5 Follow-up and efficacy evaluation
Patients came to our hospital for follow-up visits every 3 months after surgery. ESR, CRP and RBPT were used to evaluate the control of inflammation; VAS score was used to evaluate the relief of lumbocrural pain; ODI was used to evaluate the impact of lumbocrural pain on daily life function; ASIA neurological classification was used to evaluate the recovery of spinal cord function; BMI was used to evaluate the nutritional status of patients. All patients underwent imaging evaluation, the stability of spine, fusion of bone graft and fixation of pedicle screw were evaluated by X-ray. 16 patients with ponytail or nerve root injury before operation were examined by MRI to evaluate spinal cord, ponytail or nerves. Root decompression situation. MRI was performed in 16 patients with cauda equina or nerve root injury before operation to evaluate the decompression of spinal cord, cauda equina or nerve root. Standard of bone graft fusion [11]: no tenderness, throbbing pain, or abnormal activity in the diseased spinal segment, and internal fixation is stable; imaging shows that the bone graft particles in the intervertebral space do not fall off or be absorbed, the intervertebral space is fuzzy and there is bone trabecula passing through, no pseudojoint formation, and bone remodeling is obvious.
1.6 Statistical methods
Statistical Product and Service Solutions (SPSS) 21.0 statistical software was used to analyze the data. The data of ESR and CRP were expressed by mean ± standard deviation. VAS score, ODI score, Asia grade and BMI were tested by independent sample t-test, the test standard was p < 0.05.