摘要目的对比分析单纯后路、单纯前路与前后联合入路治疗成人腰椎结核患者5年随访的临床和影像学资料，探讨单纯后路病灶清除椎体间植骨融合的关键技术及其优势。方法自2004年6月至2010年1月收治成人腰椎结核患者311例，共137例纳入研究。男83例，女54例；年龄20~75岁，平均65.6岁。单节段53例，双节段57例，三节段及以上27例。单纯后路组（行单纯后路病灶清除椎体间植骨融合术，共63例），单纯前路组（行单纯前路病灶清除植骨融合术，共32例），前后联合入路组（行前路病灶清除植骨融合后路内固定术，共42例）。对比分析三组患者的创伤指标：包括出血时间、出血量、住院时间、并发症，影像学指标：包括节段后凸Cobb角（segment kyphotic angle，SKA）、融合时间、SKA矫正率、矫形角度丢失；中期临床疗效评价指标：Oswestry功能障碍指数（Oswestry disability index，ODI）、疼痛视觉模拟评分（visual analogue scale，VAS）、Frankel分级、Macnab评分优良率，并进行统计学分析。结果单纯后路组的手术时间（207.9±30.9） min、术中出血量（409.5±107.9）ml、并发症发生率12.95%均低于单纯前路组[（270.7±32.0）min、（649.0±120.0）ml、30.95%]和前后联合入路组[（349.7±38.9）min、（840.0±168.7）ml、25%]，差异有统计学意义；前后联合入路组手术时间、术中出血量、并发症发生率及住院时间高于其他两组，差异有统计学意义。单纯前路组患者SKA的矫正率（52%±5.45%）低于单纯后路组（74%±5.04%）和前后联合入路组（69%±7.95%），而矫正角度丢失高于其他两组，差异均有统计学意义。随访时间为5~11年，平均6.5年。各组植骨融合时间的差异无统计学意义；通过手术治疗各组患者的生活质量均得到明显改善，末次随访时单纯后路组ODI改善率（80.6%±2.1%）、VAS改善率（81.7%±1.6%）、Macnab优良率（95.24%）与单纯前路组[79.8%±1.5%、79.7%±2.0%、92.95%]、前后联合入路组[81.3%±1.1%、79.9%±0.8%、90.63%]的差异均无统计学意义。结论三种手术方式治疗成人腰椎结核的中期随访结果显示临床疗效满意；对于成人单节段腰椎结核单纯后路病灶清除、椎体间植骨融合术，相对于单纯前路及前后路联合术式，具有微创、高效的优点。

abstractsObjective To compare the minimum 5?year follow?up outcomes of surgical management by posterior only, anterior only and combined posterior and anterior approaches for lumbar tuberculosis in adults, evaluate the mid?term follow?up results of the surgery for the treatment of lumbar tuberculosis and explore its advantages and indications. Methods From Jun 2004 to Jan 2010, 311 adult patients with lumbar tuberculosis were treated surgically. The clinical data of 137 cases that met the enrolled criteria and had integrity following?up data was analyzed retrospectively. It included the patients who had the surgical indication of the posterior only surgery but underwent the anterior only or the combined posterior and anterior ap?proaches before 2008. There were 83 cases of male and 54 cases of female. The age ranged from 20 to 75 years, with a mean of 65.6 years. Among these patients, 63 cases were treated with single?stage posterior debridement, interbody fusion and instru?mentation (the posterior group); 42 cases were treated with posterior instrumentation, and anterior debridement and bone graft in a single or two?stage procedures (the combined group) and 32 cases were treated with anterior debridement and strut graft?ing with instrumentation (the anterior group). Trauma index (the operation time, blood loss, the length of hospital stay, compli?cations);imaging parameters (Segment kyphotic angle, corrective rate, loss angle, bone fusion time) and the quality?of?life indi?cators (Oswestry Disability Index、Frankle grade、visual analogue scale、Macnab score) were compared among three groups. Re?sults The mean operation time, mean blood loss and the complications rate were (207.9 ± 30.9) min, (409.5 ± 107.9) ml and 12.95%in the posterior group;(270.7±32.0) min, (649.0±120.0) ml and 30.95%in the anterior group;(349.7±38.9) min, (840.0± 168.7) ml and 25%in the combined group. The operation time, blood loss and the complications rate of the posterior group were less than the anterior group and the combined group, and the difference was significant;The combined group consumed the longest operation time, associated with the most intraoperative blood loss, the highest complication rate and the longest hospital stay among the three groups, and the difference was significant. The correction rate of kyphosis achieved of the anterior group ( 52%± 5.45%) was significantly inferior to the posterior group (74%±5.04%) and the combined group (69%±7.95%), while the loss of cor?rection in the anterior group (2.5°) was higher than both the posterior group (0.8°) and the combined group (1.1°), and the differ?ence was significant. The average follow?up was(6.5±1.96)years (range, 5-11). The mean bone fusion time of the posterior group, the anterior group and the combined group were (6.0±1.5) months, (6.2±1.3) months and (6.5±1.6) months respectively, and there was no statistic difference. After the surgery, the quality of life was improved obviously in all patients. At the time of the latest fol?low?up, the improvement rate of the ODI,VAS and the excellent and good rate according to the Macnab score were 80.6%±2.1%, 81.7%± 1.6%and 95.24%in the posterior group;79.8%± 1.5%, 79.7%± 2.0%and 92.95%in the anterior group;81.3%± 1.1%, 79.9%±0.8%and 90.63%in the combined group. There was no significant difference among the groups in the improvement rates of the ODI, VAS, Frankel grade and the excellent and good rate of the Macnab score. Conclusion The Mid?term follow?up of the different surgical procedures for the treatment of the lumbar tuberculosis in adults were basically satisfactory. Compared with the traditional surgery, the posterior?only surgery is a safe, minimally invasive and effective method in the management of monoseg?ment lumbar tuberculosis in adults.