原发性椎管内脓肿的诊断与治疗

doi:10.19723/j.issn.1671-167X.2020.02.013

摘要/Abstract

摘要：

目的总结原发性椎管内脓肿的特点以及治疗方法,以期提高原发性椎管内脓肿的诊断与治疗水平.方法: 回顾性分析北京大学第三医院近20年来收治的13例原发性椎管内脓肿的病例,分别对其病史,病因,病原学,手术方式以及预后进行分析.结果: 所有病例病程从7 d到6个月不等,所有病例均以疼痛起病,有10例自觉肢体无力,有5例患者有发热史,8例血常规白细胞升高.13例中颈椎管内脓肿1例,颈胸段1例,胸段1例,胸腰段4例,腰骶段6例.病原学中,细菌培养阳性4例,病理学诊断结核3例,1例因发病前感染布氏杆菌(Brucella)按该细菌感染治疗,其余病例病原学结果均阴性.所有病例均行手术治疗,并获得组织病理学诊断.手术目的主要为清除病灶并减压,引流.术后根据病原学结果及临床经验予以抗感染及激素治疗.有2例术后形成切口脓肿再次行手术治疗,手术为清创及转移肌瓣修复.随访0.5~3.0年,平均1.8年.随访期1例术后复发并沿椎管扩散,再次手术治疗.所有病例最后炎症均完全恢复,神经系统体征较术前均有不同程度好转.结论: 原发性椎管内脓肿发病相对较急,主要以疼痛起病,腰骶部最好发,细菌培养多以阴性为主.建议早期手术,使用广谱,足量抗生素.术后如出现切口脓肿形成,宜在清创基础上转移肌瓣修复.术后为缓解脊髓和神经根水肿,可在抗生素保障下使用激素.

关键词: 椎管内脓肿, 手术, 抗生素, 激素, 肌瓣修复

Abstract:

Objective: To summarize the feature and treatment of the primary intraspinal abscess in order to improve the prognosis.Methods: In the study, 13 cases of primary intraspinal abscess of the recent 20 years were retrospectively analyzed. The history, etiology, pathogen, surgical methods and prognosis were summarized.Results: The course of the illness ranged from 7 days to 6 months. All the cases began with pain. Of the 13 patients, 10 had limb weakness. Five had a fever and 8 had increased white blood cells. As for distribution, 1 was in cervical vertebra, 1 in cervicothoracic junction, 1 in thoracic vertebra, 4 in thoracolumbar junction, and 6 in lumbosacral segment. The results of bacterial culture were positive in 4 cases, 3 cases were diagnosed as tuberculosis by pathological examination, and 1 case was recognized as infection of Brucella melitensis bacteria because of prior brucellosis. The pathogen of the remaining cases were unclear. All the cases received surgical treatment and pathology examination. The surgical aim was mainly removal of the lesion, decompression and drainage. Postoperatively anti-infection and glucocorticoid therapy were performed according to the pathogeny results and clinical experience. Incision abscesses were seen in 2 cases and reoperations including debridement and repair with transferred muscle flap were performed. Postoperative follow-up ranged from 6 months to 3 years (mean 1.8 years). One case suffered postoperative recurrence and the abscess spread along the vertebral canal. Reoperation was performed. Infections of all the cases were recovered completely and the nervous system signs were all improved in different degrees.Conclusion: The onset of primary intraspinal abscess is relatively urgent, mainly with pain. The lumbar and sacral vertebra is the predilection site. The bacterial culture is mostly negative. Early operation and use of sufficient amount of broad-spectrum antibiotic are recommended. If the incision abscess forms after the operation, it is advisable to transfer the muscle flap to repair the coloboma on the basis of debridement. In order to relieve edema of spinal cord and nerve root, the glucocorticoid can be used in the escort of antibiotics.

Key words: Intraspinal abscess, Surgery, Antibiotics, Glucocorticoid, Muscle flap

中图分类号:

R632.5

马长城,王振宇,林国中. 原发性椎管内脓肿的诊断与治疗[J]. 北京大学学报（医学版）, 2020, 52(2): 275-280.

Chang-cheng MA,Zhen-yu WANG,Guo-zhong LIN. Diagnosis and treatment of primary intraspinal abscess[J]. Journal of Peking University (Health Sciences), 2020, 52(2): 275-280.

图/表 6

表1

患者一般资料"

Case	Gender	Age	Predisposing factor	Course/d	Onset symptom	Temperature	Neurological signs
1	Female	13	Diabetes mellitus	30	Low back pain and lower extremity pain	Normal	Weakness of lower limb and loss of lower limb tendon reflex
2	Female	15	None	180	Right upper limb pain	Normal	Weakness and hypoesthesia in the right upper limb
3	Male	18	Malignancy	7	Low back pain and lower extremity pain	Fever	Local tenderness, hypoesthesia between T10 to L1 and hyperesthesia between L2-L5
4	Female	24	Long term use of glucocorticoid	7	Low back pain	Fever	Weakness of lower limb, hypoesthesia below T12, hyporeflexiaof lower limb tendon reflex and relaxation of anal sphincter
5	Male	30	History of brucellosis	20	Neck pain	Normal	Weakness of right limb, positive right Babinski's sign and hypoesthesia at C2
6	Female	34	None	180	Low back pain	Fever	Local tenderness, hypoesthesia of right lower limb, weakness of lower limb, hyporeflexia of lower limb tendon reflex and meningeal irritation sign
7	Female	46	Malignancy, Diabetes mellitus	18	Low back pain	Normal	Weakness of lower limb and hyporeflexia of lower limb tendon reflex
8	Female	51	Local dermal sinus	15	Low back pain	Normal	Weakness of lower limb, hyperreflexia of lower limb tendon reflex, hypermyotonia and hyperesthesia of lower limb
9	Male	54	Local dermal sinus	10	Low back pain	Normal	Weakness of lower limb, hyperreflexia of lower limb tendon reflex, hypermyotonia and hyperesthesia of lower limb
10	Male	56	None	14	Low back pain	Fever	Local tenderness, weakness of lower limb and meningeal irritation sign
11	Female	58	None	20	Chest back pain	Normal	Weakness of lower limb, hyperreflexia of lower limb tendon reflex, pathological signs and hypoesthesia below T6
12	Female	64	None	30	Lumbosacral pain	Fever	Local tenderness, weakness of lower limb and hyporeflexia of lower limb tendon reflex
13	Male	68	Adjacent skin infection	7	Low back pain	Normal	Paralysis of lower limbs and relaxation of anal sphincter

表1

表2

图1

表3

表4

图2

参考文献 26

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Case	Inflammatory markers			MRI
Case	WBC	ESR	CRP	MRI
1	Normal	High	NA	Subdural lesion between L4-S1 with significant enhancement
2	Normal	High	NA	Epidural lesion between C7-T3 with area of cystoid variation and necrosis and significant enhancement of solid area
3	High	NA	NA	Epidural lesion in the thoraco-lumbo-sacral spinal canal with posterior vertical spine muscle strip enhancement, posterior lamellar muscle enhancement
4	High	NA	NA	Epidural cystic lesion between T12-L2 with enhancement of cyst wall
5	Normal	Normal	High	Epidural lesion ventral to spinal cord between C2-C4 with significant homogeneous enhancement and edema of corresponding spinal cord
6	Normal	NA	NA	Multiple subdural lesions between T12-L3 with significant homogeneous enhancement
7	Normal	High	NA	Intraspinal cystic lesion between T8-L2 with ring enhancement of cyst wall
8	High	NA	NA	Intramedullary abnormal signal between L2-L3 with ring enhancement, dermal sinus at L4-L5 connected to the spinal canal with tethered cord
9	High	NA	NA	Intramedullary abnormal signal between L2-L3 with ring enhancement, dermal sinus at L2-L3 connected to the spinal canal
10	High	NA	NA	Intraspinal lesion between L3-L5 with ring enhancement
11	High	NA	NA	Extramedullary epidural lesion between T4-T5 with ring enhancement
12	High	High	High	Multiple intraspinal and paravertebral cystic lesions between S1-S3 with ring enhancement
13	High	NA	NA	Epidural cystic lesions between T9-L1 with ring enhancement

Case	Treatment				Location	Abscess character
Case	Surgery	Antibacterials	Glucocorticoid	Mannitol	Location	Abscess character
1	Yes	Yes(anti-TB)	No	No	L4-S1, epidural, ventral	Gelatinous and caseous
2	Yes	Yes(anti-TB)	No	No	C7-T3, epidural	Thinning pus and gray granuloma
3	Yes	Yes	No	No	L4-S1, epidural	Yellowish-white thinning pus
4	Yes	Yes	Yes	No	T12-L2, epidural	Beige pus
5	Yes	Yes	Yes	Yes	C3-C7, epidural, ventral	Purple-red granuloma
6	Yes	Yes	No	No	T12-L3,intra-extramedullary	Yellow sticky pus and granuloma
7	Yes	Yes	Yes	No	T8-L2, epidural	Much yellow pus with granuloma
8	Yes	Yes	Yes	Yes	L2-L3,intra-extramedullary	Yellowish-white pus with much pus mosses
9	Yes	Yes	Yes	Yes	L2-L3,subdural	Yellowish-white pus
10	Yes	Yes	No	No	L3-L5, epi-subdural	Yellowish-white pus with pus mosses and granuloma
11	Yes	Yes	Yes	Yes	T4-T5, intramedullary	Yellowish-white pus
12	Yes	Yes	No	No	S1-S3, epi-subdural and paravertebral	Yellowish-white pus with pale yellow granuloma
13	Yes	Yes	No	No	T9-L1, epidural	Beige pus with little granuloma and much pus mosses

Case	Pyoculture	Blood culture	Pathology	Possible way	Outcome
1	Negative	Negative	Tuberculosis	Hematogenous	Complete recovery
2	Negative	NA	Tuberculosis	Hematogenous	Complete recovery
3	Negative	NA	NA	Hematogenous	Complete recovery
4	Staphylococcus aureus	NA	Pus	Hematogenous	No abscess or pain, light hypoesthesia, muscle strength grade IV, occasional urine incontinence
5	NA	NA	NA	Hematogenous	No abscess or pain, euesthesia, muscle strength grade Ⅳ
6	Negative	NA	Pus	Hematogenous	Recurrence 1 year later, complete recovery finally
7	Negative	NA	Tuberculosis	Hematogenous	No abscess or pain, euesthesia, muscle strength grade Ⅳ
8	Enterococcus faecalis	NA	Dermal sinus, necrosis and granulation tissue	Direct spread	Complete recovery
9	Escherichia coli	NA	Dermal sinus	Direct spread	Complete recovery
10	Negative	NA	Pus	Hematogenous	No abscess or pain, euesthesia, muscle strength grade Ⅳ
11	Negative	NA	Pus	Hematogenous	No abscess or pain, hypoesthesia, no provement in muscle strength
12	Negative	Negative	Pus	Hematogenous	Wound abscess which restored after debridement and repair with muscle flap, complete recovery finally
13	Staphylococcus aureus	NA	Pus	Hematogenous	Wound abscess which restored after debridement and repair with muscle flap. No abscess or pain, hypoesthesia, muscle strength grade Ⅳ, occasional urine incontinence finally