transthoracic tuberculosis debridement

1. Applicable to 5-11 tuberculosis in the thoracic spine. More than 5 thoracic vertebrae and 11 thoracic vertebrae, due to the limitations of the thoracic and diaphragmatic muscles, difficult to operate, other procedures should be used. 2. Thoracic tuberculosis with more than 2 vertebral bodies, or marginal bone tuberculosis that invades most thoracic vertebrae. 3. Paravertebral abscess of thoracic tuberculosis is broken into the lobe. Treatment of diseases: acute abscess of bone tuberculosis Indication 1. Applicable to 5-11 tuberculosis in the thoracic spine. More than 5 thoracic vertebrae and 11 thoracic vertebrae, due to the limitations of the thoracic and diaphragmatic muscles, difficult to operate, other procedures should be used. 2. Thoracic tuberculosis with more than 2 vertebral bodies, or marginal bone tuberculosis that invades most thoracic vertebrae. 3. Paravertebral abscess of thoracic tuberculosis is broken into the lobe. Contraindications 1. Thoracic tuberculosis with heart and lung dysfunction. 2. Old age or child under 10 years of age. Preoperative preparation 1. Acquire patient cooperation: Bone and joint tuberculosis is a chronic disease with a long course of treatment and often has a certain degree of dysfunction after treatment. Therefore, most patients have irritable mood and ideological burden. Before the operation, we must thoroughly explain the work, and truthfully seek the treatment plan and consequences (including the number of operations, external fixation and bed time, medication time and possible dysfunction) to the patient and their families to obtain cooperation. 2. Perform the necessary examinations: Careful examination and chest fluoroscopy should be performed before surgery to find out if there are other tuberculosis lesions in the body. For patients with long disease period and many sinus secretions, liver and kidney function should be checked. X-ray examination should be performed on the lesions. If necessary, spinal tuberculosis and paraplegia should be performed by CT examination to understand the lesions for surgical design. 3. Improve the general condition: bed rest should be taken immediately after admission, and bed defecation training should be carried out to avoid difficulty in defecation due to unaccustomed postoperative. In general, TB patients have poor appetite and should seek to improve their appetite before surgery. Strengthen nutrition as much as possible to improve the general condition. 4. Drug treatment: The application of anti-tuberculosis drugs is an important part of preoperative preparation, mainly to prevent the spread of lesions. Once the diagnosis is confirmed. Anti-tuberculosis drugs should be applied. Single drug treatment is not effective, and it is easy to cause bacterial resistance. In general, streptomycin is used in combination with isoniazid. The amount of streptomycin varies depending on the age, 0.25g per day for children under 5 years old, 0.33g for 5 to 10 years old, 0.5 to 1.0g for adults, and intramuscular injection once or twice. Isoniazid is taken daily for 5 to 10 mg/kg, orally or in three divided doses. After 1 week of anti-tuberculosis drugs, the symptoms of tuberculosis poisoning can begin to improve; in about 2 weeks, most patients have improved symptoms and can be operated on. Sodium salicylate is easy to cause gastrointestinal symptoms, affect appetite, and is less clinically applicable. However, when the efficacy of streptomycin or isoniazid is not good, sodium salicylate can be added in an amount of 8 to 10 g per day, orally or intravenously. 5. Local Brake: Patients with spinal tuberculosis should be placed in a hard bed or plaster bed, tuberculosis in the extremities, especially those with joint pain or severe muscle spasm, which should be externally fixed or pulled to relieve pain and paralysis. Rest, and can prevent pathological dislocation or gradually correct deformity, reducing the difficulty of surgical operation. 6. Selection of the surgical side: the surgical side should be determined according to the paraspinal abscess, vertebral destruction, pleural adhesion and diseased vertebrae. Generally, the side with large abscess and obvious destruction and no adhesion to the pleura is selected. However, the middle thoracic vertebrae are more convenient to enter through the right chest, and can be affected by the heart beat. The lesions below the thoracic vertebrae are affected by the diaphragm and the liver in the right thoracic cavity, and it is convenient to enter through the left chest. 7. Selection of the ribs to be removed: According to the site of the diseased vertebrae, any one of the 5th to 9th ribs can be removed. 5 to 9 tuberculosis of the thoracic vertebra should be removed and destroyed the ribs of the corresponding plane of the most obvious vertebral body. Such as the sixth, seventh, and eighth thoracic tuberculosis, the destruction of the thoracic vertebra 7 is the most significant, the seventh rib should be removed, can directly enter the lesion, clear vision, easy to operate; such as intraoperative spinal canal is also simpler. However, the thoracic vertebrae 10 to 11 tuberculosis should be removed from the 9th rib. Surgical procedure 1. Position: lateral position, lateral side, chest under the bolster, the two upper limbs stretch forward, placed on the upper limb frame. 2. Incision, open chest: the posterior lateral incision is made along the rib that is scheduled to be resected, and the posterior side is from the outer edge of the iliac spine muscle, ending at the anterior line of the ankle. The thoracotomy step is the same as thoracotomy. The cut ribs should be kept in a safe place for bone grafting. After the chest is opened, if the stump on the posterior side of the rib is too long and protrudes into the wound, it may puncture the lung or interfere with the operation. If there is pleural adhesion, the gauze ball or the gauze-covered finger can be used to separate the lung lobe and the paraspinal abscess is completely revealed. 3. Expose and clear the lesion: After opening the chest, shake the operating table so that the patient's back is at an angle of 60° to the ground. Open the lungs and reveal the lesions. If necessary, the right side can cut off the azygous vein; the left side can cut off the lower ligament to increase exposure. Before cutting the abscess, use saline gauze to protect and isolate the surrounding tissue to prevent pus from flowing out of the contaminated chest. If the abscess is not large and the lesion is limited to two vertebral bodies, the abscess wall can be cut transversely in the direction of the center of the rib, so as not to damage the auxiliary blood vessel that enters the abscess wall through the lower edge of the rib. If the intercostal blood vessels are accidentally cut, they should be sewed immediately. If the abscess is large, the vertebral body lesions are extensive, and after the intercostal vessels are sutured, the lesions can be fully revealed after longitudinal or t-cut and open the abscess wall. The steps of removing the lesion and interbody fusion were the same as those of the assisted bone and transverse process for the removal of tuberculosis. If the paraspinal abscess breaks into the lung lobes, the pleural adhesions are more serious. The separation of the mediastinal pleura should be as close as possible to the visceral pleura, so as to avoid accidentally injuring the mediastinum, nerves, and even the contralateral pleura. After the separation is completely clear, the sinus between the lung and the lesion is cut off. Generally, the lesions in the lobes are not large, and can be sutured after scraping or wedge-shaped resection. If the lung lobe is severe, consider a lobectomy or a segmentectomy. If the paraplegia or dead bone is located in the posterior part of the vertebral body, 1 or 2 pedicles can be exposed and excised, the dura mater can be exposed, the spinal cord can be protected, and the anterior and intervertebral bone grafts can be performed. See the section "Spine wall of the spinal canal." Excision of lesion removal." 4. Stitching and drainage: 1 g of streptomycin powder was built in the lesion, and the abscess wall and parietal pleura were layered. The thoracic cavity was flushed with normal saline, and after drainage in the lowest position of the posterior iliac crest line, the thoracic cavity was closed by layer-by-layer suture according to the thoracotomy. complication Treatment of thoracic exudate: After the lung surgery, generally within 24 hours, the chest cavity will have 200 ~ 400ml of oozing and exudate flowing out through the drainage tube, the blood color of the drainage fluid should gradually fade. After about 24 to 72 hours, the effusion can be drained and the drainage tube can be removed. When pulling the drainage tube, the drainage tube should be disinfected near the skin and the skin around the drainage port, and the fixed line should be cut. The pad with 4 to 5 layers of Vaseline gauze pad should be placed in the drainage port and the other hand should hold the drainage tube. After the patient inhales deeply, he does not exhale and quickly pulls out the drainage tube. At the same time, the Vaseline gauze and the cotton pad are pressed against the drainage port, and the tape is pressure-wrapped to prevent the air from leaking into the chest cavity.