Removal of lumbosacral spinal tuberculosis lesions

Lumbar sacral spinal tuberculosis refers to tuberculosis from the third lumbar vertebra to the third sacral vertebra. Clinically used anterior side exposure pathways can be divided into two types: transperitoneal and transperitoneal. Transabdominal lesion removal is a midline abdominal incision, incision of the peritoneum, push open the intestine, and then open the peritoneum to reveal and clear the lesion. Because the incision is centered, although it is relatively straightforward, it is inconvenient to treat the psoas abscess on both sides, or it can be removed by another posterior peritoneal incision. Because of the abdominal cavity operation, the abdominal cavity is disturbed more, the pelvic stimulation is also heavier, and it is prone to abdominal distension, urinary retention, etc. after surgery, and may even cause intestinal adhesion or intra-abdominal tuberculosis infection. Extraperitoneal lesion removal is a transabdominal incision that pushes the peritoneum and reveals and clears the lesion after the retroperitoneum. The disadvantage is that one incision can not remove the lesions on both sides, and the other side of the incision should be used for surgery or partial surgery. In addition, the incision is lateral to the side, and the treatment of vertebral lesions is not direct enough. However, if the operation technique can be improved, the lesion can be completely eliminated, and the shortcomings of the transabdominal approach can be avoided, and it is safer. Therefore, extraperitoneal lesions are often used clinically. Only after repeated failure of the extraperitoneal approach, it is estimated that there is severe adhesion, and it is difficult to remove the lesion from the extraperitoneal to the lesion. Treatment of diseases: simple spinal tuberculosis, spinal tuberculosis Indication Lumbosacral spinal tuberculosis Surgical procedure 1. Position, incision and exposure: see the laparoscopic extraperitoneal exposure route. 2. Clear the lesion: Use a saline gauze pad to protect the peritoneum and its contents from the abscess wall and the ureter, abdominal aorta (or inferior vena cava) and its branches, and lead to the opposite side to fully reveal the abscess. Cut the abscess and drain the pus. Abscess in the anterior aspect of the psoas muscle, the anterior wall is thin, generally does not hurt the lumbar plexus when incision; but when the psoas muscle abscess is large and deep, local inflammatory infiltration is obvious, the diaphragm and the psoas muscle gap When it is unclear, it is more difficult to identify the femoral nerve. During the operation, it is necessary to extend the finger examination to avoid damage to the femoral nerve. At the same time, when the abscess wall incision is enlarged downward, the finger should be bluntly divided, and the knife should not be cut so as not to damage the total or external movement or vein. Then, scrape the granulation tissue on the inner wall of the abscess, and carefully search for the sinus after the heat is stopped. Subsequent surgical procedures vary depending on the location of the lesion and the local anatomy. If the tuberculosis above the fifth lumbar vertebrae, after the removal of the psoas muscle abscess, the sinus can be found locally. If the sinus is larger, the lesion can be removed; if the sinus is small, the large blood vessels in front of the vertebral body are carefully protected and then the periosteum is cut in the anterior lateral part of the vertebral body with a sharp-edged knife. After cutting off the lumbar motion and vein, use the periosteal stripper to adhere to the vertebral body to peel forward and backward, enlarge the exposure, and then enlarge the sinus ostium to clear the lesion. However, in the following cases, it is not appropriate to use the above sinus enlargement method: 1 If the sinus is located near the intervertebral foramen, if the sinus ostium is cut upward or downward, it may damage the lumbar nerve root. 2 If there is a tendon-like cord (possibly lumbar nerve root) around the sinus ostium, it should not be cut off casually, but should be avoided. 3 Sometimes the sinus is broken down along the lumbar tendon bundle, which is far from the diseased vertebrae. It is not suitable to remove the lesion through the sinus. 4 The sinus is small and tortuous, and it is difficult to clear the lesion through the sinus. In this case, the lesion can only enter the outside of the abscess; the peritoneum and its contents are pulled to the opposite side, the retroperitoneal large blood vessels are exposed, the abdominal aorta (or inferior vena cava) is separated, and the lumbar artery is ligated and cut, and the large blood vessels are opened. , the shape of the incision and peeling of the periosteum and anterior longitudinal ligament to reveal the diseased vertebra. Before cutting the vertebral periosteum, first confirm the lesion. Most sinus sites are diseased vertebrae, and positioning is not difficult. If the sinus ostium is far from the lesion, the probe can be used to locate the sinus, or according to an anatomical landmark (such as the abdominal aortic bifurcation in the 4th lumbar plane). If it is the fifth lumbar vertebrae or sacral tuberculosis, the outside is located below the bifurcation of the abdominal aorta and inferior vena cava. The anterior lateral part of the lesion is covered by the common iliac artery. It is difficult to damage the vertebral body with the above side. Large blood vessels; direct and safe if exposed from the front of the vertebral body. The peritoneum and organs, ureters, bladder, and rectum can be pulled through the midline to reveal the anterior sacral abscess. After recognizing the location of the large blood vessels, surgery is performed in the triangle below the aortic bifurcation. Separate, ligature, and cut off the middle and middle sacral veins. After the puncture is confirmed as an abscess, the worker or the "Shi" shape cuts the wall of the abscess. If there is a psoas abscess, the abscess can be removed and the finger is inserted into the abscess. After the posterior side of the large blood vessel, it is ejected in the lower triangular region of the bifurcation, and then the abscess wall is cut there to reveal and clear the lesion. If the sinus tract is not large, it can be used for subperiosteal stripping and enlargement, but it is necessary to avoid damage to blood vessels. After the lesion is removed, if the local conditions are suitable, it can be used for interbody fusion. After removing the lesion on one side of lumbar tuberculosis, if the patient is in good condition and there is a lesion on the opposite side of the vertebral body, the same procedure can be used to perform the contralateral lesion removal from the contralateral abdominal wall. When removing the lesion, the sinus tracts should be connected to each other as much as possible so that they can be completely removed. If the lesion has been completely removed by one side of the surgery, the contralateral psoas abscess can be removed by a small oblique incision in the contralateral abdominal wall. 3. Stitching: After clearing the lesion, flush the wound with normal saline, add 1g of streptomycin powder to the lesion, suture the lumbar fascia intermittently, remove the hook, let the peritoneum return to the in situ, and then suture the transverse abdominis and abdominal oblique Muscle and external oblique muscles. Finally suture the skin without placing a flow strip.