全脊椎整块切除术治疗胸腰椎肿瘤及稳定性重建结果  

Treatment of thoracolumbar tumors with total en bloc spondylectomy and the results of spinal stability reconstruction

作　　者：杨强[1] 李建民[1] 杨志平[1] 李昕[1] 李振峰[1] 阎峻[1] 

机构地区：[1]山东大学齐鲁医院骨外科,济南250012

出　　处：《中华肿瘤杂志》2013年第3期225-230,共6页Chinese Journal of Oncology

基　　金：山东省科技攻关计划项目（2011GGH21831）

摘　　要：目的探讨全脊椎整块切除术治疗胸腰椎肿瘤的效果及稳定性重建的结果。方法2007年1月至2011年6月，18例胸腰椎肿瘤患者拟行全脊椎整块切除术。肿瘤位于胸椎10例，腰椎8例。血管瘤7例，骨巨细胞瘤5例，恶性神经鞘瘤、浆细胞瘤、神经母细胞瘤、骨母细胞瘤、转移性恶性纤维组织细胞瘤和乳腺癌转移瘤各1例。18例患者均在脊髓电生理检测下行全脊椎整块切除术，其中14例为一期后路手术，4例为一期后前联合入路。前方椎体重建方式为钛网植骨或骨水泥15例，带加强环的钛网2例，人工椎体1例。后路固定方式为椎弓根钉棒系统长节段固定15例，短节段固定3例；配合后方大块桥接植骨13例，碎块植骨5例。结果18例患者中，15例成功整块切除，3例改为分块切除。15例顺利完成全脊椎整块切除患者的平均手术时间为450．7min，平均出血量为4850ml，术中平均输血量为4200ml。手术相关并发症有血气胸、肋间神经疼和应激性溃疡出血等。术后1年，有神经功能障碍者中由A级恢复为D级1例，其余均恢复为E级，视觉模拟评分法疼痛评分平均为0．5分。至随访结束，1例浆细胞瘤患者和1例k转移瘤患者发生全身肿瘤进展，但仍带瘤生存；1例L3转移性恶性纤维组织细胞瘤患者术后16个月死于局部复发并肺转移，1例L4神经母细胞瘤患者死于其他原因；其余患者均无局部复发。术后，病椎邻近上下椎体间矢状面Cobb角平均为-2．57°（-26．7°～12．0°）。至末次随访或翻修术前，病椎上下相邻椎体间矢状面Cobb角平均为11．5°（-17．5°～57．2°）。钛网均有不同程度塌陷人椎体，平均下陷7．5min。钉棒断裂2例，内固定松动2例。3例行翻修手术，其中2例行前后路翻修，1例仅行后路手术更换断棒。结论全脊椎整块切除手术难度大，出血多，但明显提高了脊柱肿瘤的治疗效果Objective To investigate the therapeutic effect of total en bloc spondylectomy （TES） for thoracolumbar tumors and the results of spinal stability reconstruction. Methods From January 2007 to June 2011 there were 18 patients with thoracolumbar tumors distributed in the thoracic vertebrae （n = 10） and lumbar vertebrae （ n = 8 ）. There were 7 haemangiomas, 5 giant cell tumors of bone, 1 malignant schwannoma, 1 solitary plasmocytoma, 1 neuroblastoma, 1 osteoblastoma, 1 metastatic malignant fibrous histiocytoma, and 1 metastasis of breast cancer. All the 18 patients were treated with improved TES under electrophysiological monitoring of spinal cord. Four patients were treated through one-stage combined anteroposterior approach and 14 patients through one-stage posterior approach. The anterior reconstructions included titanium mesh cages filled with bone or bone cement in 15 cases, titanium mesh cage with strengthened rings in 2 cases and artificial vertebral body replacement in 1 case. The posterior reconstruction included multiple segmental fixation with pedicle screw-rod system in 15 cases and short segmental fixation in 3 cases. Massive bone auto-graft was employed in 13 cases and fragmental bone ~aft in 5 cases. Results The total en bloc spondylectomy was performed successfully in 15 patients and unsuccessful in 3 whose spinal tumors were resected by piecemeal technique. In 15 patients with successfully performed TES, the duration of surgery was from 340 to 610 min （average, 450.7 min）, the blood loss was from 3000 to 10 200 ml （average, 4850 ml）, and the intraoperative blood transfusion was from 2800 to 9600 ml （average, 4200 ml）. The operation-related complications comprised hemopneumothorax, intercostal nerve pain, stress ulcer and bleeding, and so on. One year after operation, the patients with neurological dysfunction recovered from grade A to grade D in one patient, and to grade E in the other 14 cases. The average visual analog scale （VAS） scores was 0.5. One patient with plasma

关 键 词：脊柱 骨肿瘤 外科手术 骨重建 

分 类 号：R73[医药卫生—肿瘤]