一期后路全脊椎整块切除术治疗L4椎体肿瘤的临床经验  

Total en bloc spondylectomy for spinal tumors of the fourth lumbar spine via a posterior approach： our clinical experience

作　　者：黄稳定 魏海峰 严望军 蔡维泺 许炜 杨兴海 吴志鹏 刘铁龙 黄权 肖建如 Huang Wending;Wei Haifeng;Yan Wangjun;Cai Weiluo;Xu Wei;Yang Xinghai;Wu Zhipeng;Liu Tielong;Huang Quan;Xiao Jianru(Department of Orthopaedics, Hongkou Medicine Center, Changhai Hospital, Navy Military Medical University, Shanghai 200081, China;Department of Orthopaedic Oncology, Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China;Department of Musculoskeletal tumor surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China)

机构地区：[1]海军军医大学附属长海医院虹口院区骨科,上海200081 [2]海军军医大学附属长征医院骨肿瘤科,上海200003 [3]复旦大学附属肿瘤医院骨软组织外科,上海200032

出　　处：《中华骨科杂志》2018年第10期580-587,共8页Chinese Journal of Orthopaedics

基　　金：上海市科委资助项目（15411963400）

摘　　要：目的探讨一期后路全脊椎整块切除术治疗L4椎体肿瘤的可行性及安全性，评估临床效果。方法回顾性分析2011年3月至2015年12月经后路实施全脊椎整块切除的21例L4肿瘤患者的临床资料。男9例，女12例；年龄15～71岁，平均（47．1±15．6）岁。原发性肿瘤12例，转移性肿瘤9例，所有患者均为孤立性病灶。术前对患者进行详细的影像学评估，严格筛选患者。对手术时间、术中出血量、肿瘤切缘、并发症、内固定失败情况、术前术后神经功能改变情况、术前术后VSA评分、局部控制率及生存情况进行分析。结果所有患者均完成一期后路全脊椎整块切除术。手术时间225-420min，平均（297．6＋44．6）min。术中出血量为900-4100ml，平均（2247．1±904．5）ml。广泛切除者7例，边缘切除者9例，经瘤切除者5例。术后4例（19．0％）患者出现脑脊液漏，发生L4神经根麻痹者5例（23．8％），术后2-4周基本恢复至术前水平，术后6个月恢复至术前或正常水平。术后随访24-79个月，平均（50．4±17．1）个月。术前VAS评分平均为（6．2±1．6）分，术后平均为（1．5±1．4）分，与术前相比差异有统计学意义（P=0．008），疼痛较术前均有明显改善。随访期内死亡3人，均为转移癌患者。钛网下沉7例（33．3％），无因内固定失败需要翻修的病例。结论单纯后路全脊椎整块切除术治疗L4椎体肿瘤是可行的，但术中神经并发症较多，手术适应证较窄，对病例的选择有严格要求。Objective To study the feasibility and safety of total en bloc spondylectomy （TES） for bone tumors of the fourth lumbar spine and evaluate the clinical outcomes. Methods From March 2011 to December 2013, 21 patients undergone total en bloc spondylectomy in posterior-only approach were retrospectively reviewed. The patients included 9 males and 12 females, with a mean age of 47.1±15.6 years old （range, 15-71 years old）. This series included 12 cases of primary bone tumors and 9 cases of solitary metastases. Preoperative evaluation according to clinical, imaging and pathologic features was performed meticu - lously to select patients. The length of surgery, estimated blood loss, surgical margins, instrumentation failure, perioperative complications, Frankel scale, visual analogue scale （VAS） for pain, local control rate and overall survival were reviewed and analyzed. Results Total en bloc spondylectomy was performed successfully in all patients. Average operative time and estimated blood loss were 297.6±44,6 rain （range, 225-420 rain） and 2 247.1±904.5 ml （range, 900-4100 ml）, respectively. The mean follow-up time was 50.4±17.1 mons （range, 24-79 mons）. All patients encountered nerve roots stretch and 5 patients （23.8%） showed lower extremeties neurological dysfunction. All of them improved in 2-4 weeks postoperatively and recovered completely at 6-month follow -up. Cerebrospinal fluid leak was found in 4 patients （19.0%）. The VAS score was 1.5±1.4 at post-operation, which was significant-ly lower than the 6.2±1.6 in average at operation （P=0.008）. Three patients with metastatic tumors died during the follow-up. Tita- nium mesh cage subsidence was observed in 7 patients （33.3%）. No implant failure was occurred during the follow-up. Conclusion Total en bloc spondylectomy for tumors of the fourth lumbar spine in a posterior-only approach is feasible. However, there are many intraoperative neurological complications and the indications for TES are extremely limited.

关 键 词：腰椎 脊柱肿瘤 外科手术 治疗结果 

分 类 号：R738.1[医药卫生—肿瘤]