一期en-bloc切除术治疗伴有神经压迫的腰椎软骨肉瘤
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摘要
目的探讨一期en-bloc切除术治疗伴有神经症状的腰椎软骨肉瘤的安全性和有效性。方法 2010年1月—2012年12月采用en-bloc切除术治疗腰椎软骨肉瘤患者29例。采用视觉模拟量表(VAS)评分评价患者疼痛程度,采用美国脊髓损伤协会(ASIA)分级评价患者神经功能,对临床疗效及围手术期并发症发生情况进行分析。结果所有患者肿瘤组织均一期en-bloc切除,单纯后路/后外侧入路23例,前后联合入路6例。患者平均随访49.2个月,平均手术时间为265 min,平均出血量为2 150 mL。术前VAS评分(7.69±1.25)分,术后恢复至(1.57±0.53)分。术前ASIA分级C级2例,D级11例,E级16例;术后1例C级患者恢复至D级,1例D级患者因压迫时间过长无恢复,其余C级和D级患者均恢复至E级,E级者无变化。所有患者术中未发生大血管损伤、邻近脏器误伤或死亡。1例患者因肿瘤包绕单侧L5神经行牺牲神经根的肿瘤en-bloc切除术,术后左足下垂,其余28例患者术后疼痛症状消失,术前伴下肢疼痛麻木者症状均有明显改善。术中出现脑脊液漏2例,行腰大池引流后顺利拔管,体温恢复正常。1例坠积性肺炎患者经抗炎治疗后痊愈;1例患者术后半个月发生右下肢深静脉血栓,取栓后半个月恢复。5例患者随访时出现局部肿瘤复发,行相应部位肿瘤再次切除。1例患者术后发生肺转移,6个月后死亡。其余患者无复发或转移征象。结论腰椎软骨肉瘤的治疗虽棘手,en-bloc切除术可安全有效地解除腰椎软骨肉瘤造成的神经压迫。术前详细的手术方案制定有助于更好地理解肿瘤与周围组织的解剖关系,减少毗邻大动脉、大静脉及周围神经组织的损伤,是精准医疗的有力措施。
Objective To investigate the strategy and efficacy of one-stage en-bloc resection of the lumber chondrosarcoma with the neurological symptoms. Methods From January 2010 to December 2012,29 cases of lumbar chondrosarcoma with neurological symptoms were treated by en-bloc resection. The visual analogue scale(VAS) score was used to evaluate the pain level of the patients. The American Spinal Cord Injury Association(ASIA) classification was used to evaluate the neurological function. The clinical efficacy and the incidence of complications during the perioperative period were analyzed. Results All the operations were successfully performed by en-bloc resection via posterior/posterolateral approach in 23 cases and combined anterior and posterior approaches in 6 cases. The mean followed-up period was 49.2 months. The mean operation time was 265 min,and the mean blood loss was 2 150 mL. The preoperative VAS score was(7.69±1.25),and(1.57±0.53) at postoperation. The ASIA grade of neurologic function was C in 2 cases,D in 11,and E in 16 at pre-operation. After operation,1patient recovered from C to D,and 1 grade D patient had no recovery because of prolonged compression time,and the remaining C and D patients were restored to E,while the patients with grade E had no change. There were no cases with major vessel or adjacent organ injury or died during operation. Only 1 patient with tumor wrapping around the unilateral L5 nerve underwent en-bloc resection with sacrifice of the L5 nerve root,resulting in left foot drop at post-operation;in the remaining 28 cases pain symptoms disappeared at post-operation,and symptoms of lower limb numbness and pain were significantly improved. The body temperature of 2 patients with the leakage of cerebrospinal recovered to normal after lumbar cistern drainage. One patient with hyposatic pneumonia recovered after anti-inflammatory treatment. Right lower extremity deep venous thrombosis occurred in 1 case half a month after operation,and recovered after thrombectomy in half a month. Five patients with tumor recurrence received reoperation. Pulmonary metastasis occurred in 1 patient after the operation,who died after 6 months. The remaining patients had no signs of recurrence or metastasis. Conclusion Though technically challenging,it is safe and efficient to relieve the local compression with the en-bloc resection in lumber chondrosarcoma. Detailed preoperative strategies can enable doctors better to understand the anatomical relationship between the tumor and lumbar spine,and reduce the injury to the adjacent large arteries,large veins and peripheral nerve tissue,which is a powerful measure for precision medicine.
Objective To investigate the strategy and efficacy of one-stage en-bloc resection of the lumber chondrosarcoma with the neurological symptoms. Methods From January 2010 to December 2012,29 cases of lumbar chondrosarcoma with neurological symptoms were treated by en-bloc resection. The visual analogue scale(VAS) score was used to evaluate the pain level of the patients. The American Spinal Cord Injury Association(ASIA) classification was used to evaluate the neurological function. The clinical efficacy and the incidence of complications during the perioperative period were analyzed. Results All the operations were successfully performed by en-bloc resection via posterior/posterolateral approach in 23 cases and combined anterior and posterior approaches in 6 cases. The mean followed-up period was 49.2 months. The mean operation time was 265 min,and the mean blood loss was 2 150 mL. The preoperative VAS score was(7.69±1.25),and(1.57±0.53) at postoperation. The ASIA grade of neurologic function was C in 2 cases,D in 11,and E in 16 at pre-operation. After operation,1patient recovered from C to D,and 1 grade D patient had no recovery because of prolonged compression time,and the remaining C and D patients were restored to E,while the patients with grade E had no change. There were no cases with major vessel or adjacent organ injury or died during operation. Only 1 patient with tumor wrapping around the unilateral L5 nerve underwent en-bloc resection with sacrifice of the L5 nerve root,resulting in left foot drop at post-operation;in the remaining 28 cases pain symptoms disappeared at post-operation,and symptoms of lower limb numbness and pain were significantly improved. The body temperature of 2 patients with the leakage of cerebrospinal recovered to normal after lumbar cistern drainage. One patient with hyposatic pneumonia recovered after anti-inflammatory treatment. Right lower extremity deep venous thrombosis occurred in 1 case half a month after operation,and recovered after thrombectomy in half a month. Five patients with tumor recurrence received reoperation. Pulmonary metastasis occurred in 1 patient after the operation,who died after 6 months. The remaining patients had no signs of recurrence or metastasis. Conclusion Though technically challenging,it is safe and efficient to relieve the local compression with the en-bloc resection in lumber chondrosarcoma. Detailed preoperative strategies can enable doctors better to understand the anatomical relationship between the tumor and lumbar spine,and reduce the injury to the adjacent large arteries,large veins and peripheral nerve tissue,which is a powerful measure for precision medicine.
引文
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[17]尉然,郭卫,杨荣利.整块切除与分块切除治疗骶骨软骨肉瘤的预后分析[J].中国脊柱脊髓杂志,2014,24(11):979-983.
[18]Leerapun T,Hugate RR,Inwards CY,et al. Surgical management of conventional grade I chondrosarcoma of long bones[J]. Clin Orthop Relat Res,2007,463:166-172.
[19]HannaSA,AstonWJ,BriggsTW,etal.Sacral chordoma:can local recurrence after sacrectomy be predicted?[J]. Clin Orthop Relat Res,2008,466(9):2217-2223.
[20]Tang X,Guo W,Yang R,et al. Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection[J]. J Bone Joint Surg Am,2010,92(8):1747-1753.
[21]Xu W,Li X,Huang W,et al. Factors affecting prognosis of patients with giant cell tumors of the mobile spine:retrospective analysis of 102 patients in a single center[J]. Ann Surg Oncol,2013,20(3):804-810.
[22]Hsu W,McCarthy E,Gokaslan ZL,et al. Clear-cell chondrosarcoma of the lumbar spine:case report and review of the literature[J]. Neurosurgery,2011,68(4):E1160-1164.
[23]Rao G,Suki D,Chakrabarti I,et al. Surgical management of primary and metastatic sarcoma of the mobile spine[J].J Neurosurg Spine,2008,9(2):120-128.
[24]Clarke MJ,Dasenbrock H,Bydon A,et al. Posterioronly approach for en bloc sacrectomy:clinical outcomes in 36 consecutive patients[J]. Neurosurgery,2012,71(2):357-364.
[25]Miles WK,Chang DW,Kroll SS,et al. Reconstruction of large sacral defects following total sacrectomy[J].Plast Reconstr Surg,2000,105(7):2387-2394.
[26]Chen KW,Yang HL,Lu J,et al. Risk factors for postoperative wound infections of sacral chordoma after surgical excision[J]. J Spinal Disord Tech,2011,24(4):230-234.
[27]Ruggieri P,Angelini A,Pala E,et al. Infections in surgery of primary tumors of the sacrum[J]. Spine(Phila Pa 1976),2012,37(5):420-428.
[28]Yin H,Zhou W,Meng J,et al. Prognostic factors of patients with spinal chondrosarcoma:a retrospective analysis of 98 consecutive patients in a single center[J].Ann Surg Oncol,2014,21(11):3572-3578.
[2]Yang X,Wu Z,Xiao J,et al. Chondrosarcomas of the cervical and cervicothoracic spine:surgical management and long-term clinical outcome[J]. J Spinal Disord Tech,2012,25(1):1-9.
[3]Douis H,Saifuddin A. The imaging of cartilaginous bone tumours.I. Benign lesions[J]. Skelet Radiol,2012,41(10):1195-1212.
[4]Lee SH,Ahn BK. Sacral Chordoma:challenging for resection margin[J]. Ann Coloproctol,2014,30(3):104-105.
[5]Boriani S,Weinstein JN,Biagini R. Primary bone tumors of the spine. Terminology and surgical staging[J].Spine(Phila Pa 1976),1997,22(9):1036-1044.
[6]Enneking WF. A system of staging musculoskeletal neoplasms[J]. Clin Orthop Relat Res,1986(204):9-24.
[7]Tomita K. Reconstruction of the pelvic ring based on classification following resection of bone tumors[J]. Gan To Kagaku Ryoho,1988,15(4 Pt 2-3):1521-1527.
[8]American Spinal Injury Association. Standards for neurological classification of spinal injury patients[M].Chicago:American Spinal Injury Association,1992.
[9]Huskisson EC. Measurement of pain[J]. Lancet,1974,2(7889):1127-1131.
[10]Puri A,Agarwal MG,Shah M,et al. Decision making in primary sacral tumors[J]. Spine J,2009,9(5):396-403.
[11]Veth R,Schreuder B,van Beem H,et al. Cryosurgery in aggressive,benign,and low-grade malignant bone tumours[J]. Lancet Oncol,2005,6(1):25-34.
[12]Rhomberg W,Eiter H,B?hler F,et al. Combined radiotherapyandrazoxaneinthetreatmentof chondrosarcomas and chordomas[J]. Anticancer Res,2006,26(3B):2407-2411.
[13]Moussavi-Harami F,Mollano A,Martin JA,et al.Intrinsic radiation resistance in human chondrosarcoma cells[J]. Biochem Biophys Res Commun,2006,346(2):379-385.
[14]Levine AM,Tulpule A,Quinn DI,et al. Phase I study of antisense oligonucleotide against vascular endothelial growth factor:decrease in plasma vascular endothelial growth factor with potential clinical efficacy[J]. J Clin Oncol,2006,24(11):1712-1719.
[15]Cleton-Jansen AM,van Beerendonk HM,Baelde HJ,et al. Estrogen signaling is active in cartilaginous tumors:implications for antiestrogen therapy as treatment option of metastasized or irresectable chondrosarcoma[J]. Clin Cancer Res,2005,11(22):8028-8035.
[16]Amendola L,Cappuccio M,De Iure F,et al. En bloc resections for primary spinal tumors in a 20 years of experience:effectiveness and safety[J]. Spine J,2014,14(11):2608-2617.
[17]尉然,郭卫,杨荣利.整块切除与分块切除治疗骶骨软骨肉瘤的预后分析[J].中国脊柱脊髓杂志,2014,24(11):979-983.
[18]Leerapun T,Hugate RR,Inwards CY,et al. Surgical management of conventional grade I chondrosarcoma of long bones[J]. Clin Orthop Relat Res,2007,463:166-172.
[19]HannaSA,AstonWJ,BriggsTW,etal.Sacral chordoma:can local recurrence after sacrectomy be predicted?[J]. Clin Orthop Relat Res,2008,466(9):2217-2223.
[20]Tang X,Guo W,Yang R,et al. Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection[J]. J Bone Joint Surg Am,2010,92(8):1747-1753.
[21]Xu W,Li X,Huang W,et al. Factors affecting prognosis of patients with giant cell tumors of the mobile spine:retrospective analysis of 102 patients in a single center[J]. Ann Surg Oncol,2013,20(3):804-810.
[22]Hsu W,McCarthy E,Gokaslan ZL,et al. Clear-cell chondrosarcoma of the lumbar spine:case report and review of the literature[J]. Neurosurgery,2011,68(4):E1160-1164.
[23]Rao G,Suki D,Chakrabarti I,et al. Surgical management of primary and metastatic sarcoma of the mobile spine[J].J Neurosurg Spine,2008,9(2):120-128.
[24]Clarke MJ,Dasenbrock H,Bydon A,et al. Posterioronly approach for en bloc sacrectomy:clinical outcomes in 36 consecutive patients[J]. Neurosurgery,2012,71(2):357-364.
[25]Miles WK,Chang DW,Kroll SS,et al. Reconstruction of large sacral defects following total sacrectomy[J].Plast Reconstr Surg,2000,105(7):2387-2394.
[26]Chen KW,Yang HL,Lu J,et al. Risk factors for postoperative wound infections of sacral chordoma after surgical excision[J]. J Spinal Disord Tech,2011,24(4):230-234.
[27]Ruggieri P,Angelini A,Pala E,et al. Infections in surgery of primary tumors of the sacrum[J]. Spine(Phila Pa 1976),2012,37(5):420-428.
[28]Yin H,Zhou W,Meng J,et al. Prognostic factors of patients with spinal chondrosarcoma:a retrospective analysis of 98 consecutive patients in a single center[J].Ann Surg Oncol,2014,21(11):3572-3578.