骶骨肿瘤患者行全骶骨切除后腰骶部稳定性的重建
|
摘要
背景:骶骨肿瘤切除是骨肿瘤外科治疗的一个难题。既往文献报道多侧重于肿瘤的切除方法,对于骶骨肿瘤切除后稳定性重建的研究较少。目的:探讨全骶骨肿瘤切除后腰骶部稳定性重建的方法。方法:回顾分析2000年7月至2015年12月,63例全骶骨肿瘤切除后腰骶部稳定性重建患者的临床资料。男38例,女25例,年龄18-62岁,平均42.1岁。病理诊断:软骨肉瘤9例,脊索瘤25例,骶骨恶性神经鞘瘤5例,骨肉瘤13例,尤文肉瘤4例,孤立性转移瘤2例,未分化肉瘤2例,骨巨细胞瘤3例。前后路联合全骶骨切除术23例,单纯后路全骶骨切除术40例。结果:所有患者随访时间5~97个月,平均45个月。16例内固定失败出现在术后8~24个月,平均17.1个月。本组病例中共9例出现螺钉松动移位,7例患者出现金属棒断裂。6例患者出现植骨未愈合,其中3例术后曾接受放射治疗。结论:全骶骨肿瘤切除后,钉棒系统重建最常出现金属连接棒的断裂。内固定失败可能与金属连接棒过细,固定节段不合理,植骨不愈合有关。通过合理的翻修手术可以较好地解决内固定断裂问题。
Background:Resection of sacral tumor is a difficult point in surgical treatment of bone tumors.Previous studies have focused on the resection of tumors,and there are few studies on the reconstruction after total sacrectomy.Objective:To retrospectively review the rate and category of mechanical fixation in patients with spinopelvic reconstruction after total sacrectomy.Methods:Between July 2000 and December 2015,spinopelvic reconstruction following total sacrectomy were carried out in 63 patients.There were 38 males and 25 females with a mean age of 42.1 years(range,18-62 years).The pathological diagnosis included 9 chondrosarcomas,25 chordomas,5 malignant schwannomas,13 osteosarcomas,4 Ewing sarcomas,2 solitary metastatic tumors,2 undifferentiated pleomorphic sarcomas,and 3 giant cell tumors.Total sacrectomy was performed in 23 patients through combined anterior and posterior approaches,in the other 40 patients through single posterior approach.Results:The mean duration of follow-up was 45 months(range,5-97 months).Mechanical fixation failure occurred in 25% of patients(16/63) at a mean time of 17.1 months(range,8-24 months) postoperatively.Rods breakage and pedicle screws failure occurred in 7 and 9 patients,respectively.Nonunion of bone grafts was observed in 6 patients,and three of them received radiotherapy.Conclusions:Rods breakage is frequently encountered in reconstruction after total sacrectomy.The failure of the reconstruction may be related to extremely slim rod,improper internal fixation and nonunion of bone grafts.Revision surgery should be carried out in these patients.
Background:Resection of sacral tumor is a difficult point in surgical treatment of bone tumors.Previous studies have focused on the resection of tumors,and there are few studies on the reconstruction after total sacrectomy.Objective:To retrospectively review the rate and category of mechanical fixation in patients with spinopelvic reconstruction after total sacrectomy.Methods:Between July 2000 and December 2015,spinopelvic reconstruction following total sacrectomy were carried out in 63 patients.There were 38 males and 25 females with a mean age of 42.1 years(range,18-62 years).The pathological diagnosis included 9 chondrosarcomas,25 chordomas,5 malignant schwannomas,13 osteosarcomas,4 Ewing sarcomas,2 solitary metastatic tumors,2 undifferentiated pleomorphic sarcomas,and 3 giant cell tumors.Total sacrectomy was performed in 23 patients through combined anterior and posterior approaches,in the other 40 patients through single posterior approach.Results:The mean duration of follow-up was 45 months(range,5-97 months).Mechanical fixation failure occurred in 25% of patients(16/63) at a mean time of 17.1 months(range,8-24 months) postoperatively.Rods breakage and pedicle screws failure occurred in 7 and 9 patients,respectively.Nonunion of bone grafts was observed in 6 patients,and three of them received radiotherapy.Conclusions:Rods breakage is frequently encountered in reconstruction after total sacrectomy.The failure of the reconstruction may be related to extremely slim rod,improper internal fixation and nonunion of bone grafts.Revision surgery should be carried out in these patients.
引文
[1]Dhawale AA,Gjolaj JP,Holmes L Jr,et al.Sacrectomy and adjuvant radiotherapy for the treatment of sacral chordo-
[2]Fuchs B,Dickey ID,Yaszemski MJ,et al.Operative manmas:a single-center experience over 27 years.Spine(Phila Pa 1976),2014,39(5):E353-E359.agement of sacral chordoma.J Bone Joint Surg Am,2005,87(10):2211-2216.
[3]Li D,Guo W,Tang X,et al.Surgical classification of different types of en bloc resection for primary malignant sacral tumors.Eur Spine J,2011,20(12):2275-2281.
[4]Harimaya K,Mishiro T,Lenke LG,et al.Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs.Spine(Phila Pa 1976),2011,36(20):1701-1710.
[5]Jutte PC,Castelein RM.Complications of pedicle screws in lumbar and lumbosacral fusions in 105 consecutive primary operations.Eur Spine J,2002,11(6):594-598.
[6]Fujibayashi S,Neo M,Nakamura T.Palliative dual iliac screw fixation for lumbosacral metastasis.Technical note.JNeurosurg Spine,2007,7(1):99-102.
[7]Thambiraj S,Forward DP,Thomas J,et al.A novel"pelvic ring augmentation construct"for lumbo-pelvic reconstruction in tumour surgery.Eur Spine J,2012,21(9):1797-1803.
[8]Oshima Y,Miyoshi K,Mikami Y,et al.Pelvic ring reconstruction with a vascularized pedicle iliac bone graft for a large sacral schwannoma.J Spinal Disord Tech,2005,18(2):200-202.
[9]Stener B,Gunterberg B.High amputation of the sacrum for extirpation of tumors.Principles and technique.Spine(Phila Pa 1976),1978,3(4):351-366.
[10]Bederman SS,Shah KN,Hassan JM,et al.Surgical techniques for spinopelvic reconstruction following total sacrectomy:a systematic review.Eur Spine J,2014,23(2):305-319.
[11]Varga PP,Lazary A.Chordoma of the sacrum:"en bloc"total sacrectomy and lumbopelvic reconstruction.Eur Spine J,2010,19(6):1039-1040.
[12]Gallia GL,Suk I,Witham TF,et al.Lumbopelvic reconstruction after combined L5 spondylectomy and total sacrectomy for en bloc resection of a malignant fibrous histiocytoma.Neurosurgery,2010,67(2):E498-E502.
[13]Wuisman P,Lieshout O,van Dijk M,et al.Reconstruction after total en bloc sacrectomy for osteosarcoma using a custom-made prosthesis:a technical note.Spine(Phila Pa1976),2001,26(4):431-439.
[14]Tomita K,Tsuchiya H.Total sacrectomy and reconstruction for huge sacral tumors.Spine(Phila Pa 1976),1990,15(11):1223-1227.
[15]Doita M,Harada T,Iguchi T,et al.Total sacrectomy and reconstruction for sacral tumors.Spine(Phila Pa 1976),2003,28(15):E296-E301.
[16]Zhang HY,Thongtrangan I,Balabhadra RS,et al.Surgical techniques for total sacrectomy and spinopelvic reconstruction.Neurosurg Focus,2003,15(2):E5.
[17]Hugate RR Jr,Dickey ID,Phimolsarnti R,et al.Mechanical effects of partial sacrectomy:when is reconstruction necessary?Clin Orthop Relat Res,2006,450:82-88.
[18]Gunterberg B,Romanus B,Stener B.Pelvic strength after major amputation of the sacrum.An exerimental study.Acta Orthop Scand,1976,47(6):635-642.
[19]Gokaslan ZL,Romsdahl MM,Kroll SS,et al.Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms.Technical note.J Neurosurg,1997,87(5):781-787.
[20]Sim FH,Choong PF,Weber KL.Orthopaedic Oncology and Complex Reconstruction.Wolters Kluwer/Lippincott Williams&Wilkins Health,2011.
[21]Stambough JL.Lumbosacral instrumented fusion:analysis of 124 consecutive cases.J Spinal Disord,1999,12(1):1-9.
[22]Shen FH,Harper M,Foster WC,et al.A novel"four-rod technique"for lumbo-pelvic reconstruction:theory and technical considerations.Spine(Phila Pa 1976),2006,31(12):1395-1401.
[23]Yu Y,Zhu R,Zeng ZL,et al.The strain at bone-implant interface determines the effect of spinopelvic reconstruction following total sacrectomy:a strain gauge analysis in various spinopelvic constructs.PLo S One,2014,9(1):e85298.
[24]Guo W,Tang X,Zang J,et al.One-stage total en bloc sacrectomy:a novel technique and report of 9 cases.Spine(Phila Pa 1976),2013,38(10):E626-E631.
[25]Poffyn B,Sys G,Mulliez A,et al.Extracorporeally irradiated autografts for the treatment of bone tumours:tips and tricks.Int Orthop,2011,35(6):889-895.
[2]Fuchs B,Dickey ID,Yaszemski MJ,et al.Operative manmas:a single-center experience over 27 years.Spine(Phila Pa 1976),2014,39(5):E353-E359.agement of sacral chordoma.J Bone Joint Surg Am,2005,87(10):2211-2216.
[3]Li D,Guo W,Tang X,et al.Surgical classification of different types of en bloc resection for primary malignant sacral tumors.Eur Spine J,2011,20(12):2275-2281.
[4]Harimaya K,Mishiro T,Lenke LG,et al.Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs.Spine(Phila Pa 1976),2011,36(20):1701-1710.
[5]Jutte PC,Castelein RM.Complications of pedicle screws in lumbar and lumbosacral fusions in 105 consecutive primary operations.Eur Spine J,2002,11(6):594-598.
[6]Fujibayashi S,Neo M,Nakamura T.Palliative dual iliac screw fixation for lumbosacral metastasis.Technical note.JNeurosurg Spine,2007,7(1):99-102.
[7]Thambiraj S,Forward DP,Thomas J,et al.A novel"pelvic ring augmentation construct"for lumbo-pelvic reconstruction in tumour surgery.Eur Spine J,2012,21(9):1797-1803.
[8]Oshima Y,Miyoshi K,Mikami Y,et al.Pelvic ring reconstruction with a vascularized pedicle iliac bone graft for a large sacral schwannoma.J Spinal Disord Tech,2005,18(2):200-202.
[9]Stener B,Gunterberg B.High amputation of the sacrum for extirpation of tumors.Principles and technique.Spine(Phila Pa 1976),1978,3(4):351-366.
[10]Bederman SS,Shah KN,Hassan JM,et al.Surgical techniques for spinopelvic reconstruction following total sacrectomy:a systematic review.Eur Spine J,2014,23(2):305-319.
[11]Varga PP,Lazary A.Chordoma of the sacrum:"en bloc"total sacrectomy and lumbopelvic reconstruction.Eur Spine J,2010,19(6):1039-1040.
[12]Gallia GL,Suk I,Witham TF,et al.Lumbopelvic reconstruction after combined L5 spondylectomy and total sacrectomy for en bloc resection of a malignant fibrous histiocytoma.Neurosurgery,2010,67(2):E498-E502.
[13]Wuisman P,Lieshout O,van Dijk M,et al.Reconstruction after total en bloc sacrectomy for osteosarcoma using a custom-made prosthesis:a technical note.Spine(Phila Pa1976),2001,26(4):431-439.
[14]Tomita K,Tsuchiya H.Total sacrectomy and reconstruction for huge sacral tumors.Spine(Phila Pa 1976),1990,15(11):1223-1227.
[15]Doita M,Harada T,Iguchi T,et al.Total sacrectomy and reconstruction for sacral tumors.Spine(Phila Pa 1976),2003,28(15):E296-E301.
[16]Zhang HY,Thongtrangan I,Balabhadra RS,et al.Surgical techniques for total sacrectomy and spinopelvic reconstruction.Neurosurg Focus,2003,15(2):E5.
[17]Hugate RR Jr,Dickey ID,Phimolsarnti R,et al.Mechanical effects of partial sacrectomy:when is reconstruction necessary?Clin Orthop Relat Res,2006,450:82-88.
[18]Gunterberg B,Romanus B,Stener B.Pelvic strength after major amputation of the sacrum.An exerimental study.Acta Orthop Scand,1976,47(6):635-642.
[19]Gokaslan ZL,Romsdahl MM,Kroll SS,et al.Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms.Technical note.J Neurosurg,1997,87(5):781-787.
[20]Sim FH,Choong PF,Weber KL.Orthopaedic Oncology and Complex Reconstruction.Wolters Kluwer/Lippincott Williams&Wilkins Health,2011.
[21]Stambough JL.Lumbosacral instrumented fusion:analysis of 124 consecutive cases.J Spinal Disord,1999,12(1):1-9.
[22]Shen FH,Harper M,Foster WC,et al.A novel"four-rod technique"for lumbo-pelvic reconstruction:theory and technical considerations.Spine(Phila Pa 1976),2006,31(12):1395-1401.
[23]Yu Y,Zhu R,Zeng ZL,et al.The strain at bone-implant interface determines the effect of spinopelvic reconstruction following total sacrectomy:a strain gauge analysis in various spinopelvic constructs.PLo S One,2014,9(1):e85298.
[24]Guo W,Tang X,Zang J,et al.One-stage total en bloc sacrectomy:a novel technique and report of 9 cases.Spine(Phila Pa 1976),2013,38(10):E626-E631.
[25]Poffyn B,Sys G,Mulliez A,et al.Extracorporeally irradiated autografts for the treatment of bone tumours:tips and tricks.Int Orthop,2011,35(6):889-895.