单一后路三节段全脊椎切除治疗脊柱恶性肿瘤
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摘要
目的全脊椎切除术(total en bloc spondylectomy,TES)可显著降低术后脊柱恶性肿瘤的局部复发率,三节段TES较单节段更为复杂。本研究探讨了单一后路三节段TES治疗脊柱恶性肿瘤的手术技巧及中短期随访结果。方法回顾性分析了2010～2012年,在我科接受单一后路三节段TES的5例患者,包括乳腺癌脊柱转移2例,肾透明细胞癌脊柱转移1例,脊柱原发上皮样血管内皮瘤1例,脊柱原发间叶软骨肉瘤1例,病变节段分布于T4～11之间。按照Tomita外科分型均属于第6型,脊髓损伤中Frankel C级4例,Frankel D级1例。Tomita评分平均为3.4分。Karnofsky功能状态评分平均为48%。脊柱不稳定性SINS平均得分13分。术前除1例间叶软骨肉瘤患者外均接受了肿瘤滋养血管栓塞手术,所有患者均成功实施了三节段TES。结果平均手术时间6.8 h,平均失血量6260 ml。术中结扎双侧三对根动脉和神经根后脊髓监护未发生明显改变,术后患者亦未发生明显功能障碍。5例30～62个月(平均45个月)随访。随访期间1例局部复发,进行了二次减压手术,目前带瘤生存;1例死于肺转移;其余3例均为无瘤生存。患者VAS疼痛评分从术前平均7.8 (7～9)分降至术后平均1.6 (1～2)分;脊髓损伤Frankel评分从术前4例C级,1例D级术后均恢复至E级。所有标本术后病理证实均达到切缘阴性。结论本研究证明,在严格掌握手术适应证和熟练掌握手术技巧的情况下,三节段TES治疗脊柱恶性肿瘤仍可以取得令人满意的结果。
Objective Total En Bloc Spondylectomy( TES) is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Three-level EBS are aggressive procedures associated with complications and morbidity. This study aims to report the surgical technique and results of tumor control after 3-level TES for spinal tumors. Methods We conducted a retrospective study of 5 patients treated with 3-level TES between 2010 and 2012. Surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. There were 5 malignant tumors: 2 metastatic breast cancer, 1 metastatic kidney clear cell carcinoma, 1 chondrosarcoma, 1 epithelioid haemangioendothelioma. All patients belonged to Tomita's Type 6. The mean score of Tomita grading system and Karnofsky performance were 3.4 and 48%, respectively. Four patients with spinal injury were classified into Frankel C and 1 into Frankel D. All patients received pre-operative arterial embolization expect one with chondrosarcoma. Results The mean surgical time was 6.8 h and estimated blood loss was 6260 ml. The mean follow-up was 45 months( range: 30-62 months). At the last follow-up, 3 patients were alive with no evidence of diseases, 1 alive with pulmonary metastasis, and 1 dead of diseases. Only 1 patient had local recurrence. Five patients with Frankel C and D had full neurological recovery. Histopathological assessment of specimen showed the margins were free of tumor. The mean VAS score decreased from 7.8 to 1.6 after operation. Conclusions 3-level TES can be offered to patients to prevent local recurrence. With strict surgical indication and skillful surgical technique, it is proven to be beneficial.
Objective Total En Bloc Spondylectomy( TES) is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Three-level EBS are aggressive procedures associated with complications and morbidity. This study aims to report the surgical technique and results of tumor control after 3-level TES for spinal tumors. Methods We conducted a retrospective study of 5 patients treated with 3-level TES between 2010 and 2012. Surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. There were 5 malignant tumors: 2 metastatic breast cancer, 1 metastatic kidney clear cell carcinoma, 1 chondrosarcoma, 1 epithelioid haemangioendothelioma. All patients belonged to Tomita's Type 6. The mean score of Tomita grading system and Karnofsky performance were 3.4 and 48%, respectively. Four patients with spinal injury were classified into Frankel C and 1 into Frankel D. All patients received pre-operative arterial embolization expect one with chondrosarcoma. Results The mean surgical time was 6.8 h and estimated blood loss was 6260 ml. The mean follow-up was 45 months( range: 30-62 months). At the last follow-up, 3 patients were alive with no evidence of diseases, 1 alive with pulmonary metastasis, and 1 dead of diseases. Only 1 patient had local recurrence. Five patients with Frankel C and D had full neurological recovery. Histopathological assessment of specimen showed the margins were free of tumor. The mean VAS score decreased from 7.8 to 1.6 after operation. Conclusions 3-level TES can be offered to patients to prevent local recurrence. With strict surgical indication and skillful surgical technique, it is proven to be beneficial.
引文
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[13]Chan P,Boriani S,Fourney DR,et al.An assessment of the reliability of the enneking and weinstein-boriani-biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group[J].Spine,2009,34(4):384-391.
[14]Tomita K,Kawahara N,Baba H,et al.Total en bloc spondylectomy for solitary spinal metastases[J].Int Orthop,1994,18(5):291-298.
[15]Abe E,Sato K,Murai H,et al.Total spondylectomy for solitary spinal metastasis of the thoracolumbar spine:a preliminary report[J].Tohoku J Exp Med,2000,190(1):33-49.
[16]Nambu K,Kawahara N,Kobayashi T,et al.Interruption of the bilateral segmental arteries at several levels:influence on vertebral blood flow[J].Spine,2004,29(14):1530-1534.
[17]Woodard JS,Freeman LW.Ischemia of the spinal cord;an experimental study[J].J Neurosurg,1956,13(1):63-72.
[18]Ueda Y,Kawahara N,Tomita K,et al.Influence on spinal cord blood flow and spinal cord function by interruption of bilateral segmental arteries at up to three levels:experimental study in dogs[J].Spine,2005,30:2239-2243.
[19]Druschel C,Disch AC,Melcher I,et al.Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy:description of technique and report of two cases[J].Eur Spine J,2012,21(1):1-9.
[2]Weinstein JN.Surgical approach to spine tumors[J].Orthopedics,1989,12:897-905.
[3]Fisher CG,Schouten R,Versteeg AL,et al.Reliability of the Spinal Instability Neoplastic Score(SINS)among radiation oncologists:an assessment of instability secondary to spinal metastases[J].Radiat Oncol,2014,9:69-76.
[4]Lièvre JA,Darcy M,Pradat P,et al.Giant cell tumor of the lumbar spine;total spondylectomy in 2 states[J].Rev Rhum Mal Osteoartic,1968,35(3):125-130.
[5]Sundaresan N,DiGiacinto GV,Krol G,et al.Spondylectomy for malignant tumors of the spine[J].J Clin Oncol,1989,7(10):1485-1491.
[6]Roy-Camille R,Saillant G,Mazel C H,et al.Total vertebrectomy as treatment of malignant tumors of the spine[J].Chir Organi Mov,1990,75(1 Suppl):S94-96.
[7]Enneking WF,Spanier SS,Goodman MA.A system for the surgical staging of musculoskeletal sarcoma.1980[J].Clin Orthop Relat Res,2003,415:4-18.
[8]Stener B,Johnsen OE.Complete removal of three vertebrae for giant-cell tumour[J].J Bone Joint Surg Br,1971,53(2):278-287.
[9]Tomita K,Toribatake Y,Kawahara N,et al.Total en bloc spondylectomy and circumspinal decompression for solitary spinal metastasis[J].Paraplegia,1994,32(1):36-46.
[10]Tomita K,Kawahara N,Murakami H,et al.Total en bloc spondylectomy for spinal tumors:improvement of the technique and its associated basic background[J].J Orthop Sci,2006,11(1):3-12.
[11]Chow R,Chiu N,Bruera E,et al.Inter-rater reliability in performance status assessment among health care professionals:a systematic review[J].Ann Palliat Med,2016,5(2):83-92.
[12]Campos M,Urrutia J,Zamora T,et al.The spine instability neoplastic score:an independent reliability and reproducibility analysis[J].Spine J,2014,14(8):1466-1469.
[13]Chan P,Boriani S,Fourney DR,et al.An assessment of the reliability of the enneking and weinstein-boriani-biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group[J].Spine,2009,34(4):384-391.
[14]Tomita K,Kawahara N,Baba H,et al.Total en bloc spondylectomy for solitary spinal metastases[J].Int Orthop,1994,18(5):291-298.
[15]Abe E,Sato K,Murai H,et al.Total spondylectomy for solitary spinal metastasis of the thoracolumbar spine:a preliminary report[J].Tohoku J Exp Med,2000,190(1):33-49.
[16]Nambu K,Kawahara N,Kobayashi T,et al.Interruption of the bilateral segmental arteries at several levels:influence on vertebral blood flow[J].Spine,2004,29(14):1530-1534.
[17]Woodard JS,Freeman LW.Ischemia of the spinal cord;an experimental study[J].J Neurosurg,1956,13(1):63-72.
[18]Ueda Y,Kawahara N,Tomita K,et al.Influence on spinal cord blood flow and spinal cord function by interruption of bilateral segmental arteries at up to three levels:experimental study in dogs[J].Spine,2005,30:2239-2243.
[19]Druschel C,Disch AC,Melcher I,et al.Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy:description of technique and report of two cases[J].Eur Spine J,2012,21(1):1-9.