伴脊髓压迫的脊椎侵袭性血管瘤手术方式选择

Surgical treatment of aggressive vertebral hemangiomas with compressive myelopathy

中文关键词:  脊椎血管瘤  脊髓压迫  脊椎切除  减压

英文关键词:Spine hemangioma  Spinal cord compression  Spondylectomy  Decompression

中文摘要:

  【摘要】 目的：探讨伴有脊髓压迫的脊椎侵袭性血管瘤的手术治疗方法。方法：2000年1月~2015年10月，收治26例伴有脊髓压迫的脊椎血管瘤患者，男11例，女15例，年龄15~69岁（23.0±4.5岁），单发性血管瘤6例，多发性20例，责任节段位于颈椎6例，胸椎18例，腰椎2例。术前Frankel分级A级1例，C级5例，D级18例，E级2例，硬膜外脊髓压迫（ESCC）分级Ⅰ级5例，Ⅱ级15，Ⅲ级6例。18例术前穿刺病理检查明确诊断，8例行术中快速病理检查确诊。手术方式包括单纯减压、椎体成形、内固定术11例；病椎切除、重建术15例，其中前路椎体肿瘤切除减压重建术6例，后路全脊椎切除重建术8例，一期前后路枢椎肿瘤切除重建1例。随访评估术中出血量、围手术期并发症、肿瘤控制效果、脊髓神经功能、脊柱稳定性重建等。结果：病椎切除组15例患者术中出血量平均为3927±4137ml，减压加椎体成形组11例情况出血量为1355±703ml。1例术后胸腔出血，1例术后迟发性感染，经对症处理后痊愈。随访时间12~194个月（75±51个月），共4例出现肿瘤进展，3例为后路减压术后，2例再行病椎切除，1例行立体定向放射外科治疗；1例为枢椎血管瘤，生育后肿瘤复发进展，行后路减压和放疗，恢复良好。4例患者出现内固定相关并发症，包括3例内固定松动，1例内固定断裂，均行内固定翻修术。26例患者术后半年脊髓功能Frankel分级D级4例，E级22例。结论：伴有脊髓压迫的脊椎侵袭性血管瘤需要手术治疗，病椎切除能较好控制肿瘤，但手术创伤大，术中出血和术后并发症多；姑息减压结合椎体成形术能挽救脊髓功能，但有肿瘤复发风险，复发后再行病椎切除手术可取得良好效果。

英文摘要:

  【Abstract】 Objectives: To investigate the surgical methods for the aggressive vertebral hemangiomas with compressive myelopathy. Methods: Twenty-six patients suffering from aggressive vertebral hemangiomas with compressive myelopathy between January 2000 and October 2015 were reviewed. There were 11 males and 15 females, with the age of 15-69 years(23.0±4.5 years). Solitary tumors occurred in 6 patients and multiple tumors in 20 patients. The responsible segment located at cervical spine in 6 cases, thoracic spine in 18 cases and lumbar spine in 2 cases. The Frankel grade ranked A in 1 case, C in 5 cases, D in 18 cases, E in 2 cases. The ESCC grade was Ⅰ in 5 cases, Ⅱ in 15 cases, Ⅲ in 6 cases. The pathologic diagnosis was clear in 18 cases through preoperative needle biopsy and 8 cases through intraoperative fast pathologic examination. The operation applied decompression, vertebroplasty and internal fixation in 11 cases, vertebral tumor resection and reconstruction through anterior approach in 6 cases, total spondylectomy through posterior approach in 8 cases, tumor resection and reconstruction through one-stage combined anterior and posterior approach for axial hemangiomas in 1 case. The assessments included intraoperative blood loss, perioperative complications, tumor control, spinal cord function and spinal stability. Results: The average blood loss was 3927±4137ml in 15 cases with the vertebral tumor resection and 1355±703ml in 11 cases with decompression and vertebroplasty. The postoperative complications included pleural hemorrhage in 1 case and delay infection in 1 case, which were cured by using corresponding treatment. The follow-up time was 12-194 months(75±51 months). The tumor progression occurred in 4 cases, in whom 3 cases in decompression group were treated by total spondylectomy(2 cases) and stereotactic radiosurgery(1 case), the other 1 patient with axis tumor progressed after delivery and was treated by decompressive surgery and radiotherapy. The internal fixation related complications occurred in 4 cases, including 3 cases of internal fixation loosening, 1 case of internal fixation fracture, which were all treated with revision surgery. The Frankel grade was D in 4 cases and E in 22 cases at half year after operation. Conclusions: Aggressive spinal hemangioma with spinal cord compression requires surgical treatment. The vertebral resection gains better decompression and tumor controlling, but with huge surgical trauma, more intraoperative bleeding and postoperative complications. Palliative decompression combined with vertebroplasty can also save the spinal cord function, but will face the risk of tumor recurrence in some patients who recover well after spondylectomy.