原发性骶骨肿瘤的手术治疗

Surgical treatment of primary sacral tumor

中文关键词:  原发性骶骨肿瘤  手术治疗  并发症  预后

英文关键词:Primary sacral tumors  Surgical treatment  Complications  Prognosis

中文摘要:

  【摘要】 目的：总结手术治疗原发性骶骨肿瘤的临床经验。方法：1991年1月～2009年8月我科手术治疗26例原发性骶骨肿瘤患者，男17例，女9例。就诊时年龄17~71岁，平均48岁。术前结合临床表现、影像学和CT引导下穿刺活检病理结果明确诊断。肿瘤累及S2及以上者15例，采用前后联合入路手术，其中9例瘤体巨大的恶性肿瘤患者术前置入主动脉球囊术中行腹主动脉临时阻断；肿瘤累及S3及以下者11例，采用单纯后路手术。术中尽量保留双侧S2及以上神经根和一侧S3神经根。9例切除S1椎患者同时行腰椎髂骨内固定。结果：所有患者均顺利完成手术，无围术期死亡及严重术中并发症。单纯后路手术患者术中出血量为200～5000ml，平均1995±2076ml；前后联合入路手术者术中出血量为400～6300ml，平均2400±1678ml，其9例术中行腹主动脉球囊阻断者术中出血量为2333ml。术后伤口发生并发症11例，6例不愈合，4例感染，2例皮肤坏死，1例窦道形成，均经换药及清创处理，其中2例行二期肌皮瓣转移术，均治愈。23例术前穿刺活检者22例与术后病理检查结果相符。术后早期神经功能损害加重者11例，随访期间8例完全恢复，3例部分恢复。24例获得9~198个月随访，平均45.6个月，1例恶性周围神经鞘瘤患者术后11个月死于多器官功能衰竭；局部复发9例，其中脊索瘤5例，恶性外周神经鞘瘤3例，神经鞘瘤1例，初次平均复发时间12.2个月。末次随访时，17例患者日常生活和大小便功能基本正常。结论：对于骶骨原发肿瘤术前CT引导下穿刺活检有助于明确诊断；肿瘤累及S3及以下者可采用单纯后路手术，肿瘤累及S2及以上的病例宜采用前后联合入路手术，术中腹主动脉球囊临时阻断可有效减少出血；保留双侧S2以上神经根和至少一侧S3神经根可提高患者生活质量。

英文摘要:

  【Abstract】 Objective：To summarize the surgical outcome for primary sacral tumors.Method：26 cases （including 17 males and 9 females） with sacral tumor from January 1991 to Ａｕｇｕｓｔ 2009，underwent surgical protocol.The mean age at admission was 50 years（range，17-71 years）.The clinical presentation，imaging and needle biopsy were used to determine the diagnoses.Combined anterior-posterior approach（APA） was used in 15 patients with tumors involving S2 and above.Among them，balloon dilation catheter（BDC） was used in 9 cases with huge malignant tumors.Single posterior approach（PA） was used in 11 patients with tumors involving vertebrae below S2.Bilateral S1 and S2 nerve roots and at least unilateral S3 nerve root were preserved in the surgery.Lumboiliac fixation was performed in 9 patients due to the removal of S1.Result：All patients underwent the operations successfully with no perioperative death or serious complications.The blood loss in PA group ranged from 200ml to 5000ml（mean，1995±2076ml），whereas that in APA group ranged from 400ml to 6300ml（mean，2400±1678ml），and the mean blood loss for BDC was 2333ml.Skin incision complications were noted in 11 cases including non-healing in 6 cases，infection in 4 cases，skin necrosis in 2 cases and sinus formation in 1 case.Two of them healed after skin flap transplantation and the others healed through debridement and dressing change.11 cases presented with neurological deterioration at the early following up，including weakness and numbness of lower extremity，saddle numbness and bladder and bowel dysfunction.Of them，8 cases recovered completely and 3 cases recovered incompletely after an average of 27 months follow up.One patient with malignant peripheral nerve sheath tumors died of multiple organ failure 11 months later.9 cases were noted to have local recurrence including 5 chordoma，3 malignant peripheral nerve sheath tumors and 1 nerve sheath tumors.The primary local recurrence was dated at 12.2 months on average.At final follow-up，17 patients recovered routine life and normal cauda equina function.Conclusion：CT-guided biopsy is valuable.We recommend single posterior approach for tumors involving vertebrae below S2 and combined anterior-posterior approach for tumors involving S2 and above，BDC is helpful to blood control.Bilateral S1 and S2 nerve roots and at least unilateral S3 nerve root should be preserved to improve life quality.