上颈椎原发肿瘤全脊椎切除术的术中及术后并发症

Complications of total spondylectomy of upper cervical spine primary tumor

中文关键词:  脊柱肿瘤  全脊椎切除术  并发症  上颈椎  手术  手术入路

英文关键词:Spine tumor  Spondylectomy  Complication  Upper cervical spine  Surgery  Surgical approach

中文摘要:

  【摘要】 目的：总结上颈椎原发肿瘤全脊椎切除术的术中和术后并发症。方法：2005年3月~2013年7月采用分块全脊椎切除术治疗上颈椎原发肿瘤23例，其中男12例，女11例，年龄17~70岁，平均39岁。病变节段：C2 11例，C1、C2 2例，C2、C3 10例。21例患者术前诊断与术后病理诊断相符，其中脊索瘤10例，软骨肉瘤2例，骨巨细胞瘤7例，恶性周围神经鞘瘤1例，骨母细胞瘤1例。2例患者术前诊断与术后病理诊断不符，其中1例术前穿刺活检提示为骨母细胞瘤，术后病理确诊为纤维异常增殖症；1例术前病理检查提示为骨巨细胞瘤，术后病理诊断为低度恶性梭形细胞肿瘤。均行分块全脊椎切除术，手术采用前后联合入路，前路分颌下、经口或劈下颌骨入路三种方式；后方重建方式为枕颈固定，前方为钛板和自体髂骨块、钛板和钛网或单独异形钛网固定。术后辅助Halo架外固定。19例患者于围手术期行放射治疗，其中术前放疗8例，术后放疗11例。统计术中与术后并发症。结果：8例患者出现术中并发症，包括一侧椎动脉损伤5例、脊髓损伤1例、硬膜撕裂2例、喉上神经损伤2例。12例患者发生术后并发症，其中钛网前移压迫气管引起气道梗阻死亡和口咽粘膜感染大出血死亡各1例，迟发性椎动脉破裂出血1例，深部伤口感染6例，咽后壁粘膜延迟愈合6例、不愈合2例，肺炎4例，上消化道出血1例；内固定失败3例，植骨吸收内固定松动5例，植骨融合于倾斜的位置3例。结论：上颈椎原发肿瘤全脊椎切除手术并发症的发生率较高，主要并发症为术中椎动脉损伤、术后咽后壁伤口感染及后期内固定移位等。

英文摘要:

  【Abstract】 Objectives: To summarize the intra-and post-operative complications of the total spondylectomy of the upper cervical spine primarty tumor in order to make the surgery safer and improve the outcomes. Methods: 23 cases with upper cervical primary tumor underwent total intralesional spondylectomy from March 2005 to July 2013. 12 males and 11 females were included with a mean age of 39 year(17-70 years). The defects included C2 in 11 patients, C1 to C2 in 2 patients, and C2 to C3 in 10 patients. Preoperative and postoperative histology results were same in 21 patients, which included 10 chordomas, 2 chondrosarcomas, 7 giant cell tumors, 1 malignant nerve sheath tumor and 1 osteoblastoma. 2 patients showed different histology results before and after the surgery. Preoperative osteoblastoma under biopsy turned out to be fibrous dysplasia after operation in 1 patient. Preoperative giant cell tumor turned out to be low-grade malignant spindle cells tumor in the other patient. Combined anterior and posterior approaches were performed including anterior-posterior procedure in 11 cases and posterior-anterior procedure in 12 cases. 3 types of anterior approaches including transmandibular approach in 3 patients, transoral approach in 11 patients and high retropharyngeal approach in 9 patients were performed. Anterior reconstructions were also carried out in 3 different ways, including plate and iliac crest strut graft in 4 patients, plate and mesh cage in 4 patients, and Harms mesh cage alone in 15 patients. Posterior occipitocervical fixations were carried out in all patients. Halo-vest was all used routinely. Results: Intraoperative complications occurred in 8 patients, which included one side vertebral artery injuries in 5 patients, spinal cord injury in 1 patient, dura tear in 2 patients, and superior laryngeal nerve injury in 2 patient. Postoperative complications occurred in 12 patients, which included one death of respiratory failure due to mesh cage dislocation, one death of oral wound delayed bleeding, and vertebral artery injury in 1 patient, wound infection in 6 patients, non-healing or delayed-healing of oral mucosa in 8 patients, pneumonia in 4 patients, and upper gastrointestinal bleeding in 1 patient. Failure of fusion was found in 3 patients, bone graft absorbed and hardware loosening in 5 patients and malpositional fusion in 3 patients. Conclusions: Upper cervical spondylectomy is a demanding surgery with high rate of perioperative complications. The complications mainly included intraoperative vertebral artery injuries, instrument failure and pharyngeal infections.