胸腰椎肿瘤全脊椎切除手术入路的选择与评价

Choosing of surgical approach for total spondylectomy in thoracic or lumbar spine tumor

中文关键词:  肿瘤  胸椎  腰椎  手术入路  全脊椎切除术

英文关键词:Tumor  Thoracic spine  Lumbar spine  Surgical approach  Total spondylectomy

中文摘要:

  【摘要】 目的：探讨胸腰椎肿瘤全脊椎切除手术的入路选择，初步评价不同手术入路的临床意义。方法：2001年10月~2013年12月共收治74例胸腰椎肿瘤患者，男31例，女43例；年龄11~69岁，平均40.2岁。分别采用单纯后正中入路、后路联合前路或后路联合侧前方入路手术完成肿瘤的全脊椎切除。分析脊柱肿瘤WBB分期及肿瘤所在部位、是否首次手术与手术入路选择的关系。结果：选择后正中入路手术者25例，肿瘤位于B~D、3~9区15例，其中单节段12例，两节段3例；B~D、1~12区4例，其中单节段3例，两节段1例；肿瘤软组织肿块较小、位于A~D/E、3~9区4例，其中单节段3例，两节段1例；A~D/E、1~12区单节段2例。整块切除24例，大块经瘤切除1例。上胸椎2例，胸椎及胸腰段21例，中下腰椎2例。后路联合前方入路手术者30例，肿瘤侵袭A~D/E、累及1~12区20例，单节段11例，两节段及以上9例，其中复发肿瘤12例；累及3~9区8例，单节段5例、两节段及以上3例，其中上胸椎5例（复发肿瘤2例）；累及B~D、3~9区的L4和L5肿瘤各1例。整块切除8例，大块经瘤切除22例。上胸椎7例，下腰椎（L4-L5）5例，胸椎或胸腰段18例。后路联合侧前方入路19例，肿瘤累及A~D/E、1~12区10例，单节段肿瘤9例，2节段1例；累及A~D/E、3~9区的单节段初次手术的胸腰段肿瘤5例，软组织肿块位于脊椎的侧方；累及B~D、1~12区的中下腰椎单节段肿瘤2例，胸腰段肿瘤2例。整块切除3例，大块经瘤切除16例。胸椎及胸腰段10例，中下腰椎9例。结论：胸、腰椎肿瘤全脊椎切除手术入路应根据肿瘤侵袭范围及所在脊椎部位进行选择。局限在脊椎骨内或椎旁肿块较小的单及两节段肿瘤选择单纯后正中入路；肿瘤突破脊椎致前方有较大肿块、复发肿瘤及侵袭椎旁的上胸椎肿瘤多选择联合前方入路；软组织侵袭位于脊椎侧方的肿瘤多选择后路联合侧前方入路。

英文摘要:

  【Abstract】 Objectives: To discuss the choosing of surgical approach for total spondylectomy in thoracic on lumbar spine tumor. Methods: 74 cases with thoracic or lumbar spine tumor underwent total spondylectomy from October 2001 to December 2013. The study included 31 males and 43 females with a mean age of 40.2 years(range 11-69 years). The clinical difference of Weinstein-Boriani-Biagini spinal tumor classification system, location, primary or not among the posterior approach, the combined posterior and anterior approach, or combined posterior and lateral approach was analyzed respectively. Results: Twenty-five cases underwent the posterior approach. B-D levels with 3-9 sectors(12 single segment and 3 double segments) were involved in 15 cases; B-D levels with 1-12 sectors(3 single segment and 1 double segments) were involved in 4 cases. A-D/E levels with 3-9 sectors(3 single segment and 1 double segments) were involved in 4 cases, A-D/E levels with 1-12 sectors(single segment) were involved in 2 cases. 2 cases had diseased level in the upper thoracic vertebra, 21 cases in thoracic or thoracolumbar spine and 2 in lumbar spine(L4-L5). 30 cases underwent the combined posterior and anterior approach. A-D/E levels with 1-12 sectors(11 single segment and 9 more segments with 12 recurrence) were involved in 20 cases; A-D/E levels with 3-9 sectors(5 single segment and 3 more segments with 2 recurrence) were involved in 8 cases. B-D levels with 3-9 sectors(one in L4, the other in L5) were involved in 2 cases. 7 cases had diseased level in the upper thoracic vertebra, which contained 5 cases of the upper thoracic vertebra(2 cases recurrence); 5 in the lumbar spine(L4-L5) and 18 in thoracic or thoracolumbar spine. 19 cases underwent the combined posterior and lateral approach. A-D/E levels with 1-12 sectors(9 single segment and 1 more segments with 2 recurrence) were involved in 10 cases; A-D/E levels with 3-9 sectors(single segment) were involved in 5 cases. B-D levels with 3-9 sectors(2 in L4-L5 and 2 in the thoracolumbar spine) were involved in 4 cases. 10 cases had diseased level in the thoracic or thoracolumbar spine and 9 in lumbar spine(L4-L5). Conclusions: The surgical approach should be determined according to the tumor lesion and location. Tumor limited in the spine or with small extent of paravertebra progression in single and double segments, the posterior approach is appropriate for the total spondylectomy. For tumor combined with large soft tissue infiltration in front of vertebra, tumor recurrence combined posterior and anterior approach should be choosed. Tumor combined with large soft tissue infiltration at lateral side of vertebra, the combined posterior and lateral approach is appropriate for the total spondylectomy.