胸腰椎椎旁占位性病变的临床分型和手术方案选择

Clinical classification and surgical option of thoracolumbar paravertebral space-occupying lesion

中文关键词:  胸腰椎  椎旁病变  手术入路  切除  部位  分型

英文关键词:Thoracolumbar spine  Paravertebral lesion  Surgical approach  Resection  Location  Type

中文摘要:

  【摘要】 目的：提出胸腰椎椎旁占位性病变新的临床分型并评价其对手术治疗方案选择的参考价值。方法：收集2013年1月~2019年12月接受手术切除治疗的35例胸腰椎椎旁占位性病变患者的临床资料，其中男15例，女20例，年龄7～70岁（42.4±16.1岁）。后正中入路6例，经椎旁肌间隙切除横突入路7例，腹膜后间隙入路17例，病变后方直接切除5例。依据占位病变的影像学特点，将胸腰椎椎旁占位性病变按部位分为3型：Ⅰ型，病变位于椎体旁，小部分沿神经根向椎间孔生长，未突入中央椎管；Ⅱ型，病变位于椎体旁椎间孔之外；Ⅲ型，病变位于椎弓后方的竖脊肌。每型按占位大小进一步分为a、b两个亚型，病变长轴≤50mm为a型，＞50mm为b型。3名观察者先后进行两次评估分型（间隔1周），并进行Kappa一致性检验。手术前后及末次随访时行疼痛VAS评分，并结合影像学复查进行疗效评定。结果：35例患者中Ⅰa型4例，Ⅰb型3例，Ⅱa型9例，Ⅱb型14例，Ⅲa型3例，Ⅲb型2例。3位观察者分型自身一致性的Kappa值为0.924～1，观察者之间一致性的Kappa值为0.849～0.924，均高度一致。6例经后正中入路切除患者为胸段Ⅰa（1例）、Ⅱa（5例）型，7例经椎旁肌间隙入路切除患者为腰段Ⅰa（3例）、Ⅱa（4例）型，17例经腹膜后间隙入路切除患者为腰段Ⅰb（3例）、Ⅱb（14例）型，5例病变后方直接切除患者为胸、腰段Ⅲa（3例）、Ⅲb（2例）型。34例一期全切，1例未能全部切除。术后患者症状明显缓解，神经功能均未见明显缺失。33例患者获得3～90个月（42.5±33.3个月）随访，其中32例复查MRI未发现病变复发，1例脂肪肉瘤复发。VAS评分术前为7.7±1.6分，术后1个月2.4±1.3分，末次随访时1.2±1.1分。结论：基于胸腰椎椎旁占位性病变的部位和大小，进行合理临床分型，并制定相应的手术治疗策略能够获得良好的临床疗效。

英文摘要:

  【Abstract】 Objectives: To propose a new clinical classification of paravertebral space-occupying lesions of thoracolumbar spine and evaluate its reference value for the selection of surgical treatment. Methods: From January 2013 to December 2019, 35 patients with paravertebral space-occupying lesions of the thoracolumbar spine underwent surgical resection, including 15 males and 20 females, aged from 7 to 70 years (42.4±16.1 years). There were 6 cases of posterior median approach, 7 cases of paraspinal sacrospinalis muscle-splitting approach, 17 cases of retroperitoneal space approach and 5 cases of lesion posterior approach. The imaging features were retrospectively analyzed, and the paravertebral space-occupying lesions were divided into three types: type Ⅰ, located near the vertebral body, with a small part growing along the nerve root to the intervertebral foramen and not protruding into the central spinal canal; type Ⅱ, located outside the intervertebral foramen beside the vertebral body; and type Ⅲ, located in the erector spinae behind the vertebral arch. Each type was further divided into two subtypes of a and b according to the size of space-occupying lesions. Among them, patients with a long axis ≤50mm were classified as subtype a, and those with that more than 50mm were classified as subtype b. Three observers evaluated the classification twice(interval 1 week). The consistency of the analysis results was checked by Kappa-test. VAS score was compared before and after the operation, and at the last follow-up. The curative effect was evaluated combined with imaging results. Results: Among the 35 cases, 4 cases were of type Ⅰa, 3 cases type Ⅰb, 9 cases type Ⅱa, 14 cases type Ⅱb, 3 cases type Ⅲa, and 2 cases type Ⅲb. The Kappa of inter-observer agreement was 0.924-1, and the Kappa of intra-observer was 0.849-0.924, which were highly consistent. 6 cases were resected through the posterior median approach, which belonged to the thoracic segment Ⅰa(1) and Ⅱa(5) patients; 7 cases were resected through paraspinal sacrospinalis muscle-splitting approach, which belonged to the lumbar segment Ⅰa(3) and Ⅱa(4) patients; 17 cases were resected through the retroperitoneal space approach, belonged to the lumbar segment Type Ⅰb(3) and Ⅱb(14) patients; 5 cases were resected directly behind the lesion, and they were type Ⅲa(3) and Ⅲb(2) patients. 34 cases were completely removed at one stage, and 1 case failed to be completely resected. The patient′s symptoms improved significantly. There was no obvious loss of neurological function after operation. 33 patients were followed up for 3 to 90 months(42.5±33.3 months). Among them, 32 cases did not find tumor recurrence on MRI, and 1 case had recurrence of liposarcoma. The average VAS score was 7.7±1.6 points before operation, 2.4±1.3 points 1 month after operation, and 1.2±1.1 points at the last follow-up. Conclusions: Based on the location and size of paravertebral space-occupying lesions of the thoracolumbar spine, the reasonable clinical classification was proposed and the corresponding surgical treatment strategy can achieve satisfactory clinical outcomes.