CAJ | 학술논문

目的探讨改良一期后路全脊椎整块切除术治疗胸腰椎肿瘤的手术要点、器械改进及短期疗效.方法改良一期后路全脊椎整块切除术的整套器械包括:自制0.81 mm的钢缆式线锯、线锯改向器、L形骨刀和叉形骨刀;将Tomita后路全脊椎整块切除手术方法改良为前锯后刀会师两步截断法,即将线锯由前向后切割至约为椎间盘中后1/3处,再用L形骨刀经两侧由后向前凿至与线锯切割水平处会师,进而完成整个椎间盘的截断.而对于线锯引导过椎弓根困难的病例,则改为应用叉形骨刀截断椎弓根.用本术式治疗10例胸腰椎肿瘤患者,均有中重度疼痛和不同程度的脊髓神经受累表现.结果 7例胸椎肿瘤患者中,5例患者术后神经学功能均较术前提高ASIA分级1级,2例无变化;3例腰椎肿瘤患者术后神经根痛明显缓解,肌力均恢复至4级以上.平均手术时间7.8 h(6.0～10.3 h),平均术中出血2100 ml(1200～3500ml).未发生硬膜撕裂、脑脊液漏、医原性脊髓损伤和大血管损伤,术中胸膜撕裂2例,均予以留置胸腔闭式引流.术后平均随访8.1(3.3～18.1)个月,均无局部复发和内植物失败.结论应用改良一期后路全脊椎整块切除术治疗胸腰椎肿瘤的易操作性和安全性增加.
목적 탐토개량일기후로전척추정괴절제술치료흉요추종류적수술요점、기계개진급단기료효.방법 개량일기후로전척추정괴절제술적정투기계포괄:자제0.81 mm적강람식선거、선거개향기、L형골도화차형골도;장Tomita후로전척추정괴절제수술방법개량위전거후도회사량보절단법,즉장선거유전향후절할지약위추간반중후1/3처,재용L형골도경량측유후향전착지여선거절할수평처회사,진이완성정개추간반적절단.이대우선거인도과추궁근곤난적병례,칙개위응용차형골도절단추궁근.용본술식치료10례흉요추종류환자,균유중중도동통화불동정도적척수신경수루표현.결과 7례흉추종류환자중,5례환자술후신경학공능균교술전제고ASIA분급1급,2례무변화;3례요추종류환자술후신경근통명현완해,기력균회복지4급이상.평균수술시간7.8 h(6.0～10.3 h),평균술중출혈2100 ml(1200～3500ml).미발생경막시렬、뇌척액루、의원성척수손상화대혈관손상,술중흉막시렬2례,균여이류치흉강폐식인류.술후평균수방8.1(3.3～18.1)개월,균무국부복발화내식물실패.결론 응용개량일기후로전척추정괴절제술치료흉요추종류적역조작성화안전성증가.
Objective To investigate the operation key points, instrument improvement and shortterm effects in total en bloc spondylectomy (TES) via a single posterior approach for thoracic and lumbar tumors. Methods A series of modified instruments have been designed for the TES, including threadwire saw (T-saw) with a diameter of 0.81 mm, director and clamping for the saw, L shape and furcation osteotomes.The corpectomy of original TES which was defined as "one step dissection" from anteriorly to posteriorly, was modified into "two step dissection" which means that corpectomy was performed with saw cutting anteriorposteriorly and the L shape cutting posterior-anteriorly. In the cases with difficulty in pediculotomy using a T-saw, furcation osteotome was used for pediculotomy. Ten patients with thoracic or lumbar tumors were treated with the modified TES. There were 1 case of bone giant cell tumor, 1 case of bone neurilemmoma and 8 cases of metastatic tumors. All patients suffered moderate-severe pain and neurological deficit. Results The average follow-up period was 8.1(3.3-18.1) months. The average operating time was 7.8 h(6.0-10.3 h),and average blood loss was 2100 ml (1200-3500 ml). No disruption of dural mater, the leakage of cerebrospinal fluid, iatrogenic spinal cord injury and major vessel damage occurred. Two patients who underwent pleura disruption happened during the operation were treated with intrathoracic drain remedy. Among 7 cases with thoracic tumors, significant improvement in neurological function were achieved in 5 patients with the improvement of one grade in ASIA classification, while no change was found in 2 cases. In 3 cases with lumbar tumor, lumbar nerve root pain relieved and the muscle strength had recovered to grade 4 at least postoperatively. Conclusion Significant improvement has been achieved in the maneuverability and safety of the modified surgical techniques in TES with a single posterior approach for thoracic and lumbar tumors.