CAJ | 학술논문

目的探讨后路I期全脊椎整块切除(totalenblocspondylectomy，TES)治疗胸腰椎原发和转移性肿瘤的疗效。方法回顾性分析2007年1月至2012年7月，我科行TES的21例，男11例，女10例，年龄21～66(平均47.8)岁。原发肿瘤8例，孤立性转移瘤13例。原发肿瘤分别为骨巨细胞瘤3例，浆细胞瘤2例，骨肉瘤、软骨肉瘤及上皮样血管内皮瘤各1例；转移性肿瘤原发肿瘤分别为乳腺癌4例，肺癌3例，肾癌2例，甲状腺癌、前列腺癌、膀胱癌和原发灶不明转移性腺癌各1例。肿瘤节段分布于T3～L3，其中胸椎12例、腰椎9例，单一椎体19例、多椎体2例(均位于3个相邻胸椎)。根据Tomita脊柱肿瘤外科分期进行评估：I型5例、II型10例、III型1例、V型2例、VI型3例。术前均有顽固性腰背痛或神经功能损害。切除椎体的骨缺损用钛网＋自体骨或异体骨＋钉棒系统进行固定和重建。手术均经后路I期完成。结果手术时间4.0～8.5h，平均6.4h；出血量1300～11600ml，平均4500ml。本组21例均获12～80个月的随访，平均40个月，术后腰背部局部疼痛均达到缓解。脊髓功能损伤的患者术后Frankel分级均有一级以上恢复，和术前Frankel分级比较，差异有统计学意义(Z＝-2.232，P＜0.05)。3例死亡，平均死亡时间为术后16个月，4例带瘤生存，14例无瘤存活，总生存率为85.7%。局部复发3例，复发率为14.3%，复发时间为平均术后22个月。本组除1例胸腔积液伴肺部感染、1例气胸伴双肺感染、1例左侧L3神经根一过性麻痹外，未出现严重并发症，并发症发生率14.3%。所有病例均无术中由于大血管或节段血管引起的大出血发生，植骨均完全愈合，无内固定失败或钛网移位。结论后路I期TES治疗脊柱原发恶性肿瘤、侵袭性良性肿瘤和孤立性转移瘤能有效降低局部复发率，无严重的并发症，是一种有效的手术方式。目的探討後路I期全脊椎整塊切除(totalenblocspondylectomy，TES)治療胸腰椎原髮和轉移性腫瘤的療效。方法迴顧性分析2007年1月至2012年7月，我科行TES的21例，男11例，女10例，年齡21～66(平均47.8)歲。原髮腫瘤8例，孤立性轉移瘤13例。原髮腫瘤分彆為骨巨細胞瘤3例，漿細胞瘤2例，骨肉瘤、軟骨肉瘤及上皮樣血管內皮瘤各1例；轉移性腫瘤原髮腫瘤分彆為乳腺癌4例，肺癌3例，腎癌2例，甲狀腺癌、前列腺癌、膀胱癌和原髮竈不明轉移性腺癌各1例。腫瘤節段分佈于T3～L3，其中胸椎12例、腰椎9例，單一椎體19例、多椎體2例(均位于3箇相鄰胸椎)。根據Tomita脊柱腫瘤外科分期進行評估：I型5例、II型10例、III型1例、V型2例、VI型3例。術前均有頑固性腰揹痛或神經功能損害。切除椎體的骨缺損用鈦網＋自體骨或異體骨＋釘棒繫統進行固定和重建。手術均經後路I期完成。結果手術時間4.0～8.5h，平均6.4h；齣血量1300～11600ml，平均4500ml。本組21例均穫12～80箇月的隨訪，平均40箇月，術後腰揹部跼部疼痛均達到緩解。脊髓功能損傷的患者術後Frankel分級均有一級以上恢複，和術前Frankel分級比較，差異有統計學意義(Z＝-2.232，P＜0.05)。3例死亡，平均死亡時間為術後16箇月，4例帶瘤生存，14例無瘤存活，總生存率為85.7%。跼部複髮3例，複髮率為14.3%，複髮時間為平均術後22箇月。本組除1例胸腔積液伴肺部感染、1例氣胸伴雙肺感染、1例左側L3神經根一過性痳痺外，未齣現嚴重併髮癥，併髮癥髮生率14.3%。所有病例均無術中由于大血管或節段血管引起的大齣血髮生，植骨均完全愈閤，無內固定失敗或鈦網移位。結論後路I期TES治療脊柱原髮噁性腫瘤、侵襲性良性腫瘤和孤立性轉移瘤能有效降低跼部複髮率，無嚴重的併髮癥，是一種有效的手術方式。
목적탐토후로I기전척추정괴절제(totalenblocspondylectomy，TES)치료흉요추원발화전이성종류적료효。방법회고성분석2007년1월지2012년7월，아과행TES적21례，남11례，녀10례，년령21～66(평균47.8)세。원발종류8례，고립성전이류13례。원발종류분별위골거세포류3례，장세포류2례，골육류、연골육류급상피양혈관내피류각1례；전이성종류원발종류분별위유선암4례，폐암3례，신암2례，갑상선암、전렬선암、방광암화원발조불명전이성선암각1례。종류절단분포우T3～L3，기중흉추12례、요추9례，단일추체19례、다추체2례(균위우3개상린흉추)。근거Tomita척주종류외과분기진행평고：I형5례、II형10례、III형1례、V형2례、VI형3례。술전균유완고성요배통혹신경공능손해。절제추체적골결손용태망＋자체골혹이체골＋정봉계통진행고정화중건。수술균경후로I기완성。결과수술시간4.0～8.5h，평균6.4h；출혈량1300～11600ml，평균4500ml。본조21례균획12～80개월적수방，평균40개월，술후요배부국부동통균체도완해。척수공능손상적환자술후Frankel분급균유일급이상회복，화술전Frankel분급비교，차이유통계학의의(Z＝-2.232，P＜0.05)。3례사망，평균사망시간위술후16개월，4례대류생존，14례무류존활，총생존솔위85.7%。국부복발3례，복발솔위14.3%，복발시간위평균술후22개월。본조제1례흉강적액반폐부감염、1례기흉반쌍폐감염、1례좌측L3신경근일과성마비외，미출현엄중병발증，병발증발생솔14.3%。소유병례균무술중유우대혈관혹절단혈관인기적대출혈발생，식골균완전유합，무내고정실패혹태망이위。결론후로I기TES치료척주원발악성종류、침습성량성종류화고립성전이류능유효강저국부복발솔，무엄중적병발증，시일충유효적수술방식。
Objective To evaluate the clinical outcomes of one-stage posterior total en bloc spondylectomy ( TES ) in the treatment of primary and metastatic tumors of the thoracolumbar spine. Methods From January 2007 to July 2012, 21 patients with primary and metastatic tumors of the thoracolumbar spine underwent TES, whose clinical data were retrospectively analyzed. There were 11 males and 10 females, whose average age was 47.8 years old ( range;21-66 years ). There were 8 cases of primary tumors and 13 cases of solitary metastatic tumors. Among the 8 cases of primary tumors, there were 3 cases of giant cell tumors of bone, 2 cases of plasmacytoma, 1 case of osteosarcoma, 1 case of chondrosarcoma and 1 case of epithelioid hemangioendothelioma. Among the 13 cases of metastatic tumors, there were 4 cases of breast cancer, 3 cases of lung cancer, 2 cases of renal cancer, 1 case of thyroid cancer, 1 case of prostate cancer, 1 case of bladder cancer and 1 case of unknown adenocarcinoma. The tumors were located from T3 to L3, including the thoracic vertebra ( n=12 ) and the lumbar vertebra ( n=9 ). The tumors were detected in the single vertebral body in 19 cases and multiple vertebral bodies ( 3 adjacent vertebral bodies ) in 2 cases. According to Tomita surgical classiifcation system, there were 5 cases of type I, 10 cases of type II, 1 case of type III, 2 cases of type V and 3 cases of type VI. All the patients had intractable back pain or neurologic disturbances before the operation. Vertebral bone defects were repaired, and internal ifxation and reconstruction were performed with titanium mesh, allograft or autograft and pedical screws. The operation was completed in all patients through the posterior approach at the ifrst stage. Results The mean operation time was 6.4 hr ( range;4.0-8.5 hr ). The average amount of blood loss was 4500 ml ( range;1300-11 600 ml ). Perioperative complications occurred in 2 cases, including 1 case of pleural effusion and pulmonary infection and 1 case of pneumothorax and bilateral pulmonary infection. All patients were followed up for an average period of 40 months ( range;12-80 months ). Remarkable relief of local back pain was achieved after the surgery. As to the patients with spinal cord injuries, at least a one-grade improvement was obtained after the surgery based on the Frankel scale, when compared with that before the operation. The differences between them were statistically signiifcant ( Z=-2.232, P<0.05 ). A total of 3 patients died, and the mean death time was at 16 months after the operation. Four patients lived with tumors and 14 patients lived without tumors. The total survival rate was 85.7%. Local recurrence was detected in 3 patients, and the recurrence rate was 14.3%. The mean recurrence time was at the 22nd months after the operation ( range;12-36 months ). No serious complications were noticed, and the complication rate was 14.3%. No uncontrollable bleeding in the great vessels or segmental vessels was found during the operation. All patients obtained bone union, without internal ifxation failure or titanium mesh displacement. Conclusions One-stage posterior TES is an effective surgical method in the treatment of primary malignant tumors, invasive benign tumors and solitary metastatic tumors of the thoracolumbar spine, with the advantages of lower local recurrence rate and no serious complications.