改良Sundaresan法治疗上胸椎肿瘤

Surgical treatment of upper thoracic spinal tumor using the modified Sundaresan's method

目的探讨采用改良Sundaresan法治疗上胸椎肿瘤的效果。方法自1999年1月～2003年10月共治疗上胸椎肿瘤患者14例,男9例,女5例;年龄26～65岁,平均43岁。原发性肿瘤10例(71.4%),转移瘤4例(28.6%)。T1肿瘤7例,T2肿瘤5例,T3肿瘤2例。采用改良Sundaresan手术入路,经下颈部和胸锁关节切口,切除胸锁关节的锁骨端,显露椎体肿瘤病灶,切除肿瘤椎体及其相邻椎间盘,解除对脊髓的压迫。椎体间采用切除的锁骨植骨或植入钛质网笼,颈椎前路带锁钢板内固定。脊髓损伤程度按Frankel分级标准评定。结果术后随访6个月～2年,平均10个月。采用改良Sundaresan手术入路可以较好地显示手术区域,利于病灶清除和内固定,避免损伤脊髓。术后脊髓功能均有不同程度改善,1例A级,恢复至B级;1例B级,恢复至D级;2例C级,1例恢复至D级,1例恢复至E级;4例D级,2例恢复至E级,2例无变化;6例E级无改变。所有患者肩关节功能未受到明显影响,肩关节外展术前90°～130°,平均125°;术后80°～120°,平均110°。结论采用改良Sundaresan法治疗上胸椎肿瘤效果好,创伤小,对肩关节功能无明显影响,适用于脊髓前方存在压迫的上胸椎椎体肿瘤。

Objective To explore the effectiveness of modified Sundaresans method, including exposure through the incision involving both of the sternoclavicular joint and lower cervical region with sternum retention, in the treatment for upper thoracic spinal tumor. Methods From January 1999 to October 2003, 14 patients, 9 males and 5 females, aged from 26 to 65 years with a mean of 43 years underwent the modified Sundaresans procedure. The anterior cervico-thoracic incision was made, the medial part of clavicle close to the sternoclavicular joint was removed. After the exposure of the tumor, the involved vertebral body and contiguous discs were resected, the spinal cord was decompressed, then followed by implanting part of resected clavicle or titanium mesh with an anterior locking plate system. Neurological status was graded according to Frankel grading system. Results The duration of follow-up ranged from 6 months to 2 years with an average of 10 months. This approach displayed the upper thoracic region clearly for removal of the tumor and internal fixation,in avoiding the neurological injury. All patients had their neurological improvement at different level. According to Frankel grading system, one patient improved from grade A pre-operation to B post-operation, while another patient from B to D. Of 2 cases with grade C before operation, one improved to D and the other to E. Of 4 patients with grade D, 2 improved to E, while the other 2 left unchanged. There were 6 cases keeping the same grade before and after operation. Resection of sternoclavicular joint almost had no effect on the movement of shoulder. The abduction of the shoulder joint in 14 patients from 90°-130°(average, 125°) preoperatively became 80°-120°(average, 110°) postoperatively. Conclusion The modified Sundaresans method for the upper thoracic tumors has many advantages, such as satisfactory outcome, less invasion and no loss of the shoulder function. It is especially indicated to the tumors, where the spinal compression is located anteriorly.