一期经前后路全脊椎整块切除术治疗腰椎肿瘤

One-stage total en bloc spondylectomy by anterior and posterior approaches for lumbar vertebral tumors

目的探讨一期前后路全脊椎整块切除术（TES）治疗腰椎肿瘤的可行性，为临床治疗腰椎肿瘤提供更可靠有效的手术方式。方法2003年4月至2007年8月，行一期前后路TES治疗21例腰椎肿瘤患者。其中男性14例，女性7例；年龄28～69岁，平均47．6岁。腰椎原发性肿瘤13例，转移瘤8例（术前已切除原发病灶或同期切除病灶）。病灶均为单节段，位于L13例、L23例、L，8例、L45例、L52例；按Enneking分期：原发良性肿瘤s3期8例，其中6例伴病理骨折；原发恶性肿瘤IA期3例，Ⅱ期2例；8例转移性肿瘤按Tokuhashi预后评分系统均小于8分，且预计生存时间大于半年以上。按Tomita外科分型，2型3例，3型7例，4型5例，5型5例，6型1例。按Frankel分级：B级1例，C级4例，D级9例，E级7例。18例患者术后按病理类型给予相应的综合治疗。治疗前后资料采用X^2检验进行统计学分析。结果平均手术时间250min，术中平均失血量2100ml。术后随访1．0～5．5年，平均2．7年。所有病例术后疼痛消失或减轻，其中14例疼痛完全消失，7例疼痛明显缓解。除2例转移性肿瘤术后12个月内死亡未行神经功能Frankel分级评估外，19例患者术后1年脊髓神经功能有明显的改善，其中C级1例，D级2例，E级16例；与术前比较差异有统计学意义（X^2=10．950，P〈0．01）；原发腰椎肿瘤患者中，1例骨巨细胞瘤术后12个月肿瘤局部复发，行局部病灶清理手术，1例骨肉瘤和1例骨巨细胞瘤患者分别与术后13个月和18个月死于肺转移；转移性腰椎肿瘤患者中1例前列腺癌、1例肺癌的患者分别于术后7至12个月由于多器官转移死亡，1例肾癌转移患者局部肿瘤复发放弃治疗。其余的患者均存活至今，未发现局部复发和其他部位转移灶。结论一期经前后联合入路TES治疗腰椎肿瘤是安全可行的。在严格把握手术适应证条件下，可获得较好的治疗效果。

Objective To investigate the surgical results of one stage total en bloc spondylectomy （TES） by anterior and posterior approaches for lumbar vertebral tumors and evaluate its benefit for these tumors. Methods A total of 21 patients with the lumbar vertebral tumor treated with on stage TES by posterior and anterior approaches from April 2003 to August 2007 were reviewed, which included 14 males and 7 females with an average age of 47.6 years. Thirteen patients were suffered with the primary lumbar vertebral tumors and 8 patients were diagnosed for the lumbar vertebral metastasis tumors. There were 8 of S3, 3 of I A and 2 of 11 according to Ennekinng stage system. And there were 1 of Grade B, 4 of Grade C, 8 of Grade D, and 6 of Grade E according to Frankel grade system. The spinal reconstruction was obtained by titanium mesh filled with autograft for benign and low-grade malignant tumors and methylmethacrylatefilled titanium mesh for malignant tumors. The spinal stability was enhanced by posterior internal fixation with rod-screw system. Results The operation time was 250 min and bleed loss was 2100 ml on average. The follow-up period lasted from 1.0 to 5.5 years. All cases had pain before operation, among which 14 cases obtained complete relief and 7 cases obtained partly relief after operation. In all cases with neurological deficit, they improved neurologically by more than one grade using the Frankel grading system. Up to now, 1 patient had be local recurrence after operation and 4 patients were dead on the following time. The others still are alive and no local recurrence. Conclusion One-stage TES by anterior and posterior approaches for lumbar vertebral tumor is feasible, safe and effective to lumbar vertebral tumor resection and stability reconstruction, which has many advantages such as controlling local recurrence, spinal cord decompression thoroughly, relieving the pain, improving the life quality and prolonging the lifetime.