胸腰椎肿瘤全脊椎切除术后的稳定性重建及其并发症

Stability reconstruction and related complications after total spondylectomy for thoracolumbar tumors

目的探讨胸腰椎肿瘤全脊椎切除术后与稳定性重建相关的并发症。方法1997年1月至2009年12月接受全脊椎切除术且随访及存活时间超过18个月的胸腰椎肿瘤患者34例，男20例，女14例；年龄15-72岁，平均43岁。胸椎27例，腰椎7例。脊柱转移瘤6例，原发骨肿瘤28例。全脊椎分块切除23例，整块切除11例。后路椎弓根钉棒系统短节段固定19例，长节段固定13例，短节段前路固定2例。前方椎体重建采用钛网植骨20例，钛网骨水泥7例，骨水泥填塞2例，单纯植骨2例，带加强环的钛网植骨1例，人工椎体植骨2例；后方碎块植骨26例，大块桥接植骨8例。结果随访18-128个月，平均43个月。7例死亡。4例原发肿瘤行分块切除者复发，1例行整块切除者复发。25例椎体间植骨者融合不良5例。术后患椎上、下椎体间矢状面Cobb角平均-6°（-34．2°-15．5°），末次随访或翻修术前9．3°（-17．5°-57．2°），丢失16．0°（1．2°-65．4°），后方多节段固定者丢失14．1°（0．8°-36．5°），短节段固定者丢失21．5°（4．4°-65．4°）。内固定断裂5例、内固定松动2例，钛网下沉6例、移位3例。人工椎体置换病例无明显下沉和移位。2例行前后路翻修，2例更换断棒，1例更换螺钉。结论全脊椎切除术后与脊柱稳定性重建相关的并发症较多。后方长节段经椎弓根固定配合大块桥接植骨、前方应用人工椎体置换与植骨可使脊柱获得坚强的临时固定与长期融合。

Objective To investigate the spinal stability reconstruction and related complications after total spondylectomy for thoracolumbar tumors. Methods From January 1997 to December 2009, 34 cases with thoracolumbar tumors treated with total spondylectomy, including 20 males and 14 females with an average age of 43 years. The tumors were located in thoracic vertebra in 27 cases and lumbar vertebra in 7, including 6 spinal metastases and 28 primary tumors. The total spondylectomy was piecemeal in 23 cases and en bloc in 11. The reconstruction methods included posterior short-segment fixation in 19 cases, multi- segmental fixation in 13, anterior intervertebral fixation in 2, titanium mesh with auto-bone graft in 20 cases, titanium mesh with bone cement in 7, bone cement filling in 2, auto-bone strut graft in 2, titanium mesh with strengthened rings in 1, artificial vertebral body replacement in 2, posterior massive bone bridging graft in 8 and bone particles graft in 26. Results The mean follow-up time was 43 months. Seven patients died, 5 suffered recurrence. Poor grafted bone fusion was found in 5 cases. The intervertebral sagittal Cobb angle of adjacent vertebra was -6° after operation, 9.3° at the end of follow-up or before revision operation. The average lost angle was 14.1° for cases with multi-segmental fixation, and 21.5° with short-segment fixation. Complications included internal fixation broken （5） and loosening （2）, titanium mesh subsidence （6） and displacement （3）. There were 5 revision surgeries. Conclusion There are relative more complications about spinal stability reconstruction after total spondylectomy. To achieve temporary stiff fixation and long-term fusion, the posterior multi-segment fixation and massive bone bridging graft combined with the anterior artificial vertebral body replacement are effective.