经颌下入路切除枢椎肿瘤及前方内固定应用

Anterior construction after resection for axis tumors through the sub mandible approach

目的探讨经颌下胸锁乳突肌内侧缘入路切除枢椎肿瘤及前方内固定的应用。方法2004年12月至2010年6月，采用经颌下胸锁乳突肌内侧缘人路联合后路行枢椎肿瘤切除前后内固定术治疗枢椎肿瘤17例，男11例，女6例；年龄23-77岁，平均49岁；C2 11例，C2,3 4例，C2-4 2例；8例累及椎体，9例累及椎体及附件。原发性肿瘤14例，其中骨巨细胞瘤4例，浆细胞瘤4例，脊索瘤2例，嗜酸性肉芽肿2例，血管外皮瘤、淋巴瘤各1例；转移性肿瘤3例。前路肿瘤切除后采用钛网植骨及钛板垂直放置螺钉固定、钛网植骨及钛板斜行放置螺钉固定、钛网修剪后植骨螺钉固定3种方式行上颈椎前路内固定，均一期联合后路肿瘤切除枕颈内固定。结果术后患者局部疼痛缓解，神经症状减轻或消失。术后随访6个月至6年。1例采用钛网植骨及钛板垂直放置螺钉固定的患者术后1个月发生螺钉松动退出，经翻修后融合，余16例患者均获融合。1例患者于术后9个月死于脑梗死。2例脊索瘤患者分别于术后13和18个月局部复发，1例死于高位瘫痪、呼吸衰竭，1例带瘤生存。2例转移癌患者分别于术后12和18个月因全身多处转移、衰竭而死亡。结论经颌下胸锁乳突肌内侧缘入路可获得枢椎肿瘤切除与重建的良好显露。应用颈椎内固定系统可实现枢椎肿瘤切除后上颈椎稳定的前方重建。

Objective To investigate procedure and therapeutic effect of resection and reconstruction for axis tumors through the sub mandible approach. Methods Between December 2004 to June 2010, 17 patients with axis neoplasm underwent tumor resection and antero-posterior reconstruction through the combined the sub mandible-inner sternocleidomastoid muscle （SMIS） approach and posterior approach. Tumor lesions involved C2 in 11 cases, C2-3 in 4, C2-4 in 2. Eight cases involved vertebral body, and 9 involved both vertebral body and element. Fourteen primary lesions including 4 giant cell tumors, 4 plasmocytomas, 2 chordomas, 2 eosinophilic granulomas, 1 hemangiopeficytomas and 1 lymphoma, and 3 metastatic lesions were involved in this study. Three types of reconstruction in upper cervical spine including titanium mesh plus vertically placed titanium plate, titanium mesh plus obliquely placed titanium plate and trimmed titanium mesh alone, were adopted after anterior tumor resection, and then posterior tumor resection and reconstruction were performed. Results All patients experienced pain relief and neurological improvement after surgery. Except for one incidence of screw pull-out which was corrected by a revision surgery, solid fusion was achieved in all patients. A follow-up period of 6 months to 6 years was available for this study. One patient died of cerebral infarction 9 months postoperative. Two patients with chordoma relapsed 13 months and 18 months postoperative, respectively, of whom one died of high plegia and respiratory failure, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases 12 months and 18 months postoperative, respectively. Conclusion Through the SMIS apporach, a satisfactory exposure can be obtained for axis tumor resection and reconstruction. Anterior reconstruction of upper cervical spine after tumor resection can be achieved with internal fixation system of cervical spine, which can improve intraoperative safety. The combined anterior reconstruction and posterior occipito-cervcial fixation can provide immediate stability, and benefit maintaining stability of upper cervical spine.