侧前方经胸手术入路治疗钙化的巨大胸椎椎间盘突出

Thansthoracic approach in treatment of patients with calcified giant herniated thoracic discs

目的探讨侧前方经胸手术入路治疗钙化的巨大胸椎椎间盘突出的安全性及有效性。方法 2004年4月～2010年9月,15例钙化的巨大胸椎椎间盘突出患者行侧前方经胸减压内固定融合术,其中男11例,女4例;33～61岁,平均46岁。回顾性分析15例患者的手术效果和并发症。记录椎间盘突出的节段、类型,手术时间,出血量,手术前后Frankel分级和日本骨科学会(Japanese Orthopedic Association,JOA)评分,以及术后并发症。通过手术前后影像学资料分析减压、脊柱序列及内固定情况。结果 15例患者中,2例患者为双节段胸椎椎间盘突出。突出钙化的巨大椎间盘位于T6～12各间隙,主要位于T11/T12(60%);40%为中央型突出,60%为旁中央型突出。通过侧前方经胸手术,成功切除所有突出钙化的巨大椎间盘。平均手术时间为179 min(140～210 min),平均出血量为840 mL(300～2 000 mL)。术后9例患者Frankel分级有所改善,末次随访时12例患者的Frankel分级改善1级,没有Frankel分级降低的情况。术后JOA评分由4.9升至7.7,改善率为(46.8±21.41)%。所有患者均自觉症状较术前有所好转。平均随访时间为45个月(7～77个月)。1例患者术后并发肺炎,1例出现心脏意外,2例出现切口处肋间神经痛。经有效治疗,4例患者最终均获得满意疗效。结论钙化的巨大胸椎椎间盘突出导致脊髓严重受压,手术难度大、风险高,侧前方经胸减压内固定植骨融合术是有效安全的手术方法。

Objective To investigate the safety and effective of thansthoracic approach in the treatment of patients with calcified giant herniated thoracic discs（HTDs）.Methods Fifteen consecutive patients,11 male and 4 female,with a mean age of 46 years（range 33 to 61）,suffering from calcified giant HTDs,underwent trhansthoracic decompression and segmental instrumentation with interbody fusion in our department from November 2004 to September 2010.Outcomes and complications were retrospectively assessed in this patient series.Clinical records were scrutinized to assess levels and types of disc herniation,operative time,blood loss,pre-and postoperative Frankel grades and Japanese Orthopedic Association（JOA） score,and complications.Pre-and postoperative imaging studies were reviewed to assess the decompression,alignment,and accuracy of instrumentation.Results Of the 15 patients,2 had HTDs at 2 levels.The levels of calcified giant HTDs were T6~12,mainly at the level of T11/T12（60%）.Discs were classified as central（40%） or paracentral（60%）.All discs were successfully removed with no incidence of wrong-level surgery or CSF leakage.The mean operative time was 179 min（range 140 to 210 min）,and the mean estimated blood loss was 840 mL（range 300 to 2 000 mL）.Frankel grades improved in 9 patients postoperatively and in 12 patients at the final follow-up,without degrading in any patient.JOA scores improved on average from 4.9 to 7.7,with a recovery rate of（46.8±21.41）%.All patients reported improvement in symptoms compared with preoperative status.The average duration of follow-up was 45 months（range 7 to 77 months）.Eleven patients had no complications.Pneumonia occurred in 1 patient,cardiac accident in 1 patient,and pain was present at the site of the skin incision in other 2 patients.All the 4 patients were treated with effective measures,resulting in satisfied consequences.Conclusion Patients with calcified giant HTDs often present with severe myelopathy and experienced bad functional outcomes.Based on the experience,open thoracotomy is safe and effective for the treatment of calcified giant HTDs.