前方入路手术治疗上胸椎转移瘤

Surgical treatment of upper thoracic spine metastatic tumor via anterior approach

目的：探讨前方入路行上胸椎肿瘤切除、椎体重建、钛板内固定的技术及方法,分析手术治疗效果及相关并发症.方法：2004年6月～2011年7月我科收治上胸椎（T1～T4）转移瘤患者17例,其中男6例,女11例,年龄55.17±7.3岁（47～68岁）.术前神经功能按Frankel分级：B级3例,C级4例,D级8例,E级2例.肿瘤位置；T1 7例,T25例,T3 3例,T42例.按Tokuhashi脊柱转移瘤评分系统评分为9～12分；根据WBB分区理论肿瘤病灶位于4～9区.对于T1椎体病灶患者采用低位下颈椎前方入路；对于T2～T4椎体病灶患者采用前方劈开胸骨经头臂干外侧间隙入路.结果：所有患者均能很好耐受手术,低位下颈椎前方入路手术时间为94.1±5.0min （90～102min）,出血量为186.6±100.2ml （100～400ml）；前方劈开胸骨经头臂干外侧间隙入路手术时间为121.0±16.5（100～150min）,出血量为352.0±134.4ml（220～600ml）.术后病理学检查：6例来源于肺癌,5例来源于乳腺癌,2例来源于甲状腺癌,2例来源于胃肠道癌,2例来源不明.术后2例前方劈开胸骨经头臂干外侧间隙入路手术患者出现肺部感染、肺不张,经对症治疗后治愈.3例（其中1例为低位下颈椎前方入路手术患者）出现喉返神经牵拉伤致一过性声音嘶哑,术后1个月内声音恢复正常.随访19.7±9.8个月（6～48个月）,9例患者神经功能有不同程度改善,其中3例Frankel分级B级患者2例改善为E级,1例改善为D级；4例C级2例改善到E级,2例改善到D级；2例D级患者改善到E级.5例患者在术后6～14个月因多处转移、全身衰竭死亡.结论：前方入路是治疗上胸椎转移瘤可供选择的有效入路,该入路可以充分显露前方椎体病变,有效切除病灶,彻底解除来自脊髓前方的压迫,改善患者症状.

Objectives： To discuss the techniques and outcomes of anterior approach for metastasis resection and reconstruction with titanium plate for upper thoracic vertebral tumor. Methods： From June 2004 to July 2011, there were 6 males and 11 females with the average age of 55.1±7.3 years（range, 47-68 years） with the upper thoracic（T1-T4） metastatic tumor underwent anterior resection and fixation. Their neurological func- tion was assessed by Frankel classification as following, 3 cases with grade B, 4 cases with grade C, 8 cases with grade D and 2 cases with grade E. The tumors located at T1 in 7 cases, T2 in 5 cases, T3 in 3 cases, T4 in 2 cases. Tokuhashi scoring system of 17 cases ranged from 9 to 12 points. The tumors located in the vertebral body of sectors 4-9 based on the WBB staging system. For T1 lesion, low anterior cervical ap- proach was used, and for T2-T4 lesion, anterior transsternal approach of outside window of brachiocephalic artery was used. Results All patients survived the surgery, the operation time of anterior cervical approach was 90-102min（average： 94.1±5.0min）, blood loss was 100-400ml（average： 186.6±100.2ml）; the operation time of anterior transsternal approach outside window of brachiocephalic artery was 100-150min （average： 121.0± 16.5min）, blood loss was 220-600ml （average： 352.0～134.4ml）. Pathological examination revealed metastatic lung cancer in 6 patients, metastatic breast cancer in 5 patients, metastatic thyroid carcinoma in 2 patients, metastatic gastrointestinal cancer in 2 patients and uncertainly metastatic tumor in 2 patients. Pneumonia and atelectasis occurred in 2 patients and recovered well after proper treatment; 3 patients appeared transienthoarseness and returned to normal 1 month later. The mean follow-up was 19.7_±9.8 months（range, 6 to 48 months）. Neurological function improved in 9 cases, 2 patients improved from grade B to E, 1 patient im- proved from grade B to grade D; 2 patients in grade C improved to grade E, 2 patients in grade C improved to grade D and 2 patients in grade D improved to grade E. 5 patients died of systemic failure due to multi- ple metastases at 6-14 months. Conclusions： The anterior approach is reliable for thoracic spinal metastasis, which is superior for sufilcient exposure and removal of vertebral defects.