全脊椎整块切除术治疗原发性胸腰椎肿瘤的并发症分析

Complications of total enbloc spondylectomy in primary thoracolumbar spine tumor

目的:总结全脊椎整块切除术(total enbloc spondylectomy,TES)治疗原发性胸腰椎肿瘤的术中及术后并发症,并探讨其处理策略。方法:2005年1月~2014年12月采用全脊椎整块切除术治疗原发性胸腰椎肿瘤41例,其中男23例,女18例,年龄27~60岁(41.7±3.5岁)。病变节段:T7 1例,T11 3例,T12 6例,L1 10例,L2 10例,L3 7例,L4 4例。病理诊断:骨巨细胞瘤18例,骨肉瘤10例,骨母细胞瘤4例,组织细胞肉瘤7例,脊索瘤2例。Tomita分型均为3~5型,WBB分型累及4~8区或5~9区29例,4~9区12例。其中30例行单一后路全脊椎整块切除术,11例行前后联合入路全脊椎整块切除术。肿瘤切除后均一期行脊柱稳定性重建,前方采用钛网或人工椎体重建,后方在病椎上下各两个节段行椎弓根螺钉固定。统计术中与术后并发症发生情况。结果:所有患者均顺利完成手术,手术时间为150~350min(215±49min)。术中出血量为1900~3600ml(2800±340ml)。随访15~120个月(42.0±7.1个月),共有12例(12/41)患者出现17例次手术并发症,术中出现9例次并发症,包括1例一侧髂血管损伤,术中予缝合;2例大出血,术中予结扎、止血材料止血及输血;1例脊髓损伤、2例神经根牵拉伤,术中予大剂量激素冲击治疗,术后予神经营养药,脊髓损伤患者末次随访时Frankel分级由B级转为C级,神经根牵拉患者1个月随访时神经根放射痛逐渐缓解;2例硬膜撕裂、1例淋巴管破裂,术中予以修补并加压包扎。术后发生8例次并发症,包括1例浅层伤口感染,经清创及抗感染治疗后愈合;1例胸腔积液,经胸腔闭式引流及抗感染后积液完全吸收;1例脑脊液漏并淋巴管漏、1例脑脊液漏,采用头高脚低位平压引流后切口愈合;2例钛网下沉松动并内固定断裂,行翻修手术;2例复发,未行二次手术。结论:原发性胸腰椎肿瘤一期行全脊椎切除术并发症发生率较高,早期积极对症处理能够获得满意疗效。

Objectives： To summarize intraoperative and postoperative complications of total enbloc spondylectomy（TES） in primary thoracolumbar spine tumor, and to discuss the preventive strategies. Methods： From January 2005 to December 2014, 41 cases of primary thoracolumbar spine tumor received TES surgery, including 23 males and 18 females. The average age was 41.7±3.5 years old（27 to 60 years old）. Pathological segments included： T7 in 1 case, T11 in 3 cases, T12 in 6 cases, L1 in 10 cases, L2 in 10 cases, L3 in 7 cases, L4 in 4 cases. Pathological diagnosis included： 18 cases of giant cell tumor, 10 cases of osteosarcoma, 4 cases of osteoclastoma, 7 cases of histiocytoma, and 2 cases of chordoma. Tomita staging was 3-5 in all the 51 cases. Tumors site： WBB 4-8/5-9 in 29 cases and WBB 4-9 in 12 cases. Among them, 30 cases underwent single posterior total enbloc spondylectomy, 11 cases underwent combined anterior and posterior approaches. The spinal reconstruction was performed immediately after tumors resected by using anterior titanium mesh or artificial vertebral body with posterior two segmental pedicle screw fixation. Statistic analysis was applied to analyze the intraoperative and postoperative complications. Results： All patients were operated successfully. The average operation time was 215±49min（150-350min）. The average blood loss was 2800±340ml（1900-3600ml）. Patients were followed up for 15 to 120 months with an average of 42.0±7.1 months. There were 17 complications in 12 patients, 9 intraoperative and 8 postoperative complications. Of the intraoperative complications, 1 case of unilateral iliac vascular injury received intraoperative suture; 2 cases of hemorrhoea received intraoperative blood transfusion, ligature and hemostasis; 1 case of spinal cord injury and 2 cases of nerve root traction injury received intraoperative steroid impulse and postoperative neurotrophic agents. At the last follow-up, the Frankel grade of patient with spinal cord injury changed from grade B to grade C. The radicular pain gradually relieved at 1-month follow-up. 2 cases of dural tear and 1 case of lymphatic rupture received intraoperative repair and compression bandage. Of the postoperative complications, 1 case occurred shallow wound infection, the incision was healed after debridemen and antibiotic treatment; 1 case occurred hydrothorax, the pleural effusion was completely absorbed after closed drainage and antibiotic treatment. 1 case of CSF leakage combined with lymphatic fistula and 1 case of CSF leakage healed after plain pressure drainage at dorsal elevated position; 2 cases of titanium mesh subsidence combined with internal fixation failure received revision operation; 2 cases of recurrence but received no second operations. Conclusions： The incidence rate of intraoperative and postoperative complications of primary thoracolumbar tumors is high, which can be controlled by carefully intraoperative procedure.