颈后路联合经口前路手术治疗颅脊交界区原发性恶性骨肿瘤

An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction

目的探讨颅脊交界区原发性恶性骨肿瘤的手术方法及效果。方法回顾分析2010年9月-2019年4月收治的7例颅脊交界区原发性恶性骨肿瘤患者临床资料,其中男5例,女2例;年龄23~75岁,中位年龄56岁。经口肿瘤活检明确诊断为脊索瘤4例、浆细胞瘤2例、纤维肉瘤1例。病程0.7~36.0个月,平均12.2个月。病变部位:C_(0、1) 1例,C_2 3例,C_(1、2) 1例,C_(2、3) 1例,C_(0~2) 1例。术前疼痛视觉模拟评分(VAS)为(6.7±2.1)分,日本骨科学会(JOA)评分为(15.6±2.4)分;美国脊髓损伤学会(ASIA)分级:C级1例,D级1例,E级5例;术前脊柱恶性肿瘤Enneking分期:ⅠB期1例,ⅡB期2例,Ⅲ期4例;WBB分期:5~8/A^D 1例、4~9/A^D1例、6~7/B^D 1例、6~7/A^D 1例、1~12/A^D 2例、3~10/A^D 1例。所有患者均行颈后入路肿瘤扩大性切除植骨融合内固定,一期或二期经口前路或下颌下入路肿瘤边界性切除,同时前路钛笼植骨融合内固定手术治疗。结果手术时间307~695 min,平均489.57 min;术中失血量400~2 000 mL,平均1 107.14 mL。术中未发生椎动脉及脊髓损伤,术后无切口感染、颅内感染、肺部感染等相关并发症发生。所有患者均获随访,随访时间3~57个月,平均21个月。X线片和CT示内固定螺钉牢靠、位置满意,术后3~6个月植骨已融合。术后颈部疼痛、肢体麻木乏力等症状均有不同程度改善。术后3个月VAS评分改善至(1.7±0.8)分,与术前比较差异有统计学意义(t=7.638,P=0.000);JOA评分改善至(16.1±1.5)分,但与术前比较差异无统计学意义(t=1.549,P=0.172)。术前1例ASIA分级为C级的患者术后3个月改善至D级,其余患者分级无变化。术后4例复发,均为首次手术前肿瘤恶性程度高,且波及斜坡或周围软组织范围广泛、无法完整切除者,其中1例再次行经口肿瘤清除手术,另3例放弃治疗;余3例未见复发。结论通过经口或下颌下入路可将颅底交界区原发性恶性骨肿瘤完整切除,结合异形钛笼支撑重建前方稳定结构、术后配合放化疗等,可延长患者生存时间、减少肿瘤复发。

Objective To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction(CVJ)and its effectiveness.Methods The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ,which collected between September 2010 and April 2019,were retrospectively analyzed.There were 5 males and 2 females,aged 23 to 75 years(median,56 years).All patients were diagnosed as chordoma in 4 cases,plasmacytoma in 2 cases,and fibrosarcoma in 1 case.The disease duration ranged from 0.7 to 36.0 months,with an average of 12.2 months.Lesion location:1 case of C0,1,3 cases of C2,1 case of C1,2,1 case of C2,3,and 1 case of C0-2.Preoperative visual analogue scale(VAS)score was 6.7±2.1,the Japanese Orthopaedic Association(JOA)score was 15.6±2.4.According to American Society of Spinal Cord Injury(ASIA)grading system,there was 1 case of grade C,1 case of grade D,and 5 cases of grade E.According to Enneking stage of spinal malignant tumor,there was 1 case of stageⅠB,2 cases of stageⅡB,and 4 cases of stageⅢ.According to Weinstein-Boriani-Biagini(WBB)stage,there was 1 case of 5-8/A-D,1 case of 4-9/A-D,1 case of 6-7/B-D,1 case of 6-7/A-D,2 cases of 1-12/A-D,and 1 case of 3-10/A-D.All these patients were treated with tumor extended resection,bone graft fusion,and internal fixation via posterior cervical approach,as well as tumor(stageⅠor stageⅡ)boundary resection via transoral or submandibular approach.Meanwhile,anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation.Results The operation time was 307-695 minutes(mean,489.57 minutes),and the intraoperative blood loss was 400-2000 mL(mean,1107.14 mL).There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications,including incision infection,intracranial infection,and pulmonary infection.All the patients were followed up 3-57 months(mean,21 months).Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position,and the bone graft was fused at 3-6 months after operation.Symptoms such as neck pain,limb numbness,and fatigue relieved to different degrees after operation.At 3 months after operation,the VAS score improved to 1.7±0.8(t=7.638,P=0.000);while the JOA score improved to 16.1±1.5,but no significant difference was found when compared with preoperative score(t=1.549,P=0.172).According to ASIA grading system,1 patient with grade C had upgraded to grade D after operation,while the remaining patients had no change.There were 4 cases of recurrence after operation,in which those patients were with high malignancy of tumors before the first surgery.Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed.Among the 4 cases,1 patient underwent transoral tumor removal operation again,while the other 3 cases gave up further treatment.There was no recurrence among the remaining 3 cases.Conclusion Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach.Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen.These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.