寰枢椎肿瘤的手术治疗（附22例报告）

目的：探讨不同手术入路,切除术式及内固定治疗寰椎,枢椎肿瘤的效果,方法：回顾性分析22例寰椎和枢椎肿瘤患者的病理类型,临床表现,各种手术途径,术式及其预后,结果：22例中,寰椎肿瘤4例,枢椎肿瘤18例;原发性肿瘤19例,转移性肿瘤3例,9例行囊内切除,8例包膜切除,3例广泛切除,单纯枕颈后路植骨CD Cervical或Cervifix内固定术2例,1例骨巨细胞瘤患者术后10d因呼吸循环衰竭死亡,1例转移癌患者术后13d因肺部感染,呼吸循环衰竭死亡,术后随访3个月至4年,20例术后近期疗效较满意,局部疼痛和神经症状改善或缓解,2例转移癌患者分别于术后13个月和19个月全身多处转移,全身衰竭死亡,1例骨母细胞瘤,1例软骨肉瘤术后1年局部复发。结论：应根据寰枢椎肿瘤的具体部位,范围选择相应的手术入路和术式,肿瘤的性质,手术方式及术后综合治疗对患者预后具有重要影响。枕颈CD Cervical或Cervifix内固定术有利于保持上颈椎的稳定。     

枢椎肿瘤切除与重建技术探讨

目的：研究枢椎肿瘤的不同手术入路，肿瘤切除术及内固定重建的治疗效果。方法：对枢椎肿瘤的性质，病理类型，临床表现，各种手术途径，术式及其预后进行分析，本组18例中，骨巨细胞瘤6例，骨母细胞瘤1例，软骨肉瘤1例，骨髓瘤2例，脊索瘤2例，血管内皮细胞瘤1例，恶性淋巴瘤1例，神经纤维瘤1例，转变癌3例。5例行囊内切除，5例包膜切除，6例广泛切除，单纯枕颈后路植骨CD Cervical或Cervifix内固定术2例。结果：1例骨巨细胞瘤患进术后10d因四肢瘫痪状加重，呼吸循环衰竭死亡，1例转移癌患者术后13d因肺部感染，高热，呼吸循环衰竭死亡，术后随访6个月－4年，16例术后近期疗效较满意，局部疼痛和神经症状改善或缓解，2例转移癌患者分别于术后13个月和19个月全身多处转移，全身衰竭死亡，1例骨细胞瘤、1例软骨肉瘤术后1个局部复发。结论：应根据枢椎肿瘤具体部位，范围选择相应的手术入路和术式。肿瘤的性质，手术方式极术后综合治疗对患者预后具有重要影响。枕颈CD Cervical或Cervifix内固定术有利于保持上颈椎的稳定。     

颈椎原发性骨肿瘤的外科分期及其手术治疗

目的探讨颈椎原发性骨肿瘤的临床特点、外科分期、不同手术入路与术式的治疗效果。方法脊柱肿瘤的外科分期为4期。共观察45例病例,Ⅰ期10例,Ⅱ期11例,Ⅲ期9例,Ⅳ期15例。11例行囊内切除,18例包膜切除,15例广泛切除,1例仅单纯行后路固定。结果术后随访6个月～10年,平均3年,1例上颈椎肿瘤术后高位瘫痪,因呼吸衰竭死亡。余44例术后近期疗效均较满意,局部疼痛和神经症状改善或缓解,2例眩晕患者术后症状消失;1例恶性神经鞘瘤和1例软骨肉瘤患者分别于术后13、24个月发生全身多处转移而衰竭死亡;1例骨母细胞瘤、1例软骨肉瘤、1例骨巨细胞瘤术后1年局部复发。结论应根据颈椎肿瘤的部位、外科分期选择相应的手术入路和术式。肿瘤的性质、手术方式及术后综合治疗对患者的预后具有重要影响。     

前、后联合入路全脊椎切除附加内固定治疗颈椎骨肿瘤39例报告

目的探讨对颈椎骨肿瘤采用前后联合入路全脊椎切除、内固定重建技术的疗效及其预后。方法1998年10月至2003年10月,对39例颈椎(C3-7)骨肿瘤患者实施全脊柱切除术。其中原发性骨肿瘤34例,包括骨巨细胞瘤14例,浆细胞瘤6例,神经鞘瘤(侵及椎体)1例,软骨肉瘤4例,骨母细胞瘤4例,恶性神经鞘瘤2例,动脉瘤样骨囊肿2例,脊索瘤1例;转移性肿瘤5例,原发灶来源于甲状腺癌、前列腺癌各2例,肺癌1例。经前后联合入路行单椎节切除29例、双椎节切除7例、3个椎节切除3例。经一期或二期前后联合入路行肿瘤切除与内固定重建。前路采用钛网植骨加AO、Orion、Zephir或者Codman等带锁钢板内固定,后路Cervifix、AXIS内固定重建。结果术后随访6个月至5年,绝大多数患者术后近期疗效较满意,局部疼痛和神经症状均有不同程度改善或缓解,19例脊髓神经功能完全恢复。1例术后出现一过性瘫痪加重,1例恶性神经鞘瘤术后1年局部复发,1例转移癌患者于术后25个月因全身衰竭死亡。结论全脊椎切除能显著降低颈椎原发性骨肿瘤局部复发率,改善脊髓神经功能,提高手术疗效。     

脊柱转移瘤的外科治疗效果

目的：探讨脊柱转移瘤患者手术治疗的适应证与疗效。方法：对1998年7月至2003年7月5年间收治的167例脊柱转移瘤患者的临床资料进行回顾性分析。胸椎转移99例，腰椎转移53例．颈椎转移15例。男性96例，女性71例。出现神经系统受损者112例，其中Frankel分级A级17例．B级11例．C级22例．D级62例。患者均有不同程度的疼痛，手术根据肿瘤破坏脊椎的部位行前路椎体切除、钢板内固定术或后路病变椎板切除、肿瘤切除、椎管减压、经椎弓根内固定术。结果：167例患者中，155例（92．8％）术后疼痛得到缓解。112例有神经功能损害的患中，67例（59．8％）术后Frankel分级有不同程度的改善。随访6～48个月．术后存活1年以上的患者117例，约占患者总数的70％。结论：由于转移瘤所致椎体塌陷或不稳定造成严重的神经损害或机械性不稳脊柱痛疼的患者，手术治疗可改善其神经功能，增加脊椎稳定性．提高生存质量。     

脊柱转移性肿瘤的外科治疗策略

目的：探讨脊柱转移性肿瘤的临床特点、手术治疗策略及其预后。方法：对103例脊柱转移性肿瘤患者的临床特点、手术适应证、外科治疗方式及其预后进行分析。结果：术后随访6个月－5年。85例患者术后局部疼痛、神经根痛缓解甚至消失，脊髓压迫症状改善或缓解；术后6个月、1、2、3、4年的生存率分别为97．1％、90．3％、44．7％、29．1％、8．7％。结论：脊柱转移性肿瘤患者多数表现为局部疼痛，部分患者有脊髓、神经根损害的表现。手术必须考虑全身情况，限于脊柱不稳、神经功能进行性损害、局部疼痛剧烈且原发病灶已积极处理、或原发灶不明手术作为明确病理诊断以指导进一步治疗的患者。根据肿瘤侵犯部位、患者耐受手术情况、预期寿命等选择前路、后路或前后联合入路的一期或二期手术。手术能够稳定和重建脊柱，减轻或缓解疼痛，维持或改善神经功能，从而改善患者的生活质量。     

脊柱转移瘤病椎切除及稳定性重建

目的 探讨脊柱转移瘤切除、融合及稳定性重建在治疗转移性脊柱肿瘤中的必要性和可行性.方法 2002年6月-2007年8月对11例脊柱转移瘤患者行前路病椎切除自体髂骨植骨钛板内固定术或联合后路椎板切除减压术治疗,随访观察患者术后局部疼痛缓解,脊髓神经功能恢复及脊柱稳定性情况.结果 术后颈肩腰背痛及放射痛基本缓解,早期开始肢体功能锻炼,术后3～5周佩戴支具离床活动.随访5个月～2年,患者神经压迫症状明显改善.内固定物无松动、断钉现象,椎体尤塌陷结论前路手术切除病变椎体并自体髂骨植骨前路钛板内固定重建脊柱稳定性或联合后路椎板切除减压治疗脊柱转移瘤是可行性的,可提高患者生存期内的生活质量.     

寰椎Jefferson骨折伴横韧带损伤的诊治

目的 分析总结寰椎Jefferson骨折伴横韧带损伤的诊断和治疗。方法 1995年3月-2005年3月收治26例寰椎Jefferson骨折伴横韧带损伤患者。其中新鲜骨折20例，陈旧性骨折6例。所有患者均伴有不同程度的横韧带损伤，23例有神经损害表现。X线检查显示寰椎弓环及侧块不同部位骨折，寰齿间距（ADI）为4．7mm。5例行非手术治疗，其余21例行颈椎后路枕颈融合术或寰枢椎融合术治疗。结果所有患者术后获6～24个月（平均15个月）随访，21例手术治疗患者术后临床症状缓解；5例非手术治疗患者中，4例成功，另1例失败再行颈后路寰枢椎融合术治疗，术后疗效满意。结论 寰椎Jefferson骨折伴横韧带损伤患者的临床表现主要取决于韧带断裂后寰椎前脱位的程度以及是否造成脊髓压迫，诊断以ADI为主、并结合外伤史及临床表现。对于可能存在寰枢椎不稳或已有横韧带损伤且存在典型神经症状的患者，应早期行寰枢椎融合术或枕颈融合术治疗。     

上颈椎骨折脱位的外科治疗

目的探讨上颈椎骨折脱位的诊断及治疗方法。方法2005年1月—屯009年9月收治16例创伤性上颈椎骨折脱位患者。其中齿状突骨折7例,寰枢椎脱位5例,Hangman骨折2例,Jefferson骨折2例。9例伴有神经功能障碍者脊髓神经功能按ASIA分级：B级3例,c级4例,D级2例。除7例采用颈椎牵引及支具固定外,齿状突中空螺钉固定术2例,Apofix寰枢椎后路固定＋植骨融合2例,枕颈融合术1例,寰枢椎后路经椎弓根螺钉固定术4例。所有患者术后均行头颈胸支具外固定3个月。结果16例患者术后获6—36个月随访。所有病例未出现脊髓损伤、椎动脉破裂等并发症。经6个月以上随访骨折或植骨获愈合,未见内置物断裂或感染等并发症发生。1例患者枕颈融合术后2年因呼吸道感染并发症死亡。9例神经功能障碍患者中均有不同程度改善。上颈椎不稳均获得有效治疗。结论上颈椎外伤性失稳的诊断和治疗方式选择取决于骨折类型和移位状况。AndersonI、Ⅲ型齿状突骨折和LevineI、Ⅱ型Hangman骨折经保守治疗可获得满意的临床疗效。齿横韧带损伤合并寰枢关节脱位及不稳定的Jefferson骨折和Hangman骨折应手术治疗。寰枢椎后路组合固定技术是治疗上颈椎外伤性失稳的有效方法,具有固定可靠、短节段固定、三维固定、融合率高、可早期功能锻炼的优点。     

一期前后路手术治疗寰枢椎结核合并神经功能损害

[目的]分析评价一期前后路联合手术治疗寰枢椎结核合并神经功能损害的临床疗效。[方法]2005年1月~2015年1月,12例寰枢椎结核合并神经功能损害患者采用一期前后路手术治疗。所有患者术前颈椎CT及MRI检查提示寰椎单侧或双侧侧块骨质破坏及枢椎齿突不同程度骨质破坏,寰枢椎稳定性丢失,结核病灶突入椎管内,导致相应节段脊髓受压。术前神经功能评估ASIA分级为:C级4例,D级8例。所有患者术前及术后均使用四联敏感抗结核药物规律治疗。通过对患者NDI评分和JOA评分变化情况进行统计学分析来评价临床手术疗效。[结果]手术时间平均(228±65.32)min;出血量平均(460±116.38)ml。平均随访(5.77±3.62)(2~12)年,在随访期内未见内固定松动、断裂、失败等情况出现。患者NDI评分及JOA评分分别由术前(39.67±4.32)分和(7.63±2.38)分改善至末次随访时(10.82±4.63)分和(15.58±1.21)分,差异有统计学意义(P0.05)。末次随访时12例患者神经功能ASIA分级均恢复至E级。[结论]对于寰枢椎结核合并神经功能损害的治疗,采用一期前后路联合手术能够完成结核病灶的彻底清除、脊髓的彻底减压及上颈椎稳定性的重建,通过中长期随访观察能够取得良好的临床疗效。     

Primary tumors of the cervical spine: a retrospective review of 35 surgically managed cases.

BACKGROUND CONTEXT: Primary tumors of the cervical spine are rare, and many issues regarding their surgical management remain unanswered yet. PURPOSE: To demonstrate results of surgery for primary tumors of the cervical spine and to elucidate which factors influence outcome. STUDY DESIGN/SETTING: Retrospective study. PATIENT SAMPLE: Sixty-six surgeries were performed on 35 patients, ranging in age from 7 to 70 years. OUTCOME MEASURES: Preoperative and postoperative degree of pain and neurological status were quantified. Radiological investigations were used to detect recurrence and evaluate the stability and fusion. METHODS: Data were collected on patient characteristics, therapy, and results. Follow-up ranged from 6 months to 15 years (mean 59.9 months). RESULTS: Posterior (26), anterolateral (24), retropharyngeal (9), combined (4), lateral (2), and transmandibular approaches (1) were used. Chordomas (n=8) and 17 different types of tumors were encountered. One patient died 3 weeks postoperatively and 5 died of their disease at follow-up. Twenty patients had no evidence of disease, and 7 patients had recurrent tumors. According to the Weinstein-Boriani-Biagini classification, tumor extension into both anterior and posterior columns of a vertebra was correlated with a poor outcome. Incomplete resections resulted in tumor recurrence which warranted subsequent surgeries (up to 9), especially in chordoma cases. CONCLUSIONS: Complete tumor resection is the oncologically best surgical strategy and should be attempted whenever possible. However, this may not be feasible in every case because of the complexity of the cervical spine. In these cases, acceptable mortality-morbidity rates and symptom-free years could be achieved by subtotal resections, even for malignant tumors.     

胸腰椎转移瘤的外科治疗策略和效果分析

目的：探讨胸腰椎转移瘤的外科治疗策略和效果。方法：回顾性分析2009年1月到2010年12月收治的行外科手术干预治疗并获得随访的胸腰椎转移瘤患者共42例。男30例,女12例;平均年龄56.8岁（28～76岁）;胸椎转移瘤25例,腰椎转移瘤17例;单节段34例,双节段6例,3节段2 例。2例无症状,40例有腰背部或下肢疼痛。18例脊髓功能受损,其中ASIA分级 A级5例,B级3例,C级4例,D级6例。Tomita评分2～7分,术前根据Tomita评分制定手术目标,根据Tomita外科分期制定具体手术方案,分别行全椎体切除,肿瘤彻底刮除及姑息性椎管减压稳定手术。术后1周、3个月、6个月、1年及2年对患者疼痛、脊髓功能、肿瘤局部控制、生存、内置物情况进行评估。结果：42例术中死亡1例。术后1周38例疼痛缓解,5例完全性瘫痪中2例神经功能恢复至E级,2例恢复至D级,1例未恢复,13例不全瘫痪者均有1级以上恢复。随访24～48个月,内固定物失效1例,5例局部肿瘤复发或失去控制。术后3个月、6个月、1年及2年存活率分别为95.2%、85.7%、58.2%和37.6%.结论：对于脊柱转移瘤患者,通过Tomita评分和外科分型选择合适手术方式,可缓解疼痛,改善神经功能,增加脊柱稳定性,控制局部病灶,提高患者生存质量。     

瘤椎全切与重建治疗胸腰椎肿瘤伴神经功能障碍

目的探讨瘤椎全切与重建,治疗胸腰椎肿瘤伴神经功能障碍的手术适应证及临床疗效。方法1999年1月～2005年12月收治胸腰椎肿瘤伴神经功能障碍16例。男10例,女6例;年龄16～62岁,平均31.5岁。原发肿瘤10例,其中骨巨细胞瘤4例,软骨肉瘤3例,动脉瘤样骨囊肿术后复发2例,骨肉瘤1例;转移瘤6例。肿瘤侵犯T53例,T6、T6、7、T9、T11、L2、L4及L5各1例,T8、L1及L3各2例。Tomita外科分型：4型9例,5型6例,6型1例。Frankel神经功能分级：A级1例,B级4例,C级7例,D级4例。采用前后路联合手术,行瘤椎彻底切除,椎管减压,植骨重建。术后根据肿瘤病理类型行相应的辅助治疗。结果术后16例获随访10～63个月,平均27.5个月。患者疼痛均完全缓解,术后神经功能恢复至D级5例（其中1例术前为A级）,E级11例。10例原发肿瘤中,1例骨肉瘤术后18个月双肺转移死亡,余9例均无瘤生存。6例转移瘤中,2例全身转移死亡,1例术后10个月肺部带瘤无症状生存,3例均无瘤生存。16例随访期内手术部位均无肿瘤复发。结论瘤椎全切与重建是治疗胸腰椎肿瘤伴神经功能障碍的一种安全有效的手术方法,可缓解疼痛,改善神经功能,减少肿瘤局部复发。手术适用于胸腰椎原发恶性肿瘤,有复发倾向的侵袭性肿瘤及Tomita外科分型为3～5型的胸腰椎单发转移瘤。     

Surgical treatment of metastatic lesion of the spine. A review of 51 consecutive cases operated

Abstract Metastatic lesions of the spine have recently become a debated topic in orthopaedics, because more and more patients survive long enough to require surgical treatment. The aim of this study is to review a series of 51 patients affected by metastatic lesions of the spine. Fifty-one patients affected by metastatic lesions of the spine were treated between 1987 and 2000. In 5 cases the cervical spine was involved, in 27 the thoracic and in 19 the lumbar spine. Surgery was planned according to the following labelling factors: type of malignancy, life expectancy, neurological involvement, pain, site of lesion, lesion extension and spine stability. Surgical treatment consisted of: minimally invasive cord decompression in 3 cases, posterior stabilization in 21, posterior stabilization and cord decompression in 13 cases, anterior resection and reconstruction of anterior column associated or not at posterior stabilization in 14 cases. Two patients died due to complications related to surgery. At the last available follow-up of 4 (±2.5) years, 29 patients had excellent results, 16 had good results, 2 fair and 2 poor results. One fair and 1 poor result had recurrence of the metastatic lesions of the spine and needed another operation. We believe that surgical treatment of metastatic lesion of the spine has a positive cost/benefit ratio for the patient's condition; in fact most of our patients had improvement of quality of life. The labelling factors of each lesion have to be carefully studied together with the oncologist to decide the correct surgical option because unsatisfactory results could be sometimes related to incorrect evaluation of the evolution of the neoplasm.     

Surgical management of primary and metastatic sarcoma of the mobile spine

OBJECT: Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series. METHODS: A retrospective review of patients undergoing resection for sarcomas of the mobile spine between 1993 and 2005 was undertaken. Sarcomas were classified by histology study results and as either primary or metastatic. Details of the surgical approach, levels of involvement, and operative complications were recorded. Outcome measures included neurological function, palliation of pain, local recurrence, and overall survival. RESULTS: Eighty patients underwent 110 resections of either primary or metastatic sarcomas of the mobile spine. Twenty-nine lesions were primary sarcomas (36%) and 51 were metastatic sarcomas (64%). Intralesional resections were performed in 98 surgeries (89%) and en bloc resections were performed in 12 (11%). Median survival from surgery for all patients was 20.6 months. Median survival for patients with a primary sarcoma of the spine was 40.2 months and was 17.3 months for patients with a metastatic sarcoma. Predictors of improved survival included a chondrosarcoma histological type and a better preoperative functional status, whereas osteosarcoma and a high-grade tumor were negative influences on survival. Multivariate analysis showed that only a high-grade tumor was an independent predictor of shorter overall survival. American Spinal Injury Association scale grades were maintained or improved in 97% of patients postoperatively, and there was a significant decrease in pain scores postoperatively. No significant differences in survival or local recurrence rates between intralesional or en bloc resections for either primary or metastatic spine sarcomas were found. CONCLUSIONS: Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.     

Percutaneous anterolateral balloon kyphoplasty for metastatic lytic lesions of the cervical spine

The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient’s complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesis. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral ballon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications.     

颈椎转移瘤外科治疗效果及不同术式选择策略

目的 探讨不同解剖节段颈椎转移瘤外科治疗术式选择策略及疗效.方法 回顾性分析20018月至2009年接受手术治疗的31例颈椎转移瘤患者的临床资料,将颈椎按照解剖特点分为上颈椎(C1,C2)和下颈椎及颈胸段(C3～T1).分别对患者的疼痛程度、神经功能、预期生存时间和一般状态进行评价.分析患者术后的症状改善、生存时间及术式选择的特点.结果 31例患者中24例获得随访,患者颈痛症状和生活质量明显改善,术后中位生存时间为45个月.依解剖特点不同采用不同的术式:C1,C2转移瘤患者根据手术方式不同分为后路枕颈固定联合125I放射性粒子植入组(粒子植入组)和其他外科治疗组,粒子植入组术后中位生存时间(48.0±27.0)个月长于其他外科治疗组(22.0±8.3)个月.C3～T1转移瘤患者根据手术方式不同分为前路椎体切除组和前后路联合切除组,前后路联合切除组术后中位生存时间45.0个月长于前路椎体切除组18.0个月.结论 外科治疗能有效地缓解颈椎转移瘤患者的疼痛症状、维持或改善神经功能、提高生活质量.上颈椎转移瘤外科治疗以稳定为主,常选择后路枕颈固定术,联合放射性粒子植入有助于局部病灶的控制.下颈椎及颈胸段转移瘤外科治疗以前路椎体次全切除、内固定为主,满足相应条件者可行前后联合入路全脊椎切除术.