经口咽下颌骨劈开入路处理上颈椎或上、下颈椎腹侧病变

目的：探讨经口咽下颌骨劈开入路处理上颈椎或上、下颈椎腹侧病变的临床效果。方法：采用经口咽唇面下颌骨劈开入路处理伴有下颌关节僵直的陈旧性寰枢椎脱位1例，行TARP钢板内固定术；处理枢椎体肿瘤1例，行C2椎体肿瘤切除，异形钛网笼置入重建椎体，同期行后路C1～C3椎弓根钉棒植骨内固定术。采用经口、舌、唇面下颌骨劈开入路处理C1～C5肿瘤1例，行肿瘤切除，异形钛网笼置入重建C2～C4椎体，同期后路C1～C5附件肿瘤切除．枕颈植骨融合内固定术。随访观察治疗效果。结果：病变部位显露满意，顺利完成手术操作。随访12～24个月。2例肿瘤患者的肿瘤切除彻底，前路椎体重建满意，后路内固定稳妥，临床症状消失，行走正常；1例寰枢椎陈旧性脱位患者的寰枢椎达解剖复位，颈髓减压充分，C1～C2前路内固定稳妥，临床症状消失。结论：经口咽下颌骨劈开扩大入路适合于处理同时累及上下颈椎的腹侧病变或患者张口困难的上颈椎腹侧病变。     

寰枢椎肿瘤切除和重建技术的初步报告

目的 总结寰枢椎肿瘤手术显露和彻底切除的方法,评价异形钛网植骨融合内固定在寰枢椎肿瘤切除术后枕颈稳定性重建中的作用和价值.方法 2005年3月至2007年8月手术治疗6例寰枢椎肿瘤患者,男3例,女3例;年龄17～70岁,平均43.7岁;脊索瘤4例,骨巨细胞瘤1例,骨纤维异常增殖症1例.病变累及所有患者的椎体及侧块或后方结构.全部采用前方颌下颈动脉三角入路联合后方枕颈入路,按照"无瘤操作"的原则行病椎全脊椎切除,前路行异形钛网植骨融合内固定,后路行枕颈固定术,同时行Halo-vest架外固定,术后随访6～16个月.结果 C1.2切除1例,C2.3切除2例,C2切除3例.平均手术时间7.2h,平均术中出血量2400 ml.所有患者局部疼痛和神经症状减轻或消失,未出现神经、血管损伤,1例脊索瘤患者术后1年出现局部复发.至末次随访时所有患者头部位置良好,均达到枕颈区稳定,未出现内固定松动、断裂和移位.结论 按"无瘤操作"的原则行包膜外肿瘤切除可以获得较好的疗效;异形钛网植骨融合内固定术结合枕颈固定术,同时辅以Halo-vest架外固定,可以提高手术的安全性,并能在寰枢椎肿瘤切除术后有效地重建上颈椎的稳定性,实现即刻稳定,便于患者早期下床活动,提高患者生活质量,且手术操作简便易行,适合在寰枢椎肿瘤切除术中应用.     

寰枢椎后路"三点式"经椎弓根固定治疗C1、2层面椎管哑铃形肿瘤

[目的]探讨后正中入路切除C1、2层面椎管哑铃形肿瘤并使用寰枢椎后路三点式经椎弓根固定的治疗效果及手术技巧。[方法]回顾性分析16例经后正中入路切除C1、2层面椎管哑铃形肿瘤并使用寰枢椎后路三点式经椎弓根固定的病人的临床资料及手术治疗效果。[结果]16例均一次手术切除椎管内外肿瘤,16例随访12～15个月,患者的症状和神经功能均有不同程度的改善,随访期间无肿瘤复发、无内固定松动和后凸畸形发生。[结论]C1、2层面哑铃形椎管肿瘤可经颈后正中入路一次切除,寰枢椎后路三点式经椎弓根固定可维持肿瘤切除后寰枢椎的稳定性。     

颈椎转移瘤全椎节切除与重建术的疗效及预后分析

脊柱是恶性肿瘤最常见的转移部位，其中颈椎转移性肿瘤危害更大，椎体不稳、塌陷、疼痛及脊髓压迫症状常较早被发现，严重时会发生高位瘫痪甚至导致死亡。因此对出现上述症状或具备高椎体塌陷风险的颈椎转移性肿瘤患者行肿瘤病灶清除及稳定性重建有着重要的意义。C3～7椎体及附件转移性肿瘤主要行全椎节切除＋前路钛网、钢板、骨水泥及后路椎弓根钉或侧块螺钉固定，有别于寰枢椎转移性肿瘤行全椎节切除＋后路枕颈融合固定。因而此处只针对在2000年1月～2006年6月间收治并行全椎节切除与重建术的25例C3～7椎体及附件转移肿瘤患者进行回顾性总结分析。     

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.     

后路改良经关节螺钉内固定术治疗寰枢椎不稳定

[目的]探讨寰枢椎不稳定的手术方法与疗效.[方法]采用以枢椎下关节突下缘中点为进钉点的后路改良经关节螺钉内固定加自体颗粒样松质骨植骨术治疗寰枢椎不稳定20例,其中,新鲜外伤4例,陈旧性外伤14例,先天性畸形1例,椎管内肿瘤1例.术后定期观察椎体复位、内固定、骨融合、临床表现变化及并发症发生情况.[结果]双侧螺钉内固定20例,加后路钢丝固定3例.寰枢椎获解剖复位19例,大部分矫正1例,内固定位置均良好.随访16～64个月,寰枢椎于术后2～3个月均获得骨性融合,临床症状缓解,无并发症发生.[结论]后路改良经关节螺钉内固定术,操作简便,疗效可靠,可作为治疗寰枢椎不稳定的有效术式.     

内窥镜辅助下经颈前入路上颈椎重建技术

目的 评价内窥镜辅助下经颈前入路上颈椎重建技术治疗上颈椎疾病的临床疗效.方法 回顾性分析2005年1月～2007年12月内窥镜辅助下经颈前路手术治疗的6例上颈椎疾病患者,其中3例为固定性寰枢关节脱位,3例为C2椎体肿瘤.均采用内窥镜辅助下颈前入路C2椎体切除、脊髓减压、自体髂骨重建和后路内固定融合术.评价内容包括:颈...     

一期前路松解后路椎弓根钉固定融合治疗难复性寰枢椎脱位

目的 探讨经口咽入路前路松解一期后路寰枢椎椎弓根钉内固定植骨融合治疗难复性寰枢椎前脱位的临床疗效,方法 2005年1月～2010年2月,采用经口咽入路前路松解,一期后路寰枢椎椎弓根钉内固定植骨融合治疗难复性寰枢椎脱位合并高位颈脊髓压迫共21例.男15例,女6例;年龄26～70岁,平均51岁;病程6～30年.陈旧性齿状突...     

前后联合入路一期全脊椎切除脊柱重建治疗颈胸交接部脊椎肿瘤

目的 探讨颈胸交接部脊椎肿瘤通过前后联合入路一期全椎切除脊柱重建治疗的可行性.方法 对8例颈胸交接部脊椎肿瘤选用改良的颈胸交接部前方入路及传统后方入路,一期行病椎全椎切除,脊柱重建方法.结果 术后1个月,除1例T2血管瘤神经功能A级恢复至C级,其余患者为E级(3例E级术后未加重).结论 选用改良的颈胸交接部前方入路及传统后方入路,一期行病椎全椎切除、椎体间植骨、前后联合固定重建脊柱,为治疗颈胸交接部脊椎肿瘤的一种可行方法.     

前后路联合一期全椎体切除脊柱重建治疗胸腰椎恶性肿瘤

[目的]探讨前后路联合一期全椎体切除脊柱重建治疗胸腰椎肿瘤的疗效及优越性。[方法]应用前路全椎体切除、钛网植骨或钛网骨水泥椎体重建和后路椎弓根钉系统内固定治疗胸腰椎恶性肿瘤24例。[结果]术后随访9—35个月。所有患者疼痛症状均消除，9例不完全截瘫患者平均恢复1．8级（Frankel分级），2例大小便功能障碍者均恢复，4例远处重要脏器转移死亡，所有随访达6—9个月的病例均骨性融合，无内固定松动断裂，1例术后1年复发。[结论]前后路联合一期全椎体切除脊柱重建治疗胸腰椎恶性肿瘤能有效切除肿瘤、重建脊柱稳定性、提高病人生活质量。     

Total spondylectomy for primary tumor of the thoracolumbar spine

STUDY DESIGN: Six patients with primary malignant tumor of the thoracolumbar spine who underwent total spondylectomy (TS) by en bloc resection were reviewed retrospectively. OBJECTIVES: To report surgical technique and preliminary results of TS and to evaluate its oncological curability. SETTING: Japan. METHODS: Six patients were treated by TS by en bloc resection of the vertebral tumor. TS through a posterior approach was performed in three cases (T1 osteosarcoma, L1 osteosarcoma and L1 chordoma) and in the others through a single stage anterior and posterior combined approach (T6-8 recurrent giant cell tumor. L4 chordoma and L5 giant cell tumor). Surgical margins of the specimens were evaluated histologically. All patients were followed, and their status was evaluated by clinical and imaging studies. RESULTS: There were no complications related to surgery. Programmed sacrifice of nerve roots were performed in three cases for oncologic excision. A wide surgical margin was achieved in one case, a marginal one in four, and an intralesional margin in one. Five patients were alive without evidence of tumor and one was alive with disease at follow-up evaluation after 2.0-4.8 years. Local recurrence was found in one case of T1 osteosarcoma with an intralesional margin. CONCLUSIONS: These preliminary results suggested that TS is an effective procedure in control of local recurrence with acceptable complications.     

脊柱肿瘤的手术治疗

目的 :探讨对于脊柱肿瘤一期全脊椎切除及脊柱稳定性重建的手术方法和临床效果。方法 :对 12例脊柱肿瘤行前、后路或前、后联合入路Ⅰ期全脊椎切除、脊髓减压 ,椎间植骨融合、内固定术。结果 :术后 11例获得随访 ,按照Frankel分级较术前均有 1级以上提高 ,所有患者局部疼痛症状消失。术后复查平均植骨融合时间 3个月。1例脊索瘤术后 1年复发 ,1例巨细胞瘤术后 9个月复发。结论 :针对脊柱肿瘤的性质、部位 ,通过不同的手术入路行一期全脊椎切除、植骨融合内固定 ,彻底切除肿瘤 ,重建脊柱稳定性并体现了个体化的治疗方向     

颈胸段脊柱肿瘤的外科治疗

目的 观察比较不同手术入路方法治疗颈胸段脊柱肿瘤的疗效。方法 本组９例,共１０例次。对其中４例肿瘤同时累及椎体及椎体后部结构的患者,选择前后路同期手术,经前路切除肿瘤、椎管减压及钢筋骨水泥或前路钢板固定,并同期行后路肿瘤切除术,其中１例行Ｌａｕｑｕｅ棒固定;对４例肿瘤仅累及椎体者,选择经前路切除肿瘤、椎管减压、钢筋骨水泥固定;另２例肿瘤单纯累及椎体后部结构者,经后路行肿瘤切除和椎管减压术。术后４例     

Extensive total spondylectomy for recurrent giant cell tumor in the thoracic spine. Case report

The authors report the case of a 47-year-old woman who harbored a giant cell tumor at the T-5 level. She had undergone curettage of the tumor via a combined anterior and posterior approach at a regional hospital and was later referred to the authors' institution for treatment after the tumor recurred. On examination she exhibited progressive paraparesis and was nonambulatory due to cord compression caused by the tumor, which had invaded the spinal canal and extended to the right paravertebral muscles and right thoracic cavity. A spondylectomy was performed through a single posterior approach. The tumor, together with a portion of the dura mater, pleura, and muscles, was resected en bloc from T-4 to T-6. After resection, spinal reconstruction was performed by placement of an anterior titanium mesh cage as well as posterior pedicle screw and rod instrumentation. The patient's postoperative course was uneventful, and she exhibited substantial neurological recovery and became ambulatory. Two and a half years after surgery, the patient was tumor free. En bloc resection of a recurrent giant cell tumor was successfully achieved through a single posterior approach. This surgical technique can be an effective option for this pathological condition, which is difficult to manage using other conventional treatment options including repeated curettage and radiotherapy.     

经颌下入路切除枢椎肿瘤及前方内固定应用

目的 探讨经颌下胸锁乳突肌内侧缘入路切除枢椎肿瘤及前方内固定的应用.方法 2004年12月至2010年6月,采用经颌下胸锁乳突肌内侧缘入路联合后路行枢椎肿瘤切除前后内固定术治疗枢椎肿瘤17例,男11例,女6例;年龄23～77岁,平均49岁;C2 11例,C2.34例,C2-42例;8例累及椎体,9例累及椎体及附件.原发性肿瘤14例,其中骨巨细胞瘤4例,浆细胞瘤4例,脊索瘤2例,嗜酸性肉芽肿2例,血管外皮瘤、淋巴瘤各1例;转移性肿瘤3例.前路肿瘤切除后采用钛网植骨及钛板垂直放置螺钉固定、钛网植骨及钛板斜行放置螺钉固定、钛网修剪后植骨螺钉固定3种方式行上颈椎前路内固定,均一期联合后路肿瘤切除枕颈内固定.结果 术后患者局部疼痛缓解,神经症状减轻或消失.术后随访6个月至6年.1例采用钛网植骨及钛板垂直放置螺钉固定的患者术后1个月发生螺钉松动退出,经翻修后融合,余16例患者均获融合.1例患者于术后9个月死于脑梗死.2例脊索瘤患者分别于术后13和18个月局部复发,1例死于高位瘫痪、呼吸衰竭,1例带瘤生存.2例转移癌患者分别于术后12和18个月因全身多处转移、衰竭而死亡.结论 经颌下胸锁乳突肌内侧缘入路可获得枢椎肿瘤切除与重建的良好显露.应用颈椎内固定系统可实现枢椎肿瘤切除后上颈椎稳定的前方重建.

Abstract：

Objective To investigate procedure and therapeutic effect of resection and reconstruction for axis tumors through the sub mandible approach. Methods Between December 2004 to June 2010,17 patients with axis neoplasm underwent tumor resection and antero-posterior reconstruction through the combined the sub mandible-inner sternocleidomastoid muscle (SMIS) approach and posterior approach. Tumor lesions involved C2 in 11 cases, C2-3 in 4, C2-4 in 2. Eight cases involved vertebral body, and 9 involved both vertebral body and element. Fourteen primary lesions including 4 giant cell tumors, 4 plasmocytomas, 2 chordomas, 2 eosinophilic granulomas, 1 hemangiopericytomas and 1 lymphoma, and 3 metastatic lesions were involved in this study. Three types of reconstruction in upper cervical spine including titanium mesh plus vertically placed titanium plate, titanium mesh plus obliquely placed titanium plate and trimmed titanium mesh alone, were adopted after anterior tumor resection, and then posterior tumor resection and reconstruction were performed. Results All patients experienced pain relief and neurological improvement after surgery. Except for one incidence of screw pull-out which was corrected by a revision surgery, solid fusion was achieved in all patients. A follow-up period of 6 months to 6 years was available for this study. One patient died of cerebral infarction 9 months postoperative. Two patients with chordoma relapsed 13 months and18 months postoperative, respectively, of whom one died of high plegia and respiratory failure, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases 12 months and 18 months postoperative, respectively. Conclusion Through the SMIS apporach, a satisfactory exposure can be obtained for axis tumor resection and reconstruction. Anterior reconstruction of upper cervical spine after tumor resection can be achieved with internal fixation system of cervical spine, which can improve intraopera-tive safety. The combined anterior reconstruction and posterior occipito-cervcial fixation can provide immediate stability, and benefit maintaining stability of upper cervical spine.     

经口咽入路松解Ⅱ期后路器械融合治疗寰枢椎脱位

目的：评价经口咽入路松解、Ⅱ期后路器械融合治疗陈旧性寰枢椎脱位。方法：经口咽入路寰枢椎前方松解颅骨牵引复位、Ⅱ期后路寰枢椎融合内固定治疗6例陈旧性寰枢椎脱位患者,术后对脊髓功能和颈椎影像学进行评定。结果：术后2年脊髓功能改善2级3例,改善1级2例,无变化1例。术后X线显示寰枢椎复位理想和后方融合满意,MRI显示脊髓压迫解除。结论：经口咽入路行寰枢椎前方松解后颅骨牵引复位、Ⅱ期后路器械融合术治疗陈旧性寰枢椎脱位,临床和影像学评估满意。     

Dorsal approach in giant cell tumor of the thoracic spine

Summary The incidence of giant cell tumors accounts for less than 5 % of all bone tumors. In the thoracic spine these tumors are extremely rare (1–1.5 % of the giant-cell tumors). The potential malignant character of giant cell tumors of the spine usually leads to wide surgical extirpation by ventral approach. The filling of bone defects with palacos cement after tumor resection is sufficient in the metaphysis of long bones. The case presented here is a giant cell tumor of the upper thoracic spine with primarily posterior destruction of the vertebral body and left arch. A single dorsal approach allowed for intralesional resection and filling of the defect with bone cement. This procedure was sufficient to achieve a solid fixation without recurrence of the giant cell tumor.      

经口咽齿突切除结合H—V环复位治疗重度陈旧性寰枢椎脱位

目的：探讨经口咽齿突切除结合H－V环复位治疗重度陈旧性寰枢椎脱位的方法及重度寰枢椎脱位的病理机制。方法：对2例重度陈旧性寰枢椎脱位患者采用经口咽齿突切除前方松解、减压,结合H－V环缓慢复位,二期行后路减压枕颈融合方法治疗。结果：1例术前Frankel C级恢复至正常,1例术前Frankel C级恢复至D级。结论：重度陈旧性寰枢椎脱位,在寰椎前弓与枢椎体间形成纤维组织增生,这种纤维连接使寰枢椎相对趋向稳定是障碍复位的主要因素。结合H－V环缓慢牵引,复位制动,经口咽入路行齿突切除前方松解减压,二期行后路减压枕颈融合,确能从前后方解除致压因素,结合H－V环制动、复位能够保障复位和手术过程中头颈部的运动在H－V环控制下,对手术和复位提供了极大的安全保证。     

Navigated transoral approach to the cranial base and the craniocervical junction: technical note

OBJECTIVE: The transoral approach is an elegant reliable surgical procedure that provides anterior exposure of the cranial base and the craniocervical junction. Our objective was to demonstrate the advantages of neuronavigation in planning and performing the transoral approach. METHODS: Three patients with chordomas and one patient with rheumatoid atlantoaxial subluxation were considered for a neuronavigated transoral procedure. For image guidance, the Stryker navigation system (Stryker Instruments, Kalamazoo, MI) was used. Registration was performed with individually constructed occlusal splints with four markers. RESULTS: The transoral approach was successfully used for two patients with chordomas involving the cranial base and the upper spine and for one patient with dislocation of the dens and medullary compression. In one case, preoperative simulation of the approach and trajectory planning demonstrated that adequate resection could not be achieved via the transoral route, and a paracondylar suboccipital approach was used. The registration accuracy achieved with the occlusal splint was less than 1 mm. CONCLUSION: Neuronavigation is a useful tool for planning and performing a transoral approach. It optimizes preoperative planning, clarifies and secures resection limits, and reduces overall surgical morbidity. Registration with an occlusal splint with four markers proved to be an attractive alternative to conventional systems.     

Usefulness of three-dimensional full-scale modeling of surgery for a giant cell tumor of the cervical spine

STUDY DESIGN: Case report. OBJECTIVES: To report a case with giant cell tumor (GCT) of C6 vertebra, in which three-dimensional (3-D) full-scale modeling of the cervical spine was useful for preoperative planning and intraoperative navigation. SETTING: A university hospital in Japan. CASE REPORT: A 27-year-old man with a GCT involving the C6 vertebra presented with severe neck pain. The C6 vertebra was collapsed and the tumor had infiltrated around both vertebral arteries (VAs). A single-stage operation combining anterior and posterior surgical procedures was scheduled to resect the tumor and stabilize the spine. To evaluate the anatomic structures within the surgical fields, we produced a 3-D full-scale model from the computed tomography angiography data. The 3-D full-scale model clearly showed the relationships between the destroyed C6 vertebra and the deviations in the courses of both VAs. Using the model, we were able to identify the anatomic landmarks around the VAs during anterior surgery and to successfully resect the tumor. During the posterior surgery, we were able to determine accurate starting points for the pedicle screws. Anterior iliac bone graft from C5 to C7 and posterior fixation with a rod and screw system from C4 to T2 were performed without any complications. Postoperatively, the patient experienced relief of his neck pain. CONCLUSION: The 3-D full-scale model was useful for simultaneously evaluating the destruction of the vertebral bony structures and the deviations in the courses of the VAs during surgery for GCT involving the cervical spine.