微创治疗中脊柱转移瘤椎体成形骨水泥注入及射频消融和放射疗法

背景:微创技术的发展明显降低了脊柱转移瘤手术并发症,目前微创治疗方法主要有椎体骨水泥增强、射频消融联合椎体成形、术中放疗联合椎体成形3大类。目的:总结上述3大类微创治疗脊柱转移瘤的研究进展。方法:以"脊柱转移瘤,椎体成形,射频消融,放射治疗;spinal metastases,vertebroplasty,radiofrequency ablation,radiotheray"为关键词,检索Pub Med、万方数据库文献。结果与结论:骨水泥增强技术应用广泛、止痛效果很好,有效率达80%-90%,但骨水泥产热杀灭肿瘤的效果非常有限,不能控制肿瘤生长;射频消融及放疗能够杀灭肿瘤,但不能重建稳定性,将不同技术结合可以提高脊柱肿瘤的治疗效果。术中应用放射线、植入放射性粒子或放射性骨水泥是近年发展起来的新技术,因报道较少,缺乏长期随访,目前还不能得出优于单纯骨水泥增强技术的结论。尤其是针对椎体后壁破坏及部分侵入椎管的转移瘤患者,虽然做了很多尝试,但骨水泥渗漏导致神经功能加重的风险依旧很高,所以目前还没有一种完善的微创治疗方法。     

脊柱转移瘤的外科治疗原则

随着人口老龄化和癌症诊治水平的提高,脊柱转移瘤发病率呈现上升趋势。脊柱转移瘤治疗提倡多学科联合合作。骨科医师作为团队中的一员,位置重要且无法替代,手术能够为患者缓解难治性疼痛,维持或重获行走功能,提高患者的生存质量,促进患者能够更好地接受后续系统性肿瘤治疗。骨科医师在选择合适的治疗方法和手术策略时需综合考虑患者的临床表现、脊柱稳定性、转移瘤数量和部位、肿瘤放化疗敏感性、预期生存期以及影像学表现,以确保手术效益大于围手术期风险。脊椎肿瘤整块手术切除和全脊椎切除虽可使患者获得长期无瘤生存,但因手术适应证狭窄,风险大,并发症发生率高,而备受争议。微创化是脊柱转移瘤手术的发展趋势,各类微创手术层出不穷。本文就脊柱转移瘤的外科治疗进展和原则作一综述。     

脊柱转移瘤姑息性切除减压内固定联合骨水泥填充的临床疗效研究

目的探讨姑息性切除减压内固定联合骨水泥填充对脊柱转移瘤的临床疗效。方法对2016年1月至2017年12月在本院行姑息性切除减压内固定联合骨水泥填充术的37例患者行回顾性研究。其中,男21例,女16例;年龄23～71岁,平均(55.0±10.4)岁;受侵犯椎体数为64个,其中胸椎37个,腰椎27个。记录术中出血量、手术时间、单个椎体骨水泥注入量,以及术前、术后视觉模拟评分(visual analogue score,VAS)和Oswestry功能障碍指数(ODI),通过影像学资料评估术前及术后椎体前缘、椎体中部高度变化。结果所有患者手术顺利,随访时间12～18个月,平均(14.7±2.0)个月。随访期间,未出现内固定松动者,1例患者出现手术切口感染,经抗生素治疗及换药后好转,无需外科干预。1例患者于术后16个月因肿瘤转移引起多器官衰竭而死亡。患者术后1周、术后半年及术后1年时的VAS评分及ODI指数和术前相比,差异有统计学意义(P0.05)。术后1周、术后半年及术后1年时的椎体前缘高度及椎体中部高度与术前相比,差异无统计学意义(P0.05)。结论脊柱转移瘤姑息性切除减压内固定联合骨水泥填充术能明显缓解患者疼痛,改善功能障碍,维持椎体高度,保护脊柱生物力学稳定性,治疗效果持久,对于改善晚期肿瘤患者的生存质量有积极的意义。     

经皮椎体后凸成形术治疗腰椎压缩性骨折的临床疗效和对疼痛的影响分析

目的经皮椎体后凸成形术治疗腰椎压缩性骨折的临床疗效和对疼痛的影响分析。方法选取本院2015年2月至2017年12月收治的50例骨质疏松性腰椎压缩性骨折患者作为研究对象,共58个椎体,随机分成实验组和对照组。实验组患者有28个椎体采取经皮椎体后凸成形术(PKP)治疗,对照组患者有30个椎体采用经皮椎体成形术(PVP)治疗。比较两组患者的治疗效果及对疼痛的影响。结果术后实验组患者椎体高度恢复情况明显优于对照组,差异具有统计学意义(P0.05);术后两组患者VAS评分均明显下降,且实验组患者VAS评分降低程度比对照组更明显,差异具有统计学意义(P0.05)。结论经皮椎体后凸成形术作为脊柱外科常用的微创技术,在恢复椎体高度及缓解脊柱疼痛感上有着良好的临床疗效。     

虚拟仿真技术构建三维模型在腰椎转移性肿瘤中的应用

背景:脊柱转移瘤往往破坏椎体和附件,患者会患有严重的疼痛,并发症发生率较高,例如截瘫和脊柱后凸畸形等。脊柱转移瘤治疗原则是早期诊断,手术完全切除,术后化疗。影像学技术如CT可判断脊柱转移瘤的转移情况,进行准确的术前定位。目前可视化仿真手术及虚拟现实技术已经逐渐应用于整形外科领域。目的:通过探索虚拟现实技术来寻找一种实行经前后路联合治疗腰椎转移性肿瘤的途径。方法:基于腰椎的64排螺旋CT连续薄层二维图像,Mimics软件分别重建正常腰椎、破坏病椎、腹主动脉及双侧肾脏的三维可视化结构,在三维模型拟行经前路病灶清除、钛网骨水泥支撑、后路椎弓根螺钉内固定。结果与结论:基于Dicom格式数据进行三维重建图像结构清晰,可真实再现腰椎病椎和邻近脏器的结构,整个虚拟仿真手术真实直观。虚拟仿真手术准确重建腰椎恶性肿瘤及邻近结构的三维立体结构,明确病椎清除范围,经后路重建脊柱序列,此方法可为个体化的治疗方案提供了客观的依据。     

经皮椎体成形术联合唑来磷酸治疗椎体转移性肿瘤

脊柱是骨肿瘤转移最常发生的部位之一,肿瘤组织对椎体侵袭破坏可导致剧烈的腰背部疼痛,严重影响患者的生活和工作。治疗脊柱转移性肿瘤的目的是为了缓解和控制骨痛,促进骨修复,提高生活质量。经皮椎体成形术﹙PVP﹚为椎体恶性肿瘤的治疗带来了一种有效的方法。双磷酸盐已成为治疗和预     

经皮椎体成形术治疗脊柱转移瘤病人的护理

脊柱转移瘤占脊柱恶性肿瘤的一半以上,以腰椎多见,其次为胸椎、骶椎、颈椎。脊柱转移瘤的根治较为困难。临床症状主要是剧烈疼痛,因而缓解疼痛,提高病人生活质量成为治疗护理的主要内容。经皮椎体成形术是在影像学技术(如CT、X线等)引导下,应用骨穿针经皮肤穿刺到病变椎体,然后     

脊柱结核与脊柱转移瘤的磁共振弥散加权成像影像学特征分析

目的:探讨磁共振弥散加权成像(MRI-DWI)技术诊断脊柱结核与脊柱转移瘤的临床价值。方法:选取经病理学检查确诊的脊柱结核患者48例、脊柱转移性肿瘤62例,收集时间为2015年1月到2016年8月。所有患者均行MRI-DWI检查,对两组患者的影像学资料进行分析,探讨MRI-DWI鉴别诊断脊柱结核与脊柱转移性肿瘤的临床价值。结果:在b=500 s/mm~2时,脊柱结核组患者的正常椎体表观弥散系数(ADC)值与脊柱转移瘤患者的正常椎体ADC值比较,差异无统计学意义(P0.05);脊柱结核患者椎体病灶、骨髓水肿、椎旁病变组织的ADC值显著高于脊柱转移瘤患者,差异均具有统计学意义(P0.05)。脊柱结核组患者的信噪比与脊柱转移瘤患者比较,差异无统计学意义(P0.05)。脊柱结核患者衰减百分比显著高于脊柱转移瘤患者,差异具有统计学意义(P0.05)。MRI-DWI鉴别诊断脊柱结核与脊柱转移瘤的灵敏度为93.55%、特异度为93.75%、漏诊率为6.45%、误诊率为6.25%,诊断一致性kappa值为0.871。结论:MRI-DWI技术鉴别诊断脊柱结核与脊柱转移瘤具有较高的灵敏度和特异度,与病理学结果的一致性较高。     

经皮椎体成形术联合缓释氟尿嘧啶治疗椎体转移瘤

目的 评估经皮椎体成形术（PVP）联合缓释氟尿嘧啶治疗椎体转移瘤的疗效及安全性.方法 入选椎体转移瘤患者共72例.其中PVP＋缓释氟尿嘧啶组37例,单纯PVP 35例,通过临床症状、生存分析及影像学评估疗效及安全性.结果 PVP＋缓释氟尿嘧啶组椎体肿瘤局部控制率67.6%（25,37）,疼痛缓解率达89.2%（33,37）;单纯PVP组椎体肿瘤局部控制率42.9%（15,35）,疼痛缓解率85.7%（30/35）,两组间局部肿瘤控制率差异有统计学意义（P=0.035）.两组病例的生活质量、疼痛缓解及生存期差异无统计学意义（P值分别为0.124、0.462和0.498）.结论 经皮椎体成形术联合缓释氟尿嘧啶治疗椎体转移瘤是安全、有效的新方法.可明显缓解晚期恶性肿瘤椎体转移带来的剧烈疼痛,改善患者生存质量,并对椎体转移病灶具有一定控制作用.     

经皮椎体成形术联合缓释氟尿嘧啶治疗椎体转移瘤

目的 评估经皮椎体成形术(PVP)联合缓释氟尿嘧啶治疗椎体转移瘤的疗效及安全性.方法 入选椎体转移瘤患者共72例.其中PVP+缓释氟尿嘧啶组37例,单纯PVP 35例,通过临床症状、生存分析及影像学评估疗效及安全性.结果 PVP+缓释氟尿嘧啶组椎体肿瘤局部控制率67.6%(25,37),疼痛缓解率达89.2%(33,37);单纯PVP组椎体肿瘤局部控制率42.9%(15,35),疼痛缓解率85.7%(30/35),两组间局部肿瘤控制率差异有统计学意义(P=0.035).两组病例的生活质量、疼痛缓解及生存期差异无统计学意义(P值分别为0.124、0.462和0.498).结论 经皮椎体成形术联合缓释氟尿嘧啶治疗椎体转移瘤是安全、有效的新方法.可明显缓解晚期恶性肿瘤椎体转移带来的剧烈疼痛,改善患者生存质量,并对椎体转移病灶具有一定控制作用.     

Surgical Impacts of Metastatic Non-small Cell Lung Cancer to the Thoracic and Lumbar Spine

BackgroundSurgery for spinal metastasis is rapidly increasing in frequency with procedures ranging from laminectomy to spondylectomy combined with stabilization. This study investigated the effect of various surgical procedures for spinal metastasis of non-small cell lung cancer (NSCLC).MethodsA single-center consecutive series of patients who underwent surgery for spinal metastasis of NSCLC were retrospectively reviewed. Patients'' characteristics, radiographic parameters, operative data, clinical outcomes, and complications were analyzed. Surgical outcomes were assessed according to pain and performance status before and after surgery. Overall survival (OS) rate was estimated using the Kaplan-Meier method. Multivariate analysis was performed to detect factors independently associated with OS using a Cox proportional hazards model.ResultsTwenty-one patients were treated with laminectomy, 24 with corpectomy, 13 with spondylectomy (piecemeal or total en bloc fashion), and all procedures were combined with stabilization. Back pain and performance status improved significantly after surgical treatment among the three groups. Revision surgery due to tumor progression at the index level or spinal metastasis at another level were four patients (19.0%) in the laminectomy group, six patients (25.0%) in the corpectomy group, and one patient (7.7%) in the spondylectomy group. A Charlson comorbidity index and the number of spinal metastasis negatively affected OS (hazard ratio [HR], 19.613 and 2.244). Postoperative chemotherapy, time to metastasis, spondylectomy, and corpectomy had favorable associations with OS (HR, 0.455, 0.487, 0.619, and 0.715, respectively).ConclusionPostoperative chemotherapy was the most critical factor in OS of patients with metastatic NSCLC to the spine. An extensive surgical procedure (corpectomy/spondylectomy) with stabilization also could be beneficial for limited patients with spinal metastasis of NSCLC.     

Surgical treatment of spine deformities in patients with systemic hereditary spine diseases

Experience in treatment of 55 patients with spine deformities developed on the background of systemic hereditary spine diseases is presented. Algorithm of the examination and treatment tactics for this group of patients is presented. Features of surgical technique in dorsal, ventral and combined approaches are described.     

胸腰椎脊柱内固定手术流程的优化与一次性集约手术器械的研发

目的 优化胸腰椎脊柱内固定手术流程并研制一次性、轻质化、模块化脊柱外科手术器械包,为在特殊条件下完成脊柱外科手术提供必备条件,进而提高脊柱脊髓损伤患者的救治率。方法 通过将《新型冠状病毒肺炎疫情期骨科诊疗规范化流程的专家共识》与胸腰椎脊柱内固定手术实际情况相联系,对胸腰椎脊柱内固定手术流程进行优化,同时选择高强度高分子材料代替原有金属材料,减轻器械的质量,实现轻质化;通过优化减少工具数量,使得一物多用,减少工具的数量,实现集成化;通过对植入物的改造,实现单向、万向螺钉的一体化,满足手术中的多种需求。结果 优化胸腰椎脊柱内固定手术流程,同时研制出一系列、独立包装的一次性手术器械,一套器械控制在1 kg以内,不超过20件手术器械,可以满足完成一台胸腰椎内固定手术。结论 通过优化胸腰椎脊柱内固定手术流程达到有效救治患者、避免交叉感染、保护人员安全的目的。同时,一次性、轻质化、模块化脊柱外科手术器械包可在战争、灾难、疫情等特殊条件下,以及在我国边远医疗条件落后地区开展并完成脊柱手术,解决脊柱脊髓损伤伤员早期救治等问题,提高我国平时、战时的后勤保障能力。     

三维可视化技术在复杂骨与软组织肿瘤手术中的临床应用

目的 探讨三维可视化技术在复杂骨与软组织肿瘤外科手术治疗中的临床应用价值。方法 回顾性研究。纳入2019年4—12月中国科学技术大学附属第一医院(西区)骨科11例复杂骨与软组织肿瘤患者的临床资料,其中男5例、女6例,年龄16～67(52.6±15.9)岁。11例患者术前均行CT常规二维扫描及三维可视化技术重建,于重建模型上观察肿瘤与周围组织尤其是血管的关系、评估肿瘤的可切除性及安全切缘、指导制定手术方案并模拟手术操作;对比常规CT二维扫描与三维可视化重建影像的观察结果,并于肿瘤切除手术中观察验证术前三维可视化重建影像评估的准确性。结果 本组11例患者CT二维扫描图像经三维可视化技术重建后,可清晰显示肿瘤形态、大小及其与周围组织的关系。对比CT二维扫描影像,三维可视化技术在手术策略精准制订和指导手术操作方面更具有优势。除1例因腹腔转移未予手术治疗外,余10例患者经三维可视化技术评估后均顺利完成安全边界外肿瘤完整切除术,无血管损伤并发症发生,术中探查结果与术前三维可视化模型的判断基本一致。结论 在复杂骨与软组织肿瘤术前应用三维可视化技术可以提高术前评估的准确性,指导个体化精准手术方案的制订,协助确定肿瘤外科边界并完整切除肿瘤,使患者获得更好的疗效。     

Endoscopic thoracic laminoforaminoplasty for the treatment of thoracic radiculopathy: report of 12 cases

Background: Spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions. Due to the close proximity to thoracic and abdominal organs, surgical operations can be difficult and carry a greater risk of complications. The most efficacious intervention for thoracic stenosis, whether central or foraminal, refractory to conservative management is uncertain. We aimed to evaluate the efficacy of endoscopic laminoforaminoplasty (ELFP) in the treatment of thoracic radiculopathy.Methods: Twelve patients with radicular pain involving the lower thoracic levels (at or below T6) were treated with ELFP.Results: Seven of twelve patients showed marked improvement in pain scores. Average follow-up scores were 2.9 and 12.08 on the Visual Analog Scale (VAS) and Oswestry Disability Index, respectively. The significance was 0.005 between the pre and post surgical data. One patient with moderate symptoms, two with severe symptoms, and two with crippling symptoms did not report significant improvement on VAS or Oswestry. No complications were encountered.Conclusions: Endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates. Patients additionally benefit from a decrease risk of complications, short hospital stay, and faster recovery.     

Palliative surgical approach to rehabilitate spinal injury patient in Indian rural setup

Objective:

To evaluate the usefulness of conventional spinal surgery as palliative procedure to rehabilitate dorsolumbar injuries in a rural setup.

Materials and Methods:

Twenty-three patients with dorsolumbar spine injury with complete paraplegia were assessed on the clinical and social rehabilitation parameters after surgical stabilization at Acharya Vinoba Bhave Rural Hospital Sawangi, Wardha, India. The study group comprised 21 male and 2 female patients. The dorsolumbar spine injury was fixed by conventional posterior instrumentation using short-segment pedicle screw system and Harrington rod system with or without fusion. Functional and neurologic outcome was recorded in the follow-up period by using Functional Independence Measure and Frankel grade, respectively. Correlation and analysis of results was established statistically.

Results:

Functional outcome showed statistically significant improvement. Social cognition was found intact in a significant number of patients.

Conclusion:

This study demonstrates the usefulness of conventional instrumentation as palliative surgical approach to stabilize and rehabilitate patients from deprived sector of rural India.     

“腰三针”干预腰多裂肌损伤大鼠多种氧化应激因子的表达

文题释义：多裂肌：是椎旁肌群中的重要肌肉之一,对脊柱稳定性的维持有重要作用。在腰椎后路手术过程中,多裂肌也是最容易被损伤的肌肉之一。 腰三针：由肾俞穴、大肠俞穴和委中穴组成,是临床治疗腰椎间盘突出症、椎管狭窄、腰肌劳损等腰部相关疾病的重要穴位。 氧化应激：是指机体氧化与抗氧化失衡,活性氧自由基生成与堆积过多,伴或不伴抗氧化能力下降引起的细胞化学损害及功能障碍。氧化应激和炎症反应可相互作用发生,氧化应激可诱发炎症,炎症亦可加重氧化应激。 背景：腰椎后路手术是目前临床进行诸多手术如椎间盘切除、椎管减压等的主要手术入路,但有10%-40%的腰椎后路手术患者在术后不久可再次出现腰背部疼痛及相关功能障碍,这与手术过程中对椎旁肌如多裂肌的过度牵拉或钝性损伤有关。 目的：观察腰三针对大鼠腰多裂肌损伤后氧化应激因子丙二醛、活性氧、超氧化物歧化酶、谷胱甘肽过氧化物酶及磷酸化蛋白激酶B表达的影响。方法：将24只雄性SD大鼠随机分为3组,每组8只。模型组、腰三针组分别采用0.5%布比卡因盐酸盐肌内注射复制大鼠腰多裂肌损伤模型;对照组予生理盐水肌内注射。对照组与模型组造模后不进行针刺干预,腰三针组造模后给予针刺靳三针之“腰三针”,即大肠俞、肾俞、委中,针刺后连接电针,波形选用疏密波,电针频率采用2 Hz/10 Hz,电流强度选择1 mA,持续干预20 min,每天干预1次,共干预7 d。电针干预7 d后,通过苏木精-伊红染色观察损伤部位多裂肌形态学变化,采用试剂盒检测各组大鼠多裂肌中丙二醛、活性氧、超氧化物歧化酶、谷胱甘肽过氧化物酶的表达;采用Western-blot法检测多裂肌中磷酸化蛋白激酶B蛋白的表达。实验经广东省第二中医院实验动物伦理委员会批准,伦理批准号：048617。结果与结论：①苏木精-伊红染色显示,干预7 d后,模型组可见肌纤维损伤明显,但已出现部分修复,但炎性细胞数量仍较多;腰三针组可出现较多新生的肌纤维,炎性细胞明显减少;②腰三针组肌纤维横截面积明显优于模型组(P < 0.01);③干预后,模型组丙二醛、活性氧表达量明显高于对照组(P < 0.01);腰三针组丙二醛、活性氧表达明显低于模型组(P < 0.01),超氧化物歧化酶、谷胱甘肽过氧化物酶表达高于模型组(P < 0.01或P < 0.05);腰三针组磷酸化蛋白激酶B蛋白表达明显高于模型组(P < 0.01);④结果说明,腰三针干预可显著降低多裂肌损伤后氧化应激水平,可能与提高磷酸化蛋白激酶B的表达有关。 ORCID: 0000-0003-3561-0602(白振军) 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

Clinical aspects, diagnosis and surgical treatment of developmental anomalies of the cervical spine

The examination of 20 patients with abnormal cervical spine has identified Klippel-Feil disease in 12 of them, isolated vertebral synostoses of the cervical spine in 8. In 2 patients with Klippel-Feil anomaly neurovascular syndrome was reported which resulted from compression of the neurovascular bundle by extra cervical ribs. Indications to surgical treatment in Klippel-Feil disease are specified. The authors performed operations to correct the cosmetic defect and relieve compression of the neurovascular bundle in neurovascular syndrome.     

CT三维成像在颈后路经皮脊柱内镜术中“V”点定位的作用

目的 探讨CT三维成像（three-dimensional computed tomography,3D-CT）技术在颈椎后路经皮脊柱内镜椎间孔减压髓核摘除术中“V”点确定的应用价值。 方法 回顾分析2016年1月至2019年3月行颈椎后路经皮脊柱内镜椎间孔减压髓核摘除术并成功随访的患者50例,均为单侧症状的神经根型颈椎病,经保守治疗6周以上无效,且颈椎动力位X线片未发现颈椎失稳。其中男性27例,女性23例,平均年龄54.2（40~75）岁,C4/5节段14例,C5/6节段25例,C6/7节段11例。患者分为两组,术中常规C臂X线机下定位“V”点为Ａ组（26例）,术前通过3D-CT技术确定“V”点为Ｂ组（24例）,比较二组平均住院时间、手术时间、术中透视次数和手术疗效,并进行统计学分析。 结果 50例患者平均随访时间（7.20±2.56）月（3~13月）,Ａ组平均手术时间和术中透视次数多于Ｂ组（P<0.05）;平均住院时间、术后随防评分、颈椎曲度、手术节段椎间隙高度及颈椎稳定性,二组无显著差异（P>0.05）。 结论 3D-CT技术在颈椎后路经皮脊柱内镜手术中“V”点定位有重要意义。     

Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients

The prognosis of prostate cancer is mainly determined by the presence or absence of metastases. Nevertheless, the metastatic pathways in prostate cancer are not entirely understood. Among 19,316 routine autopsies performed from 1967 to 1995 on men older than 40 years of age, the reports from those 1,589 (8.2%) with prostate cancer were analyzed. Hematogeneous metastases were present in 35% of 1,589 patients with prostate cancer, with most frequent involvement being bone (90%), lung (46%), liver (25%), pleura (21%), and adrenals (13%). Several lines of evidence suggested the existence of a backward metastatic pathway through veins from the prostate to the spine in addition to classical hematogeneous tumor spread via the vena cava. First, there was an inverse relationship between spine and lung metastases, suggesting that metastasis to the spine is independent of lung metastasis. Second, the maximum frequency of spine involvement occurred in smaller tumors (4 to 6 cm) as compared with the maximum spread to lung (6 to 8 cm) and liver (>8 cm), suggesting that spine metastases precede lung and liver metastases in many prostate cancers. Third, there was a gradual decrease in spine involvement from the lumbar to the cervical level (97% v 38%), which is consistent with a subsequent upward metastatic spread along spinal veins after initial lumbar metastasis. The results of this study show that bone, lung, and liver are the most frequent sites of distant prostate cancer metastases. Besides the cava-type of metastasis through lung passage, there are strong arguments for the existence and clinical significance of a backward venous spread to the spine, which is likely to occur early in the metastatic process.