手术治疗老年脊柱结核患者的临床研究和评估

[目的]探讨老年脊柱结核的发病特点和手术治疗疗效及风险。[方法]2001年7月～2007年1月,18例活动期老年脊柱结核患者,男14例,女4例;年龄62～84岁,平均70.2岁,在营养支持治疗下,正规四联抗结核化疗2～3周后行根治性病灶清除植骨内固定术;术后继续正规抗结核化疗1～1.5年。测量手术前后的ESR值和脊柱后凸角及终末随访时后凸角,根据Barthel指数记分法评定患者康复情况。[结果]手术中无严重并发症发生,术后随访2～4.2年,平均3.6年。所有患者植骨全部骨愈合,骨愈合时间4～10个月,平均7.3个月;无结核复发和窦道形成。术前后凸成角5°～48°,平均为(25.0±11.39)°;术后后凸成角0～15°,平均为(7.33±4.14)°;术后终末随访时后凸角0°～15°,平均为(9.11±3.92)°;术前与术后以及终末随访时相比差异有统计学意义(P<0.05)。神经损害Frankel分级:术前B级2例,C级10例,D级2例;术后C级3例,D级10例,E级1例。抗结核化疗2周后ESR值与入院时ESR值比较,差异无显著性(P>0.05);手术后2周和手术后3个月ESR值显著低于入院时ESR值,差异有显著性(P<0.01)。日常生活活动能力(Barthel指数)术前均值为(47.78±12.15),术后均值为(89.72±7.95)。t值=13.38,P<0.005。[结论]老年脊柱结核手术治疗安全有效,需根据患者具体情况制定个体化治疗方案。     

老年脊柱结核的手术治疗

目的 探讨老年脊柱结核患者的围手术期特点、手术入路及手术治疗效果.方法 回顾性分析2002年4月至2007年5月收治的45例老年胸腰椎结核患者的临床资料.男26例,女19例;平均年龄为67(61～78)岁.单个椎体破坏8例,两个椎体破坏27例,三个或三个以上椎体破坏10例.病程1～8个月,平均4.5个月.部位:胸椎(T2～T10)9例,胸腰段(T11～2)14例,腰椎(L3、L4)16例,腰骶段(L5、S1)6例.Frankel分级:B级7例,C级21例,D级11例,E级6例.45例患者均合并一种或多种其他疾病,其中21例合并心脑血管疾病,10例合并糖尿病.术前对这些患者进行合理治疗,术后随访.术前均行抗结核治疗2～3周.T2～T7椎体结核采用经后路病灶清除植骨融合、后路钉-棒系统内固定术,腰骶段椎体结核采用后路椎弓根螺钉固定加前路结核病灶清除髂骨植骨融合术,其余采用一期前路结核病灶清除加植骨内固定手术.45例患者均获得随访,随访时间24～40个月,平均28.5个月.结果 所有患者术中及住院期间无死亡及严重并发症发生.44例治愈,1例复发.植骨于12～18个月内均获融合.Frankel分级明显改善,B级1例,C级6例,D级11例,E级27例.结论 围手术期对并存疾病进行有效处理后,老年脊柱结核患者可以耐受手术治疗.如手术入路选择合理,病灶清除、内固定并植骨融合术可以提供足够的稳定性和较好的疗效.

Abstract：

Objective To discuss perioperative features, operative approach and surgical effects of spinal tuberculosis in older patients. Methods Retrospective analysis was conducted to analyze the clinical data of 45 patients with spinal tuberculosis ranging in age from 61 to 78 years (average, 67 years). The lesion was located in thoracic vertebrae in 9 patients, thoracolumbar vertebrae in 14, lumbar in 16, and lumbosacral in 6. Preoperative Frankel grades were B in 7 cases, C in 21, D in 11 and E in 6. Among them, 21 had cardio-cerebrovascular disease, 10 had diabetes mellitus. With preoperative medicine and chemotherapy for 2-3 weeks, all patients were treated surgically. The surgical procedures included: 1) Posterior focus debridement, bone grafting and one-stage posterior transpedicular screw system fixation in thoracic vertebrae (T2-T7). 2) Anterior debridement, bone grafting and one-stage posterior transpedicular instrumental fixation in lumbosacral vertebrae (L5-S1). 3) Anterior focus elimination, bone grafting and one-stage anterior plate fixation in the other vertebrae. Results Forty-five patients were followed up for 24 to 40 months, with the average of 28.5 months. No severe complication occurred during and after operation. Forty-four cases had recovered and 1 recurred. Spinal fusion occurred 12-18 months after operation. Frankel neurological grades improved significantly. Conclusion With the effective management of comorbidities in perioperative period,the elderly could tolerate surgical treatment. The appropriate approaches, thorough debridement and reasonable bone grafting with internal fixation are key to therapeutic success.     

脊柱转移瘤分离手术联合立体定向放疗的研究进展

随着癌症治疗水平的不断提升,脊柱转移瘤患者的生存期得到显著延长。当前脊柱转移瘤的治疗呈现多模式趋势,临床采用的手术方式包括椎体肿瘤切除椎管减压重建内固定术、分离手术、微创手术和经皮消融技术等,放疗技术包括传统外照射治疗、立体定向放疗和近距离放疗等。椎体肿瘤切除椎管减压重建内固定术的手术风险较大,术中和术后并发症的发生率较高,术后恢复期的延长可能造成后续放疗和其他内科治疗的延误,对患者的生存期和治疗信心都造成严重影响。而传统外照射治疗的精准度不高,脊髓耐受性的限制使得放疗剂量常难以达到控制放疗不敏感肿瘤的目的。随着放疗和手术技术的发展,精准性更高的立体定向放疗和手术创伤更小的分离手术脱颖而出,成为目前临床医生关注的焦点。本文就分离手术联合立体定向放疗的Hybrid治疗的研究进展作一综述。     

老年脊柱结核外科治疗体会

老年脊柱结核外科治疗体会赵振久，陈晓亮，邹云雯，葛文学，田炳基，丁同联，肖兴国老年脊柱结核外科治疗的文献报道较少。由于患者合并症多，病情复杂，使临床手术治疗困难。我院从１９７８年至今共收治６０岁以上脊柱结核１７例。现将我们的治疗体会报告如１临床资料性...     

脊柱转移瘤的临床研究近况

脊柱转移瘤（metastatic spine tumors，MST）是脊柱外科临床研究难点之一。近年来，对MST发病概率、临床诊断、手术指征、评估标准、手术疗效和预后等方面的研究都取得了许多重要的进展，现综述如下。     

脊柱骨转移瘤MRI诊断价值

作者报告５５例脊椎转移瘤ＭＲＩ表现，并与Ｘ线平片、平扫及增强ＣＴ、椎管造影、椎管造影ＣＴ（ＣＴＭ）等方法相比较，在显示肿瘤的解剖关系，包括骨破坏、椎管内侵犯、椎旁软组织延伸、病理压缩性骨折等方面，ＭＲＩ明显优于Ｘ线平片，平扫及增强ＣＴ，至少等于脊髓造影和ＣＴＭ，但是ＭＲＩ诊断脊椎转移瘤，大多数病例不需要椎管内注射造影剂。ＭＲＩ作为一种新的可供选择的技术，对脊椎转移瘤的诊断有重要价值。在大多数病例中可以替代脊髓造影和ＣＴＭ     

“分离手术”在脊柱转移瘤硬膜外脊髓压迫症治疗中的应用及疗效观察

目的探讨分离手术在脊柱转移瘤硬膜外脊髓压迫症治疗中的安全性及有效性。方法回顾分析自2014-04—2018-11采用后路环形减压、病椎骨水泥强化、长节段椎弓根钉内固定的分离手术治疗的21例脊柱转移瘤硬膜外脊髓压迫症,记录手术时间、术中出血量以及术后生存、并发症、神经功能改善情况,比较术前及术后3 d疼痛VAS评分。结果 21例手术均顺利完成,手术时间160~370 min,平均223.3 min;术中出血量200~2 000 mL,平均557.1 mL。随访期间13例患者去世,生存时间1~21个月,中位生存时间15个月。未出现内固定松动、断裂等相关并发症。术后1例出现术区血肿压迫脊髓,1例于术后3 d出现自发性蛛网膜下腔出血而昏迷;2例出现切口感染,1例上胸段转移瘤术后出现切口积液,1例于术后6个月出现更高节段的硬膜外脊髓压迫症状而放弃进一步治疗。术后3 d疼痛VAS评分较术前明显降低,差异有统计学意义(P<0.05)。术后1例神经功能Frankel A级患者无明显变化;3例B级中1例恢复到C级,2例无变化;10例C级中8例恢复到D级,1例恢复到E级,1例无明显变化;7例D级中5例恢复到E级,2例无明显变化。结论 分离手术治疗脊柱转移瘤硬膜外脊髓压迫症安全有效,可有效缓解患者疼痛,改善神经功能等级,值得进一步在临床中推广。     

脊柱多发转移瘤的诊断与治疗

病例简介患者男性,54岁,汉族,因背部疼痛及右小腿外侧胀痛3个月,加重1个月入院。患者3个月前无明显诱因出现胸背、腰背部疼痛,同时伴右侧腰部麻木和右小腿外侧胀痛,不影响工作和生活,未进行诊治。1个月前上述症状加重,行走易疲     

骨转移瘤综合治疗

肿瘤患者严重并发症骨转移瘤的有效治疗可改善和提高患者生存状态、生活质量,减轻患者痛苦.综合应用化疗、内分泌治疗、放疗、放射性核素治疗、双膦酸盐治疗及手术治疗等是骨转移瘤治疗的有效手段,新药、分子靶向治疗等将进一步控制病情进展,延长生存期.该文就骨转移瘤综合治疗方面的研究作一综述.     

Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression

Background and Context

Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management.

The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors

Background contextSpine metastases occur frequently in patients with cancer. A variety of surgical approaches, including anterior transcavitary, lateral extracavitary, posterolateral, and/or combined techniques are used for spinal cord decompression and restoration of spinal stability. The incidence of symptomatic hardware failure is unknown for the majority of these approaches.PurposeThe purpose of this study was to determine the incidence of symptomatic hardware failure and the associated risk factors in patients with metastatic epidural spinal cord compression (MESCC).Study design/settingThis was a retrospective study.Patient sampleThe current series analyzes a cohort of 318 patients who underwent separation surgery, which involves single-stage posterolateral decompression and posterior segmental instrumentation for MESCC.Outcome measuresThe event of interest was hardware failure; the competing event was death resulting from any cause. All patients were monitored for survival analysis. A competing risk analysis was conducted to examine univariately a number of potential risk factors associated with hardware failure, including junctional level, gender, construct length, and the presence or absence of prior chest wall resection.MethodsA retrospective analysis and chart review were performed for 318 consecutive patients who underwent posterolateral decompression and posterior screw-rod fixation without supplemental anterior fixation from March 2004 to June 2011 at our institution. The median follow-up time for survivors without hardware failure was 399 days (range, 9–2,828), with a mean operative time of 3 hours. A total of 78% of patients died during the 7-year study period.ResultsOf the 318 patients, nine (2.8%) exhibited signs and symptoms of hardware failure and required revision of the instrumentation. Patients with chest wall resection and those with initial construct length greater than six contiguous spinal levels exhibited a statistically significantly higher risk of symptomatic hardware failure than their counterparts. We observed a trend toward an increased risk of failure in women compared with men (p=.09).ConclusionsThe incidence of hardware failure is low in patients with MESCC who undergo posterolateral decompression and posterior screw-rod instrumentation. Moreover, the short operative time and low morbidity profile associated with this approach make it a reliable and acceptable method for the surgical treatment of MESCC. Patients with constructs spanning six or more levels or those with prior chest wall resection are at higher risk for instrumentation failure.     

在胸腰椎转移瘤分离手术中应用短节段骨水泥强化椎弓根螺钉固定的临床研究

【摘要】 目的：探讨在胸腰椎转移瘤分离手术中应用骨水泥强化椎弓根螺钉固定的临床疗效。方法：回顾性分析2018年2月~2019年10月于我院行分离手术治疗的伴有硬脊膜外脊髓压迫症（epidural spinal cord compression,ESCC）的胸腰椎转移性肿瘤患者59例,其中男25例,女34例,年龄56.2±7.5岁（45～76岁）。所有患者均采用骨水泥强化椎弓根螺钉固定,共置入236枚螺钉。统计手术时间、术中失血量、输血量、术后住院天数,患者术前、术后3个月的Frankel脊髓损伤分级,患者术前、术后7d、3个月及末次随访的疼痛视觉模拟评分（visual analogue scale,VAS）及Karnofsky功能评分,围手术期相关并发症情况。收集患者术前、术后7d及末次随访时手术节段正侧位X线片,随访观察有无内固定失败及手术节段矢状位Cobb角的变化。结果：患者随访时间为18.3±3.9个月（5～34个月）;患者手术时间为169.0±23.7min（125～210min）,术中出血量为535±120.0ml（200～1300ml）,术中输少浆血1.2±0.6u（0～6u）、血浆105±32ml（0～400ml）;术后住院时间6.5±2.3d（5～11d）。术中发生骨水泥渗漏2例,均为椎前静脉少量渗漏,暂停注射后渗漏未进展,术后无不良反应;脑脊液漏1例,患者俯卧位以及补液等对症处理后痊愈;伤口愈合不良2例,予以清创缝合后伤口愈合。术后VAS评分、Frankel分级、Karnofsky功能评分与术前相比均有显著性改善（P＜0.05）。无内固定失败,末次随访时手术节段Cobb角较手术后即刻无显著性差异（22.5°±2.1° vs 21.2°±1.8°,P>0.05）。结论：对伴有ESCC的脊柱转移瘤患者行分离手术时,应用骨水泥强化椎弓根螺钉可以提供更加坚强的脊柱稳定性。     

Cardiac surgery in patients aged 80 years and older

OBJECTIVE: We studied disease and surgical outcomes in an 80-plus age group to determine the feasibility of cardiac surgery at this age. METHODS: Between January 1991 and August 2000, we statistically analyzed 19 variables in 62 consecutive cases of cardiac surgery in the 80-plus age group to predict in-hospital and long-term mortality. Cases were classified by disease type (ischemic heart disease (IHD), n = 39; valvular heart disease (VHD) n = 19; and mechanical complications associated with acute myocardial infarction, n = 4; and by surgical status (emergency, n = 6; urgent, n = 10; and elective, n = 46). We compared these with 370 patients 70 to 79 years undergoing similar procedures during the same interval. RESULTS: No significant difference was seen between groups in total in-hospital mortality--9.7% vs. 3.8%--or in-hospital mortality for IHD--2.6% vs. 4.2%--or VHD--10.5% vs. 2.8%. We found cardiopulmonary bypass time > 150 min. and dialysis to be independent risk factors for hospital death. Actuarial survival at 7.5 years overall was 39% in the 80-plus age group vs. 53% in the 70-79 age group for VHD and 38% in the 80-plus age group vs. 62% in the 70-79 age group. No significant difference was seen in survival between groups for IHD. Stroke proved to be an independent prognostic factor. CONCLUSIONS: Cardiac surgery is conducted feasibly in selected octogenarians, providing acceptable mortality and results similar to those achieved in those 70 to 79 years old.     

转移瘤硬膜外脊髓压迫症运动功能障碍与影像学及临床特征相关性分析

目的：探讨转移瘤硬膜外脊髓压迫症（metastaticepiduralspinalcordcompression,MESCC）运动功能障碍与影像学及临床特征的相关性。方法：自2006年7月至2008年12月对连续收治的26例MESCC患者43个主要病变椎体进行MRI及CT扫描评估,并进行运动功能障碍评分。结果：26例MESCC患者中,12例发生内脏转移,其中10例发生运动功能障碍;14例无内脏转移,其中4例发生运动功能障碍（P=O．0079）。主要病变椎体连续组中,16椎发生运动功能障碍;主要病变椎体非连续组中,9椎发生运动功能障碍（P=0．1034）。主要病变椎体累及椎板组中,11椎发生运动功能障碍;主要病变椎体未累及椎板组中,14椎发生运动功能障碍（降0．0205）。主要病变椎体后壁向后突出组中,12椎发生运动功能障碍;主要病变椎体后壁无向后突出组中,13椎发生运动功能障碍（P=0．0334）。侵犯椎管内硬膜外组织组中,11椎发生运动功能障碍;未侵犯椎管内硬膜外组织组中,14椎发生运动功能障碍（P=O．0036）。转移瘤患者年龄、性别、术前接受正规化疗、转移灶部位腰背部疼痛程度、原发肿瘤已行根治手术、原发肿瘤治疗效果、脊柱外骨转移灶数目、主要受累脊椎数目、主要病变椎体节段、连续病变椎体节段、累及椎体、椎体前柱骨折、椎体后壁骨折、累及椎弓根等因素对MESCC运动功能障碍影响均无统计学意义（P〉0．05）。结论：发生内脏转移、主要病变椎体累及椎板、椎体后壁向后突出、转移瘤侵犯椎管内硬膜外组织的MESCC较易发生运动功能障碍,转移瘤连续病椎的发生率于颈椎和上胸椎组最高。     

Management of malignant spinal cord compression

Metastatic cord compression is one of the most serious complications of cancer. It is an emergency that requires rapid decision making involving several specialities, given the risk of permanent spinal cord injury. Patients may present with various clinical signs such as pain and neurological dysfunction with interventions aiming to improve both of these. Diagnosis is made through detailed history and examination followed by specific radiological investigations. The standard of care in most cases is rapid initiation of corticosteroids in combination with either surgical decompression in case of an operable candidate, followed by radiation therapy or radiotherapy alone. This process has recently been improved by the use of decision frameworks such as NOMS (neurologic, oncologic, mechanical, and systemic), to help clinicians’ direct treatment. This article represents an overview of the pathogenesis, investigations and management of metastatic cord compression. It references up-to-date national guidance and evidence-based protocols which should inform both surgical and nonsurgical clinicians.     

Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases

We present survival, neurological function, and complications in a consecutive series of 282 patients operated for spinal metastases from January 1990 to December 2001. Our main surgical indication throughout this time period was neurological deficit rather than pain. Metastases from cancer of the prostate accounted for 40%, breast 15%, kidney 8%, and lung 7%. In 78% the level of decompression was thoracic and lumbar in 22%. Thirteen percent had a single metastases only, 64% had multiple skeletal metastases, and 23% had non-skeletal metastases also. Preoperatively 64% were non-walkers (Frankel A-C), 30% could walk with aids (Frankel D) and 8% had normal motor function (Frankel E). Posterior decompression and stabilization was applied in 212 patients, 47 had laminectomy only, and 23 had anterior decompressions and reconstruction. Complications were recorded at a level of 20%, and systemic complications were often associated with early death. The survival rate was 0.63 at 3 months, 0.47 at 6 months, 0.30 at 1 year, and 0.16 at 2 years. Twelve of 255 (5%) patients with motor deficits were worsened postoperatively, whereas 179 (70%) improved at least one Frankel grade. The ability to walk postoperatively was retained during follow-up in more than 80% of the patients. This study shows that important improvement of function can be gained by surgical treatment, but the complication rate was high and many patients died of their disease within the first months of surgery.