脊柱原发性恶性肿瘤切除术后的稳定性重建

目的探讨脊柱原发性恶性肿瘤切除术后的稳定性重建方式。方法收集1999年1月至2009年1月手术治疗的脊柱原发性恶性肿瘤38例,其中椎体切除13例16个节段,后弓切除7例8个节段,全脊椎切除11例12个节段,其余类型7例。根据不同肿瘤切除范围,采取椎体重建、前方椎体内固定、后路植骨内固定或联合运用等稳定性重建方式。观察植骨融合、上下节段终板间距离、内固定断裂等情况,比较末次随访与术前的视觉模拟评分（visual analogue scale,VAS）、神经功能Frankel评分和SF-36评分。结果随访12～89个月,平均29.7个月。6例于随访过程中死亡,5例因肿瘤复发而再次行手术治疗。术后末次随访时VAS评分明显优于术前（[6.2±2.2）分vs（1.8±1.3）分;t=-17.080,P=0.000],疼痛改善优良率达86.8%;神经功能Frankel分级改善一级21例,改善二级8例,无明显改善1例;SF-36评分亦明显优于术前（[30.7±7.2）分vs（58.3±16.5）分;t=19.037,P=0.000]。除复发外,植骨全部融合,无植骨骨折,5例伴有植骨吸收,终板均有不同程度的下沉,术中、术后无严重神经损伤并发症。结论根据WBB分期及三柱理论,结合肿瘤切除范围的大小选择相应的重建方式,可恢复脊柱稳定性,促进植骨融合,中短期疗效满意。重建方式应综合考虑节段、预后和骨强度等情况。

Stability reconstruction after resections of primary malignant spinal tumors

Objective To review the methods of the stability reconstruction after resections of primary malignant spinal tumors. Methods From January 1999 to January 2009, 38 cases of primary malignant spinal tumors underwent tumor removal including vertebrectomies in 16 segments of 13 cases, posterior arch resections in 8 segments of 7 cases, total spondylectomies in 12 segments of 11 cases, and other types of resections in 7 cases. According to the different tumor excisions, various stability reconstructions were chosen such as vetebral body reconstruction, anterior vertebral body replacement with internal fixation, posterior pedicle screw fixation with bone grafting, or combination surgery. Bone graft for fusion, distance between upper to lower endplate, failure of internal fixation were observed. Preoperative visual analogue scale （VAS）, Frankel neural function scores and SF-36 scores were compared between the last follow-up and preoperation. Results Patients were followed up from 12 to 89 months with average 29.7 months. Six cases died during the follow-up period and 5 cases relapsed and performed sugery again. At the last follow up, VAS improved from 6.2 ± 2.2 to 1.8 ± 1.3 （t = -17.080, P = 0.000）, with excellent-to-good rate of pain relief 86.8%; Frankel neural function scores improved by one level in 21 cases, two levels in 8 cases, and one case had no improvement; SF-36 scores improved from 30.7 ± 7.2 to 58.3 ± 16.5 （t = 19.037, P = 0.000）. All of grafts were fused without graft fractures. Bone absorption happened in 5 cases. The endplate subsidence varied in different reconstructions. There was no serious neural impairment after operation. Conclusions Reconstruction following excision of primary malignant spinal tumors based on WBB staging system and three-column theory, shows good fusion and stability, and then achieves satisfactory short-term and mid-term therapeutic effects. The location of tumors, prognosis and bone strength should be considered.