颈胸段脊柱骨肿瘤术后再手术

目的 探讨颈胸段脊柱骨肿瘤术后再手术的因为及其手术策略.方法 2000年7月至2008年1月,对14例颈胸段脊柱骨肿瘤术后患者施行再手术.软骨肉瘤5例,骨巨细胞瘤5例,血管肉瘤、侵袭性骨母细胞瘤、副神经节瘤、动脉瘤样骨囊肿各1例.经前后联合入路行单个椎节切除6例、两个椎节切除2例、三个椎节3例,经后外侧入路行单个椎节切除1例、两个椎节切除2例.除2例三个椎节切除分二期进行外,其余均为一期完成.前路采用钛网或植骨、骨水泥加带锁钉板内固定系统或单棒内固定,后路采用钉棒内固定系统重建.术后血管肉瘤患者接受化疗和局部放疗,其余患者接受局部放疗.结果 术后所有患者局部疼痛均有不同程度缓解,脊髓神经功能改善.3例脑脊液漏,经引流、换药处理后愈合,2例Horner综合征和1例声音嘶哑于术后2～5周自行恢复.随访18～108个月,平均45个月.7例患者分别于术后12～22个月再次复发,其中5例分别于术后30～38个月瘫痪、死亡,2例带瘤生存.结论 颈胸段脊柱骨肿瘤术后再手术的主要因为是肿瘤局部复发或肿瘤残存.复发与肿瘤病理类型、切除方式和相关综合治疗的衔接有关.应该珍惜第一次手术机会,力争将肉眼可见的肿瘤彻底切除.与初次手术相比,再手术具有更高的风险及难度,术者应熟悉颈胸段脊柱的解剖结构.

Reoperation for spinal tumors at the cervicothoracic junction

Objective To investigate the causes and operative technique of reoperation for spinal tumors at cervicothoracic junction.Methods The records of 14 consecutive patients underwent reoperation between July 2000 and January 2008 were retrospectively studied.Pathological types included chondrosarco-ma in 5 cases,giant cell tumor in 5,and hemangiosarcoma,invasive osteoblastoma,chromaffinoma,aneurys-mal bone cyst in 1 case,respectively.There were mono-segment spondylectomy in 6 cases,di-segments in 2and tri-segments in 3 cases.Eleven patients underwent tumor resection through combined anterior and poste-rior approach,while 1 case had mono-segment spondylectomy and 2 cases had di-segments spondylectomy through a posterolateral approach.Tumor resections had accomplished in one stage for all cases exeept that 2cases of tri-segments spondylectomy were performed in two-stage.Anterior reconstruction was achieved by titanium mesh filled with bone graft or bone cement plus locking screw-plate system or single rod fixation while screw-rod system was used for posterior reconstruction.The patient with hemangiosarcoma accepted chemotherapy and local radiotherapy,while other patients received local radiotherapy as adjuvant therapy af-ter reoperation.Results Local pain relieved and neurofunction improved in all patients in various degrees.Postoperative complications included leakage of cerebral spinal fluid in 3 cases healed by drainage and dressing,Horner syndrome in 2 cases and transient hoarse voice in 1 case recovered 2 to 5 weeks after op-eration.All patients were followed up from 18 months to 9 years.Seven cases developed local recurrence 12to 22 months after reoperation.Among them,5 cases died 30-38 months after reoperation while 2 cases were alive with tumor lesion.Conclusion The influencing factor of local recurrence includes pathological type of tumor,resection fashion and relative adjuvant therapy.Operative rationale and resection fashion are crucial for surgical therapy.The opportunity of first operation should be cherished.Gross radical resection and post-operative adjuvant therapy according to pathology is necessary.Reoperation has higher risk and is more dif-ficult.Care should be taken to protect anatomical structures to prevent the occurrence of complications.