寰枢椎肿瘤的手术治疗（附22例报告）

目的：探讨不同手术入路,切除术式及内固定治疗寰椎,枢椎肿瘤的效果,方法：回顾性分析22例寰椎和枢椎肿瘤患者的病理类型,临床表现,各种手术途径,术式及其预后,结果：22例中,寰椎肿瘤4例,枢椎肿瘤18例;原发性肿瘤19例,转移性肿瘤3例,9例行囊内切除,8例包膜切除,3例广泛切除,单纯枕颈后路植骨CD Cervical或Cervifix内固定术2例,1例骨巨细胞瘤患者术后10d因呼吸循环衰竭死亡,1例转移癌患者术后13d因肺部感染,呼吸循环衰竭死亡,术后随访3个月至4年,20例术后近期疗效较满意,局部疼痛和神经症状改善或缓解,2例转移癌患者分别于术后13个月和19个月全身多处转移,全身衰竭死亡,1例骨母细胞瘤,1例软骨肉瘤术后1年局部复发。结论：应根据寰枢椎肿瘤的具体部位,范围选择相应的手术入路和术式,肿瘤的性质,手术方式及术后综合治疗对患者预后具有重要影响。枕颈CD Cervical或Cervifix内固定术有利于保持上颈椎的稳定。     

一期经口前路肿瘤切除和前后路椎体重建治疗枢椎骨巨细胞瘤

目的：探讨枢椎肿瘤切除和椎体重建的新方法.方法：采用经口咽入路枢椎体肿瘤切除,改良异形钛笼重建椎体,同期后路寰椎椎弓根和第三颈椎侧块钉棒固定植骨融合治疗枢椎体骨巨细胞瘤,并辅以放疗.结果：术后患者临床症状立即消失,行走正常,影像学示肿瘤切除干净,脊椎重建固定稳妥.结论：一期经口前路联合后路行枢椎肿瘤切除椎体重建是治疗枢椎肿瘤的可行方法,但远期疗效有待观察.     

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.     

枢椎肿瘤切除与重建技术探讨

目的：研究枢椎肿瘤的不同手术入路，肿瘤切除术及内固定重建的治疗效果。方法：对枢椎肿瘤的性质，病理类型，临床表现，各种手术途径，术式及其预后进行分析，本组18例中，骨巨细胞瘤6例，骨母细胞瘤1例，软骨肉瘤1例，骨髓瘤2例，脊索瘤2例，血管内皮细胞瘤1例，恶性淋巴瘤1例，神经纤维瘤1例，转变癌3例。5例行囊内切除，5例包膜切除，6例广泛切除，单纯枕颈后路植骨CD Cervical或Cervifix内固定术2例。结果：1例骨巨细胞瘤患进术后10d因四肢瘫痪状加重，呼吸循环衰竭死亡，1例转移癌患者术后13d因肺部感染，高热，呼吸循环衰竭死亡，术后随访6个月－4年，16例术后近期疗效较满意，局部疼痛和神经症状改善或缓解，2例转移癌患者分别于术后13个月和19个月全身多处转移，全身衰竭死亡，1例骨细胞瘤、1例软骨肉瘤术后1个局部复发。结论：应根据枢椎肿瘤具体部位，范围选择相应的手术入路和术式。肿瘤的性质，手术方式极术后综合治疗对患者预后具有重要影响。枕颈CD Cervical或Cervifix内固定术有利于保持上颈椎的稳定。     

CT监测下经皮穿刺寰枢椎侧块关节植骨融合术

目的报告自行设计的CT监测下经皮穿刺寰枢椎侧块关节植骨融合术并探讨其临床应用。方法在对56具成人寰枢椎干燥骨标本行解剖学研究的基础上,1999年3月～2001年3月,9例寰枢椎脱位患者经牵引复位后,采用Halo-Vest外固定架固定4例,前路经枢椎体寰椎侧块螺钉内固定5例。在CT监测下,应用自行研制的手术器械,后外侧入路经皮穿刺将寰枢椎侧块关节后外侧的关节囊、关节软骨去除,做好植骨床并将用穿刺法钻取的髂骨松质骨骨柱植入。结果9例术后随访2～17个月,平均12.7个月,其中8例超过6个月。3例术后3个月去除了Halo-Vest架。8例均摄过伸、过屈及张口位X线片,显示寰枢椎稳定;其中6例在术后3～4个月行CT扫描及三维重建显示侧块关节达到植骨融合。结论此术式为创新设计,其创伤小,出血少,融合时间相对缩短,融合率高。     

原发性颈胸段脊柱肿瘤的临床特点与外科治疗

目的研究颈胸段脊柱肿瘤的临床特点、诊断、手术入路、肿瘤切除术式、前路植骨、钛网、Orion/Zephier或AO钢板内固定重建的治疗效果.方法分析本院1998年1月～2001年12月期间收治的33例原发性颈胸段脊柱肿瘤的病理类型、临床表现、诊断、各种手术途径、术式及其预后.结果本组33例中骨巨细胞瘤14例,骨髓瘤8例,嗜酸性肉芽肿4例,软骨肉瘤3例,恶性淋巴瘤2例,恶性神经鞘瘤1例,骨软骨肉瘤1例.肿瘤切除方式囊内切除11例,包膜切除13例,广泛切除9例.根据肿瘤的病理类型,术后给予相应的放疗或化疗.术后随访6～48个月.术后近期疗效均较满意,32例患者术后神经功能均有不同程度的改善.1例T1～T2骨巨细胞瘤和1例软骨肉瘤患者分别于囊内切除术后8个月、13个月局部复发,1例软骨肉瘤患者于囊内切除术后24个月因肺部转移,全身衰竭死亡.结论根据其临床特点和影像学检查可确定诊断.根据肿瘤的部位、性质、范围选择相应的手术途径及肿瘤切除方式,前路植骨、钛网、Orion或AO钢板内固定术有利于颈胸段脊柱稳定性重建.     

前后联合入路治疗陈旧性寰枢椎旋转脱位合并侧块关节绞锁

 目的探讨经颈前咽后入路寰枢椎撬拨复位、后路寰枢椎植骨融合内固定术治疗陈旧性寰枢椎旋转脱位合并侧块关节绞锁的临床疗效。方法回顾性分析2010年10月至2013年6月,采用经颈前咽后入路寰枢椎撬拨复位、后路寰枢椎植骨融合内固定术治疗8例陈旧性寰枢椎旋转脱位合并单侧侧块关节绞锁患者资料,男4例,女4例;年龄11~57岁,平均31岁;病程29~180 d,平均70.6 d;右侧侧块关节绞锁5例,左侧侧块关节绞锁患者3例。8例患者行颅骨或枕颌带牵引2~4周均未见复位征象,改行经颈前咽后入路寰枢椎撬拨复位、后路寰枢椎植骨融合内固定术。结果8例患者中,除1例因全身情况无法耐受前后路联合手术而Ⅰ期行经颈前咽后入路寰枢椎撬拨复位,14 d后Ⅱ期行经后路寰枢椎植骨融合内固定术外,余均Ⅰ期行前后路联合手术。手术时间160~260 min,平均205 min;术中出血量100~300 ml,平均210 ml。术后除1例青少年患者取髂骨处发生疼痛,经对症治疗1周好转外,余均未发生手术相关并发症。8例患者均获得随访,随访时间5~37个月,平均14.8个月。术后植骨均融合,融合时间为2~4个月,平均3.1个月。末次随访时,无一例发生寰枢椎旋转脱位复发、植骨不融合、断钉、断棒。结论经颈前咽后入路寰枢椎撬拨复位、后路寰枢椎植骨融合内固定术治疗陈旧性寰枢椎旋转脱位伴侧块关节绞锁效果良好,手术创伤小,操作相对简单安全,手术并发症发生率低。     

肩胛下经胸入路切除及重建治疗上胸椎肿瘤

目的 探讨肩胛下经胸入路切除及重建上胸椎肿瘤的技术及方法 ,分析患者的手术治疗效果及手术相关并发症.方法 收集自2003年2月至2005年2月北京大学人民医院骨肿瘤科手术治疗的上胸椎椎体(T1-4)肿瘤患者21例,转移癌11例,嗜酸性肉芽肿2例,骨肉瘤1例,尤文肉瘤2例,软骨肉瘤2例.骨巨细胞瘤2例,淋巴瘤1例.采用经肩胛下胸腔入路行上胸椎肿瘤切除、脊髓减压,结合人工椎体植入或者单纯植骨、前路侧方内固定术.结果 所有患者术后疼痛均得到缓解.3例出现截瘫症状的患者术后Frankel分级由A级改善为D级,2例患者下肢感觉肌力恢复正常.术后2例患者出现肺部炎症、肺不张,1例患者出现脑脊液胸腔漏,1例患者术后出现胸主动脉破损出血.术后随访11～58个月,其中9例患者死亡,包括7例转移癌、1例尤文肉瘤、1例骨肉瘤患者.结论 经肩胛下胸腔入路切除颈胸段及上胸椎肿瘤是处理上胸椎病变的理想入路,尤其是对于累及椎体及一侧椎弓根的患者尤为适宜.该手术方式可以充分显露前方椎体的病变,可以有效地解除来自前方椎体的脊髓压迫.     

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。     

颈后入路手术治疗寰枢椎硬膜下髓外神经鞘膜肿瘤

目的探讨颈后入路手术治疗寰枢椎硬膜下髓外神经鞘膜肿瘤的方法及疗效。方法 2012年1月—2017年3月,收治9例寰枢椎硬膜下髓外神经鞘膜肿瘤患者。其中男7例,女2例;年龄25～62岁,平均45.4岁。神经鞘瘤8例,神经纤维瘤1例;肿瘤位于C1 1例、C1、2 8例。病程5～120个月,平均45.9个月。术前美国脊髓损伤协会(ASIA)分级为D级8例,E级1例;日本骨科协会(JOA)评分为(12.8±2.5)分。所有患者均接受颈后入路手术治疗,肿瘤切除后其中2例行椎板回植内固定;均未行寰枢或枕颈固定。结果手术时间90～343 min,平均179.2 min;术中失血量50～1 000 mL,平均335.6 mL。术中及术后无手术相关并发症发生。患者均获随访,随访时间6～21个月,平均11.1个月。术后X线片复查示寰枢椎稳定性良好;肿瘤均切除彻底、未见复发;椎板回植内固定融合效果满意。术前3例ASIA分级为D级患者,术后3个月时改善为E级;其余患者分级无变化。术后6个月JOA评分为(15.1±1.4)分,较术前显著改善(t=4.221,P=0.003)。结论颈后入路手术可完全切除寰枢椎硬膜下髓外神经鞘膜肿瘤(包括腹侧肿瘤),必要时枢椎椎板可回植并采用微型钛板或椎板螺钉固定,无需行寰枢或枕颈内固定。     

Extensive posterolateral exposure and total removal of the giant extraforaminal dumbbell tumors of cervical spine: surgical technique in a series of 16 patients

Background contextRemoval of cervical dumbbell tumors can be particularly challenging because of unique exposure requirements and proximity of the vertebral artery (VA). There are no reports describing the treatment of giant cervical spine dumbbell tumors (CSDTs).PurposeTo introduce an extensive posterolateral approach to CSDTs involving total lateral mass resection and laminectomy.Study designProspective study of all the patients with multilevel CSDTs treated by this new procedure between December 2002 and March 2006.Patient sampleSixteen patients (3 men and 13 women) with CSDTs underwent the procedure we describe. The follow-up periods ranged from 9 to 51 months (average 9 months). Average age at surgery was 45 years (range 23–68 years).Outcome measuresAxial symptoms and Japanese Orthopedic Association scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs.MethodsAfter making a midline incision, we preferred exposing the extraforaminal component of the tumor before performing a semilaminectomy and lateral mass resection. Any lateral extension of a tumor can be attained by detachment of the adjacent three or more segments of the lateral mass muscle insertion. The most lateral portion can be separated beneath the tumor's superficial muscle flap, and then when the tumor is retracted medially, the whole portion of the lateral component can be totally exposed. We then performed total lateral mass resection and laminectomy to expose the tumor at the foramina and cervical canal.ResultsWe were able to completely resect the tumors in every patient. The average duration of surgery was 150 minutes. Blood loss was minimal (average 400 mL). All patients were monitored for a minimum of 9 months (range 9–51 months; mean 28 months). The follow-up period was uneventful, and no patients developed spinal instability.ConclusionsExtensive posterolateral exposure enables surgeons to reach the lateralmost portion of CSDTs and also facilitates septation of the VA and resection of vertebral body encroachment of the tumor.     

A case of giant cell tumor in atlas

We report a rare case of giant cell tumor in the atlas. A 50-year-old female presented with severe pain in her right neck and shoulder. The preoperative magnetic resonance images showed a tumor mixed with solid and cystic components in the right side of the atlas. CT scan showed that the anterior and posterior arches of the atlas were destroyed. Preoperative biopsy led to the pathological diagnosis of giant cell tumor with multinuclear giant cells and mononuclear stromal cells. A preoperative vertebral angiogram demonstrated tumor stain supplied from the muscular branches. To reduce intraoperative bleeding, the embolization of the right vertebral artery by GDC was performed before surgical removal. The tumor was subtotally removed following ligation of the right external carotid artery to reduce bleeding of tumor. We used the Olerud cervical system to prevent cervical instability after resection of the tumor. Although the symptoms disappeared completely after surgery, regrowth of tumor was observed in follow-up MRI 4 months after the operation. For this reason, local radiation therapy was performed (50 Gy). Then, the size of the tumor has not changed in the 1.5 years since the operation.     

Posterior resection of fifth lumbar giant schwannoma combined with a recapping transiliac approach: case report and technical note

A two-stage combined anterior and posterior approach is commonly used for total resection of giant spinal tumors. However, an anterior approach at the lower lumbar level is technically challenging because of the anatomy of the iliac wing, major vessels and nerves of the lumbosacral plexus. We report a case of fifth vertebral tumor treated posteriorly with a newly devised surgical procedure combined with a recapping transiliac approach. A 45-year-old female diagnosed with giant schwannoma of the fifth lumbar vertebra underwent single-stage posterior tumor resection combined with osteotomy of the lateral part of the iliac crest. Without an anterior approach, tumor excision was completed with a wide view into the fifth lumbar vertebral body. Autogenous bone graft was harvested and used to treat the bone defect. The resected iliac bone was recapped and fixed with screws. The patient was monitored for 8 years without recurrence, and postoperative lumbar alignment remained unchanged. This surgical procedure is safe and a useful adjunct approach for posterior total resection of giant spinal tumors at the lower lumbar level.

     

Posterolateral approach to the atlas and the axis.

We have developed a new surgical approach to the atlas and the axis including the odontoid process, in which the vertebral artery is transposed and an access to their lateral aspects without exposing the anterior structures of the neck is achieved. A case of successful excision of a bone tumor of the lateral mass of the atlas and a hypertrophic odontoid process by this approach is described.     

经后路寰椎椎弓根螺钉系统内固定融合术治疗上颈椎疾患

目的探讨经后路寰椎椎弓根螺钉系统内固定融合术治疗上颈椎疾患的可行性、方法、疗效和适应证。方法2004年10月～2006年1月,采用后路寰椎椎弓根螺钉系统内固定融合术治疗17例上颈椎疾患患者。男13例,女4例;年龄19～52岁。寰枢椎脱位14例,其中先天性齿状突不连3例,陈旧齿状突骨折4例,新鲜齿状突骨折（C型）2例,寰椎横韧带断裂3例,寰椎骨折2例;枢椎肿瘤2例;C2、3巨大神经鞘膜瘤1例。术前JOA评分8.3±3.0分。结果17例手术时间2.1～3.4h,平均2.7h;出血量300～750ml,平均490ml。术中未发生椎动脉和脊髓损伤。1枚寰椎椎弓根螺钉前端穿透侧块内上皮质约3mm,但未影响寰枕关节活动,余位置满意。患者全部获3～18个月定期随访。螺钉位置良好,无钉棒断裂、变形及松动,3～6个月后患者均获植骨融合。术后3个月JOA评分14.6±2.2分,恢复率73%～91%,平均82%。结论经后路寰椎椎弓根螺钉系统内固定融合术治疗上颈椎疾患具有可行性,若术中操作得当,其疗效较好,适应证较广。     

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     

计算机辅助技术在髋臼周围恶性肿瘤治疗中的应用研究

目的探讨计算机辅助技术在髋臼周围肿瘤手术中的应用研究及临床效果。方法应用CT数据及快速成型技术,模拟髋臼周围肿瘤切除术,设计手术切除范围,确定截骨面,模拟修复重建,制造病变髋臼精确模型和个体化假体后,进行手术治疗。2003年6月到2007年6月,共有8位患者应用计算机辅助技术进行了髋臼肿瘤切除重建术,其中男3例,女5例,骨巨细胞瘤4例,脊索瘤1例,软骨肉瘤2例,骨肉瘤1例。根据Enneking骨盆肿瘤分区：Ⅱ区3例,同时累及Ⅱ区和Ⅲ区5例。随访时间为2—6年。结果手术中病变切除彻底,假体安装顺利,术中平均出血5700ml。术后有2例（25％）患者复发,其中骨肉瘤1例,术后18个月死于双肺转移;软骨肉瘤1例,术后13个月局部复发,术后17个月死亡;1例术后2年时出现螺钉松动,并发股动脉损伤,行动脉修复术后,患者可持拐行走,其余5例患者假体无松动。肢体功能评分参照人工全髋关节置换术后Harris评分标准,60～69分1例,70～79分5例,80～90分2例。结论应用计算机辅助技术参与髋臼周围肿瘤的模拟切除重建,保证了手术的顺利进行和精确的假体重建,临床效果优良,有着良好的应用前景。     

Tumeur à cellules géantes de C2 colonisée par un kyste anévrismal. À propos d’un cas

Giant cell tumor is colonized by aneurismal bone cyst in only 15% of cases and cervical localisation accounts for less than 1% of giant cell tumors. We are reporting a rare case of a C2 hypervascularized giant cell tumor colonized by an aneurismal bone cyst treated with an effective preoperative Onyx embolization followed by a full tumor resection. The patient experienced a moderate cervical spine injury 2 months prior admission followed by a progressive stiff neck and cervicalgia. CT and MRI identified a lytic lesion of the body and lateral masses of the C2 with encasement of both vertebral arteries. The angiography showed a hypervascularization of the lesion from the vertebral and external carotid arteries as well as a thrombosis of the V3 segment of the right vertebral artery at the C1 level. A posterior occipito-C3/C4 fixation and a tumor biopsy were performed. Histopathological examination concluded to a giant cell tumor colonized by an aneurismal bone cyst. Three weeks later, the patient developed a right upper extremity deficit. The MRI showed an increased C1-C2 stenosis and an increase of the hypervascularization. Three sessions of embolization by the onyx were performed. During surgery a near total tumor devascularisation was observed and a complete resection of the tumor was achieved through an anterolateral approach. Reconstruction consisted of a cementoplasty of the C2 body and odontoïd process with an anterior C3-prosthesis plate. The postoperative course was uneventful.     

Abdominosacral Approach for Retrorectal Tumors

The relative rarity and anatomical position of retrorectal tumors may lead to difficulty in diagnosis and surgical treatment. The clinical features and management of 20 such tumors (chordoma 8, neurilemmoma 3, teratoma 3, hemangiopericytoma 1, chondrosarcoma 1, osteosarcoma 1, dermoid 1, lipoma 1, and undifferentiated sarcoma 1) have therefore been reviewed. Low back or sacral pain was present in 18 patients and, although all tumors were palpable on rectal examination, pain had been present for a median of 12 months before diagnosis. Mean tumor size was 9.4 cm (range: 2.5-17 cm). Sacral bone destruction was demonstrated radiographically in all chordomas and three sarcomas, but in none of the benign tumors. Three patients had undergone previous partial removal of their tumors. Surgical resection was carried out using a combined abdominal and transsacral approach in 13, a transsacral approach in the right lateral position in four and transabdominally in three. There was one operative death following secondary operation for chbrdoma. Four of 12 patients with malignant tumors are alive and well at seven months to eight years. One died of a myocardial infarct without recurrence at 11 years. For small benign tumors, the right lateral position permits maximal flexibility for resection either by the transsacral, transabdominal or a combined approach. For bulky or malignant tumors, a combined abdominal transsacral approach in the right lateral position permits vascular control and provides good exposure for protection of vital structures and wide resection.