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。     

经口咽前、后路一期手术治疗难复性寰枢椎脱位伴脊髓压迫症

目的：总结经口咽前路同时后路减压枕颈内固定治疗难复性寰枢椎脱位的临床效果。方法：C地10例难复性寰枢椎脱位,根据术前临床分型安排前后路手术顺序。同时期进行经口咽前路减压松解复位和后路减压,枕颈CD或Cervifix枕颈内固定。按JOA17分法颈脊髓损害功能评定标准进行手术前后颈髓功能评定,并测量比较脊髓矢径的变化。结果：平均随访8个月。仍髓功能改善率达58．3％,颈髓减压改善率平均达69％。结论：经口咽前路减压同时行后路减压枕颈内固定手术的临床疗效佳,适用于难复性寰枢椎脱位或不可复性寰枢椎脱位伴颈髓压迫症。     

单纯后路手术切除骨盆环重建治疗骶骨骨巨细胞瘤

笔者于2009年12月采用单纯后路手术切除骨盆环重建治疗骶骨骨巨细胞瘤1例,报告如下。1临床资料1.1一般资料患者,女,39岁。因腰骶部疼痛3年就诊,近1个月来自觉右下肢感觉减退伴大便排出困难。查体:鞍区及双     

经口咽入路肿瘤切除钛网植骨融合术治疗枢椎肿瘤1例报告

患者女性，32岁，因间断颈痛5年，加重伴恶心，呕吐，心悸40d，于2005年11月14日入院，患者于5年前无明显诱因出现颈后部间歇性疼痛，项肌僵硬，未予治疗。40d前颈部扭伤后颈痛加重，伴恶心，呕吐，心悸，低头，扭头时明显，颈部活动明显受限。     

骶骨整块切除骨盆环重建治疗骶骨骨巨细胞瘤的疗效观察

目的:探讨骶骨整块切除及骨盆环重建治疗骶骨骨巨细胞瘤的方法与疗效.方法:2003年1月～2006年1月加州大学洛杉矶分校Santa Monica骨科医院脊柱外科中心收治骶骨骨巨细胞瘤患者8例,男5例,女3例,手术时年龄30～72岁,平均46岁.术前腰骶部CT扫描和MRI检查证实肿瘤均累及S1,采用一期前后路联合手术,术中结扎髂内动脉、髂腰动脉和骶正中动脉,显微镜下将肿瘤组织连同整块骶骨完整切除,用骨盆环假体重建腰骶髂关节稳定性.术后采用Toronto Extremity Salvage Score (TESS)评分系统对患者的功能恢复情况进行评价.结果:术中失血量800～2500ml,平均1200ml,手术时间490～720min,平均600min.病理学诊断:骨巨细胞瘤ⅡB期5例,Ⅲ期3例.术后卧床6～14d,平均10d,无1例患者术后并发切口感染.出院时患者均能不借助拐杖行走,恢复了日常生活自理能力.所有患者随访28～64个月,平均43个月,TESS评分由术前平均56.38分提高到73.25分.1例患者(Ⅲ期)术后18个月发生肺转移,接受肺叶切除,同时行放疗,随访至40个月时仍然存活;其余7例患者至末次随访时均存活,没有发现局部复发.结论:骶骨肿瘤累及S1时可行骶骨全切以提高肿瘤切除的彻底性,改善预后;采用骨盆环假体重建稳定性术后可早期活动.     

枢椎骨巨细胞瘤继发动脉瘤样骨囊肿1例报告

患者女,30岁.于2008年6月因"颈部不适6个月加重3个月"来我院就诊.6个月前无明显诱因出现颈部不适,在当地医院按"落枕"行理疗,无明显好转.3个月前颈部酸胀不适加重,遂来我院就诊.既往体健,无低热、寒战、盗汗,否认外伤史.     

瘤体骨切除灭活再植一期骨关节重建治疗膝部巨细胞瘤

体内刮除及灭活植骨治疗膝部巨细胞瘤(GCT)的复发率高。作者自1991年1月采用瘤体骨切除,离体灭活再植,与骨残端体内灭活相结合。骨缺损采用自家腓、髂骨移植,L-梯形加压钢板(L-TCP)或梯形加压钢板(TCP)固定、治疗膝部GCT 13例,其中8例保留关节,5例做膝关节融合。本组无菌创口感染1例,1例复发恶变做截肢。在保留关节的8例中7例关节功能恢复优良,1例差。表术式疗效确实,复发率低。保留关节术式适于关节破坏较轻(≤1/2)者,结舍关节残端体内灭活和有效的骨结构重建,有利恢复关节功能。如关节面累及>1/2,宜做骨关节端切除,灭活再植,关节融合或人工关节置换术。     

经口前路枢椎腹侧解剖学观察与临床意义

目的 对枢椎腹侧进行解剖学观察测量研究,探讨经口前路枢椎腹侧多个螺钉固定的可行性及临床意义.方法 随机选取15具完整头颈尸体标本,对枢椎腹侧骨性结构进行观察测量,观察枢椎腹测形态结构.结果 枢椎腹侧结构特殊,两侧枢椎体凹陷,椎动脉在枢椎体两侧基本呈直线向上进入侧块再折转向后外方.枢椎体腹侧高度为(20.42±0.90)...     

一期后路半椎切除治疗成人半椎畸形

目的探讨一期后路椎弓根螺钉固定、半椎切除、矫形、植骨融合治疗成人半椎畸形的临床疗效。方法 2008-03-2010-07,对11例半椎所致侧后凸畸形患者行一期后路椎弓根螺钉固定、半椎切除、矫形植骨融合术。患者年龄24~38岁,平均27岁,术后随访6个月~2年,平均14个月。通过术前、术后及随访时站立位脊柱正位和侧位X线片测量,评价冠状面及矢状面的矫形效果。结果平均手术时间220 min;术中平均失血量1400 ml。术后所有患者躯干平衡良好,均无感染及严重神经系统并发症发生。术后2周节段侧凸角矫正率85%,后凸角矫正率为80%。末次随访时侧凸及后凸矫形均无明显丢失。结论一期后路椎弓根螺钉固定、半椎切除、矫形植骨融合治疗成人半椎畸形可获得良好的矫形效果,建议半椎畸形患者早期接受手术治疗。     

瘤体骨切除灭活再植一期骨关节重建治疗膝部巨细胞瘤

体内刮除及灭活植骨治疗膝部巨细胞瘤(GCT)的复发率高。作自1991年1月采用癌体骨切除，离体死活再植，与骨残端体内灭活相结合。骨缺损采用自家腓、髂骨移植，L-梯形加压钢板(L-TCP)或梯形加压钢板(TCP)固定、治疗膝部GCT13例，其中8例保留关节，5例做膝关节融合。本组无菌创口感染1例，1例复发恶变做截肢。在保留关节的8例中7例关节功能恢复优良，1例差。本术式疗效确实，复发率低。保留关节术式适于关节破坏较轻(≤1／2)，结合关节残端体内灭活和有效的骨结构重建，有利恢复关节功能。如关节面累及>1／2，宜做骨关节端切除，灭活再植，关节融合或人工关节置换术。     

Iatrogenic giant cell tumor at bone graft harvesting site

30 year old female patient with giant cell tumor of the distal tibia initially treated at a peripheral nononcological center by curettage and autologous bone grafting from the ipsilateral iliac crest reported to us with local recurrence and an implantation giant cell tumor at the graft harvesting site which required extensive surgeries at both sites. The risk of iatrogenic direct implantation of tumor, often attributable to inadequate surgical planning or poor surgical techniques, and the steps to prevent such complication is reported here.     

Bilateral giant cell tumor of tendo Achilles: A case series on reconstruction by peroneus brevis - tibialis posterior tendon

Giant cell tumor of tendon sheath usually is localized painless solitary benign swelling, which presents as a firm nodular gradually growing mass. Giant cell tumor is infrequent in the lower limb and its incidence in the tendo Achilles is rare. It is often diagnosed and treated conservatively as tendinitis in the initial stages. The slow growth and limited functional deficit is the reason for its late presentation where excision of the mass leaves a large residual defect, for which reconstruction of the tendo Achilles has to be done by mobilizing different tendons. A case series of bilateral giant cell tumor of tendo Achilles and study the functional outcome of the reconstructed tendo Achilles using peroneus brevis - tibialis posterior tendons - are presented. The outcome of reconstruction using peroneus brevis - tibialis posterior tendon gave satisfactory outcome at the end of one year.Level of evidenceLevel 4.     

骨巨细胞瘤干细胞的分离鉴定

目的 探索从骨巨细胞瘤（giant cell tumor of bone,GCTB）中分离肿瘤干细胞的方法.方法 对临床GCTB患者的手术标本进行原代培养,并对获得的细胞株进行特定条件下的培养获得球体细胞,在此基础上对球体细胞进行自我更新能力和干细胞相关基因检测,并通过免疫缺陷小鼠对该亚群致瘤能力进行评价.结果 从GCTB中分离出表达干细胞相关基因的球体细胞群,该球体细胞群高表达干性基因OCT4、NANOG、SOX2,具备更强的侵袭性,动物实验表明球体细胞致瘤能力比原代细胞更强.结论 GCTB中存在肿瘤干细胞,可成功进行分离鉴定,在此基础上对该亚群的生物学特性进行的初步探索,为将来进一步的研究和寻找临床治疗方法提供了理论基础.     

脊柱骨巨细胞瘤的手术治疗策略

目的:探讨脊柱骨巨细胞瘤合理的手术治疗策略.方法:回顾性分析1998年7月至2007年6月我科收治的41例良性脊柱骨巨细胞瘤患者的临床资料,男21例,女20例,平均年龄31岁,初次手术27例,外院治疗后复发14例.患者均有不同程度疼痛症状.病变累及颈椎3例,胸惟25例,腰椎13例 14例患者术前行动脉造影,同时栓塞肿瘤节段血管.18例肿瘤只累及椎体的患者采用经前路肿瘤切除椎管减压术,前路植自体骨或人工椎体重建切除的椎体,并应用钢板螺钉固定;16例病灶同时累及椎体及附件的患者采用前后联合入路,术中先行椎管后路减压,切除附件内肿物,并应用椎弓根钉行内固定术,后行前路椎体肿瘤切除手术;4例患者一般情况较好,肿瘤只破坏1～2个脊椎、没有明显的软组织肿块,行一期后路全脊椎切除术;3例椎体部分受累的患者行后路次全脊椎切除术,随访观察治疗效果结果:行节段动脉栓塞组14例.平均出血约3100ml;未栓塞组27例,平均出血量约4500ml.2例复发的患者最终未能彻底切除肿瘤,术后行放疗,分刖随访35及29个月,荷瘤生存.其余39例患者中,36例(92.3%)术后疼痛得到明显缓解;术后平均随访52.9个月,16例复发(41.0%).初治的27例患者9例复发(33.3%).其中单纯前路手术11例,复发6例;前后路联合手术12例,复发3例;全脊椎切除术4例,未见复发.12例外院复发病例7例再次复发(57.1%),其中2例因肿瘤发展,全身衰竭死亡.21例随访3年以上,其中13例末见复发,所有病例均未见内固定松动、移位或折断.结论:对于脊柱骨巨细胞瘤,首次冶疗选择较为彻底的手术方案是降低复发率的关键.     

Clinical outcome of a conservative approach to giant cell tumor of ankle and foot bones

Giant cell tumor of the bone (GCTB) affecting foot and ankle is rare, and the literature available on their clinical behavior and reconstructive options is scarce. Many authors consider these sites a special subset with high rates of local recurrence. Eighteen patients with GCTB of foot and ankle were treated from (March 2014 to February 2020). Extended curettage was offered wherever feasible. Twelve patients underwent extended curettage, three underwent resection and reconstruction, one patient had ray amputation, one had below knee amputation. One patient with multifocal disease was treated conservatively with denosumab. There were 11 females and the mean age was 31.7 years. Distal tibia (11 patients) was the commonest location, followed by the first metatarsal (four patients). At a median follow up of 46 months, two patients out of the 17 operated had a local recurrence. GCTB affecting the foot and ankle have a clinical course comparable to those at other locations. They should be treated with a conservative approach, where radical resection and amputation are reserved for only the non-curettable tumors.     

Dorsal approach in giant cell tumor of the thoracic spine

Summary The incidence of giant cell tumors accounts for less than 5 % of all bone tumors. In the thoracic spine these tumors are extremely rare (1–1.5 % of the giant-cell tumors). The potential malignant character of giant cell tumors of the spine usually leads to wide surgical extirpation by ventral approach. The filling of bone defects with palacos cement after tumor resection is sufficient in the metaphysis of long bones. The case presented here is a giant cell tumor of the upper thoracic spine with primarily posterior destruction of the vertebral body and left arch. A single dorsal approach allowed for intralesional resection and filling of the defect with bone cement. This procedure was sufficient to achieve a solid fixation without recurrence of the giant cell tumor.      

Imaging of giant cell tumor of bone

Giant cell tumor (GCT) of bone is a benign but locally aggressive and destructive lesion generally occurring in skeletally mature individuals. Typically involving the epiphysiometaphyseal region of long bones, the most common sites include the distal femur, proximal tibia and distal radius. On radiographs, GCT demonstrates a lytic lesion centered in the epiphysis but involving the metaphysis and extending at least in part to the adjacent articular cortex. Most are eccentric, but become symmetric and centrally located with growth. Most cases show circumscribed borders or so-called geographical destruction with no periosteal reaction unless a pathological fracture is present. There is no mineralized tumor matrix. Giant cell tumor can produce wide-ranging appearances depending on site, complications such as hemorrhage or pathological fracture and after surgical intervention. This review demonstrates a spectrum of these features and describes the imaging characteristics of GCT in conventional radiographs, computerized tomography scans, magnetic resonance imaging, bone scans, positron emission tomography scans and angiography.     

Multicentric giant cell tumor of the fourth and fifth metacarpals with lung metastases

Giant cell tumors of bone (GCTB) are generally benign neoplasms, but recently, some authors consider them to be low-grade malignant neoplasms because they have a relatively high rate of recurrence and at least some potential for metastases. The majority of GCTB are unifocal, and less than 1 % are multicentric. We report a rare case of a multicentric GCTB arising simultaneously in the non-dominant fourth and fifth metacarpals of a 25-year-old female. The patient underwent ray amputation of the two involved digits, and the surgical margins were histologically negative for tumor. The tumor had the classic histologic appearance of a benign GCTB. A year after the amputation, the patient developed pulmonary metastasis which was treated with pulmonary lobe resection. She is currently over 2.5 years postsurgical treatment of the primary lesion with no evidence of local recurrence or distant metastasis.     

瘤腔内钢板支撑联合骨水泥填充重建膝关节周围骨巨细胞瘤扩大刮除后骨缺损

目的 探讨膝关节周围骨巨细胞瘤扩大刮除后,应用锁定钢板内置于瘤腔支撑固定联合骨水泥充填骨缺损的临床效果.方法 回顾2007年2月至2011年2月,本组收治的膝关节周围CampanacciⅡ级骨巨细胞瘤16例,男7例,女9例,年龄21～43岁,平均29.3岁,其中初发12例,复发4例.手术采用扩大刮除、锁定钢板内置瘤腔支撑固定联合骨水泥充填重建骨缺损的方法,术后早期负重功能锻炼.结果 本组病例依照Jaffe组织学分级Ⅰ级5例、Ⅱ级11例,所有病例术前CT均显示瘤体较大,骨质破坏直径超过1/2骨直径,未穿破关节软骨,无病理性骨折,本组患者术后早期恢复良好,无出现严重并发症,1例术后伤口表浅感染,经换药后愈合,所有病例均随访2年以上,肿瘤复发2例（12.5%）,未出现关节面塌陷、骨折等并发症.肢体功能按Enneking评分平均（27±1.34）分.结论 对瘤体巨大并侵犯软骨下骨,骨强度及关节面稳定性受严重破坏的初发或复发性邻膝关节骨巨细胞瘤应用钢板内置的方法能增强骨水泥套的支撑力和骨强度,一定程度上避免行瘤段切除关节重建,减少术后骨折、关节面塌陷等远期并发症发生,利于关节功能恢复.     

Giant cell tumor of bone: Multimodal approach

Background:

The clinical behavior and treatment of giant cell tumor of bone is still perplexing. The aim of this study is to clarify the clinico-pathological correlation of tumor and its relevance in treatment and prognosis.

Materials and Methods:

Ninety -three cases of giant cell tumor were treated during 1980-1990 by different methods. The age of the patients varied from 18-58 yrs with male and female ratio as 5:4. The upper end of the tibia was most commonly involved (n=31), followed by the lower end of the femur(n=21), distal end of radius(n=14), upper end of fibula (n=9), proximal end of femur(n=5), upper end of the humerus(n=3), iliac bone(n=2), phalanx (n=2) and spine(n=1). The tumors were also encountered on uncommon sites like metacarpals (n=4) and metatarsal(n=1). Fifty four cases were treated by curettage and bone grafting. Wide excision and reconstruction was performed in twenty two cases. Nine cases were treated by wide excision while primary amputation was performed in four cases. One case required only curettage. Three inaccessible lesions of ilium and spine were treated by radiotherapy.

Results:

19 of 54 treated by curettage and bone grafting showed a recurrence. The repeat curettage and bone grafting was performed in 18 cases while amputation was done in one. One each out of the cases treated by wide excision and reconstruction and wide excision alone recurred. In this study we observed that though curettage and bone grafting is still the most commonly adopted treatment, wide excision of tumor with reconstruction has shown lesser recurrence.

Conclusion:

For radiologically well-contained and histologically typical tumor, curettage and autogenous bone grafting is the treatment of choice. The typical tumors with radiologically deficient cortex, clinically aggressive tumors and tumors with histological Grade III should be treated by wide excision and reconstruction.