骨血管源性恶性肿瘤的临床分析

目的 回顾性分析临床上少见的血管源性恶性骨肿瘤的诊断、治疗和临床疗效.方法 从1998年10月至2008年11月我科诊治7例骨血管源性恶性肿瘤患者,包括5例血管内皮瘤和2例血管肉瘤.男4例,女3例;年龄19～76岁,平均42.6岁.1例为多中心病变,6例为单中心.1例病变位于椎体,其余6例位于四肢骨.所有患者均以局部疼痛就诊,病变影像学表现均为溶骨性破坏.其中2例血管肉瘤伴有软组织包块.1例脊柱病变接受边缘切除和术后放疗,5例接受广泛切除重建或截肢术,未行放化疗,另外1例放弃治疗.所有患者均经病理学诊断确诊,平均随访40个月(1～89个月).结果 股骨上段血管肉瘤患者半盆截肢后于术后17个月死于肺和内脏多发转移.脊柱血管内皮瘤患者术后3年死于其他原因.胫骨上端血管内皮瘤患者术后6年出现局部软组织复发,予以再次完整切除.保守治疗的患者带瘤生存,其他3例患者均无瘤生存.结论 骨的血管源性恶性肿瘤临床少见,主要根据病理学检查确诊,同一解剖部位的多中心病灶对诊断有一定特异性.手术广泛切除为治疗四肢病变的主要手段,椎体病变瘤内刮除后可辅以术后放疗.血管肉瘤恶性程度高、预后差.     

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.     

经伤椎一侧椎弓根通道椎体内植骨并对侧椎弓根置钉固定治疗胸腰椎骨折

目的探讨经伤椎一侧椎弓根螺钉固定、另一侧经椎弓根通道椎体内植骨结合短节段椎弓根钉内固定治疗胸腰椎骨折的可行性和临床疗效。方法对26例胸腰椎骨折应用椎弓根钉棒系统后路伤椎一侧椎弓根螺钉固定,对侧经椎弓根通道采用自体髂骨或人工骨行椎体内植骨。结果所有患者椎弓根钉棒系统无松动,无断钉、断棒。伤椎高度及外形基本恢复正常,植骨愈合良好。神经功能恢复情况根据Frankel评定标准:A级1例,B级1例,C级3例,D级5例,E级16例。结论经一侧伤椎椎弓根螺钉固定、对侧经椎弓根通道椎体内植骨内固定治疗胸腰椎骨折,疗效确切,是一种治疗胸腰椎骨折较为理想的方法。     

Spinal cord compression secondary to a thoracic vertebral osteochondroma

The authors describe a case of spinal cord compression due to an osteochondroma arising from the T-6 vertebral body in a patient with hereditary multiple exostoses. This 16-year-old boy presented with spastic paraparesis. Surgical decompression was followed by resolution of the neurological impairments. Osteochondroma is the most common bone tumor. The distribution of osteochondromas greatly favors the extremities and these lesions rarely arise in the vertebral column. Osteochondromas occur in 2 distinct clinical settings--as solitary or multiple tumors, the latter being often associated with hereditary multiple exostoses. Osteochondromas are more commonly found in the posterior elements of the vertebrae. Intraspinal presentation of these tumors is usually limited to the cervical regions, with few tumors reported in the thoracic vertebrae. Based on the presented case and literature review, the authors conclude that osteochondromas of the thoracic spine that cause myelopathy usually arise from the vertebral body and pedicle. Prompt and systematic radiological investigations are important in planning surgical management. Surgical excision usually yields good results.     

Follow-up evaluation of resected lumbar vertebral chordoma over 11 years: a case report

STUDY DESIGN: A case report with an 11-year follow-up assessment after resection and reconstruction for lumbar chordoma is given. The literature relevant to this topic is reviewed. OBJECTIVES: To report the long-term outcome in a case of lumbar chordoma, to review the literature on vertebral chordoma, and to outline the rationale for surgical resection in such cases. SUMMARY OF BACKGROUND DATA: Chordoma is a malignant bone tumor that grows slowly, often recurs locally, and metastasizes late. Although different treatment approaches exist, including radiation and surgery, the only curative treatment is early and complete surgical excision of the tumor. Immediate spinal stability must be achieved with appropriate replacement or bone graft with rigid fixation. METHODS: The 11-year follow-up evaluation of a 42-year-old woman with L3 and L4 vertebral body chordoma treated with complete removal, femoral shaft allograft replacement, fusion, and rigid metal fixation is reported. The patient was observed with serial physical examinations, radiographs, and laboratory studies over 11 years. RESULTS: At this writing, 11 years after the resection of the L3 and L4 chordoma, the patient is asymptomatic without evidence of recurrence or metastasis. CONCLUSIONS: As reported, vertebral chordomas are not curable, but the authors' experience contradicts this. The surgeon should aim at a wide, or at least a marginal, excision followed by a stable reconstruction.     

化脓性脊椎炎的诊治体会(附20例报告)

目的探讨化脓性脊椎炎的临床诊断与治疗方法。方法回顾性分析自2011-04—2015-07诊治的20例化脓性脊椎炎。14例行后路病灶清除后,椎间隙植入自体碎骨粒或部分同种异体骨,再行椎弓根钉内固定。6例前后联合入路者,先俯卧位行后路椎管内病灶清除减压椎弓根钉内固定,再行前路椎体及椎间隙病灶清除,取髂骨块植骨或自体骨粒填充cage行椎体间的支撑融合。结果 20例切口均一期愈合。术后患者局部疼痛均不同程度缓解,体温逐步恢复正常,术后复查实验室检查指标均下降至正常。20例中12例细菌培养的结果为阴性,8例为金黄色葡萄球菌。14例术前合并脊髓神经损伤者神经功能均得到不同程度恢复:1例C级恢复至D级,3例C级恢复至E级;6例D级均恢复至E级;10例E级均未有神经症状加重。本组术后随访10~36个月,平均20个月,均无复发。术后3个月复查X线片提示植骨节段均达到骨性融合标准,内固定物位置正常、可靠。结论化脓性脊椎炎的早期诊断依据病史、症状、体征、影像检查(特别是MRI)及穿刺活检,在炎症得到控制的前提下积极行病灶彻底清除、椎管内有累及者行减压、椎间植骨或cage置入并椎弓根钉内固定术,效果满意。     

Primary telangiectatic osteosarcoma of the cervical spine

Telangiectatic osteosarcoma (TOS) is one of the 8 subtypes of osteosarcoma that infrequently affects the spine. The radiopathological features of TOS overlap with those of more benign entities, most commonly the aneurysmal bone cyst), and therefore is a significant diagnostic challenge. It is a rare but well-described entity in the thoracolumbar and sacral spine, and to the authors' knowledge has not been previously reported in the cervical spine. The authors report the case of a 15-year-old boy who presented with a 6-month history of neck pain and torticollis. He underwent preoperative glue embolization followed by a staged subtotal C-5 spondylectomy and posterior fusion for a C-5 vertebral body lytic expansile lesion. Histopathological examination showed the lesion to be TOS. The surgery was followed by adjuvant radiation and chemotherapy with a favorable outcome at the 1-year follow-up. This report reiterates that TOS is an important differential diagnosis for aneurysmal bone cyst and giant-cell tumor of the spine, as its biological behavior and clinical outcome differ from those of these more benign lesions, which it mimics.     

胸腰椎转移瘤后路手术中骨水泥的应用

目的:探讨骨水泥在胸腰椎转移瘤后路手术中的应用价值.方法:2004年3月～21208年12月,后方入路手术治疗胸腰椎转移性肿瘤患者26例,原发肿瘤:肺癌9例,乳腺癌7例,肝癌4例,前列腺癌2例,肾癌1例,来源不明3例.病灶累及单节段17例,两节段9例.23例伴不同程度的腰背部疼痛:神经功能按Frankel分级:B级6例,C级7例,D级11例,E级2例.术中采用骨水泥联合椎弓根螺钉重建脊柱稳定性,其中骨水泥填塞15个椎体,骨水泥前方重建9个椎体,骨水泥椎体成形11个椎体,10例合并骨质疏松患者同时采用骨水泥加强椎弓根钉道.结果:术中未发现骨水泥放热效应引起的神经功能受损.24例患者获得完整随访,随访时间3～42个月,平均18.2个月,23例术前有不同程度腰背疼痛者术后疼痛消失6例,缓解14例;术前伴神经功能障碍者17例(77%)获得神经功能改善.随访期间未发现骨水泥下沉、椎节塌陷及向前成角.1例骨水泥填塞术后3个月骨水泥界面出现松动,但未引起神经压迫症状.15例随访期间死亡.结论:在胸腰椎转移性肿瘤后路手术治疗中,根据患者的全身情况、预期寿命、肿瘤类型、转移椎体位置及骨密度,充分利用骨水泥独特的理化特性,进行多种不同方式的应用,可以减小手术创伤,提高生存质量.     

经皮椎体成形术治疗C2椎体转移性肿瘤

目的探讨经皮C2椎体成形术的方法和效果。方法1例49岁的男性肺癌患者和1例45岁的女性乳腺癌患者,出现C2椎体转移,均有明显的颈部疼痛,女性患者因疼痛已不能下床行走1个月。采取在CT引导下,用13G骨穿针,由颈椎侧方经椎动脉与颈动脉鞘之间的间隙穿刺到C2椎体内,分别注入骨水泥(聚甲基丙烯酸甲酯,PMMA)3 ml和3.5 ml。结果术后CT扫描显示骨水泥在椎体内填充分布好,无骨水泥外漏。术后两例的疼痛均有不同程度缓解,1周后疼痛完全消失,女性患者能下地自由行走。男性患者半年后死于多个器官转移引起的全身衰竭。女性患者术后配合放化疗,随访至今1年多,无任何不适。结论在CT引导下,采取颈椎侧方入路,经椎动脉与颈动脉鞘之间的间隙,行经皮椎体成形术是一种安全、有效治疗C2椎体转移性肿瘤的方法。     

Multiple myeloma presenting as a mass lesion in the frontal bone. Case report

The patient, a 51-year-old male, was hospitalized for evaluation of a frontal subcutaneous mass. There were no signs of intracranial hypertension and no neurological deficit. His general medical status was normal, but he had been diagnosed as having immunoglobulin G (IgG) lambda type multiple myeloma by bone marrow aspiration and immunoelectrophoresis. A plain skull X-ray showed a large bony defect and multiple punched-out lesions in the frontal bone. Computed tomography showed an epidural high-density mass with marked homogeneous enhancement. Carotid angiography showed a hypervascular tumor fed by the bilateral external carotid arteries. At surgery, a reddish tumor was detached from the dura mater and totally resected. The pathological diagnosis was IgG lambda type plasmacytoma. After 40-Gy radiation and chemotherapy, the postoperative course over the following year was uneventful. Although the prognosis of multiple myeloma is poor, that of solitary intracranial plasmacytoma is reportedly good. However, since there is a high incidence of transition from solitary plasmacytoma to multiple myeloma, patients with intracranial plasmacytoma should be followed for a long period.     

A case of malignant pheochromocytoma associated with von Recklinghausen's disease]

A 48-year-old woman suffering from chest and lumbar pain was referred to our clinic for treatment. She had a history of von Recklinghausen's disease with multiple café-au-lait spots and neurofibromatosis. Computed tomography demonstrated a large tumor in the left adrenal gland and a small lesion in the liver, with the levels of plasma and urinary catecholamines being elevated. 131I-metaiodobenzylguanidine (MIBG) scintigraphy showed abnormal accumulations in the left adrenal tumor and multiple-bone lesions. A diagnosis of malignant pheochromocytoma with liver and bone metastases was made, and the patient received chemotherapy. Seven months after the diagnosis of malignant pheochromocytoma, she died of pulmonary edema due to disease progression. Autopsy revealed malignant pheochromocytoma with liver, lung, bone and lymph nodes metastases. We reviewed the literature on pheochromocytoma associated with von Recklinghausen's disease. To our knowledge, only 7 cases of malignant pheochromocytoma associated with von Recklinghausen's disease have been reported in Japan.     

Angioblastic meningioma with metastases to the vertebra and adjacent bones: a case report

A case of angioblastic meningioma with multiple metastases to the vertebra and the adjacent bones is presented. A 60-year-old man was admitted to our hospital complaining of pain in the left arm, right chest and abdominal wall, the left buttock, and on the posterior surface of the both legs. He had first undergone subtotal removal of tentorial meningioma eight years before admission. Histological diagnosis of angioblastic meningioma was confirmed. He subsequently received radiation therapy when the tumor recurred six years before admission and again underwent subtotal removal of the recurrent tumor, followed by radiation therapy, four years before admission. Bone scintigrams demonstrated abnormal uptake of radionuclide by the vertebral arches of Th 1, Th 10, Th 11, the vertebral bodies of L 4, L 5, the right 7th rib, and the left iliac bone. Myelography and CT examination with intrathecal infusion of metrizamide revealed marked cord-compression by the space-occupying lesions at the level of the first and the tenth thoracic vertebral bodies. Chest roentgenograms, ultrasonograms and whole body CT examinations showed no other lesions. The tumor was partially resected from the iliac lesion. The diagnosis of metastatic meningioma was confirmed by the histological findings. Postoperative radiation therapy to the first, tenth, and eleventh portions of the thoracic vertebra, and the fourth and the fifth portions of the lumbar vertebra--the causative lesions of the pain--relieved the pain.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transuncodiscal approach to dumbbell tumors of the cervical spinal canal

A combined anterior and lateral approach to the anterior cervical spinal canal with fusion was performed on five patients with cervical dumbbell-shaped tumors. The procedure consists of anterior discectomy and ipsilateral uncectomy, and removal of the posterolateral corners and posterior transverse ridges of the upper and lower vertebral bodies at the level of the tumor. In the case of a large tumor in the spinal canal, additional removal of a limited segment from the lateral part of the vertebral body was performed. The bone defect was filled with a T-shaped iliac bone graft. Two vertebral bodies were fused in each case. The highest level of the operation was C-2 and the lowest was T-1. The authors believe that any cervical dumbbell-shaped tumor below the C-2 level can be removed via an anterolateral approach as long as no more than three levels of the spine are involved.     

手术治疗胸腰椎结核79例临床分析

目的探讨胸腰椎结核一期病灶清除、植骨融合、内固定治疗的临床疗效。方法回顾分析自2002年9月至2008年7月我院手术治疗并获得随访的79例胸腰椎结核患者,病变范围为T5～S1,病灶累及1～2个椎体72例,大于等于3个椎体7例,其中跳跃性脊柱结核4例。手术方法：a）经前路病灶清除,椎体间植骨融合并内固定术;b）后路椎弓根固定术并前路病灶清除、椎体间植骨融合术。术后佩戴支具3～6个月,抗结核药物治疗12～18个月。定期门诊随访,进行实验室检查和影像学观察。结果该组患者随访2～9年,均获临床治愈。79例前路植骨病例,界面骨性融合时间平均4.7个月,后凸畸形平均矫正18.7°,随访期内丢失2°。合并截瘫29例,术后神经症状均得到明显改善。结论一期结核病灶清除、植骨融合内固定术是治疗脊柱结核的重要手段,有效的抗结核化疗是脊柱结核治愈的基础。     

经颌下咽后入路钩状钛板内固定重建术治疗枢椎椎体肿瘤

目的评价经颌下咽后上颈椎前路钩状钛板（retropharyngeal cervical vertebra hook-plate,RCHP）内固定重建术治疗枢椎椎体肿瘤的临床效果。方法应用RCHP内固定结合植骨或骨水泥手术治疗枢椎肿瘤9例,其中恶性肿瘤7例,良性肿瘤2例。所有患者均有不同程度的枕颈部疼痛伴活动受限,均未发现明显的神经功能障碍。结果随访时间5～22个月,平均13个月。伤口均Ⅰ期愈合,术中无脊髓、重要神经及血管损伤。术后1例患者出现喝水呛咳、吞咽困难等喉上神经牵拉症状,予以神经康复治疗后1周内好转,2周内恢复正常进食。2例进行植骨的良性肿瘤患者术后3～6个月内获得植骨融合,平均4个月。所有病例均未见内固定松动。结论应用RCHP内固定治疗枢椎椎体肿瘤,可以Ⅰ期处理肿瘤病灶并进行稳定性重建,具有简便易行、安全性高、固定可靠、疗效优良等特点。     

Usefullness of intrasacral fixation in an extremely unstable lumbosacral spine

Intrasacral fixation technique devised by Jackson is said to provide rigid lumbosacral fixation. We treated 3 cases of lumbosacral lesions using this technique in which lumbosacral segment had become extremely unstable during surgical intervention adding to the effect of original lesions. In all cases, surgeries were performed in 2 stages, intrasacral fixation and anterior stabilization. Case 1: A 52-year-old male was diagnosed fungal discitis and spondylitis at L4 and L5. X-ray showed destruction of the vertebral bodies. L2, L3 and sacrum were fixed posteriorly using the intrasacral fixation technique. One week after the first operation, L4 and L5 vertebral bodies were replaced by long fibula grafts through the extraperitoneal approach. Case 2: A 25-year-old female with cauda equina syndrome and abnormal body form diagnosed as having spondyloptosis in which the entire vertebral body of L5 had descended below the endplate of S1. MR imaging revealed marked canal stenosis at the S1 level. In the first surgery, L5 vertebral body was resected through the transperitoneal approach. After 1 week of bed rest, posterior segments of L5 were resected, L4 was affixed to the sacrum and anterior stabilization was achieved with 2 mesh cages and lumbosacral spine was fixed using the intrasacral fixation technique. Case 3: A 64-year-old female was diagnosed as having pyogenic discitis and osteomyelitis at the L5-S1 level. In spite of successful medical treatment for infection, low back pain continued. Radiologically, L5 vertebral body was shown to have collapsed and slipped anteriorly over the sacrum. L3, L4 and sacrum were fixed by intrasacral fixation. One week after the first operation, the L5/S1 disc and the suppurtive vertebral bodies were resected through the extraperitoneal approach and anterior stabilization was performed with iliac bone grafts. At follow-up for a minimum of 6 months, initial fixation was maintained in all 3 cases and bony fusion was obtained. The intrasacral fixation technique was considered to be effective for extremely unstable lumbosacral lesions.     

Als Spondylodiszitis imponierende vertebrale Sarkoidose

Sarcoidosis is a multisystem disorder of unknown cause characterized by non-caseating granulomatous infiltration affecting multiple organs. Osseous involvement has been estimated to occur in up to 13% cases. Due to its rare occurrence, only a few cases of vertebral sarcoidosis have been reported. Including our case, there are only three reports of vertebral sarcoidosis causing instability being treated by surgical fusion. The 54-year-old male patient presented with severe back pain, which had significantly impeded his mobility for months. He was unresponsive to analgesic and non-steroidal anti-inflammatory drugs (NSAID) and also reported weight loss and progressive weakness. Laboratory tests showed no specific alterations. When an MRI revealed destructive vertebral lesions of the lower thoracic spine, a tentative diagnosis of pyogenic discitis was made. For spinal stabilization as well as infection control, sequential operations were performed: dorsal spinal fusion by means of an internal fixation system was followed by excision of vertebrae 7/8 and filling of the defect with an autologous tricortical iliac crest bone graft through a ventral approach. Histological section of the excised vertebrae demonstrated a non-caseating granulomatous infiltration. Once this was determined, treatment with corticosteroids was started. The patient made a complete recovery and remains pain-free.     

Surgical correction of lesions affecting the second portion of the vertebral artery

Substantial controversy has surrounded the diagnosis and management of vertebrobasilar ischemic events, with no consensus on the value of medical or surgical treatment of patients symptomatic with brain stem ischemia who have angiographically proven vertebral artery lesions. This report presents our experience with the surgical treatment of 12 of 88 patients with angiographically verified lesions in the vertebral artery who were symptomatic for 1 to 12 months before their evaluation. None experienced symptomatic relief with antiplatelet agents, nor did the administration of anticoagulants in 4 of the patients provide any benefit. The lesions included bilateral vertebral artery occlusion with distal reconstitution through muscular collaterals in 6 patients, unilateral vertebral artery hypoplasia with contralateral long-tailed lesions from the vertebral artery origin to C-5 in 3 patients, and severe bilateral vertebral artery origin lesions extending beyond the C-5 level in 3 patients. A vertebral endarterectomy and vertebral-carotid transposition in the second portion of the artery were successfully used to reestablish flow and obtain symptomatic relief in 10 of the 12 cases; 1 of these procedures had to be redone because of a persistent stenosis at C-4. Another patient had a saphenous vein graft from the common carotid to the vertebral artery at C-5. The remaining patient had an anastomosis of the distal external carotid to the vertebral artery at C-3, but this failed and an anastomosis of the occipital artery to the anterior inferior cerebellar artery had to be completed to reestablish flow.(ABSTRACT TRUNCATED AT 250 WORDS)     

腰椎滑脱症不同手术治疗方式的临床比较

[目的]通过对151例腰椎滑脱症手术植骨治疗病人的回顾性临床分析,探讨有关腰椎滑脱症的手术适应证、手术植骨方式选择及治疗效果。[方法]依据病人情况分别采取以下4种术式,A组:后路钉棒系统固定单纯椎板植骨融合术21例,均Ⅰ度滑脱。B组:减压、钉棒系统固定、复位、经椎管椎体间植骨融合术46例,Ⅰ度20例,Ⅱ度26例。C组:减压、钉棒系统固定、复位、经关节突椎间椎板植骨融合术29例,Ⅰ度6例,Ⅱ度16例,Ⅲ度7例;D组:减压、钉棒系统固定、复位、经关节突椎间、横突间椎板植骨融合术55例,Ⅰ度4例,Ⅱ度41例,Ⅲ度10例。[结果]随访8个月～6年,平均3年7个月,A组滑脱复位率63.22%,融合率76.12%,腰痛JOA评分改善率90.33%;B组滑脱复位率93.41%,融合率93.48%,JOA评分改善率84.61%;C组滑脱复位率90.54%,融合率94.11%,JOA评分改善率77.58%;D组滑脱复位率92.49%,融合率98.00%,JOA评分改善率79.64%。[结论]对腰椎滑脱应依据滑脱程度、临床症状、病人全身情况选择相应的手术方式。     

脊椎肿瘤的外科治疗

目的：探讨采用不同经路切除脊椎肿瘤与改进的人工椎体和自体植骨术治疗脊椎不同节段肿瘤的疗效。方法：对13例脊椎肿瘤采取切除瘤椎、人工椎体置换和自体植骨术;肿瘤包括颈椎4例,胸椎3例,腰椎6例。术前颈脊髓瘫痪1例,不完全瘫痪4例,肿瘤的术后病理学诊断有骨巨细胞瘤3例,骨囊肿、Ewing瘤、骨神经鞘瘤、软骨瘤、骨成纤维细胞瘤、骨纤维细胞瘤、骨嗜酸性肉芽肿、骨转移瘤、骨肉瘤和骨血管瘤各1例。结果：13例安全度过围手术期,无脊髓神经症状加重。除1例3个月恢复良好后失访外,余12例获平均4．3年随访,瘫痪5例完全恢复,12例均恢复家务和工作,X线片显示假体无松动、移位,植骨融合。结论：应根据肿瘤的脊柱节段和类型,选择手术治疗方式,采用人工椎体置换和自体植骨术,对完全切除脊椎肿瘤和重建脊椎稳定性是十分有益的。