脊柱转移瘤病椎切除及稳定性重建

目的 探讨脊柱转移瘤切除、融合及稳定性重建在治疗转移性脊柱肿瘤中的必要性和可行性.方法 2002年6月-2007年8月对11例脊柱转移瘤患者行前路病椎切除自体髂骨植骨钛板内固定术或联合后路椎板切除减压术治疗,随访观察患者术后局部疼痛缓解,脊髓神经功能恢复及脊柱稳定性情况.结果 术后颈肩腰背痛及放射痛基本缓解,早期开始肢体功能锻炼,术后3～5周佩戴支具离床活动.随访5个月～2年,患者神经压迫症状明显改善.内固定物无松动、断钉现象,椎体尤塌陷结论前路手术切除病变椎体并自体髂骨植骨前路钛板内固定重建脊柱稳定性或联合后路椎板切除减压治疗脊柱转移瘤是可行性的,可提高患者生存期内的生活质量.     

人工椎体在胸腰椎病变中的应用

[目的]观察人工椎体在胸腰椎肿瘤、结核及骨折治疗中的外科疗效。[方法]对169例胸腰椎患者(其中包括64例肿瘤、66例结核、39例爆裂性骨折)的外科疗效进行回顾性分析。其中有57例伴有胸腰椎后凸畸形,术前Cobb s角27.1°~65.4°,平均(38.5±10.7)°。对所有患者进行病变椎体大部或完整切除,椎间撬拔撑开复位,可调式中空笼状钛合金人工椎体植骨替代,辅以前路椎体钉板(棒)系统或后路椎弓根钉系统行邻近椎节固定,Ⅰ期重建脊柱稳定性,观察术后局部疼痛缓解,脊髓神经功能恢复、脊柱椎节的稳定性及后凸畸形的矫治情况。[结果]随访12~46个月,平均32个月。所有患者术后疼痛缓解,肿瘤、结核病人术后局部均无复发,脊髓神经功能无加重损伤,73例患者脊髓神经功能得到不同程度恢复。术后影像学检查提示:脊柱内固定物在位,椎体序列恢复良好,椎间高度恢复。后凸畸形者术后矫正角度(31.6±8.3),°最后随访时矫正角度丢失(4.1±3.8)°。[结论]胸腰椎病椎切除、人工椎体植骨替代并内固定,能彻底减压、缓解疼痛,能有效重建脊柱稳定,恢复脊柱序列。     

三种人工椎体置换治疗脊柱肿瘤的临床比较

目的：观察比较三种人工椎体置换治疗脊椎肿瘤的临床效果。方法：采用LIFT、Rezaian和可调式中空人工椎体治疗脊柱肿瘤19例。定期X线片检查,观察手术椎节的稳定性、疼痛改善及脊髓功能恢复情况。结果：随访7－34个月,平均11个月。术后疼痛缓解,脊髓功能恢复明显。三种人工椎体稳定,无移位。LIFT和可调式中空人工椎体体内植骨有利融合,椎节高度恢复满意。结论：椎体肿瘤切除人工椎体置换能重建手术椎节的稳定性,应根据肿瘤性质和范围酌情选择不同人工椎体。     

脊柱肿瘤切除术后稳定性重建

目的：探索脊柱肿瘤切除术后稳定性重建的方法与效果。方法：本组对28例脊柱肿瘤实施了椎体切除。扇形半脊椎切除，附件切除和全脊椎发除四种术式，同时采用了椎体间植骨，人工椎体及前，后路内固定重建技术。结果：全组病人局部疼痛及放射痛缓解。13例截瘫患者中11例肌力均有不同程度改善。11例原发良性肿瘤中2例术后4和10年复发，1例伴恶变，均再次治疗，11例原发恶性肿瘤中2例术后9和12个月死亡，1例植骨块脱出，再次手术。另1例局部肿瘤复发截瘫加重，再次手术但神经功能无恢复。内固定并发症有；钉尾螺母松动脱落1例，椎弓根螺钉位置不良4例计9枚。结论：应用椎体间植骨，人工椎体并辅以前。后路内固定可有效重建脊柱稳定性，促进患者术后早期康复。     

脊柱肿瘤的手术治疗

目的 :探讨对于脊柱肿瘤一期全脊椎切除及脊柱稳定性重建的手术方法和临床效果。方法 :对 12例脊柱肿瘤行前、后路或前、后联合入路Ⅰ期全脊椎切除、脊髓减压 ,椎间植骨融合、内固定术。结果 :术后 11例获得随访 ,按照Frankel分级较术前均有 1级以上提高 ,所有患者局部疼痛症状消失。术后复查平均植骨融合时间 3个月。1例脊索瘤术后 1年复发 ,1例巨细胞瘤术后 9个月复发。结论 :针对脊柱肿瘤的性质、部位 ,通过不同的手术入路行一期全脊椎切除、植骨融合内固定 ,彻底切除肿瘤 ,重建脊柱稳定性并体现了个体化的治疗方向     

前路一期病变椎体切除并重建治疗胸腰椎结核并后凸畸形

目的:观察前路一期病变椎体切除、人工椎体或钛网融合器植骨替代、椎体钉板或钉棒系统内固定治疗连续两个及以上节段胸腰椎结核并后凸畸形的疗效。方法:34例病变累及连续两个及两个以上椎节的胸腰椎结核患者,术前后凸Cobb角27.8°￣65.4°(38.6°±10.3°),一期行前路病变椎体切除,椎间撬拔撑开复位,人工椎体或钛网融合器植骨替代,辅以椎体钉板或钉棒系统短节段邻近椎节内固定,重建脊柱稳定性,术后均给予短疗程化疗。观察术后局部疼痛缓解、脊髓神经功能恢复、后凸畸形矫正及脊柱稳定性情况。结果:患者术后局部疼痛缓解,术前伴有脊髓神经损伤的12例患者术后神经功能均有不同程度恢复。影像学检查示脊柱内固定物位置良好,椎体序列恢复良好,椎间高度恢复。后凸Cobb角矫正至2.1°￣14.2°(7.5°±8.3°),平均矫正31.2°±8.5°。随访18￣54个月,平均35个月。末次随访时后凸矫正度丢失4.3°±3.8°,均无结核复发。结论:连续两个及两个以上节段的胸腰椎结核采用前路一期行病变椎体切除有利于病灶彻底清除,减少复发;也有利于椎管彻底减压。前路椎体替代、植骨内固定重建脊柱稳定性可更好地纠正和预防脊柱后凸畸形。     

后路一期椎体全切除治疗胸椎椎体肿瘤

目的探讨后路一期手术治疗胸椎肿瘤的疗效及方法。按脊柱肿瘤来源可分为原发肿瘤,转移肿瘤。方法 8例胸椎骨肿瘤患者实施后路全脊椎切除重建术。经胸椎后入路行单椎节切除6例,双椎节切除2例,均采用Harm钛网植骨/钛网骨水泥联合TSRH/MOSS/CDH M12椎弓根钉内固定系统重建。结果随访3个月3.5年,平均23个月。7例术后近期疗效较满意,局部疼痛和神经症状均有不同程度改善或缓解;4例脊髓神经功能完全恢复;1例术后1.5年局部复发;术后18个月死亡1例。结论胸椎后路全脊椎切除能显著降低胸椎骨肿瘤局部复发率,改善脊髓神经功能,提高手术疗效。钛网植骨/钛网骨水泥联合椎弓根螺钉系统能有效重建脊柱的前后柱稳定,同时可减少创伤、缩短手术时间、减少并发症的发生。     

后外侧入路全脊椎切除重建术治疗胸椎骨肿瘤

目的探讨胸椎骨肿瘤后外侧入路全脊椎切除方式、重建技术及其疗效。方法25例胸椎骨肿瘤患者实施后外侧入路全脊椎切除重建术。经胸椎后外侧入路行单椎节切除22例、双椎节切除3例,均采用Harms钛网植骨/钛网骨水泥联合TSRH/MOSS/CDHM8椎弓根钉内固定系统重建。结果随访3个月~6年,23例术后近期疗效较满意,局部疼痛和神经症状均有不同程度改善或缓解;21例脊髓神经功能完全恢复;1例术后出现一过性瘫痪加重;3例分别于术后1~3年局部复发;术后12和18个月各死亡1例。结论胸椎后外侧入路全脊椎切除能显著降低胸椎骨肿瘤局部复发率,改善脊髓神经功能,提高手术疗效。钛网植骨/钛网骨水泥联合椎弓根螺钉系统能有效重建脊柱的前后柱稳定,同时具有减少创伤、缩短手术时间、降低并发症的优势。     

脊柱转移性肿瘤的外科治疗策略

目的：探讨脊柱转移性肿瘤的临床特点、手术治疗策略及其预后。方法：对103例脊柱转移性肿瘤患者的临床特点、手术适应证、外科治疗方式及其预后进行分析。结果：术后随访6个月－5年。85例患者术后局部疼痛、神经根痛缓解甚至消失，脊髓压迫症状改善或缓解；术后6个月、1、2、3、4年的生存率分别为97．1％、90．3％、44．7％、29．1％、8．7％。结论：脊柱转移性肿瘤患者多数表现为局部疼痛，部分患者有脊髓、神经根损害的表现。手术必须考虑全身情况，限于脊柱不稳、神经功能进行性损害、局部疼痛剧烈且原发病灶已积极处理、或原发灶不明手术作为明确病理诊断以指导进一步治疗的患者。根据肿瘤侵犯部位、患者耐受手术情况、预期寿命等选择前路、后路或前后联合入路的一期或二期手术。手术能够稳定和重建脊柱，减轻或缓解疼痛，维持或改善神经功能，从而改善患者的生活质量。     

脊柱活动节段脊索瘤的外科治疗及其预后(附15例报告)

[目的]探讨脊柱活动节段脊索瘤外科治疗方式与疗效。[方法]对接受手术治疗的15例脊柱活动节段脊索瘤病人的临床资料进行回顾性分析。根据肿瘤WBB（Weinstein-Boriani-Biagini）分期，肿瘤主要位于椎体范围内，即4～9扇区内7例，累及椎体且超过一侧4扇区或9扇区4例，同时超过两侧4扇区和9扇区4例；肿瘤侵及A-D层13例，A—C层2例；单椎节骨质破坏9例，2个椎节骨质破坏5例，累及3个椎节1例。手术行椎体或矢状切除10例，全脊椎切除5例。后路重建4例（4例病灶均位于上颈椎），前路重建3例，前后联合重建8例。术中取大块自体骨（髂骨或肋骨）或钛网＋植骨块融合9例，钛网＋骨水泥填塞支撑6例。术后均辅以瘤灶局部放疗。[结果]患者术后临床症状改善明显，神经功能恢复满意，植骨融合率100％。随访14～123个月，平均56．2个月，局部复发7例，死亡4例，未见远处转移病例。[结论]脊柱活动节段脊索瘤临床发病较少，早期症状不典型。应注重肿瘤的早期诊断与治疗。手术切除是治疗脊柱脊索瘤的主要手段，全脊椎切除能明显降低复发率。术后辅助以肿瘤病灶局部放疗对抑制肿瘤复发或进展有积极作用。     

脊柱转移肿瘤的外科治疗方法探究

背景：脊柱是恶性肿瘤中除肺脏、肝脏外最常见的转移部位。脊柱转移肿瘤严重影响患者的生活质量,近年来患者的生存期延长,多数骨科医师选择手术治疗改善患者的生存质量。目的：初步评估脊柱转移肿瘤切除和脊柱重建的疗效。方法：2001年1月至2009年11月收治脊柱转移肿瘤患者42例,分别进行前路椎体切除,后路椎板切除减压,一期后路全椎体切除术和经皮椎体成形术。对比各种手术的手术时间、平均出血量、术后疼痛缓解率和症状缓解率。结果：随访时间为5-108个月。前路椎体切除手术平均手术时间234min,出血量1966ml,术后疼痛缓解率为83％,症状缓解率为33％;后路椎板切除减压手术平均手术时间218min,出血量1292ml,术后疼痛缓解率为85％,症状缓解率为28％;一期后路全椎体切除术手术平均手术时间290min,平均出血量2275ml,术后疼痛缓解率为100％,症状缓解率为57％;经皮椎体成形术时间短、出血量少（均未统计）,疼痛缓解率为100％,之前均无症状。结论：一期后路全椎体切除术手术时间较长,平均出血量较多,但术后症状缓解率和疼痛缓解率较高,对于单节段病变椎体或者致病椎为单节段、无重要内脏转移、一般情况较好、预期寿命超过半年的患者,应采用一期后路全椎体切除术以达到解除病痛的效果。     

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     

Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life

STUDY DESIGN: Eighty-six surgical interventions in 76 consecutive patients with symptomatic spinal metastases were reviewed retrospectively. OBJECTIVES: To evaluate the postoperative outcome and quality of life of patients surgically treated for symptomatic spinal metastases. SUMMARY OF BACKGROUND DATA: The standard surgical treatment for patients with symptomatic spinal metastases is anterior spinal cord decompression with stabilization. However, because therapy is only palliative, satisfactory quality of life and high patient acceptance are essential. METHODS: The medical records of all patients were reviewed retrospectively. Furthermore, all surviving patients or the next of kin of deceased patients were interviewed by telephone, and the family doctors or the care-providing physicians of external institutions were contacted. RESULTS: First-choice surgical treatment was anterior spinal cord decompression with stabilization. Postoperative mean survival was 13.1 months, and mean time at home after spinal surgery was 11.1 months. Neurologic improvement with regard to Frankel classification was observed in 58% of the patients, and 93% were able to walk postoperatively. Pain relief was noted in 89%. Overall, 67% of the patients achieved moderate or good general health as shown by the Karnofsky Index, and 80% were satisfied or very satisfied with the surgical intervention. Moreover, 19% of the surgical interventions were associated with complications, local tumor recurrence developed in 22% of the patients, and paraplegia ultimately developed in 18% of patients. CONCLUSIONS: Surgical management of symptomatic spinal metastases, in particular anterior decompression, is of benefit in most metastatic lesions in terms of satisfactory postoperative outcome and quality of life. However, in patients with melanoma or lung carcinoma, the authors advocate spinal surgery only in very exceptional cases.     

Synchronous vertebral decompression and posterior stabilization in the treatment of spinal malignancy

Thirty-four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single-stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single-stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy.     

原发脊柱肿瘤的外科分区与手术治疗

目的：探讨原发脊柱肿瘤的外科分区,提高手术疗效。方法：对15例原发性脊柱肿瘤患者的肿瘤进行分区,根据分区制订手术方案,手术方法有：（1）全脊椎切除5例,（2）椎体切除7例,（3）矢状扇形脊椎切除2例;（4）椎体附件扇形切除1例,9例患者术后局部脊 前路或后路内固定重建脊柱稳定性。结果：全部患者术后局部疼痛和放射痛缓解,骨力改善,有坚固内固定者术后2周在支具（石膏）保护下离床活动。7例良性肿瘤平均随访4．5年,均无局部复发,恶变与转移现象,8例恶性肿瘤平均随访3．4年,1例于术后1年死亡,1例骨瘤患者术后半年局部复发,截瘫症状加重,行二次减压手术,结论：根据WBB脊柱肿瘤外科分区而提出的手术计划是一个积极的探索,本组结果表明脊柱肿瘤切除较彻底,复发率低,近,中期疗效良好。     

开放性椎体成形术治疗脊柱转移瘤和多发性骨髓瘤

目的 探讨开放性椎体成形术治疗脊柱转移瘤和多发性骨髓瘤的适应证选择和临床治疗效果.方法 自2004年6月至2007年6月,对22例患者施行了开放性后路椎管减压内固定联合椎体成形术,5例为多发性骨髓瘤,17例为脊柱转移瘤.患者年龄36～75岁,平均56.9岁.所有患者术前均有严重的背痛或腰痛并伴有不同程度的下肢神经损害症状,平均疼痛VAS评分为7.4分(5～10分),55个以上椎体节段进行了治疗.术后第3天评估患者的疼痛缓解情况、活动能力的改善情况.出院后每3个月门诊随访1次.结果 所有患者术后3 d内疼痛缓解,平均VAS评分降至1.8分,且术前神经损害情况改善.椎体成形术中骨水泥的平均注入量为4 m1(3～6 ml).12例术中出现骨水泥泄漏,5例在椎间隙,5例在椎旁静脉,2例椎管内渗漏.术后患者均接受化疗和(或)放疗,平均随访18个月(6～36个月),14例死于原发病,8例患者病情稳定.结论 此手术一次性完成椎管减压内固定,稳定脊柱,同时行椎体成形术,可以提高患者的活动能力,减轻疼痛,临床效果显著,尤其对于体质较差,多椎体病变,椎体压缩骨折压迫脊髓,无法承受脊柱前路手术的患者提供了一种可选择的手术方式.     

Implantation of a Harms titanium mesh cylinder for vertebral body replacement in spinal metastases

OBJECTIVE: Vertebral metastases are quiet common and may result in vertebral collapse, spinal instability, and progressive neurological compromise. An anterior approach is the accepted method for decompression and stabilization by vertebral replacement. There is still need for discussion regarding the material of the replacement device. Here, the authors report on Harms' titanium cage (DePuy-Motech) for vertebral replacement. METHODS: From 1992 until 1995 17 patients with spinal metastases were treated by anterior vertebral replacement at the Orthopaedic Department, University of Magdeburg. Indications for the procedure were single metastases and respectively, progressive neurological deficit with vertebral destruction seen radiologically. Implantation of the cage was performed solely or in combination with anterior or posterior instrumentation. Pre- and postoperative assessments were evaluated by clinical scores. RESULTS: Mean follow-up was 9.3 months. At the end of our study 11 patients had died (mean survival 6.7 months). Mean follow-up of the surviving 6 was 9.8 months. Patient's daily activity (Karnofsky) improved in 8 cases, became worse in 4 cases, and did not change in 5 cases. Neurologically (Frankel) there was improvement in 3 patients, deterioration in 4 patients, and no change in 10 patients. Walking ability showed improvement in 6 cases, deterioration in 3 cases and no change in 8 cases. Relief of pain (Moskowitz) was reported by 12 patients, no patient complained of increasing pain, 5 patients reported no change, and 10 patients were pain-free. CONCLUSION AND CLINICAL RELEVANCE: In most cases with spinal metastases, the quality of life may be improved by vertebral replacement with Harms' titanium cage. Amelioration of clinical symptoms such as neurological deficit, pain, and tack of walking ability occurred in most patients.     

Spinal stabilization of vertebral column tumors

An analysis of indications, techniques, results of stabilization and decompression of 100 consecutive spinal tumour cases was carried out. Localized metastatic disease is best operated anteriorly. Primary malignancies are best treated with en bloc resection. Pain relief in metastatic disease is achieved by rigid stabilization. The unstable spine secondary to benign or malignant disease often requires stabilization for alleviation of pain; 132 stabilization procedures were performed in 100 patients. There were nine benign and 91 malignant tumors including 71 metastatic. Indications for stabilization were pathological fracture or following decompression. Anterior approaches including implant stabilization were used in those with metastatic disease limited to one to two levels or where significant kyphosis existed. Posterolateral decompression with Luque rod stabilization was indicated where disease was more widespread. In metastatic disease acrylic cement was used both anteriorly and posteriorly together with implant stabilization. Eighty-one percent had good to excellent relief of pain; 68 patients had neurological deficits. Significant neurological return was achieved in 40% of posterior decompressions and 71% of anterior decompressions in metastatic disease. All patients with benign tumors have solid fusions. In malignant disease the use of cement provided stability without loss of fixation in 87 of 91 procedures. Complications were 4% infection and failure of two Harrington rods without wiring, one Luque rod and two anterior constructs. The average longevity of patients treated for metastatic disease was 11.3 months.     

脊柱转移瘤的外科治疗

目的：脊柱转移瘤可引起顽固性疼痛及脊髓压迫，其外科治疗仍存在许多争议，探讨脊柱转移瘤外科治疗的临床效果。方法：自1998年7月－2001年7月，北京大学人民医院骨肿瘤科手术治疗脊柱转移瘤患者62例，包括颈椎转移6例，胸椎转移37例，腰椎转移19例。无明显神经系统受累者19例；出现神经系统受损者43例，其中完全瘫痪者19例，不完全瘫痪者24例。病变累及一个脊柱节段者43例，二个脊柱节段者14例，三具脊柱节段者5例。结果：62例患者中，58例（94％）术后疼痛得到缓解。43例有神经功能损害的患者中，33例术后麻痹症状改善。25例术前膀胱及直肠功能受损的患者中，术后12例膀胱及直肠功能明显改善。术前Frankel A、B级的患者，5例术后恢复到E级或D级，9例改善为C或D级。结论：从肢体功能减退到完全瘫痪所经历的时间是最重要的预后因素，在48h内完全瘫痪为预后不良的重要因素；膀胱和直肠功能的完全丧失也提示预后不良。甲状腺癌和乳腺癌的脊柱转移一般预后较好，肺癌和肝癌的脊柱转移通常存活期较短。