一期en-bloc切除术治疗伴有神经压迫的腰椎软骨肉瘤

目的探讨一期en-bloc切除术治疗伴有神经症状的腰椎软骨肉瘤的安全性和有效性。方法 2010年1月—2012年12月采用en-bloc切除术治疗腰椎软骨肉瘤患者29例。采用视觉模拟量表(VAS)评分评价患者疼痛程度,采用美国脊髓损伤协会(ASIA)分级评价患者神经功能,对临床疗效及围手术期并发症发生情况进行分析。结果所有患者肿瘤组织均一期en-bloc切除,单纯后路/后外侧入路23例,前后联合入路6例。患者平均随访49.2个月,平均手术时间为265 min,平均出血量为2 150 mL。术前VAS评分(7.69±1.25)分,术后恢复至(1.57±0.53)分。术前ASIA分级C级2例,D级11例,E级16例;术后1例C级患者恢复至D级,1例D级患者因压迫时间过长无恢复,其余C级和D级患者均恢复至E级,E级者无变化。所有患者术中未发生大血管损伤、邻近脏器误伤或死亡。1例患者因肿瘤包绕单侧L5神经行牺牲神经根的肿瘤en-bloc切除术,术后左足下垂,其余28例患者术后疼痛症状消失,术前伴下肢疼痛麻木者症状均有明显改善。术中出现脑脊液漏2例,行腰大池引流后顺利拔管,体温恢复正常。1例坠积性肺炎患者经抗炎治疗后痊愈;1例患者术后半个月发生右下肢深静脉血栓,取栓后半个月恢复。5例患者随访时出现局部肿瘤复发,行相应部位肿瘤再次切除。1例患者术后发生肺转移,6个月后死亡。其余患者无复发或转移征象。结论腰椎软骨肉瘤的治疗虽棘手,en-bloc切除术可安全有效地解除腰椎软骨肉瘤造成的神经压迫。术前详细的手术方案制定有助于更好地理解肿瘤与周围组织的解剖关系,减少毗邻大动脉、大静脉及周围神经组织的损伤,是精准医疗的有力措施。

En-bloc resection for lumbar chondrosarcoma with neurological compression

Objective To investigate the strategy and efficacy of one-stage en-bloc resection of the lumber chondrosarcoma with the neurological symptoms. Methods From January 2010 to December 2012,29 cases of lumbar chondrosarcoma with neurological symptoms were treated by en-bloc resection. The visual analogue scale(VAS) score was used to evaluate the pain level of the patients. The American Spinal Cord Injury Association(ASIA) classification was used to evaluate the neurological function. The clinical efficacy and the incidence of complications during the perioperative period were analyzed. Results All the operations were successfully performed by en-bloc resection via posterior/posterolateral approach in 23 cases and combined anterior and posterior approaches in 6 cases. The mean followed-up period was 49.2 months. The mean operation time was 265 min,and the mean blood loss was 2 150 mL. The preoperative VAS score was (7.69±1.25),and (1.57±0.53) at post-operation. The ASIA grade of neurologic function was C in 2 cases,D in 11,and E in 16 at pre-operation. After operation,1 patient recovered from C to D,and 1 grade D patient had no recovery because of prolonged compression time,and the remaining C and D patients were restored to E,while the patients with grade E had no change. There were no cases with major vessel or adjacent organ injury or died during operation. Only 1 patient with tumor wrapping around the unilateral L₅ nerve underwent en-bloc resection with sacrifice of the L₅ nerve root,resulting in left foot drop at post-operation;in the remaining 28 cases pain symptoms disappeared at post-operation,and symptoms of lower limb numbness and pain were significantly improved. The body temperature of 2 patients with the leakage of cerebrospinal recovered to normal after lumbar cistern drainage. One patient with hyposatic pneumonia recovered after anti-inflammatory treatment. Right lower extremity deep venous thrombosis occurred in 1 case half a month after operation,and recovered after thrombectomy in half a month. Five patients with tumor recurrence received reoperation. Pulmonary metastasis occurred in 1 patient after the operation,who died after 6 months. The remaining patients had no signs of recurrence or metastasis. Conclusion Though technically challenging,it is safe and efficient to relieve the local compression with the en-bloc resection in lumber chondrosarcoma. Detailed preoperative strategies can enable doctors better to understand the anatomical relationship between the tumor and lumbar spine,and reduce the injury to the adjacent large arteries,large veins and peripheral nerve tissue,which is a powerful measure for precision medicine.