病灶孤立化技术在单节段胸椎肿瘤全椎体大块切除中的临床应用研究

发布时间：2018-06-29 11:05

本文选题：胸椎肿瘤 + 全椎体切除术　；参考：《中国人民解放军医学院》2016年博士论文

【摘要】：脊柱肿瘤是临床肿瘤学中相对较为少见的一类肿瘤。而发生于脊柱的原发肿瘤则更为少见。它们占到所有骨骼肌肉系统原发肿瘤的11%,所有脊柱肿瘤的4.2%,而在这当中大约只有0.4%是恶性肿瘤。由于解剖位置及结构的特殊性且胸腰椎位置深在,又与重要血管及神经组织相毗邻,手术入路的设计和肿瘤切除一直以来是外科治疗的难点。传统的肿瘤切除方式多采用椎体肿瘤内肿瘤组织刮除(curettage)和肿瘤组织逐块咬除(piecemeal)的方式来达到切除肿瘤的目的。但是传统肿瘤切除方式容易造成肿瘤对周围组织的污染,且肿瘤组织与正常组织的边界难以确定。为了降低肿瘤切除后复发和提高患者的生存率,Stener 和 Roy-Camille于1981年首先报道了经后路胸椎全脊椎切除。20世纪90年代中期,日本学者Tomita等人报道了进一步改良的经后路全椎体整块切除术(total en bloc spondylectomy,TES),该技术通过将后弓与椎体分离后整块切除的方式以达到全脊椎切除的目的。近些年来,随着手术技术的不断进步以及术前血管栓塞的应用,TES技术已经成为脊柱肿瘤治疗的较为理想且成熟的技术。虽然有众多学者对TES的一些技术细节进行改良与发展,但目前报道的单纯后路TES技术主要包括两部分：(1)脊椎后弓附件结构的显露、切除及固定；(2)脊椎前部椎体的整体分离、整块切除及脊柱稳定性的重建。中国人民解放军总医院骨科自2003年起开始开展脊柱肿瘤的全椎体整块切除技术。经10多年的不断学习以及经验积累,TES技术已成为解放军总医院骨科治疗脊柱肿瘤的成熟技术。自2011年1月,著者对目前应用最广泛的Tomita的经典后路胸椎肿瘤TES技术的一些技术细节进行调整与改良,主要包括：先处理节段血管和神经根后使病椎完整分离,孤立并阻断肿瘤及椎体的血供后再进行后弓及前部椎体的整体切除(Tomita等报道方法为先显露并切除后弓,后处理血管及神经根并钝性分离椎体的侧、前方后再行前柱切除),著者将这些调整与改良称之为病灶孤立化技术,该技术旨在对包括肿瘤在内的整个椎体实施整体分离、孤立后再进行截骨及椎管减压以减少操作过程中的出血。著者最先将该技术应用于侵袭性胸椎血管瘤的治疗,后逐渐推广应用至其他类型胸椎肿瘤全椎体大块切除术中。本课题采用回顾性病例对照研究对病灶孤立化技术在胸椎肿瘤全椎体大块切除术中应用的可行性、安全性及临床疗效进行评估。第一部分病灶孤立化技术在合并神经功能损伤的侵袭性胸椎血管瘤全椎体大块切除术中的应用研究目的：评价病灶孤立化技术在合并神经功能损伤的侵袭性胸椎血管瘤全椎体大块切除术中应用的可行性、安全性及临床疗效。方法：回顾性分析2005年1月～2013年1月间在我院诊断为侵袭性胸椎血管瘤并行一期后路全椎体大块切除术的患者共17例。根据采取手术技术的不同分为两组,传统TES组10例(2011年1月之前),采用病灶孤立化技术TES组7例。对两组患者的一般情况及手术疗效进行评价,评价指标包括(1)一般情况：年龄、性别、病变部位、症状及症状持续时间、脊髓压迫类型、神经功能AISA评分、肿瘤的Tomita分型、胸背痛VAS评分、脊柱稳定性SINS评分；(2)手术相关指标：手术时间、术中出血量,围手术期输血量(浓缩红细胞及血浆),术后引流量及引流时间,手术并发症。结果：对17例患者进行局部肿瘤的Tomita分型Tomita Ⅳ型7例,Tomita Ⅴ型7例,Tomita Ⅵ型1例。所有17例患者均表现为椎体及后弓受累导致脊髓腹背侧的压迫。7例患者出现病理性骨折。对脊柱稳定性的评估采用SINS评分,传统TES组9.2±1.2(8-12),TES结合病灶孤立化技术组10.3±1.5(8-12),两组间差异无统计学意义(p0.05)。传统TES组手术时间平均为397.5±98.3min(320-490 min), TES结合病灶孤立化技术组手术时间为415.7±67.0(300-630 min)两组间手术时间比较无明显统计学意义(P=0.68)。传统TES组与TES结合病灶孤立化技术组术中出血量分别为2610.0±1009.3ml (980-3270 ml),1640±451.5ml (800-4000 ml),两组间术中出血量的差异有统计学意义(P=0.03)。传统TES组与TES结合病灶孤立化技术组患者围手术期输血量分别平均为17.3±4.6U(11.2-25.0U),14.0±4.8(7.8-20.3U)。两组患者围手术期输血量之间差异无统计学意义(P=0.18)传统TES组有2例患者术后出现脑脊液漏,1例出现胸腔积液,1例患者术后33个月时受外伤导致断棒行翻修手术。TES结合病灶孤立化技术组有2例患者术后出现脑脊液漏。两组患者随访28-96个月,均无肿瘤的复发。结论：对于合并有严重骨质破坏以及脊髓腹背侧受压导致神经功能损害的侵袭性胸椎血管瘤,全椎体大块切除术有助于最大限度降低其局部复发可能并能促进神经功能的有效恢复,病灶孤立化技术的应用可以有效控制术中出血,减少围手术期血液制品的使用量。同时,病灶孤立化技术的应用并不会明显增加手术时间及手术难度。第二部分病灶孤立化技术在单节段胸椎肿瘤全椎体大块切除术中的临床应用研究目的：评价病灶孤立化技术在单节段胸椎肿瘤全椎体大块切除术中应用的临床疗效、安全性及有效性。方法：回顾性研究2008年1月-2014年1月在我院诊断为单节段胸椎肿瘤并行一期后路全椎体大块切除术的患者29例,其中男16例,女13例,年龄17-63岁。平均48.7岁。原发肿瘤12例,转移性肿瘤17例。根据手术技术不同分为2组：传统手术技术组20例,病灶孤立化技术组9例。所有手术操作均由同一手术团队完成。临床疗效评价指标包括：手术前后神经功能状态、手术前后胸背痛VAS评分、术中出血量、手术时间、术后引流量、术后引流时间及相关并发症。结果：29例患者均成功实施手术,两组患者在手术前后VAS评分、手术时间、术后引流量、术后引流时间及相关并发症方面无明显统计学差异(p0.05)。两组患者在术中出血量及围手术期输血量之间存在统计学差异(p0.05)。1例转移性肿瘤患者于术后30个月肿瘤复发并死亡。结论：病灶孤立化技术不增加胸椎肿瘤全椎体切除手术时间及技术难度,但可有效减少术中出血及围手术期输血量,并可最大程度降低肿瘤细胞污染的可能性。
[Abstract]:Spinal tumors are a relatively rare type of tumor in clinical oncology. Primary tumors in the spine are more rare. They account for 11% of the primary tumors of the skeletal muscle system, 4.2% of all spinal tumors, and about 0.4% of them are malignant. The design of the surgical approach and the tumor resection have been the difficulties in surgical treatment. The traditional method of tumor resection is to use the tumor tissue curettage (curettage) and the tumor tissue to remove (piecemeal) to achieve the purpose of tumor removal. In order to reduce the recurrence of tumor and improve the survival rate of the patients, Stener and Roy-Camille first reported the posterior thoracic spinal total spinal resection in the mid 90s of the.20 century in 1981, the Japanese scholar Tomita et al and others reported that the tumor resection was difficult to determine the tumor's pollution to the surrounding tissue. Total en bloc spondylectomy (TES) has been improved to achieve the purpose of total resection of the spine by separating the posterior arch from the vertebral body after a complete resection of the vertebral body. In recent years, with the continuous progress of the surgical technique and the application of preoperative vascular embolization, TES technology has become a scoliosis. An ideal and mature technique for tumor treatment. Although a number of scholars have improved and developed some of the technical details of TES, the present reported simple posterior TES technology mainly includes two parts: (1) the exposure, resection and fixation of the posterior arch appendage structure of the spine; (2) the overall separation of the vertebral anterior vertebrae, the block resection and the stability of the spine. After 10 years of continuous learning and accumulated experience, TES technology has become a mature technique for the treatment of spinal tumors in the General Hospital of the PLA General Hospital. Since January 2011, the author has been using the most widely used Tomita classic. Some technical details of the posterior thoracic vertebra tumor (TES) technique are adjusted and improved, including the complete separation of the segmental blood vessels and nerve roots, isolated and blocked tumor and vertebral body blood supply after the whole resection of the posterior arch and anterior vertebral body (Tomita and other reports for the first exposure and after the resection of the arch, then reprocessing the blood vessels and reprocessing the blood vessels. Nerve roots and blunt separation of the side of the vertebral body and resected anterior post column. The author calls these adjustments and improvements called focus isolation. The technique aims to separate the whole vertebral body, including the tumor, and isolate the osteotomy and spinal canal decompression to reduce the bleeding during the operation. The author first applies the technique. The treatment of invasive thoracic hemangioma is gradually popularized and applied to the whole vertebral mass excision of other types of thoracic vertebrae. The feasibility, safety and clinical efficacy of the focus isolation technique in the total vertebral mass resection of thoracic vertebral tumors are evaluated by retrospective case control study. Objective: To evaluate the feasibility, safety and clinical effect of the isolation technique of the lesion in the total vertebral mass excision of invasive thoracic vertebral hemangioma with nerve function injury. Method: a retrospective analysis of 200 A total of 17 patients were diagnosed as invasive thoracic vertebral hemangioma in our hospital from January to January 2013, which were divided into two groups according to the different surgical techniques, 10 cases in group TES (before January 2011) and 7 cases in group TES with focus isolation. The general situation and surgical effect of the two groups were carried out. Evaluation, evaluation indexes include (1) general conditions: age, sex, lesion site, symptom and symptom duration, spinal cord compression type, nerve function AISA score, tumor Tomita classification, chest back pain VAS score, spinal stability SINS score; (2) operation time, intraoperative bleeding volume, perioperative transfusion volume (concentrated red blood cell) Results: 7 cases of Tomita type Tomita type Tomita IV of local tumor, 7 cases of Tomita V type and 1 cases of Tomita VI were performed in 17 patients with local tumor. All 17 cases showed the pathological fracture of the spinal cord and the posterior arch caused by the compression of the spinal dorsal side of the spinal cord and the stability of the spinal stability. The evaluation of the SINS score was 9.2 + 1.2 (8-12) in the traditional TES group and 10.3 + 1.5 (8-12) in the TES combined focus group. The difference between the two groups was not statistically significant (P0.05). The average operation time of the traditional TES group was 397.5 + 98.3min (320-490 min), and the operation time of the TES combined focus isolation group was 415.7 + 67 (300-630 min) two group operation time. There was no significant statistical significance (P=0.68). The intraoperative bleeding amount of the traditional TES group and TES combined focus group was 2610 + 1009.3ml (980-3270 ml) and 1640 + 451.5ml (800-4000 ml). The difference of intraoperative bleeding in the two groups was statistically significant (P=0.03). The average blood volume was 17.3 4.6U (11.2-25.0U) and 14 + 4.8 (7.8-20.3U). There was no significant difference between the two groups in the perioperative period of blood transfusion (P=0.18) 2 patients in the traditional TES group had cerebrospinal fluid leakage after operation, 1 cases had pleural effusion, and 1 patients were subjected to trauma at 33 months after surgery to isolate the lesion and isolate the focus of the lesion. 2 patients in the technical group had cerebrospinal fluid leakage after operation. The two groups were followed up for 28-96 months without recurrence of the tumor. Conclusion: large lump resection of the whole vertebral body may help to minimize the possibility of local recurrence and the possibility of local recurrence in the patients with severe bone destruction and the spinal dorsal and dorsal compression of the spinal cord. The application of focal isolating technique can effectively control intraoperative bleeding and reduce the use of blood products in perioperative period. At the same time, the application of isolation technique of focus will not significantly increase the time and difficulty of operation. Second partial focal isolating technique is used in the whole vertebral mass cutting of single segment thoracic vertebra tumor. Objective: To evaluate the clinical efficacy, safety and effectiveness of focal isolating technique in the total vertebral mass excision of a single segment of thoracic vertebral tumor. Methods: a retrospective study of 2 patients in our hospital in January, -2014, January 2008, which was diagnosed as single segment thoracic vertebra tumor and one stage posterior total vertebral mass excision, 2 9 cases were male 16, female 13, age 17-63 years, average 48.7 years, 12 cases of primary tumor and 17 cases of metastatic tumor. According to different surgical techniques, 2 groups were divided into traditional surgical technique group 20, and 9 cases of focus isolation technique group. All surgical operations were performed by the same operation team. The evaluation index of clinical efficacy included nerve function before and after operation. VAS score of chest and back pain, intraoperative bleeding, operation time, postoperative flow rate, postoperative drainage time and related complications. Results: 29 cases were successfully performed operation, the two groups of patients before and after the operation, the VAS score, operation time, postoperative flow rate, postoperative drainage time and related complications, no significant difference (P0.05). There was a statistical difference between the two groups of patients during intraoperative bleeding and perioperative blood transfusion (P0.05).1 patients with metastatic tumors were recurrent and died at 30 months after operation. Conclusion: the isolation technique of the lesion does not increase the time and technical difficulty of total vertebrotomy for thoracic tumors, but it can effectively reduce intraoperative bleeding and perioperative blood transfusions. It can also minimize the possibility of tumor cell contamination.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R738

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