论文部分内容阅读
目的探讨前后联合入路切除胸腰段椎管巨大哑铃形肿瘤的临床疗效。方法 2009年1月-2015年3月,采用经后正中入路联合侧前方经膈肌脚、胸膜外腹膜后入路切除胸腰段椎管巨大哑铃形肿瘤12例。男9例,女3例;年龄30~65岁,平均45岁。病程8~64周,平均12.7周。椎管外肿瘤部分位于T12、L1 6例,L1、25例,L2、3 1例;肿瘤大小范围为4.3 cm×4.0 cm×3.5 cm~7.5 cm×6.3 cm×6.0 cm。根据椎管外肿瘤累及的范围与部位,在Eden分型基础上对胸腰段Ⅱ、Ⅲ、Ⅳ型肿瘤在纵向和横向的侵犯范围进行二次评估,横向为b型5例,d型2例,e型4例,f型1例;纵向累及2个节段椎体8例,2个以上节段椎体4例。术后定期随访观察肿瘤切除情况、是否复发及脊柱稳定性等;采用语言疼痛程度分级法(VRS)评价术后疼痛改善情况。结果手术时间150~230 min,平均170 min;术中失血量270~600 m L,平均350 m L。术后切口均Ⅰ期愈合,无切口及胸腔感染等并发症发生。术后组织病理学确诊为神经鞘瘤10例,神经纤维瘤2例。12例均获随访,随访时间6个月~6年,平均31个月。神经症状均明显改善,腰背部无异常酸痛感。复查胸腰段X线片、MRI未见肿瘤残留,随访期间无病变复发及内固定物松动、断裂,脊柱侧弯等并发症发生。患者术前VRS分级为Ⅰ级2例、Ⅱ级8例、Ⅲ级2例,末次随访时恢复至0级10例、Ⅰ级2例,与术前比较差异有统计学意义(Z=—3.217,P=0.001)。结论经后正中入路联合侧前方经膈肌脚、胸膜外腹膜后入路可安全、完整地切除胸腰段椎管巨大哑铃形肿瘤,并可较好地保护胸腰段脊柱稳定性及椎旁肌肉功能,对于复杂分型的胸腰段椎管哑铃形肿瘤可取得较好疗效。
Objective To investigate the clinical effect of anterior and posterior combined approach in removing huge dumbbell tumors of the thoracolumbar spinal canal. Methods From January 2009 to March 2015, 12 cases of thoracolumbar spinal dumbbell tumor were excised via the transphincteric and pleural retroperitoneal approach with the anterolateral approach anterior approach. 9 males and 3 females; aged 30 to 65 years, mean 45 years old. Course of 8 to 64 weeks, an average of 12.7 weeks. The part of tumor outside the spinal canal was located in T12, L1 6 cases, L1,25 cases, L2,31 cases; the tumor size range was 4.3 cm × 4.0 cm × 3.5 cm ~ 7.5 cm × 6.3 cm × 6.0 cm. According to the extent and location of the extracapsular tumor involved in the classification, based on the Eden classification of thoracolumbar type Ⅱ, Ⅲ, Ⅳ in the longitudinal and transverse extent of invasion of the second evaluation of the horizontal b-type in 5 cases, d-type 2 For example, e-type in 4 cases, f-type in 1 case; longitudinally involving 2 segments of the vertebral body in 8 cases, more than 2 segments in 4 cases. Postoperative follow-up was performed to observe tumor resection, recurrence and stability of the spine. VRS was used to evaluate the postoperative pain relief. Results The operation time ranged from 150 to 230 minutes, with an average of 170 minutes. The intraoperative blood loss was 270 to 600 m L with an average of 350 m L. Postoperative incision healed at first intention, no incision and thoracic infection and other complications occurred. Postoperative histopathology diagnosed as schwannoma in 10 cases, neurofibroma in 2 cases. All 12 patients were followed up for 6 months to 6 years with an average of 31 months. Neurological symptoms were significantly improved, no abnormalities on the back and back pain. Review of thoracolumbar radiographs, MRI no tumor residues, no recurrence during the follow-up and internal fixation loosening, rupture, scoliosis and other complications. The preoperative VRS grade was grade Ⅰ in 2 cases, grade Ⅱ in 8 cases and grade Ⅲ in 2 cases. At the last follow-up, the patients were recovered to grade 0 in 10 cases and grade Ⅰ in 2 cases. The difference was statistically significant (Z = -3.217 , P = 0.001). Conclusions The posterior pleural approach combined with anterolateral approach can safely and completely remove the huge dumbbell tumor of the thoracolumbar spinal canal through the transphincterous and extrapleural retroperitoneal approach and can well protect the thoracolumbar spinal stability and paraspinal Muscle function, for complex type of thoracolumbar spinal dumbbell tumor can achieve better results.