穿刺针作为线锯引导器在胸腰椎肿瘤全脊椎整块切除术中的应用

摘要

目的 探讨应用经皮椎体成形穿刺针作为线锯引导器在胸腰椎肿瘤一期后路全脊椎整块切除术中的可操作性和安全性.方法 收集并回顾性分析2017年6月至2018年3月接受一期后路全脊椎整块切除术式治疗的胸腰椎肿瘤患者4例,男2例,女2例,年龄50～77岁,平均63.75岁.Tomita 5型T7原发弥漫大B细胞淋巴瘤1例,Tomita 3型T5肺癌骨转移1例,Tomita 5型T9前列腺癌骨转移1例,Tomita4型L2肾癌骨转移1例.利用经皮椎体成形穿刺针结合改良的“两侧锯割、中间切断”三步法椎间盘截断技术对4例胸腰椎恶性肿瘤行一期后路全脊椎整块切除术,记录手术时间、术中出血量,观察病椎切除的完整性、术后并发症,术前术后进行疼痛视觉模拟评分(visual analogue score,VAS)评估患者疼痛改善情况,采用美国脊柱损伤协会(American Spinal Injury Association,ASIA)神经功能分级评估胸椎肿瘤患者神经功能的改善情况,对受累肌群行肌力分级以评估腰椎肿瘤患者神经功能的改善情况.结果 4例病椎均获得两部分整块切除,手术时间4.0～6.5 h,平均4.9 h,术中出血量800～9000 ml,平均3 200 ml.术中未发生硬脊膜撕裂、脑脊液漏、医源性脊髓损伤和大血管损伤,术中线锯切割平面牢固定位于椎间盘层面,没有发生切割平面的滑移.术后4例患者疼痛较术前都明显缓解,VAS评分由术前平均7.5分(6～9分)降低至术后平均1.75分(1～2分),平均降低5.75分(5～7分).术后神经症状均未加重,并且3例患者ASIA分级或肌力分级较术前均提高1级,其中2例胸椎肿瘤病例ASIA分级由术前B级改善至术后C级,1例腰椎肿瘤病例受累肌群肌力由术前3级改善至术后4级.术后随访3.5～12个月,平均8.1个月,均无局部复发,1例肺癌骨转移患者出现间断性肋间神经痛.结论 采用经皮椎体成形穿刺针作为线锯引导器,无论在截断椎弓根时,还是改良三步法截断椎间盘时,均有良好的可操作性和安全性.%Objective To explore the practicability and safety of the application of Percutaneous Vertebroplasty puncture (PVP) needle as a saw guide in the Total En-bloc Spondylectomy (TES) of thoracic and lumbar tumor through single posterior approach.Methods From June 2017 to March 2018,four patients with thoracic and lumbar vertebral neoplasms were analyzed retrospectively.They included 2 males and 2 females,which aged 50-77 years with an average age of 63.75 years.There were 1 case of Tomita 5 grade T7 lymphoma,1 case of Tomita 3 grade T5 metastasis of lung cancer,1 case of Tomita 5 grade T9 metastasis of prostate cancer and 1 case of Tomita 4 grade L2 metastasis of renal cancer.The PVP needle combined with the modified "3-step" method was applied in TES for 4 cases through posterior approach.The operative time and intraoperative blood loss were recorded.The integrity of excised vertebra and postoperative complications were observed.The visual analogue score (VAS) was evaluated to assess the pain improvement.The ASIA classification was evaluated for the assessment of neurological function of thoracic vertebral tumor cases and the muscle strength grades was evaluated for the assessment of neurological function of lumbar vertebral tumor cases.Results In all 4 cases,the vertebra was removed entirely.The average operation time was 4.9 h (4.0-6.5 h)and average blood loss was 3 200 ml (800-9 000 ml).No pachymeninx injury,cerebrospinal fluid leakage,iatrogenic spinal cord injury or vascular injury occurred.During the surgery,the saw-cutting plane is firmly located in the intervertebral disc and no slippage of the cutting plane was observed.Postoperatively,the pain was significantly alleviated.The VAS score decreased to average 1.75 points (1-2 points) after surgery,average reduction of 5.75 points (5-7 points).The neurological deficit was not aggravated in all patients.The neurological improvement of one grade was observed in 3 patients.Two cases of thoracic vertebral tumor had a grade of ASIA classification improved from grade B to grade C.One case of lumbar vertebral tumor had a grade of lower limb muscle strength improved from grade 3 to grade 4.No recurrence of tumor was observed at average 8.1 months (3.5-12 months) followup and 1 case of bone metastasis of lung cancer had intermittent intercostal neuralgia.Conclusion It is feasible and safe to apply PVP puncture needle as a saw guide in TES of thoracic and lumbar tumor through single posterior approach,on the basis of this,the "3-step" intervertebral disc truncation technique is developed,which has good practicability and high safety.