本文選題：胸椎腫瘤 + 全椎體切除術(shù)��； 參考：《中國人民解放軍醫(yī)學院》2016年博士論文

【摘要】：脊柱腫瘤是臨床腫瘤學中相對較為少見的一類腫瘤。而發(fā)生于脊柱的原發(fā)腫瘤則更為少見。它們占到所有骨骼肌肉系統(tǒng)原發(fā)腫瘤的11%,所有脊柱腫瘤的4.2%,而在這當中大約只有0.4%是惡性腫瘤。由于解剖位置及結(jié)構(gòu)的特殊性且胸腰椎位置深在,又與重要血管及神經(jīng)組織相毗鄰,手術(shù)入路的設(shè)計和腫瘤切除一直以來是外科治療的難點。傳統(tǒng)的腫瘤切除方式多采用椎體腫瘤內(nèi)腫瘤組織刮除(curettage)和腫瘤組織逐塊咬除(piecemeal)的方式來達到切除腫瘤的目的。但是傳統(tǒng)腫瘤切除方式容易造成腫瘤對周圍組織的污染,且腫瘤組織與正常組織的邊界難以確定。為了降低腫瘤切除后復(fù)發(fā)和提高患者的生存率,Stener 和 Roy-Camille于1981年首先報道了經(jīng)后路胸椎全脊椎切除。20世紀90年代中期,日本學者Tomita等人報道了進一步改良的經(jīng)后路全椎體整塊切除術(shù)(total en bloc spondylectomy,TES),該技術(shù)通過將后弓與椎體分離后整塊切除的方式以達到全脊椎切除的目的。近些年來,隨著手術(shù)技術(shù)的不斷進步以及術(shù)前血管栓塞的應(yīng)用,TES技術(shù)已經(jīng)成為脊柱腫瘤治療的較為理想且成熟的技術(shù)。雖然有眾多學者對TES的一些技術(shù)細節(jié)進行改良與發(fā)展,但目前報道的單純后路TES技術(shù)主要包括兩部分：(1)脊椎后弓附件結(jié)構(gòu)的顯露、切除及固定；(2)脊椎前部椎體的整體分離、整塊切除及脊柱穩(wěn)定性的重建。中國人民解放軍總醫(yī)院骨科自2003年起開始開展脊柱腫瘤的全椎體整塊切除技術(shù)。經(jīng)10多年的不斷學習以及經(jīng)驗積累,TES技術(shù)已成為解放軍總醫(yī)院骨科治療脊柱腫瘤的成熟技術(shù)。自2011年1月,著者對目前應(yīng)用最廣泛的Tomita的經(jīng)典后路胸椎腫瘤TES技術(shù)的一些技術(shù)細節(jié)進行調(diào)整與改良,主要包括：先處理節(jié)段血管和神經(jīng)根后使病椎完整分離,孤立并阻斷腫瘤及椎體的血供后再進行后弓及前部椎體的整體切除(Tomita等報道方法為先顯露并切除后弓,后處理血管及神經(jīng)根并鈍性分離椎體的側(cè)、前方后再行前柱切除),著者將這些調(diào)整與改良稱之為病灶孤立化技術(shù),該技術(shù)旨在對包括腫瘤在內(nèi)的整個椎體實施整體分離、孤立后再進行截骨及椎管減壓以減少操作過程中的出血。著者最先將該技術(shù)應(yīng)用于侵襲性胸椎血管瘤的治療,后逐漸推廣應(yīng)用至其他類型胸椎腫瘤全椎體大塊切除術(shù)中。本課題采用回顧性病例對照研究對病灶孤立化技術(shù)在胸椎腫瘤全椎體大塊切除術(shù)中應(yīng)用的可行性、安全性及臨床療效進行評估。第一部分病灶孤立化技術(shù)在合并神經(jīng)功能損傷的侵襲性胸椎血管瘤全椎體大塊切除術(shù)中的應(yīng)用研究目的：評價病灶孤立化技術(shù)在合并神經(jīng)功能損傷的侵襲性胸椎血管瘤全椎體大塊切除術(shù)中應(yīng)用的可行性、安全性及臨床療效。方法：回顧性分析2005年1月～2013年1月間在我院診斷為侵襲性胸椎血管瘤并行一期后路全椎體大塊切除術(shù)的患者共17例。根據(jù)采取手術(shù)技術(shù)的不同分為兩組,傳統(tǒng)TES組10例(2011年1月之前),采用病灶孤立化技術(shù)TES組7例。對兩組患者的一般情況及手術(shù)療效進行評價,評價指標包括(1)一般情況：年齡、性別、病變部位、癥狀及癥狀持續(xù)時間、脊髓壓迫類型、神經(jīng)功能AISA評分、腫瘤的Tomita分型、胸背痛VAS評分、脊柱穩(wěn)定性SINS評分；(2)手術(shù)相關(guān)指標：手術(shù)時間、術(shù)中出血量,圍手術(shù)期輸血量(濃縮紅細胞及血漿),術(shù)后引流量及引流時間,手術(shù)并發(fā)癥。結(jié)果：對17例患者進行局部腫瘤的Tomita分型Tomita Ⅳ型7例,Tomita Ⅴ型7例,Tomita Ⅵ型1例。所有17例患者均表現(xiàn)為椎體及后弓受累導致脊髓腹背側(cè)的壓迫。7例患者出現(xiàn)病理性骨折。對脊柱穩(wěn)定性的評估采用SINS評分,傳統(tǒng)TES組9.2±1.2(8-12),TES結(jié)合病灶孤立化技術(shù)組10.3±1.5(8-12),兩組間差異無統(tǒng)計學意義(p0.05)。傳統(tǒng)TES組手術(shù)時間平均為397.5±98.3min(320-490 min), TES結(jié)合病灶孤立化技術(shù)組手術(shù)時間為415.7±67.0(300-630 min)兩組間手術(shù)時間比較無明顯統(tǒng)計學意義(P=0.68)。傳統(tǒng)TES組與TES結(jié)合病灶孤立化技術(shù)組術(shù)中出血量分別為2610.0±1009.3ml (980-3270 ml),1640±451.5ml (800-4000 ml),兩組間術(shù)中出血量的差異有統(tǒng)計學意義(P=0.03)。傳統(tǒng)TES組與TES結(jié)合病灶孤立化技術(shù)組患者圍手術(shù)期輸血量分別平均為17.3±4.6U(11.2-25.0U),14.0±4.8(7.8-20.3U)。兩組患者圍手術(shù)期輸血量之間差異無統(tǒng)計學意義(P=0.18)傳統(tǒng)TES組有2例患者術(shù)后出現(xiàn)腦脊液漏,1例出現(xiàn)胸腔積液,1例患者術(shù)后33個月時受外傷導致斷棒行翻修手術(shù)。TES結(jié)合病灶孤立化技術(shù)組有2例患者術(shù)后出現(xiàn)腦脊液漏。兩組患者隨訪28-96個月,均無腫瘤的復(fù)發(fā)。結(jié)論：對于合并有嚴重骨質(zhì)破壞以及脊髓腹背側(cè)受壓導致神經(jīng)功能損害的侵襲性胸椎血管瘤,全椎體大塊切除術(shù)有助于最大限度降低其局部復(fù)發(fā)可能并能促進神經(jīng)功能的有效恢復(fù),病灶孤立化技術(shù)的應(yīng)用可以有效控制術(shù)中出血,減少圍手術(shù)期血液制品的使用量。同時,病灶孤立化技術(shù)的應(yīng)用并不會明顯增加手術(shù)時間及手術(shù)難度。第二部分病灶孤立化技術(shù)在單節(jié)段胸椎腫瘤全椎體大塊切除術(shù)中的臨床應(yīng)用研究目的：評價病灶孤立化技術(shù)在單節(jié)段胸椎腫瘤全椎體大塊切除術(shù)中應(yīng)用的臨床療效、安全性及有效性。方法：回顧性研究2008年1月-2014年1月在我院診斷為單節(jié)段胸椎腫瘤并行一期后路全椎體大塊切除術(shù)的患者29例,其中男16例,女13例,年齡17-63歲。平均48.7歲。原發(fā)腫瘤12例,轉(zhuǎn)移性腫瘤17例。根據(jù)手術(shù)技術(shù)不同分為2組：傳統(tǒng)手術(shù)技術(shù)組20例,病灶孤立化技術(shù)組9例。所有手術(shù)操作均由同一手術(shù)團隊完成。臨床療效評價指標包括：手術(shù)前后神經(jīng)功能狀態(tài)、手術(shù)前后胸背痛VAS評分、術(shù)中出血量、手術(shù)時間、術(shù)后引流量、術(shù)后引流時間及相關(guān)并發(fā)癥。結(jié)果：29例患者均成功實施手術(shù),兩組患者在手術(shù)前后VAS評分、手術(shù)時間、術(shù)后引流量、術(shù)后引流時間及相關(guān)并發(fā)癥方面無明顯統(tǒng)計學差異(p0.05)。兩組患者在術(shù)中出血量及圍手術(shù)期輸血量之間存在統(tǒng)計學差異(p0.05)。1例轉(zhuǎn)移性腫瘤患者于術(shù)后30個月腫瘤復(fù)發(fā)并死亡。結(jié)論：病灶孤立化技術(shù)不增加胸椎腫瘤全椎體切除手術(shù)時間及技術(shù)難度,但可有效減少術(shù)中出血及圍手術(shù)期輸血量,并可最大程度降低腫瘤細胞污染的可能性。
[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.
【學位授予單位】：中國人民解放軍醫(yī)學院
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R738

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