| 骶椎神经源性肿瘤的外科治疗 |
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Received:June 19, 2021
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| 作者 | Author | 单位 | Unit | E-Mail |
| 任可 |
REN Ke |
东南大学附属中大医院骨科, 江苏 南京 210009 |
Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing 210009, Jiangsu, China |
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| 樊根涛 |
FAN Gen-tao |
东部战区总医院骨科, 江苏 南京 210002 |
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| 周志文 |
ZHOU Zhi-wen |
东南大学附属中大医院骨科, 江苏 南京 210009 |
Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing 210009, Jiangsu, China |
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| 吴苏稼 |
WU Su-jia |
东部战区总医院骨科, 江苏 南京 210002 |
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| 施鑫 |
SHI Xin |
东部战区总医院骨科, 江苏 南京 210002 |
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| 陆军 |
LU Jun |
东南大学附属中大医院骨科, 江苏 南京 210009 |
Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing 210009, Jiangsu, China |
lujun_southeast@126.com |
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| 期刊信息：《中国骨伤》2022年35卷，第5期，第470-475页 |
| DOI：10.12200/j.issn.1003-0034.2022.05.012 |
| 基金项目:国家自然科学基金面上项目(编号:81673017);江苏省自然科学基金面上项目(编号:BK2012775) |
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目的:观察Ⅰ期肿瘤切除手术治疗骶椎神经源性肿瘤的疗效及并发症,探讨手术相关的解剖学原理。
方法:对2001年1月至2018年1月手术治疗的26例骶椎神经源性肿瘤患者进行回顾性分析,男16例,女10例;年龄21~69(39.3±10.9)岁;病程3~56(17.9±10.1)个月;骶前肿块直径3.3~19.6(8.7±4.1) cm;骶前肿块上缘高于和不高于L5S1间隙水平者分别为6和20例。手术均先取后入路,必要时附加前入路,Ⅰ期切除肿瘤,部分患者行腰椎-骨盆内固定重建,术中视情况决定是否保留载瘤神经根。记录患者的手术时间、术中出血量、疼痛缓解程度及并发症情况。术后随访评估腰骶椎稳定性和神经功能,并检查有无局部复发和远处转移。
结果:26例均Ⅰ期完整切除肿瘤,手术时间(160.4±35.3) min,术中出血量(1 092.3±568.8) ml。单纯后入路21例,前后联合入路5例。前后联合入路者骶前肿块直径11.3~19.6(15.1±3.2) cm,单纯后入路者为3.3~10.9(7.2±2.4) cm。骶前肿块上缘高于L5S1间隙的6例患者中5例采取了前后联合入路,不超过L5S1间隙的20例均为单纯后入路。所有病例获得随访,时间6~82(45.4±18.2)个月。术后腰骶痛、下肢根性痛均明显缓解,感觉、肌力和二便功能也有不同程度改善。术后切口浅表感染1例,脑脊液漏2例。病理证实神经鞘瘤17例,神经纤维瘤7例,恶性神经鞘瘤2例。2例良性神经源性肿瘤局部复发,1例恶性神经鞘瘤术后20个月时死于肺转移。17例高位骶骨神经源性肿瘤有4例未行内固定重建,其中2例术后脊柱失稳。7例切除载瘤神经根,其中1例同时切除S2和S3神经根的患者术后出现膀胱和直肠功能异常,且未能完全恢复,另6例神经功能无明显损害或恢复良好。
结论:后入路能直接显露病灶,处理神经根和血管也方便,手术时间、术中出血量、症状缓解程度、并发症率和复发转移率均能控制在适当水平,是安全有效的手术入路;但当骶前肿块上缘高于L5S1水平或骶前肿块直径达到10 cm以上时,应考虑附加前方入路。脊柱和骨盆之间应力较高,高位骶椎神经源性肿瘤切除术中应使用内固定重建脊柱-骨盆的力学连续性。载瘤神经根多已丧失功能,切除单根载瘤神经根不易引起严重神经功能障碍,而邻近神经根具有代偿功能,术中应尽量保留。 |
| [关键词]:神经源性肿瘤 骶椎 重建术 外科手术 |
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| Surgical management of sacral neurogenic tumors |
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Abstract:
Objective: To observe the efficacy and complications of one-stage tumor resection to treat primary sacral neurogenic tumors and to discuss some details in the clinically relevant anatomy.
Methods: A retrospective analysis of 26 patients with neurogenic turors of the sacral spine who were surgically treated from January 2001 to January 2018,including 16 males and 10 females,aged from 21 to 69 years old with an average age of (39.3±10.9) years old. The courses of diseases ranged from 3 to 56 months with an average of (17.9±10.1) months. The diameters of presacral components ranged from 3.3 to 19.6 cm with an average of (8.7±4.1) cm. The proximal margin of presacral lesions was above the L5S1 level in 6 cases,and lower than L5S1 in 20 cases. A posterior incision approach for one-stage complete resection of the tumor was used firstly,and an anterior approach was combined when necessary. Spinal-pelvic reconstruction with the modified Galveston technique was also carried out in relevant cases. Whether to preserve the tumor-involved nerve roots depended on the situation during the operation. The operation time,intraoperative blood loss,pain relief,and complications were recorded. The lumbosacral spine stability and sacral plexus neurological function were evaluated during postoperative follow-up,and local recurrence and distant metastasis were examined as well.
Results: Total excision was achieved in all 26 patients,with an operation time of (160.4±35.3) mins and an intraoperative blood loss of (1 092.3±568.8) ml. Tumors have been removed via a posterior-only approach in 21 cases and via combined anterior/posterior approaches in 5 cases. The diameter of presacral masses components ranged from 11.3 to 19.6 cm with an average of (15.1±3.2) cm in patients with combined anterior/posterior approaches,and ranged from 3.3 to 10.9 cm with an average of (7.2±2.4) cm in patients with a posterior-only approach. Five of the six patients whose proximal margin of presacral masses was above the L5S1 level adopted combined anterior/posterior approaches,and 20 patients lower than the L5S1 level adopted the posterior-only approach. All the patients were followed up for 6 to 82 months with an average of(45.4±18.2)months. Postoperative lumbosacral pain and lower extremity radicular pain were significantly relieved,and sensation,muscle strength and bowel and bladder function were also improved to varying degrees. The postoperative early complications included superficial wound infection in 1 case and cerebrospinal fluid leakage in 2 cases. Pathology confirmed 17 cases of schwannoma,7 cases of neurofibroma and 2 cases of malignant schwannoma. Local recurrence was observed in two cases of benign neurogenic tumors. One patient with a malignant nerve sheath tumor had lung metastasis,who died 20 months after the operation. In 17 cases of upper sacral neurogenic tumors,4 cases did not undergo spinal-pelvic reconstruction with internal fixation,of which 2 cases suffered from postoperative segmental instability. Tumor-involved nerve roots were resected during surgery in 7 cases. One of these patients who had S2 and S3 nerve roots sacrificed simultaneously had an impaired bladder and bowel function postoperatively,and did not recover completely. In the other 6 cases,the neurological function was not damaged obviously or recovered well.
Conclusion: The posterior approach can directly expose the lesions,and it is also convenient to deal with nerve roots and blood vessels. The operation time,intraoperative blood loss,degree of symptom relief,complication rate,and recurrence and metastasis rate can be controlled at an appropriate level. It is a safe and effective surgical approach. When the upper edge of the presacral mass is higher than the L5S1 level or the diameter of the presacral mass exceeds 10 cm,an additional anterior approach should be considered. The stress between the spine and pelvis is high,and internal fixation should be used to restore the mechanical continuity of the spine and pelvis during resection of neurogenic tumors of the high sacral spine. Most of the parent nerve roots have lost their function. Resection of a single parent nerve root is unlikely to cause severe neurological dysfunction,while the adjacent nerve roots have compensatory functions and should be preserved as much as possible during surgery. |
| KEYWORDS:Neurogenic tumors Sacrum Reconstruction Surgical procedures,operative |
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| 引用本文，请按以下格式著录参考文献： |
| 中文格式: | 任可,樊根涛,周志文,吴苏稼,施鑫,陆军.骶椎神经源性肿瘤的外科治疗[J].中国骨伤,2022,35(5):470~475 |
| 英文格式: | REN Ke,FAN Gen-tao,ZHOU Zhi-wen,WU Su-jia,SHI Xin,LU Jun.Surgical management of sacral neurogenic tumors[J].zhongguo gu shang / China J Orthop Trauma ,2022,35(5):470~475 |
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