【作者】 高波；

【导师】 杨志平；

【作者基本信息】 山东大学 ， 外科学， 2010， 硕士

【摘要】 目的探讨椎弓根途径椎体成形术及开放性手术联合椎体成形术治疗椎体转移瘤、血管瘤和多发性骨髓瘤的适应症选择、手术方法和临床治疗效果。材料和方法本组12例,男7例,女5例,38-78岁,平均55.58岁,自2003年2月至2009年5月对12例胸、腰椎椎体肿瘤患者实行了椎弓根途径椎体成形术,其中行经皮穿刺椎体成形术5例,后路椎管减压内固定、椎体成形术7例。本组患者骨髓瘤8例,血管瘤1例,脊柱转移瘤3例,其中包括肺癌1例,肾癌1例,神经内分泌肿瘤1例。病变椎体分布胸椎10个椎体,腰椎椎体7个。1例患者术前曾有放疗史,1例患者曾有化疗史,所有患者均有胸腰背部疼痛。术前VAS评分平均为6.8±0.99分。其中2例有脊髓压迫和下肢症状,Frankel分级为B级1例,C级1例。本组患者行经皮穿刺椎体成形术者均经单侧椎弓根穿刺。结果所有患者分别于术后1周、3个月、6个月、12个月进行疼痛、神经症状和生活质量评价。随访平均37个月。术后3天内疼痛明显缓解,活动能力增加,患者对手术效果满意,术后第3天平均VAS评分降至1.0±0.71分,差异具有显著的统计学意义(P<0.01)。2例截瘫患者Frankle分级分别从术前的B级、C级变为D级。椎体成形术骨水泥注入量平均为3ml。1例患者骨水泥渗漏至椎体侧前方(见图1)。术后骨髓瘤患者均接受化疗。神经功能：术后未出现因骨水泥渗漏导致的神经损伤。术后随访中未发现椎体塌陷加重及邻近节段椎体发生压缩性骨折。结论椎弓根途径椎体成形术对胸腰椎椎体肿瘤有良好的止痛效果,能够稳定椎体,有效预防椎体病理性骨折的发生,明显提高患者生存质量,已得到临床循证医学的肯定,是治疗椎体溶骨性肿瘤的有效方法。椎体后壁不完整是经皮椎体成形术和后凸成形术的禁忌症,但是开放性手术可以在直视下监控骨水泥在椎管内的渗漏情况,因此开放行椎体成形术可被广泛应用。由于椎体转移性肿瘤和多发性骨髓瘤患者的全身情况一般较差,脊柱多节段受累,身体其他部位的骨骼亦有受累,需要在尽可能短的时间内解决疼痛和脊髓压迫症状,但是患者无法承受创伤较大的前路或前后路联合椎体切除,椎管减压内固定术,因此后路椎管减压内固定、椎体成形术可一次性解除脊髓压迫,稳定脊柱,减少了手术创伤和手术风险,缩短了手术时间,手术效果确切。本组病例的临床效果进一步说明了后路椎管减压内固定联合椎体成形术的有效性和安全性,可以更好地缓解疼痛,改善神经症状,提高患者的生活质量,为无法承受脊柱前路手术的患者提供了一种可选择的手术方式。更多还原

【Abstract】 Objective To evaluate the indication and clinical efficacy of vertebroplasty and open vertebroplasty in the treatment of spinal metastases, hemangioma and multiple myeloma.Materials and Methods From February 2003 to May 2009,12 patients underwent vertebroplasty. There were 7 men,5 women. Their mean age was 55.58(range,38-78).5 of 12 patients underwent percutaneous vertebroplasty.7 of them underwent posterior spinal cord decompression, internal fixation and vertebroplasty during the same operation. There were 8 patients with multiple myeloma,1 with hemangioma and 3 with metastases, including 1 with lung cancer,1 with renal carcinoma and 1 with neuroendocrine tumor.17 levels were treated.10 thoracic vertebarl bodies and 7 lumbar vertebral bodies were affected.1 patient underwent preoperative radiotherapy.1 patient underwent preoperative chemotherapy. All patients complained severe back or lumbar pain. The mean visual analog scale (VAS) was 6.8±0.99. Spinal compression and neurological deficits of lower limb preoperatively were seen in 2 patients. According to system of Frankel and neurological function,1 patient was grade B.1 was grade C. All percutaneous vertebroplasty were unipedicular.ResultsThe alleviation of pain and capability of movement were reevaluated on 1 week,3 months,6 months and 12 months after operation. All patients were followed up. The mean follow-up period was 37 months. The pain was dramatically reduced 3 days after operation. The movement capability was improved. The patients were satisfied. The mean VAS decreased to 1.0±0.71. The difference is statistical (P＜0.01). Two patients recovered from grade B and C to grade D after operation. The mean injection volume of cement was 3 ml. Cement leakage was revealed in 1 patient (figure 1). All patients suffered from multiple myeloma received postoperative chemotherapy. No procedure-related complications occurred. We did not find deteriorated vertebral body get worse and compression fracture of consecutive vertebral body.ConclusionsVertebroplasty can reduce the pain from tumor of thoracic and lumbar vertebral body satisfyingly, consolidate the vertebral body, prevent pathological fracture of deteriorated vertebral body and improve living quality. It was demonstrated by evidence-based medicine. It has been an effective way to treat osteolytic tumor. Incompleteness of posterior wall of vertebral body was contraindication of PVP and PKP. Open vertebroplasty can monitor the cement leakage in the spinal canal and be used widely. The patients suffered from spinal metastases and multiple myeloma were in poor general health and not able to bear the anterior vertebrectomy or anterior and posterior combined vertebrectomy, decompression of spinal canal. The open vertebroplasty can alleviate the spinal cord symptoms and stabilizate vertebral volumn. It can reduce operative time, surgical trauma and risks. This group of cases conformed the safety and efficacy of PVP, PKP and open vertebroplasty. This procedure provide an alternative treatment for the patients with spinal metastases and multiple myeloma. Better results of pain relief and neurologic recovery and living quality can be achieved.更多还原