Department of Orthopaedic Surgery, Keio University, Tokyo, Japan.
J Neurosurg Spine. 2011 Sep;15(3):320-7. doi: 10.3171/2011.5.SPINE10813. Epub 2011 Jun 3.
The object of this study was to investigate failures after spinal reconstruction following total en bloc spondylectomy (TES), related factors, and sequelae arising from such failures in patients with malignant spinal tumors.
Fifteen patients (12 males and 3 females, with a mean age of 46.5 years) with malignant spinal tumors who underwent TES and survived for more than 1 year were included in this analysis (mean follow-up 41.5 months). Seven patients had primary tumors, including giant cell tumors in 4 patients, chordoma in 2, and Ewing sarcoma in 1. Eight patients had metastatic tumors, including thyroid cancer in 6 and renal cell cancer and malignant fibrous histiocytoma in 1 patient each. Seven patients without prominent paravertebral extension of the tumor were treated using a posterior approach alone, and 8 patients who exhibited prominent anterior or anterolateral extension of the tumors into the thoracic or abdominal cavity were treated using a combined anterior and posterior approach. Spinal reconstruction after tumor resection was performed using a combination of anterior structural support and posterior instrumentation. The relationship between instrumentation failure and clinical and radiographic factors, including age, sex, history of previous surgery, preoperative radiotherapy, tumor histology, tumor level, surgical approach, number of resected vertebrae, rod diameter, number of instrumented vertebrae, and cage subsidence, was investigated.
Six patients (40%) with spinal instrumentation failure were identified: rod breakage occurred in 3 patients, and breakage of both the rod and the cage, combined cage breakage and screw back-out, and endplate fracture arising from cage subsidence occurred in 1 patient each. All of these patients experienced acute or chronic back pain, but only 1 patient with a tumor recurrence experienced neurological deterioration upon instrumentation failure. Cage subsidence (≥ 5 mm), preoperative irradiation, and the number of instrumented vertebrae (≤ 4 vertebrae) were significantly related to late instrumentation failure.
Late instrumentation failure was a frequent complication after TES. Although patients with instrumentation failure experienced back pain, the neurological sequelae were not catastrophic. For prevention, meticulous preparation of the graft site and a longer posterior fixation should be considered.
本研究旨在探讨全脊椎整块切除术（TES）后脊柱重建失败的原因、相关因素及由此导致的恶性脊柱肿瘤患者的后遗症。
本研究纳入了 15 名接受 TES 且存活时间超过 1 年的恶性脊柱肿瘤患者（平均随访时间为 41.5 个月）。男性 12 例，女性 3 例，平均年龄为 46.5 岁。7 例为原发性肿瘤，包括 4 例巨细胞瘤、2 例脊索瘤和 1 例尤文肉瘤；8 例为转移性肿瘤，包括 6 例甲状腺癌和 1 例肾癌、恶性纤维组织细胞瘤各 1 例。7 例无明显椎旁肿瘤延伸的患者仅采用后路治疗，8 例肿瘤有明显前侧或前外侧延伸至胸或腹腔的患者采用前路和后路联合治疗。肿瘤切除后采用前路结构支撑和后路器械固定进行脊柱重建。分析了器械失败与年龄、性别、既往手术史、术前放疗、肿瘤组织学、肿瘤水平、手术入路、切除椎体数、杆直径、固定椎体数和 cage 下沉等临床和影像学因素的关系。
发现 6 例（40%）患者发生脊柱内固定失败：3 例发生杆断裂，1 例发生杆和 cage 同时断裂、cage 断裂和螺钉退出、cage 下沉引起的终板骨折。所有这些患者均出现急性或慢性背痛，但只有 1 例肿瘤复发患者在器械失败后出现神经功能恶化。Cage 下沉（≥5mm）、术前放疗和固定椎体数（≤4 个椎体）与晚期器械失败显著相关。
TES 后晚期器械失败是一种常见并发症。尽管器械失败的患者有背痛，但神经后遗症并不严重。为了预防，应仔细准备植骨部位，并延长后路固定。
