Donnelly Dustin J, Abd-El-Barr Muhammad M, Lu Yi
Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
World Neurosurg. 2015 Nov;84(5):1484-90. doi: 10.1016/j.wneu.2015.06.018. Epub 2015 Jun 20.
Palliative tumor resection and subsequent stabilization are important for maximizing function and quality of life for patients suffering from spinal metastases. However, traditional operative techniques for spinal metastases with vertebral body destruction involve extensive soft tissue dissection. In the lumbar spine, open 2-staged spine procedures are routinely required with an anterior retroperitoneal approach for corpectomy and cage insertion and posterior decompression and stabilization with pedicle screws and rods. Both stages require extensive soft tissue dissection that results in significant surgical morbidity, long recovery time, and subsequent delay in initiating postoperative chemoradiotherapy, as well as initially hampering patients' overall quality of life. A minimally invasive approach is desirable for achieving spinal stability, pain control, functional recovery, rapid initiation of adjuvant therapies, and overall patient satisfaction, especially in patients whose medical and surgical therapies are aimed at palliation rather than cure.
A 59-year-old man with renal cell carcinoma and a known L1 vertebral body metastasis presented with severe progressive low back pain and was found to have a pathologic L1 vertebral body fracture with focal kyphosis.
Here, we describe a minimally invasive muscle-sparing, posterior-only approach for L1 transpedicular hemicorpectomy and expandable cage placement, L1 laminectomy, and T11-L3 posterior instrumented stabilization. The surgical corridor was achieved through the Wiltse muscle plane between the multifidus and longissimus muscles so that minimal muscle detachment was required to achieve transpedicular access to the anterior and middle spinal columns. The L1 nerve root was completely skeletonized to allow adequate lumbar hemicorpectomy, tumor resection, and expandable titanium cage insertion. Lastly, percutaneous pedicle screws and rods were inserted from T11 to L3 for stabilization.
The patient tolerated the procedure well with no complications and less than 200 mL estimated blood loss. Postoperative computed tomography revealed restoration of intervertebral height and adequate tumor resection with excellent placement of the expandable cage and posterior construct. The patient was discharged on postoperative day 4 and had nearly no back pain 3 weeks after surgery. Adjuvant therapies were started soon after. At the 6-month follow-up, the patient required minimal narcotic pain medication. Computed tomography scan demonstrated stable hardware with no evidence of failure.
A minimally invasive muscle-sparing, posterior-only approach is a promising surgical strategy for 360-degree decompression and stabilization for the treatment of lumbar spinal metastases with minimized blood loss, muscle detachment and postoperative pain, and fast postoperative recovery and initiation of adjuvant therapy.
姑息性肿瘤切除及后续稳定对于使脊柱转移瘤患者的功能和生活质量最大化至关重要。然而，对于椎体破坏的脊柱转移瘤，传统手术技术需要广泛的软组织剥离。在腰椎，通常需要采用开放性两阶段脊柱手术，先行经腹膜后前路椎体切除及椎间融合器植入，再行后路减压并用椎弓根螺钉和棒进行稳定固定。两个阶段都需要广泛的软组织剥离，这会导致显著的手术并发症、较长的恢复时间以及术后放化疗开始的延迟，同时最初还会影响患者的整体生活质量。对于实现脊柱稳定、控制疼痛、功能恢复、快速开始辅助治疗以及提高患者总体满意度而言，微创方法是可取的，尤其是对于那些医疗和手术治疗旨在姑息而非治愈的患者。
一名59岁的男性，患有肾细胞癌且已知L1椎体转移，出现严重的进行性下腰痛，经检查发现L1椎体病理性骨折并伴有局部后凸畸形。
在此，我们描述一种微创保留肌肉的单纯后路手术方法，用于L1经椎弓根半椎体切除及可扩张椎间融合器置入、L1椎板切除术以及T11 - L3后路器械固定。手术通道通过多裂肌和最长肌之间的Wiltse肌平面建立，这样只需最小程度的肌肉分离就能经椎弓根进入脊柱前柱和中柱。L1神经根被完全游离以确保充分的腰椎半椎体切除、肿瘤切除以及可扩张钛制椎间融合器置入。最后，从T11至L3经皮置入椎弓根螺钉和棒进行固定。
患者对手术耐受性良好，无并发症，估计失血量少于200毫升。术后计算机断层扫描显示椎间高度恢复，肿瘤切除充分，可扩张椎间融合器及后路内固定装置位置良好。患者术后第4天出院，术后3周几乎无背痛。术后不久即开始辅助治疗。在6个月的随访中，患者仅需少量麻醉性止痛药物。计算机断层扫描显示内固定稳定，无失败迹象。
微创保留肌肉的单纯后路手术方法是一种有前景的手术策略，可用于对腰椎脊柱转移瘤进行360度减压和固定，具有失血量少、肌肉分离少、术后疼痛轻、术后恢复快以及能快速开始辅助治疗等优点。
