Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
Department of Neurological Surgery, Weill Cornell Medical College, New York, New York.
Oper Neurosurg (Hagerstown). 2019 Mar 1;16(3):310-318. doi: 10.1093/ons/opy137.
Despite major advances in radiation and systemic treatments, surgery remains a critical step in the multidisciplinary treatment of metastatic spinal cord tumors.
To describe the indications, rationale, and technique of "hybrid therapy" (separation surgery and concomitant spine stereotactic radiosurgery [SRS]) along with practical nuances.
Separation surgery describes a posterolateral approach for circumferential epidural decompression and stabilization. The goal is to decompress the spinal cord, stabilize the spine, and create adequate separation between the neural elements and the tumor for SRS to achieve durable tumor control.
A transpedicular route to achieve ventrolateral access and limited resection of the tumorous vertebral body is carried out. In the setting of high-grade cord compression, caution must be taken when performing the tumor decompression. "Separation" of the ventral epidural tumor component anteriorly creates space for concomitant SRS while a simple laminectomy would not adequately achieve this goal. Dissection of the posterior longitudinal ligament allows maximal ventral decompression. Gross total tumor resection is not crucial for durable tumor control using the "hybrid therapy" model. Thus, attempts at ventral tumor resection may unnecessarily increase operative morbidity. Cement augmentation of the construct or vertebral body may improve construct stability. CT myelogram is the preferred exam for postoperative SRS planning. Radiosurgical planning constitutes a multidisciplinary effort and guidelines for contouring in the postoperative setting have recently become available.
Separation surgery is an effective, well-tolerated, and reproducible surgery. It provides safe margins for concomitant SRS. Combined, this "Hybrid Therapy" allows durable local control, maintenance of spinal stability, and palliation of symptoms, while minimizing operative morbidity.
尽管在放射治疗和全身治疗方面取得了重大进展，但手术仍然是治疗转移性脊髓肿瘤的多学科治疗的关键步骤。
描述“混合治疗”（分离手术和同期脊柱立体定向放射外科手术[SRS]）的适应证、原理和技术，以及实用的细微差别。
分离手术描述了一种用于环形硬膜外减压和稳定的后外侧入路。其目的是使脊髓减压、脊柱稳定，并在神经元件和肿瘤之间创造足够的分离，以实现 SRS 的持久肿瘤控制。
采用经椎弓根途径实现腹外侧入路，并对肿瘤性椎体进行有限切除。在高级别脊髓压迫的情况下，在进行肿瘤减压时必须小心谨慎。“分离”前部的腹侧硬膜外肿瘤成分，为同期 SRS 创造空间，而单纯椎板切除术则无法充分实现这一目标。后纵韧带的解剖允许最大限度的腹侧减压。采用“混合治疗”模型，肿瘤的完全切除对持久的肿瘤控制并不重要。因此，尝试进行腹侧肿瘤切除可能会不必要地增加手术发病率。对结构或椎体进行骨水泥增强可能会提高结构的稳定性。CT 脊髓造影是术后 SRS 计划的首选检查。放射外科计划是一项多学科的努力，最近已经有了用于术后轮廓勾画的指南。
分离手术是一种有效、耐受良好且可重复的手术。它为同期 SRS 提供了安全的边缘。这种“混合治疗”联合应用可实现持久的局部控制、脊柱稳定性的维持和症状的缓解，同时最大限度地减少手术发病率。
