Gokaslan Z L, Romsdahl M M, Kroll S S, Walsh G L, Gillis T A, Wildrick D M, Leavens M E
Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
J Neurosurg. 1997 Nov;87(5):781-7. doi: 10.3171/jns.1997.87.5.0781.
Although radical resection is the best treatment for malignant sacral tumors, total sacrectomy for such tumors has been performed in only a few instances. Total sacral resection requires reconstruction of the pelvic ring plus establishment of a bilateral union between the lumbar spine and iliac bone. This technique is illustrated in two patients harboring large, painful, sacral giant-cell tumors that were unresponsive to prior treatment. These patients were treated with complete en bloc resection of the sacrum and complex iliolumbar reconstruction/stabilization and fusion. Surgery was performed in two stages, the first consisting of a midline celiotomy, dissection of visceral/neural structures, and ligation of internal iliac vessels, followed by an anterior L5-S1 discectomy. The second stage consisted of mobilization of an inferiorly based myocutaneous rectus abdominis pedicle flap for wound closure, followed by an L-5 laminectomy, bilateral L-5 foraminotomy, ligation of the thecal sac, division of sacral nerve roots, and transection of the ilia lateral to the tumor and sacroiliac joints. Placement of the instrumentation required segmental fixation of the lumbar spine from L-3 down by means of pedicle screws and the establishment of a bilateral liaison between the lumbar spine and the ilia by using the Galveston L-rod technique. The pelvic ring was then reestablished by means of a threaded rod connecting left and right ilia. Both autologous (posterior iliac crest) and allograft bone were used for fusion, and a tibial allograft strut was placed between the remaining ilia. The patients were immobilized for 8 weeks postoperatively and underwent progressive rehabilitation. At the 1-year follow-up review, one patient could walk unassisted, and the other ambulated independently using a cane. Both patients controlled bowel function satisfactorily with laxatives and diet and could maintain continence but required self-catheterization for bladder emptying. The authors conclude that in selected patients, total sacrectomy represents an acceptable surgical procedure that can offer not only effective local pain control, but also a potential cure, while preserving satisfactory ambulatory capacity and neurological function.
尽管根治性切除是恶性骶骨肿瘤的最佳治疗方法，但针对此类肿瘤的全骶骨切除术仅在少数病例中实施过。全骶骨切除术需要重建骨盆环，并在腰椎和髂骨之间建立双侧连接。本文展示了两名患有大型、疼痛性骶骨巨细胞瘤且先前治疗无效的患者的治疗技术。这两名患者均接受了骶骨整块切除及复杂的髂腰重建/稳定和融合手术。手术分两个阶段进行，第一阶段包括中线剖腹术、内脏/神经结构解剖以及髂内血管结扎，随后进行L5-S1前路椎间盘切除术。第二阶段包括调动以下方为基底的腹直肌肌皮蒂瓣用于伤口闭合，随后进行L5椎板切除术、双侧L5椎间孔切开术、结扎硬膜囊、切断骶神经根以及在肿瘤和骶髂关节外侧切断髂骨。器械置入需要通过椎弓根螺钉对L3以下的腰椎进行节段性固定，并采用加尔维斯顿L形棒技术在腰椎和髂骨之间建立双侧连接。然后通过一根螺纹杆连接左右髂骨来重建骨盆环。自体骨（髂后嵴）和同种异体骨均用于融合，并在剩余的髂骨之间放置一根胫骨同种异体支撑物。患者术后固定8周，并进行逐步康复训练。在1年的随访复查中，一名患者可以独立行走，另一名患者使用拐杖独立行走。两名患者通过泻药和饮食均能满意地控制肠道功能，并且能够保持大小便失禁，但需要自行导尿以排空膀胱。作者得出结论，在选定的患者中，全骶骨切除术是一种可接受的手术方法，不仅可以有效控制局部疼痛，还可能实现治愈，同时保留令人满意的行走能力和神经功能。
