Heary R F, Vaccaro A R, Benevenia J, Cotler J M
Division of Neurological Surgery, University of Medicine & Dentistry of New Jersey, New Jersey Medical School, Newark, USA.
Surg Neurol. 1998 Dec;50(6):548-56. doi: 10.1016/s0090-3019(98)00078-0.
Primary tumors of the vertebral bodies have previously been treated with total or subtotal excision in a piecemeal fashion (intralesional excision). Radiation therapy has been used to help control tumor growth. Recurrence rates with an intralesional, piecemeal removal of vertebral tumors have been unacceptably high. This study describes a method to excise a lumbar vertebra "en-bloc," and in the process, to perform a marginal (extralesional) resection of a primary tumor of the mobile lumbar spine that allows for a potential surgical cure.
A combined posterior-anterior procedure allows for an extralesional, marginal resection of the tumor and the involved vertebra. All posterior bony elements, including the pedicles and the adjacent intervertebral discs, are removed via a posterior approach. An anterior, retroperitoneal approach is then used to remove the vertebral body/tumor as a single specimen. The nerve roots at the involved levels are spared and the spine is instrumented and fused both posteriorly and anteriorly.
Three patients successfully had combined posterior-anterior resections of lumbar vertebral chordomas. No permanent neurological complications occurred. Overall morbidity of the procedure was acceptable. At 31-month follow-up, no tumor recurrence has been detected.
"En-bloc" resection of a primary vertebral tumor of the lumbar spine is technically demanding, but potentially curative. The alternative approaches-intralesional excision, radiation therapy, or a combination-are unable to cure these tumors. Long-term, 10-year follow-up will be necessary to confirm whether this en-bloc approach provides a surgical cure.
椎体原发性肿瘤以往采用分次整块切除（病损内切除）或次全切除的方式进行治疗。放射治疗用于辅助控制肿瘤生长。椎体肿瘤病损内分次切除后的复发率一直高得令人难以接受。本研究描述了一种整块切除腰椎椎体的方法，在此过程中，对活动腰椎的原发性肿瘤进行边缘性（病损外）切除，从而有可能实现手术治愈。
采用前后联合手术方法对肿瘤及受累椎体进行病损外边缘性切除。通过后路手术切除所有后部骨质结构，包括椎弓根和相邻椎间盘。然后采用前路经腹膜后入路将椎体/肿瘤作为单个标本切除。保留受累节段的神经根，并对脊柱进行前后路内固定融合。
3例患者成功接受了腰椎脊索瘤的前后联合切除术。未发生永久性神经并发症。手术的总体并发症发生率可以接受。在31个月的随访中，未发现肿瘤复发。
腰椎原发性椎体肿瘤的整块切除技术要求高，但有可能治愈。其他方法——病损内切除、放射治疗或联合治疗——均无法治愈这些肿瘤。需要进行长期的10年随访，以确认这种整块切除方法是否能实现手术治愈。
