韦 峰,刘杉杉,刘忠军,刘晓光,姜 亮,李柘黄,李梓赫,许南方
(北京大学第三医院骨科 100191 北京市)
基金项目:科技部国家重点研发计划(项目编号:2016YFB1101500)
第一作者简介:男(1973-),主任医师,医学博士,研究方向:脊柱肿瘤;脊柱外科
电话:(010)82267368
E-mail:weifeng@bjmu.edu.cn
通讯作者:刘忠军
E-mail:zjliu@bjmu.edu.cn
【摘要】 目的:评估胸腰椎肿瘤整块切除后应用3D打印人工椎体重建脊柱稳定性的安全性和有效性。方法:回顾性分析我院2016年5月~2020年1月胸腰椎肿瘤整块切除术后应用3D打印人工椎体重建脊柱稳定性的42例患者。原发性骨肿瘤37例;转移性肿瘤5例。肿瘤均累及胸腰椎。手术实施整块切除,均使用3D打印人工椎体作为前方支撑结构。根据随访超过6个月患者的X线片、CT片评估3D打印假体与相邻椎体融合情况、有无内固定失败。结果:全脊椎切除者39例,矢状切除者3例。使用标准化3D打印人工椎体19例,其中1节段者15例,2节段者3例,3节段者1例;从后路放置15例,从前方放置4例。使用定制化假体23例,其中单节段者7例,2节段者3例,3节段者10例,4节段者2例,5节段者1例;通过椎弓根螺钉拧入假体内置钉孔与后方钉棒系统连接达到自稳19例,从前路放置并通过内置钉孔用螺钉固定于相邻椎体者4例。40例患者获得随访,随访时间3~47个月,中位随访时间22个月。影像学随访超过6个月的患者36例,包含确定融合者9例,可能融合者19例,可能不融合者8例;均无螺钉断裂或拔出、连接棒断裂和假体断裂移位情况;总体融合率为77.8%(28/36)。2例假体下陷超过2mm,但症状轻微未行内固定翻修手术。结论:3D打印人工椎体较大的终板面积有利于防止假体塌陷;微孔结构能促进骨长入增加骨融合;定制化设计能使其与内固定系统连接或直接固定于相邻椎体从而获得更好的即刻稳定性。
【关键词】 脊柱肿瘤;胸腰椎;3D打印假体;整块切除;全脊椎切除
doi:10.3969/j.issn.1004-406X.2020.09.02
中图分类号:R738.1,R318.1
文献标识码:A
文章编号:1004-406X(2020)-09-0774-08
Study on the safety and effectiveness of 3D printed artificial vertebral body reconstruction after en bloc resection of thoracolumbar tumor/WEI Feng, LIU Shanshan, LIU Zhongjun, et al//Chinese Journal of Spine and Spinal Cord, 2020, 30(9): 774-781
【Abstract】 Objectives: To evaluate the safety and stability of 3D printed artificial vertebrae in reconstruction of thoracolumbar tumor after total en bloc resection on the early and middle follow-up results. Methods: Between May 2016 and January 2019, 42 cases(19 males and 23 females) aged from 10 to 71 years old (39.7±16.2) were analyzed retrospectively. 37 cases were with primary bone tumors and 5 cases with metastatic tumors. There were 10 cases of recurrent tumor. All the tumors involved thoracolumbar spine, including 22 cases of single segment, 6 cases of 2 segments, 11 cases of 3 segments, 2 cases of 4 segments and 1 case of 5 segments. The en bloc resection was performed in all cases. All of them used 3D printed artificial vertebral body as the anterior support structure. According to X-ray and CT images of patients who were followed up for more than 6 months, the fusion of prosthesis and adjacent vertebral body was evaluated. Results: There were 39 cases of total spondylectomy and 3 cases of sagittal resection. In this group, 19 cases were treated with standard 3D printed prosthesis. Among them, 15 cases were in 1 segment, 3 in 2 segments and 1 in 3 segments. The prostheses were placed from the posterior approach in 15 cases, and the anterior approach in 4 cases. 23 cases were treated with customized prosthesis. Among them, 7 cases were single segment, 3 cases were 2 segments, 10 cases were 3 segments, 2 cases were 4 segments, and 1 case was 5 segments. In 19 cases, the pedicle screw was used to screw into the internal screw hole of the prosthesis to connect with the posterior screw-rod system to achieve self-stabilization; in 4 cases, the screws were placed from the anterior approach and fixed to the adjacent vertebral body through the internal screw hole. Except one died of cardiovascular disease 4 months after operation without follow-up and 1 case lost follow-up, the rest 40 patients were followed up between 3 and 47 months, with a median follow-up period of 22 months. 36 patients were followed up for more than 6 months. There were 9 cases of fusion, 19 cases of probable fusion and 8 cases of probable non-fusion. There was no screw breakage or pull-out, no rod breakage, no prosthesis breakage or displacement. The overall fusion rate was 77.8%(28/36). In 2 cases, the prostheses subsided more than 2 mm, but the pains were mild without internal fixation. Conclusions: 3D printed prosthesis is conducive to prevent collapse because of its large end plate area. Microporous structure can promote bone growth and increase bone fusion. Customized design can make it connect with internal fixation system or directly fix in adjacent vertebral body to obtain better immediate stability. Therefore, 3D printed prosthesis can reduce the failure rate of internal fixation after thoracolumbar en bloc resection.
【Key words】 Spinal tumor; Thoracolumbar; 3D printing prosthesis; En bloc resection; Spondylectomy
【Author′s address】 Orthopedics Department, Peking University Third Hospital, Beijing, 100191, China
图1 患者女性,50岁,T11椎体骨巨细胞瘤,行后路-前路T11椎体及肿瘤整块切除,定制3D打印假体从前方放置并用螺钉固定于相邻椎体。随访36个月,肿瘤无复发 a T11椎体破坏性病变及椎旁巨大肿块 b 椎旁肿块侵占胸腔 c、d 使用地舒单抗3个月后肿瘤边缘明显硬化 e 整块切除的T11椎体及椎旁肿瘤的CT扫描 f 术后CT片示3D假体与上下终板贴附良好 g 术后36个月随访X线片示3D假体位置良好,内固定稳固 h 术后36个月CT示3D假体和相邻椎体界线消失,有骨小梁长入
Figure 1 A 50-year-old female patient with giant cell tumor of T11 vertebral body underwent T11 en bloc spondylectoy resection via posterior-anterior approach. The customized 3D printing prosthesis was placed from the front and fixed to the adjacent vertebral body with screws. After 36 months of follow-up, there was no recurrence of the tumor a T11 vertebral destructive lesion and a huge paravertebral mass were found b Paravertebral mass invaded the thoracic cavity c, d After 3 months of Denosumab treatment, the tumor was obviously sclerosis e CT scan of the specimen of T11 which showed the vertebral body and paravertebral tumor was excised in one piece f Postoperative CT scan showed that the 3D prosthesis was well attached to the upper and lower end plates g 36 months after surgery, X-ray showed that the 3D prosthesis was in good position and the internal fixation was stable h At 36 months after surgery, CT showed that the gap between the 3D prosthesis and the adjacent vertebral body disappeared and trabecula grew in
图2 患者女性,17岁,T11~T12平滑肌肉瘤,行前路-后路T11~T12椎体矢状整块切除,定制3D打印假体从后方放置并用椎弓根螺钉固定于后方钉棒系统。随访25个月,肿瘤无复发 a 术前MRI示肿瘤累及T11~T12椎体并在左侧椎旁肌内形成巨大软组织肿块 b 术前MRI示肿瘤累及T11~T12椎间孔并在椎间孔前放以及椎旁肌内形成软组织肿块 c、d 整块切除的T11~T12椎体及椎旁肿瘤的CT扫描 e 术后X线片显示3D假体位置良好 f 术后CT片示3D假体与上下终板贴附良好 g 术后25个月随访X线片示3D假体位置良好,内固定稳固 h 术后25个月CT示3D假体和相邻椎体界线消失,有骨小梁长入
Figure 2 A 17-year-old female patient with T11-T12 leiomyosarcoma underwent sagittal resection of T11-T12 vertebral body via anterior-posterior approach. The customized 3D printing prosthesis was placed from the posterior appoach and fixed to the posterior screw-rod system with pedicle screws. After 25 months follow-up, there was no recurrence of the tumor a Preoperative MRI showed that the tumor involved the T11-T12 vertebral body and formed a huge soft tissue mass in the left paravertebral muscle b Preoperative MRI showed that the tumor involved the T11-T12 intervertebral foramen and formed a soft tissue mass in the intervertebral foramen and paravertebral muscle c, d CT scan of the specimen of the T11-T12 vertebral body and paravertebral tumor e Postoperative X-ray film showed good position of 3D prosthesis f Postoperative CT scan showed good attachment of 3D prosthesis to upper and lower end-plates g X-ray film of 25-month follow-up showed good position of 3D prosthesis h CT scan of 25-month follow-up showed that the internal fixation was intact and the gap between 3D prosthesis and adjacent vertebral body disappeared, with trabecula growing in
图3 患者女性,61岁,右肺低分化腺癌术后2年,查体发现T12破坏性病变。PET/CT提示T12孤立性病变。诊断为肺癌T12孤立转移。行后路T12整块全椎切除,标准化假体重建。术后放疗及靶向药物治疗。随访36个月,肿瘤无复发,无新发转移灶 a CT冠状面、矢状面和横断面片显示T12椎体骨质破坏,椎弓结构正常 b MRI T1和T2压脂像矢状面片和T2横断面片显示肿瘤累及T12椎体,椎弓未收累及 c 应用线锯锯断双侧椎弓根,分两部分切除的T12全椎体标本 d 标本的X线轴位片和侧位片 e 标准化单节段3D打印假体的腹侧面、背侧面和上表面观 f 术后X线正侧位片示假体及内固定位置良好 g 术后3年CT片示3D假体与上下终板贴附良好,无假体下陷,无螺钉松动,无内固定断裂
Figure 3 A 61-year old female patient with poorly differentiated adenocarcinoma of the right lung was found to have destructive T12 lesions in physical examination 2 years afterher lunglobectomy. PET/CT showed T12 solitary lesions. The diagnosis was T12 vertebral solitary metastasis of lung cancer. Totalen bloc spondylectomy and reconstruction with standard 3D prosthesis was undertaken via single posterior approach. Postoperative radiotherapy and targeted drug therapy were undertaken standardly. There was no recurrence or new metastasisfor 36 months follow-up a CT coronal, sagittal and transverse sections showed bone destruction of T12 vertebral body b MRI T1 and T2 fat compression images showed tumor involvement of T12 vertebral body in sagittal and T2 weighted cross sections c Axial and lateral views of T12 total vertebral body in two parts which were cut with wire saw d Axial and lateral X-ray films of the specim e Neventral, dorsal and the upper surface of the standardized single segment 3D prosthesis f Postoperative X-ray films showed 3D prosthesis and internal fixation in good position g Three years after surgery, CT showed that the 3D prosthesis was well attached to the upper and lower end plates, and there was no prothesis subsidence, screw loosening or internal fixation fracture
本文为删节版,原文见《中国脊柱脊髓杂志》2020年9月刊