栗向东,黄 海,石 磊,王凤伟,付 军,裴延军,王 臻,郭 征
(空军军医大学附属西京医院骨科 710032 陕西省西安市)
基金项目:陕西省科技统筹创新工程计划项目(编号:2016KTCQ01-44);国家重点研发计划(编号:2017YFC1104901)
第一作者简介:男(1970-),副主任医师,副教授,医学博士
研究方向:脊柱肿瘤
电话:(029)84775284
E-mail:xdlimail@yahoo.com
通讯作者:郭征
E-mail:guozheng@fmmu.edu.cn
【摘要】 目的:探讨3D打印个体化人工椎体在胸腰椎骨巨细胞瘤整块切除后脊柱稳定性重建中的作用。方法:2017年1月~2019年12月我科共收治10例经病理检查证实且行全脊椎整块切除并用3D打印个体化人工椎体进行脊柱稳定性重建的胸腰椎骨巨细胞瘤患者。其中男性1例,女性9例;年龄38.3±13.7岁。9例为我院初治病例,1例为外院治疗后复发病例。均有不同程度的顽固的局部疼痛,术前疼痛视觉模拟评分(visual analogue scale,VAS)为4.5±1.2分;2例有双下肢不完全性瘫痪伴受累节段以下平面感觉减退,余患者肌力、感觉均正常。脊髓功能Frankel分级D级2例,E级8例。肿瘤部位:胸椎6例,腰椎4例;单节段5例,双节段2例,三节段3例。根据WBB(Weinstein-Boriani-Biagini)分期,肿瘤累及A~D区和B~D区各5例。7例采用单一后路肿瘤脊椎整块切除,3例采用前后路联合的方式行肿瘤全脊椎整块切除;肿瘤切除后均采用3D打印个体化人工椎体和钉棒系统进行脊柱稳定性重建。观察患者的术中术后并发症、术后神经功能、肿瘤控制和3D打印人工椎体的状态。结果:手术时间4.5~12.0h(6.5±2.0h);术中失血2300~11500ml(4600±2444ml)。所有患者术后疼痛均明显缓解,术后VAS评分为1.3±0.5分。术后6例出现脑脊液漏,3例出现胸腔积液,无切口感染和伤口裂开等并发症发生。随访时间为7~33个月(16.0±7.9个月)。2例术前脊髓功能Frankel分级D级在术后3个月均恢复至E级。所有患者均存活,无肿瘤局部复发及肺转移。未见3D打印个体化人工椎体下沉或移位,无内固定松动或断裂。结论:对于胸腰椎骨巨细胞瘤,3D打印个体化人工椎体能够有效重建全脊椎整块切除后脊柱的稳定性。
【关键词】 骨巨细胞瘤;脊柱;3D打印;人工椎体;整块切除
doi:10.3969/j.issn.1004-406X.2020.09.05
中图分类号:R738.1,R687.3
文献标识码:A
文章编号:1004-406X(2020)-09-0797-08
3D printed custom-made prosthesis for spinal stability reconstruction in the thoracolumbar spine following total en bloc resection of giant cell tumor/LI Xiangdong, HUANG Hai, SHI Lei, et al//Chinese Journal of Spine and Spinal Cord, 2020, 30(9): 797-803, 819
【Abstract】 Objectives: To evaluate 3D printed custom-made prosthesis for spinal stability reconstruction after total en bloc spondylectomy(TES) of giant cell tumor in the thoracolumbar spine. Methods: Ten patients with giant cell tumor of the thoracolumbar spine underwent TES via a posterior approach or a combined anterior and posterior approach in our department between Jan. 2017 and Dec. 2019. 3D printed custom-made prosthesis was used to reconstruct the anterior column of the spine. The clinical data including clinical characteristics, perioperative complications, neurological status, tumor local control and the status of the prosthesis were retrospectively analyzed. There were one male and nine females with average age of 38.3±13.7 years. Nine were primary cases and one was recurrent case. All the patients had intractable back pain. The mean preoperative visual analogue scale(VAS) was 4.5±1.2. Two patients had partial paralysis accompanied by hypoesthesia below the affected segment. All other patients had normal spinal cord function. By Frankel grade, there were two grade D patients and eight grade E patients. The anatomic distribution of lesions was as follows: six in thoracic spine and four in lumbar spine. Lesion involved single segment in five cases, double segments in two cases, and three segments in three cases. According to the WBB staging, both A-D and B-D were in five cases respectively. Seven patients underwent TES from posterior approach, and meanwhile a combined anterior and posterior approach was chosen for the other three patients. 3D printed custom-made prosthesis and spinal pedicle screw system were used to reconstruct the spinal stability. Results: The average operation time was 6.5±2.0 hours(ranged 4.5-12.0 hours), and the average blood loss was 4600±2444ml(ranged 2,300-11,500ml). The back pain was relieved in all the patients after operation. The mean postoperative VAS was 1.3±0.5. Cerebrospinal fluid leakage occurred in six cases and pleural effusion in three cases during the perioperation. There was no wound infection or wound healing problems occurred. The mean follow-up period was 16.0±7.9 months(ranged 7-33 months). Of neurological function according to Frankel grade, the two patients recovered to grade E from grade D preoperatively. All the patients were alive with no evidence of tumor recurrence or metastasis. All the 3D printed custom-made prostheses were in situ and no subsidence or migration was found. There was no internal fixation loosening and fracture. Conclusions: 3D printed custom-made prosthesis can be effective in managing anterior reconstruction after TES.
【Key words】 Giant cell tumor; Spine; 3D printing; Custom-made prosthesis; Total en bloc resection
【Author′s address】 Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi′an, 710032, China
图1 3D打印个体化人工椎体 a 正面 b 侧面 c 背面 d 上表面
Figure 1 3D printed custom-made prosthesis a Frontal view b Lateral view c Dorsal view d Superior view
图2 病例1,L4骨巨细胞瘤 a 术前CT示肿瘤侵犯L4椎体和双侧椎弓根 b 术前MRI矢状位T1加权示肿瘤侵犯L4椎体并突入椎管 c 术前MRI轴位T1加权增强示肿瘤组织明显强化 d 术前穿刺活检病理检查显示骨巨细胞瘤 e 切除的肿瘤标本和待安装的3D打印个体化人工椎体 f 肿瘤整块切除人工椎体置入后情况
Figure 2 Case 1, L4 giant cell tumor of bone a Preoperative CT axial imaging examinations of case one revealed the vertebral body and bilateral pedicles of L4 were involved by the tumor b Sagittal T1W MRI showed the vertebral body of L4 was involved and the tumor protruded into the spinal canal c The tumor was enhanced on axial enhanced T1W MRI d Preoperative Tru-cut biopsy confirmed the typical diagnosis of giant cell tumor in histopathological examination e Intraoperative views of specimen and 3D printed custom-made prosthesis f Intraoperative view showed the L4 vertebral body defect was reconstructed with 3D printed custom-made prosthesis after total en bloc resection of the tumor
图3 病例1 a 术后即刻正侧位X线片显示3D打印个体化人工椎体重建脊柱前柱稳定性 b 术后即刻CT三维重建显示L4脊柱稳定性重建后情况 c 术后3个月X线正侧位片显示人工椎体无移位 d 术后3个月CT矢状位、冠状位显示人工椎体内骨和相邻椎体骨整合良好 e 术后1年X线正侧位片显示人工椎体无移位和下沉 f 术后2年X线正侧位片显示人工椎体无移位和下沉
Figure 3 Immediately postoperative and follow-up imaging examination of case one a Radiography immediately postoperatively showed the reconstruction of the anterior column of L4 using 3D printed custom-made prosthesis b Coronal and sagittal reconstruction of CT immediately postoperatively revealed the reconstruction of the L4 vertebral body defect with the prosthesis c Radiography at 3 months follow-up revealed the prosthesis was in situ d Sagittal and coronal sectional images of CT at 3 months follow-up showed good osteointegration between the prosthesis and the adjacent vertebral body e Radiography at 1 year follow-up revealed there was no subsidence or displacement of the prosthesis f Radiography showed that the prosthesis was still in situ at 2 years follow-up