Spinal tumor resection

Spinal tumors can be divided into the following three cases according to their invasion of the spine: 1, lesions of the spine attachment site osteoid osteoma and aneurysmal bone cyst often invade the posterior attachment of the spine, such as the transverse base, lamina, pedicle, etc., and invasive vertebral body is rare. Osteoblastoma and invasive osteoblastoma invade the spine attachments account for about 30%. The structure of the spine is complicated, and the overlapping and blocking of the X-ray films in the past are difficult to diagnose and locate due to the limitations of imaging conditions. After the advent of CT and MRI, the problem of complex and mutual occlusion of the spine bones was solved. The treatment is extensive resection in the lesion. 2, only on the vertebral body of the spine, the giant cell tumor of the bone invaded the vertebral body accounted for about 7%, the upper part of the spine above the tibia was breast, neck and lumbar vertebrae. Bone hemangioma most frequently invades the vertebral body of the thoracic vertebra, and the neck and lumbar vertebrae invade the second. Chondrosarcoma invaded the vertebral body accounted for about 7%. Only the vertebral body is often the early stage of the tumor, and does not absolutely invade the attachment. Tumor development during this period can be determined according to its nature. For example, radiotherapy is effective for spinal hemangioma, and giant cell tumor and chondrosarcoma should be surgically removed. In recent years, due to the advancement of anterior surgery in spinal surgery, the vertebral bodies of different segments can be satisfactorily exposed, and complete resection, parallel interbody fusion or artificial vertebral body replacement is often satisfactory. 3, the vertebral body and attachments are affected by the lesions such a wide range of lesions are often the result of the development of the aforementioned tumors, in addition to the destruction of the entire vertebral body, easy to combine spinal cord, nerve compression, for the complete treatment of the need for total vertebral resection. Technically, it includes both the complete resection of the tumor and the reconstruction of the stability of the spine. Surgery can be completed in two phases, that is, the vertebral body tumor is removed through the anterior approach of the spine, and intervertebral bone graft or artificial vertebral body replacement is performed, and then the tumor replacement and posterior fixation of the vertebral body attachment are completed in the second stage operation. Or go ahead and remove the anterior approach. Treatment of diseases: spinal metastases Indication Spinal tumor resection is applicable to: 1. Invasive benign bone tumors of the vertebral body and accessory, but highly recurrent, such as giant cell tumor of the bone, aneurysmal bone cyst, or isolated malignant primary bone tumor, and metastases limited to one spinal lesion. . 2. The number of invading vertebral bodies can be 1 segmental spine or 2 adjacent segmental spines. 3, the general condition of the patient is acceptable, no serious disease of liver, kidney, heart and lung. 4. If the patient has secondary spinal cord compression, the time of symptom onset should be as short as possible, and should not exceed 2 weeks at the latest. Contraindications 1. It is not suitable for patients with important organs in the chest and abdomen to adhere to the tumor and cannot be removed. 2. The tumor invades multiple vertebral bodies and is difficult to completely remove. Preoperative preparation 1. In order to understand the extent of tumor invasion and its relationship with vital organs around it, general X-ray films, whole body radionuclide scanning, CT and magnetic resonance examination should be completed before operation. 2, do selective segmental angiography and tumor embolization. Total vertebral resection is complicated and has a lot of blood loss. In order to reduce the fatal blood loss during operation, selective segmental angiography and tumor embolization of the thoracic and lumbar spine should be performed 24 to 48 hours before surgery. Needle puncture and insert a selective angiography tube. The catheter is guided to the aorta under fluoroscopy. In the vicinity of the lesion segment, the catheter head is inserted into the intercostal artery or the lumbar transverse artery from top to bottom. The contrast agent is injected here to show the blood supply and range of the tumor. , the same level of the opposite side of the corresponding artery. Pay attention to the presence of the Adamchiviz artery with or without a nutrient spinal cord during the angiography, if any should be avoided. After satisfactory angiography, a 1 to 2 mm gelatin sponge fragment can be slowly injected into the left and right intercostal artery or the lumbar transverse artery through the arterial catheter to supply a temporary embolization of the tumor blood circulation. Surgery should be completed within 72 hours after embolization. 3, blood preparation 3000ml. 4, ready for spinal canal decompression, tumor resection, anterior bone grafting, posterior fixation and other corresponding equipment and bipolar coagulator. Surgical procedure 1. Incision Make a inverted Y-shaped or incision in the middle of the lower back. The center of the incision is placed at the spine 2 of the waist. The angle of the Y-shaped is 120°. The length of the incision depends on the extent of the lesion and the extent of the fixation. 2, the posterior attachment of the vertebral body is exposed and removed The skin is cut open to reveal spinous processes and lamina, which should range from the upper and lower vertebral bodies of the diseased vertebra. In order to fully reveal the incision, the bilateral iliac spine muscles should be cut transversely from the level of the diseased vertebrae and retracted distally and proximally. 3. Treatment of a segmental spine invasion If a segmental spine is invaded, the scope of resection should include spinous processes, lamina, pedicle transverse processes, and vertebral bodies, the extent of which is shown in the figure. First use the rongeur and laminar to remove the diseased spinous process and lamina. If the tumor invades the spinal canal, the dura can gradually bulge outward and no pulsation. The epidural fat often disappears. The capsule is displaced or deformed by pressure. The nerve roots were found on both sides of the dural sac with nerve strippers and protected. The dural sac and the lateral nerve root can be used to remove the superior and inferior articular processes and the pedicle with the tumor tissue. Due to the preoperative application of embolization technique, there is no common threatening bleeding in the past, and the surgical field is relatively clean, which can clearly identify the edge of the tumor and the relationship between the tumor and the dural sac. After completing the above steps, the dura mater and the bilateral nerve roots of the exposed segment can be seen in the surgical field. 4, vertebral body exposure and resection Firstly, the lumbar vertebrae are exposed and excised to reveal the anterior and posterior aspect of the vertebral body. The vertebral body invaded by the tumor is often lightly and moderately enlarged, but the boundary between the edge and the surrounding tissue is clear. Gently peeling can push the surrounding tissue away, because the lumbar transverse artery has been embolized, so there is not much bleeding during operation. To dissect the vertebral body to the anterior longitudinal ligament, the surrounding tissue can be retracted with a Hohman hook, and a lateral anterior approach to the vertebral body is obtained. 5, remove the tumor Use a lancet to bite off the tumor tissue on the vertebral body, first retain the posterior edge of the vertebral body as a marker to avoid accidental injury to the spinal cord or nerve roots. After the vertebral body tumor is removed, the stripper is inserted between the posterior margin of the vertebral body and the dural sac. After gently separating the adhesion, the posterior margin of the vertebral body is pushed forward with a stripper to collapse, so as to completely remove the lesion and protect the spinal cord. Adjacent intervertebral discs often have no tumor invasion, but it is also necessary to remove the cartilage discs, remove the cartilage from the cartilage disc to the subchondral bone, and make the bone graft bed firm. If the subchondral bone is completely removed, the bone graft bed is cancellous bone. Causes the bone bed to be soft. The contralateral vertebral tumor tissue was removed by the same method. After the entire vertebral body is completely resected, the spine is extremely unstable. At this time, the operation cannot be rough, so as to prevent the vertebral body from shifting and causing spinal cord injury. 6, interbody fusion bone According to the bone defect of the vertebral body, the bone fragments and bone strips of the corresponding length are taken out from the iliac crest, and the general bone graft should be 2 to 3 mm longer than the actual bone defect. The removed bone pieces are cut neatly with a chainsaw and tied together with absorbable nylon threads. It is inserted through the lateral anterior side of the dural sac into the bone defect area and is erected therebetween. After the bone strip is implanted, a broken bone can be filled in front of the bone to fill the bone defect with bone to facilitate bone healing. 7, posterior spinal fixation Posterior spinous processes and lamina should be exposed in the upper and lower segments of the diseased vertebrae. 1mm steel wire is inserted into the spinous process under the lamina to fix the memory alloy rod and select the memory alloy rod of suitable length. They are respectively fixed on the lamina on both sides of the spinous process and keep the metal rod at a certain distance from the exposed dural capsule. At both ends of the memory alloy rod, the anti-rotation card is installed and fixed by bone cement respectively to obtain an immediate stable effect of the spine after the operation. 8, wound hemostasis Because the wound is large and there are many muscles around it, it should be fully stopped before closing the incision. Bipolar coagulation can be used to stop bleeding at the bleeding point near the dural sac. After hemostasis, the wound was washed with a pulse irrigator in physiological saline containing gentamicin. And stitched layer by layer.