胸腰交界椎旁巨大哑铃形肿瘤的手术策略

目的明确胸腰交界椎旁巨大哑铃形肿瘤定义，建立其临床分型，并根据术前临床分型选择胸腰交界椎旁巨大哑铃形肿瘤手术治疗策略。方法回顾性分析2018年1月—2023年1月南部战区总医院收治的11例胸腰交界椎旁巨大哑铃形肿瘤患者。根据肿瘤与胸腰椎相对解剖位置的关系，将横向最远端距脊柱后正中线距离≥6 cm的肿瘤定义为胸腰交界椎旁巨大哑铃形肿瘤，并制定新的临床分型，即椎旁型（肿瘤未超过椎体前缘）和椎前型（肿瘤超过椎体前缘）。对椎旁型采用后路肿瘤切除术，对椎前型行后路联合前路肿瘤切除术。术后1周、3个月、6个月、12个月及每年行X线、CT及MRI检查，评价肿瘤切除情况、是否复发及脊柱稳定性、内固定情况；定期随访并评估术后疼痛改善情况。结果椎旁型8例，5例行后路肿瘤切除术+内固定术，3例行后路肿瘤切除术。椎前型3例，2例行后路+前路肿瘤切除术，1例行后路+前路肿瘤切除术+内固定术。术前与术后JOA及VAS评分差异有统计学意义（分别为P=0.03;P＜0.001)。术后组织病理学确诊为神经鞘瘤9例，神经纤维瘤2例。11例均获随访。随访时间 6个月～2年。所有患者术后复查均未见肿瘤复发，神经症状均明显改善，胸腰背部无酸痛感，内固定无松动、断裂。结论肿瘤横向最远端距脊柱后正中线距离≥6 cm为胸腰交界椎旁巨大哑铃形肿瘤，可分为椎旁型和椎前型。椎旁型采用单纯后路肿瘤切除术即可实现满意切除；椎前型宜采用后路联合前路肿瘤切除术方能实现满意切除。

Objective To clarify the definition of giant paraspinal dumbbell tumor at thoracolumbar junction and establish the clinical classification. The surgical treatment strategy of giant paraspinal dumbbell tumor at thoracolumbar junction was selected according to the preoperative clinical classification. Methods 11 patients with giant paraspinal dumbbell tumors at the thoracolumbar junction admitted to General Hospital of the Southern Theater Command of China from January 2018 to January 2023 were analyzed retrospectively. According to the relationship between the tumor and the relative anatomical position of the thoracolumbar vertebrae, the distance between the transverse farthest end of the tumor and the posterior midline of the spine ≥6 cm was defined as a huge dumbbell tumor at the thoracolumbar junction, and a new clinical classification was established, paraspinal type (tumor not exceeding the anterior edge of vertebral body) and prevertebral type (tumor exceeding anterior edge of vertebral body). Posterior tumor resection was performed for paraspinal type and posterior combined with anterior tumor resection for prevertebral type. X-ray, CT and MRI examinations were performed at 1 week, 3 months, 6 months, 12 months and every year to evaluate tumor resection, recurrence, spinal stability and internal fixation, spinal cord nerve function was evaluated， and postoperative pain improvement was evaluated. Results In 8 cases of paraspinal type, posterior tumor resection with fixation was performed in 5, and simple posterior tumor resection was performed in 3. In 3 cases of prevertebral type, posterior combined with anterior resection was performed in 2, and posterior combined with anterior resection with fixation was performed in 1. There was a statistically significant difference in JOA and VAS scores between preoperative and postoperative(P=0.03,P＜0.001). Postoperative histopathology confirmed neurilemmoma in 9 and neurofibroma in 2. All 11 cases were followed up, and the follow-up period ranged from 6 months to 5 years. No tumor recurrence was found in all patients, the neurological symptoms were significantly improved, there was no pain in the chest, waist and back, and there was no loosening or fracture of the internal fixation. Conclusions The distance between the furthest transverse end of the tumor and the posterior midline of the spine ≥ 6cm is a huge dumbbell tumor at the thoracolumbar junction, which can be divided into paraspinal type and prevertebral type. Satisfactory resection can be achieved by simple posterior tumor resection in paraspinal type, and satisfactory resection can be achieved by posterior combined with anterior tumor resection in prevertebral type.