The Application Of Anterior Endoscopy Assisted With Posterior Approach One Stage Total En Bloc Spondylectomy For Thoracic And Lumbar Spine Tumors

Objective: To investigate the application of anterior endoscopy in combination with the posterior approach one stage total en bloc spondylectomy in the treatment of thoracic and lumbar spine tumors and review the relevant literature.Methods: 8 patiens with thoracic and lumbar spine tumors was treated by anterior endoscopy in combination with posterior approach one stage total en bloc spondylectomy in our department from January 2014 to December 2016,including 3 males and 5 females,with the average age of 44 years old(ranging from 16 to 65 years).The average course of disease is 4.03 months(ranging 0.7 to 24 months).There were 6 patients with thoracic spine tumors(T4 1 case,T6 1 case,T7 1 case,T10 2 cases,T7~8 1 cases)and 2 patients with lumbar spine tumors(L2,L4 in each of the 1 cases).The type of tumor included 5 primary tumors(1 paraganglioma,1 aggressive hemangioma,1 telangiectatic osteosarcoma,1 giant cell tumor,1 synovial sarcoma)and 3 metastatic tumors(1 lung cancer,1 prostate cancer,1 breast cancer).According to the type of Tomita spine tomours,type I in 1 case,type II in 3 acses,type IV in 1case,type V in 2 cases,type VI in 1 case.According to the WBB staging system of spinal tumors,2 cases of tumors located in the 4~9 area(vertebral body),involving the vertebral body and more than one side of the 4 area or the 9 area in 5 cases,while more than the bilateral 4 area and 9 area in 1 cases.The Frankel grade of neurologic function was D in 7,C in 1.The preoperative visual analogue score was 6.1;The Tomita scores of the 3 cases metastatic tumor were 2 points in 2 patients and 4 points in 1 patient.According to Tokuhashi score,the 3 patients were single solitary metastases,life expectancy times were more than 6 months,and in accordance with the surgical indications of total en bloc spondylectomy.The The operation time,bleeding loss,blood transfusion,postoperative pain and recovery of spinal cord function were recorded,bone graft fusion,tumor recurrence and other complications were followed up.Resluts: All the 8 patients were performed by anterior endoscopy in combination with posterior approach one stage total en bloc spondylectomy successfully,and the spinal cord function was detected by cortical somatosensory evoked potential(CSEP)during surgery period.The avsrage operation time was 277.63(249~320)min.The avsrage bleeding loss was 1195.0(850~1550)ml and the avsrage blood transfusion was 650(300~1000)ml.All patient’s preoperative pathological examination findings were consistent with preoperative.The patients were followed up from 13 to 18months(average,16.11 months).The VAS score were excellent in 7 patients and good in 1 patient at 6 months after operation.At 12 months after operation,except for the patient with preoperative stage Frankel grade D was still D,the other 6 patients(including patient with preoperative Frankel grade C)were all recovered to Frankel grade E.There were 2 patients of scoliosis including new onset scoliosis and the presence of scoliosis which had no influence on appearance and daily life.Pulmonary infection in 2 patients and improved after positive anti-inflammatory.Intercostal neuralgia in one patient,bone pain in one patient,pleural effusion in 2 patients and improved using prevention infection and delayed thoracic closed drainage extubation time.All patients had no major vascular,spinal cord and organ injury during the perioperative period,and there was no cerebrospinal fluid leakage.A patient with telangiectatic osteosarcoma local recurrenced at 13 months after surgery,received local debridement and radiotherapy again,and the patients died because the tumor recurrence and causing multiple organ failure at 16 months after first operation and 3 months after second operation.During the follow-up period,there were no internal fixation loosening,displacement,screw-rod breakdown and titanium mesh subsidence.Conclusions: Although the total en bloc spondylectomy not only significantly reduces the local recurrence rate of spinal tumor,but also prolong the survival time of patients what’s more improve the quality of life of patients with spinal tumor surgery,still face bleeding,technical difficulty,high risk.However,the application of endoscopic technique in combination with total en bloc spondylectomy in the stripping of soft tissue around the thoracic and lumbar vertebra,vertebral segment vascular ligation,vascular(thoracic and abdominal aorta,inferior vena cava)protection,and to avoid the damage to the blood vessels,reduce the amount of bleeding and surgical trauma.The improvement of the technique and the appliance of total en bloc spondylectomy has been achieved,which can reduce the spinal cord injury and improve the operation safety.However,it is necessary to change the body position duriing operation period that prolong operation time and increase the anesthesia risk.In this study,the number of cases is small,also there is no control study.The controlled studies and large samples are the focus of future research.