- 期刊
自體海綿骨重建放射線性骨壞死清創後之下顎缺損－病例報告
Reconstruction with Autogenous Cancellous Bone Graft for Mandibular Continuity Defect Resulted from Osteoradionecrosis-A Case Report
摘要
放射線性骨壞死雖無立即的生命危險，但在接受過頭頸癌高劑量放射線治療的患者身上，卻是嚴重而惱人的併發症，處理上也總是相當棘手；然而其致病機轉與治療方式，目前仍有爭議。一般認爲，初期、表淺的病灶也許有機會藉由保守性的清創達到療效；但若爲急性且廣泛的骨壞死時，則必須合併大型清創手術、高壓氧治療以及游離組織移植，方能有效重建相關軟、硬組織缺損。近年來，以顯微手術重建下顎骨缺損的技術日益精進並廣爲採用；儘管如此，用自體海綿骨移植重建這類骨缺損的優點也不應該被漠視。本病例爲一位34歲男性，罹患舌癌第四期(pT3N2bM0, Stage IV)，曾接受腫瘤切除手術及胸大肌皮瓣立即重建，並於術後接受超過8000 cGy的頭頸部放射線治療劑量，不久便發生左下顎骨廣泛、嚴重的放射線性骨壞死。我們先將腐骨區進行片段切除術，並立即以外固定裝置先維持住下顎骨缺損的空間；幾個月後再合併高壓氧治療、並以自體脛骨海綿骨與血小板濃縮血漿混合移植，成功地重建了左下顎骨長達6公分以上的大型缺損；於該移植骨再生成熟穩定後，還能植入四支人工牙根。對於某些特定的放射線性骨壞死案例，自體海綿骨移植相較於游離骨皮瓣移植，可大幅降低骨供應部位的術後不適感與併發症。此成功的案例，希望能提供臨床醫師在針對此類病患擬定重建計畫時，除了游離骨皮瓣顯微重建之外，另一項可行的替代治療方案。
並列摘要
Although not a life-threatening situation, osteoradionecrosis (ORN) of the jaws has been a seriously bothersome and refractory complication following high dose radiation therapy for head and neck cancers, and its management is always challenging. However, the pathophysiology and the concept of treatment for ORN are currently still controversial. Conservative debridement might be helpful in smaller necrotic bone area. Nevertheless, in acute and progressive URN, radical surgery including wide resection in combination with hyperbaric oxygen therapy (HBOT), and free tissue transfer for reconstruction of both hard & soft tissue defects are deemed necessary. In spite of the growing tendency of preference in micro-vascular reconstruction for mandibular continuity defect, the advantages of autogenous free bone grafts cannot be overlooked. Here we present a case of a left tongue cancer (pT3N2bMO, Stage IV) in a 34-year-old man who had undergone ablative cancer surgery, immediate P1\/IIVIC flap reconstruction and post-operative adjuvant radiation dose of more than 8000 cGy. Severe URN developed and progressed along the poorly immobilized osteotomy site at left mandibular body. After segmental resection of the necrotic jaw with immediate extra-skeletal pin fixation for jaw bone space maintenance, and delayed autogenous tibial cancellous bone grafting in combination with adjuvant HBOT and platelet rich plasma (PRP), the continuity defect of the left mandibular body, more than 6 cm lengthwise, was successfully regenerated and turned out to be a well consolidated viable bone mass where 4 regular sized dental implants were installed subsequently. Therefore, we would like to offer and advocate the alternative way of treatment for its significantly less donor site morbidity in properly selected patients who are suffering from osteoradionecrosis of the jaws.