经半椎板切除入路显微操作摘除椎管内髓外硬膜下肿瘤的手术方法及效果评价

发布时间：2018-12-13 04:31

【摘要】：目的：探讨经半椎板切除入路显微操作摘除椎管内髓外硬膜下肿瘤的手术方法，进一步阐明其临床效果。方法：回顾分析本院2009年1月～2011年12月治疗的16例髓外硬膜下肿瘤患者的临床资料。其中，男性7例，女性9例；年龄34～72岁，平均年龄49岁。病史7月～3年，平均15.7个月。肿瘤位于颈段3例，胸段4例，胸腰段9例。所有病例均有不同程度的脊髓压迫症状和体征。所有患者均行术前MRI检查显示椎管内占位并且必须包括对肿瘤的脊髓节段的精确定位。16例患者均选取静脉吸入复合麻醉,采用20mL注射器针头作为标记物插入目标棘突以确认节段，并且于C型臂透视下精确定位、减少创伤。安置显微镜进行显微操作，术中用双极电凝确切止血。术后切口外加压包扎,椎板外置负压引流，逐层缝合切口。14例患者采用半椎板入路顺利切除肿瘤；2例患者由于肿瘤体积较大且位于腹侧，难以充分显露，故改用全椎板切除入路顺利切除肿瘤。通过患者术前和术后神经功能恢复情况的Frankel分级评价半椎板入路的临床效果。结果：术中平均出血量为300mL (150～500mL)，手术时间140min (90～200min)。14例行半椎板入路平均出血量为275mL（150～350mL），2例行全椎板入路出血量分别为450mL和500mL（平均出血量为475mL）。肿瘤体积最大4cm×1.5cm×l.5cm，最小1.5cm×1.0cm×l.0cm。术后病理证实,神经鞘瘤11例，脊膜瘤4例，神经纤维瘤1例。其中，1例患者术后出现脑脊液漏，采取严密缝合、加压包扎并头低脚高位后愈合。本组16例患者术后均未出现切口感染、脊柱不稳等并发症，术后3d即可床上活动，5d即可佩戴腰围下地活动。16例患者中，术前Frankel分级B级3例，术后提高为C级；术前C级5例，术后提高为D级；术前D级7例，术后提高为E级。神经鞘瘤11例，，脊膜瘤4例，神经纤维瘤l例。所有患者均得到随访（6～40个月，平均23.7个月）。16例患者均未见复发而且脊柱稳定性良好，全部患者的疼痛及神经功能恢复的情况均获得改善。结论：半椎板切除术治疗髓外硬膜下肿瘤具有损伤较小、出血较少等优点，并且可以最大限度地维持脊柱的稳定性。对于髓外硬膜下且偏向一侧的肿瘤是该术式的最佳适应证。同时肿瘤的横径一般应小于2cm，且肿瘤的跨度限于2个椎体水平内，不宜过大。应该严格掌握适应证，在不加重脊髓损伤的基础上尽可能彻底摘除肿瘤。不论采取何种术式，均应以尽可能完全切除肿瘤为前提，而不应以残留肿瘤病灶为代价刻意追求微创术式。总体来说，经半椎板切除入路摘除椎管内髓外硬膜下肿瘤的手术效果令人满意。
[Abstract]:Objective: to explore the microsurgical method for the removal of subdural intramedullary tumors in the spinal canal and to elucidate the clinical effect. Methods: the clinical data of 16 patients with subdural extramedullary tumors treated in our hospital from January 2009 to December 2011 were retrospectively analyzed. There were 7 males and 9 females, aged 3472 years with an average age of 49 years. The history ranged from July to 3 years, with an average of 15.7 months. The tumors were located in cervical segment in 3 cases, thoracic segment in 4 cases and thoracolumbar segment in 9 cases. All cases had different degree of spinal cord compression symptoms and signs. All patients underwent preoperative MRI examination to show intraspinal space occupation and must include accurate localization of the spinal cord segment of the tumor. 16 patients were selected for intravenous inhalation combined anesthesia. The 20mL syringe needle was used as marker to insert the target spinous process to confirm the segment and to locate accurately under the C-arm fluoroscopy to reduce the trauma. The microsurgery was performed with microscopes, and the bleeding was stopped by bipolar electrocoagulation. After operation, external compression bandage, negative pressure drainage of vertebral lamina and suture of incision were performed in 14 cases, and the tumor was resected successfully by semi-laminar approach. Because the tumor was large and located on the ventral side it was difficult to be fully exposed in 2 cases so the total laminectomy approach was used to remove the tumor successfully. The clinical effect of hemivertebra approach was evaluated by Frankel grading before and after operation. Results: the mean blood loss was 300mL (150~500mL), 140min (90~200min), 275mL (150~350mL) in 14 cases, 450mL and 500mL (475mL) in 2 cases. The tumor volume was the largest 4cm 脳 1.5cm 脳 l.5cm, and the smallest was 1.5cm 脳 1.0cm 脳 l.0cm. Postoperative pathology confirmed 11 cases of neurilemmoma, 4 cases of meningioma and 1 case of neurofibroma. One patient had cerebrospinal fluid leakage after operation, was sutured tightly, bandaged under pressure and healed after high head and low foot. There were no postoperative complications such as incision infection, spinal instability and so on. The patients could move on the bed 3 days after operation and wear the floor movement under the waist at 5 days. Among the 16 cases, 3 cases had Frankel grade B before operation, but it was improved to C grade after operation. Grade C was improved to grade D in 5 cases before operation and grade E to grade E in 7 cases of grade D before operation. There were 11 cases of neurilemmoma, 4 cases of meningioma and 1 case of neurofibroma. All the patients were followed up (6-40 months, mean 23.7 months). No recurrence and good spinal stability were found in 16 patients, and the pain and neurological function were improved in all patients. Conclusion: the treatment of subdural tumors with hemilaminectomy has the advantages of less injury and less bleeding, and can maintain the stability of the spine to the maximum extent. The best indication of this procedure is for subdural and unilateral tumors. At the same time, the transverse diameter of the tumor should be less than 2 cm, and the tumor span should be limited to 2 vertebrae levels, so it should not be too large. Indications should be strictly grasped and tumors should be removed as thoroughly as possible without exacerbating spinal cord injury. No matter what operation is adopted, the complete resection of the tumor should be the prerequisite, and the minimally invasive operation should not be pursued at the expense of residual tumor focus. In general, the results of subdural resection of intraspinal extramedullary tumors are satisfactory.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.4

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