椎管重建在椎管内肿瘤术中的应用

发布时间：2018-01-28 05:02

  本文关键词： 椎管肿瘤 椎管重建 手术 脊柱畸形　出处：《安徽医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:探讨椎管内肿瘤切除术中回纳椎板-棘突复合体对手术效果的影响。方法:回顾性分析我院2014年1月至2016年3月行椎管内肿瘤手术患者的临床资料,其中重建组40例,男16例,女24例,年龄12-80岁,平均年龄49±17岁;非重建组65例,男31例,女34例,年龄14-79岁,平均年龄47±16岁。两组患者术前均行MRI平扫及增强明确椎管内病变的位置及肿瘤所在节段的精确定位,部分患者行相应节段椎管CT三维重建,所有患者术前均无脊柱畸形。术前所有患者均出现不同程度的脊髓或神经根受压、刺激症状。两组患者术前均行脊柱正侧位X线片并使用亚甲蓝精确定位,气管插管下全麻取俯卧位,非重建组采用传统的全椎板切除手术方法,肿瘤切除后弃去棘突、骨板及后部韧带复合体;重建组使用微型磨钻或铣刀将椎板-棘突复合体完整取下,切除肿瘤后将其回纳以重建椎管的解剖结构。采用Mc Cormic评分标准对患者术前、术后一周及末次随访的神经功能状态进行评价;术后定期行MRI/三维CT重建,了解有无脊柱畸形,并以Cobb角10o视为脊柱不稳;同时比较两种不同手术方式对术后平均住院时间、卧床时间及脑脊液漏等并发症的影响。结果:椎管重建组平均手术时间为156±35min,非重建组为165±34min;椎管重建组肿瘤全切35例,次全切5例,非重建组全切53例,次全切12例;椎管重建组中硬膜外、髓外硬膜下及髓内肿瘤分别是5例、30例、5例,非重建组分别是7例、44例、14例;椎管重建组病理类型以神经鞘瘤最常见为18例,其次为脊膜瘤8例、皮样囊肿6例、室管膜瘤4例、脂肪瘤2例、海绵状血管瘤2例,非重建组中神经鞘瘤32例、脊膜瘤8例、室管膜瘤6例、皮样囊肿3例、脂肪瘤5例、海绵状血管瘤7例、畸胎瘤3例、转移瘤1例。重建组术后平均住院时间及卧床时间分别是11±3d、8±4d,非重建组分别是15±4d、12±5d;重建组与非重建组术后脑脊液漏分别是1例、10例,经保守治疗后均痊愈;重建组术后随访7-30个月,非重建组术后随访7-30个月,术后远期神经功能恢复以末次随访Mc Cormic评分标准进行等级评价,重建组Ⅰ级32例、Ⅱ级7例、Ⅲ级1例,非重建组Ⅰ级37例、Ⅱ级12例、Ⅲ级16例;重建组患者有3例出现术后脊柱不稳,非重建组出现脊柱不稳15例,其中3例出现以颈背部疼痛为主的临床症状,1例患者因腰椎侧凸在外院行矫正手术。结论:椎管内肿瘤术中将椎板-棘突复合体回纳,能在一定程度上保留脊柱的骨性结构,重建脊柱后部结构、使之在一定程度上达到解剖复位,有效防止椎板去除后因脊柱失去部分骨性组织及韧带等张力性结构的支撑而发生脊柱不稳;椎管重建可缩短术后平均住院时间,并能早期下床活动,明显减少术后的卧床时间;同时可降低术后脑脊液漏的发生率、改善患者远期神经功能状态。总体而言,椎管重建手术切除椎管内肿瘤是一种安全、有效的手术方式。
[Abstract]:Objective: to investigate the effect of laminectomy combined with spinous process on the surgical effect in intraspinal tumor resection. The clinical data of patients undergoing intraspinal tumor surgery from January 2014 to March 2016 in our hospital were retrospectively analyzed. There were 40 cases in the reconstruction group, 16 males and 24 females, aged 12-80 years, with an average age of 49 卤17 years. There were 65 cases in the non-reconstruction group, 31 males and 34 females aged 14-79 years. The mean age was 47 卤16 years. MRI plain scan and enhancement were performed in both groups before operation to determine the location of intraspinal lesions and precise location of the tumor segment. Some patients underwent CT three-dimensional reconstruction of the corresponding segments of the spinal canal. All the patients had no spinal deformity before operation. All the patients had different degree of spinal cord or nerve root compression and irritation symptoms before operation. Under tracheal intubation, the prone position was taken under general anesthesia. In the non-reconstruction group, the traditional laminectomy method was used, and the spinous process, bone plate and posterior ligament complex were removed after tumor resection. In the reconstruction group, the laminum-spinous process complex was removed completely by using a micro-grinding drill or milling cutter, and the tumor was resected to reconstruct the anatomical structure of the spinal canal. The patients were evaluated with Mc Cormic score before operation. The neurological function was evaluated after one week and one last follow-up. MRI / 3D CT reconstruction was performed regularly after operation to find out if there were spinal deformities and the Cobb angle 10o was regarded as spinal instability. At the same time, the effects of two different surgical methods on postoperative average hospital stay, bed-rest time and cerebrospinal fluid leakage were compared. Results: the average operation time of spinal canal reconstruction group was 156 卤35 minutes. In non-reconstruction group, 165 卤34 min; In the spinal canal reconstruction group, there were 35 cases of total tumor resection, 5 cases of subtotal resection, 53 cases of non-reconstruction group and 12 cases of subtotal resection. In the spinal canal reconstruction group, there were 5 cases of extradural, 5 cases of subdural and intramedullary tumors respectively, and 4 cases of non-reconstruction group (7 cases, 44 cases). The pathological types of spinal canal reconstruction group were neurilemmoma (18 cases), meningioma (8 cases), dermoid cyst (6 cases), ependymoma (4 cases), lipoma (2 cases) and cavernous hemangioma (2 cases). There were 32 cases of neurilemmoma, 8 cases of meningioma, 6 cases of ependymoma, 3 cases of dermoid cyst, 5 cases of lipoma, 7 cases of cavernous hemangioma and 3 cases of teratoma. The average hospitalization time and bed rest time were 11 卤3 days and 8 卤4 days in the reconstruction group, and 15 卤4 days and 12 卤5 days in the non-reconstruction group, respectively. The cerebrospinal fluid leakage in the reconstruction group and the non-reconstruction group was 1 case or 10 cases respectively after conservative treatment. The postoperative follow-up was 7-30 months in the reconstruction group and 7-30 months in the non-reconstruction group. The long-term recovery of nerve function was evaluated by the last follow-up Mc Cormic score. In the reconstruction group, there were 32 cases of grade 鈪，

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