196例听神经鞘瘤手术切除与面神经功能保留临床体会

发布时间：2018-02-25 16:35

本文关键词： 听神经鞘瘤面神经保护乙状窦后入路　出处：《大连医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的：听神经鞘瘤是生发于听神经鞘的一种良性肿瘤，多次复发亦不发生恶变和转移，发病率约占颅内肿瘤的8%-12%，占小脑桥脑角肿瘤总数75%-95%。成年人多见，平均发病年龄37.3岁，发病年龄高峰为30-49岁，占总数的60%；15岁以下和65岁以上罕见，无明显性别差异。肿瘤大多位于一侧，基本平均分布于左、右两侧，少数为双侧，双侧听神经鞘瘤属于神经纤维瘤病，为神经纤维瘤病Ⅱ型，是一种常染色体显性遗传的系统性疾病。听神经鞘瘤的持续生长会造成颅神经的损伤，如听力的减退、听力丧失、面瘫、小脑共济失调等症状，造成患者心理、生理上的伤害。在手术治疗上，如能全切肿瘤，即可获得永久治愈。近年来随着显微技术的高速发展，神经外科医生在治疗听神经鞘瘤上，已从全切肿瘤，发展到追求更加完美的愈后，，最小的损伤、面神经功能的保留等等。本文主要从手术入路的优缺点、切口选择的利弊、术中肿瘤切除要点、术后并发症展开讨论，以求在手术切除听神经鞘瘤的同时增加面神经保留率上进一步提高。方法：回顾性分析自2002年以来，我科听神经鞘瘤手术治疗患者共196例，其中包含6例为神经纤维瘤病II型。其中男性92例，女性104例。年龄27~70岁，平均50岁。病程1个月~28年，平均3年5个月。肿瘤位于左侧89例，右侧107例。术前表现：患侧耳鸣、听力下降144例，听力丧失52例，面部麻木120例，声音嘶哑、呛咳32例，面瘫60例，肢体共济障碍80例，头痛、视力下降56例，前庭神经功能障碍12例，患侧肢体病理征阳性4例，卒中患者4例。总结手术经验，在手术入路、骨瓣成型、关键孔的选择、肿瘤切除方法等优缺点比较，探讨面神经保留手术技巧。结果：196病例中肿瘤镜下全切除181例，次全切除15例。术后病理均证实术前诊断。面神经解剖保留187例，保留未成功9例，面神经功能保留176例，术后出现小脑血肿1例，上呼吸道感染10例，无死亡病例。出院后1-12个月随访面神经功能状态H-B分级：I级88例（45.0%）、II级64例（33.0%），III级33例（17.0%），IV级11例(6.0％)，V-VI级0例。结论：通过本组手术病例的临床实践，得出90%以上听神经鞘瘤可通过“乙状窦后入路”手术治疗，全切率不低于“迷路入路”，在面神经解剖保留率可达95%以上。对于经验丰富的神经外科医师，术中电测听不是手术必须条件，我科手术中面神经解剖保留率与文献报道术中电测听保留率无明显差异，但术中电生理监测可降低手术医生技术“门槛”，对于经验不足医生在切除肿瘤过程中，更好的提高面神经保留率。针对后颅窝手术，术中严密缝合硬膜减少脑脊液漏，可降低术后发热机率。对于极个别巨大听神经鞘瘤，无需分期手术，可一期行颞底乙状窦联合入路即可。
[Abstract]:Objective: acoustic neurilemmoma is a kind of benign tumor arising from acoustic nerve sheath. The incidence rate of acoustic neurilemmoma is about 8-12 in intracranial tumors and 75-95in cerebellopontine angle tumors. The average age of onset is 37.3 years. The peak age of onset was 30-49 years old, accounting for 60% of the total number of patients under 15 years old and over 65 years old, there was no significant gender difference. Most of the tumors were located on one side, basically distributed on the left, right side, and a few on both sides. Bilateral acoustic schwannomas belong to neurofibromatosis type II neurofibromatosis, which is an autosomal dominant inherited systemic disease. The sustained growth of acoustic neurinoma causes cranial nerve damage, such as hearing loss and hearing loss. Facial paralysis, cerebellar ataxia and other symptoms cause psychological and physiological injuries to patients. In surgical treatment, if the tumor can be completely removed, it can be cured permanently. In recent years, with the rapid development of microtechnology, In the treatment of acoustic schwannoma, neurosurgeons have developed from total resection of the tumor to the pursuit of a more perfect recovery, minimal injury, preservation of facial nerve function, etc. In this paper, the advantages and disadvantages of the surgical approach, the advantages and disadvantages of the incision selection, etc. The main points of tumor resection and postoperative complications were discussed in order to increase the rate of facial nerve preservation while removing acoustic schwannoma. Methods: a total of 196 patients with acoustic schwannoma were retrospectively analyzed since 2002, including 6 patients with neurofibromatosis type II, including 92 males and 104 females aged 2770 years. The mean age was 50 years. The course of disease ranged from 1 month to 28 years, with an average of 3 years and 5 months. The tumor was located in 89 cases on the left side and 107 cases on the right side. Preoperative manifestations included tinnitus, 144 cases of hearing loss, 52 cases of hearing loss, 120 cases of facial numbness, 120 cases of hoarseness, 32 cases of choking and coughing. There were 60 cases of facial paralysis, 80 cases of limb palsy, 56 cases of headache, 56 cases of visual acuity loss, 12 cases of vestibular nerve dysfunction, 4 cases of pathological sign of affected limbs and 4 cases of stroke. To compare the advantages and disadvantages of the choice of critical foramen and the method of tumor resection, the technique of facial nerve preservation surgery was discussed. Results among them, 181 cases had total resection of tumor under microscope, 15 cases had subtotal resection. Postoperative pathology confirmed preoperative diagnosis. The facial nerve was preserved in 187 cases, failed in 9 cases, facial nerve function in 176 cases, and cerebellar hematoma in 1 case after operation. There were 10 cases of upper respiratory tract infection, and no death cases. From 1 to 12 months after discharge, the functional status of facial nerve was followed up in 88 cases with grade 1: 1 of facial nerve function. There were 64 cases with grade I of grade 45.0 and 64 cases of grade II with 33 cases of grade III and 33 cases of grade III with 17.0D grade IV. There were 11 cases of grade IV with histopathological grade (n = 11) and grade V VI (n = 6. 0). Conclusion: through the clinical practice of this group of patients, it is concluded that more than 90% acoustic neurilemmoma can be treated by "retrosigmoid sinus approach". The rate of total resection is not lower than that of "labyrinth approach", and the anatomic retention rate of facial nerve can reach more than 95%. For an experienced neurosurgeon, electric audiometry during operation is not a necessary condition for surgery. There was no significant difference between the anatomic retention rate of facial nerve in our surgery and that reported in the literature. However, electrophysiological monitoring during operation can lower the technical threshold of the surgeon. For posterior cranial fossa surgery, close suture of dural to reduce cerebrospinal fluid leakage can reduce the chance of postoperative fever. For a few giant acoustic neurinomas, there is no need for staging surgery. One-stage sigmoid sinus approach can be performed.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.4

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