高颈段椎管肿瘤的临床特点及预后分析

发布时间：2018-06-07 13:45

  本文选题：高颈段 + 椎管肿瘤　； 参考：《天津医科大学》2014年硕士论文

【摘要】：一、高颈段椎管肿瘤的显微外科治疗 [目的]探讨高颈段椎管内不同病理类型肿瘤的临床表现及影像学特点,分析高颈段椎管内肿瘤显微手术治疗效果及预后相关因素。 [方法]回顾性分析天津医科大学总医院神经外科2003年1月至2013年12月期间,经手术治疗的135例高颈段椎管内肿瘤患者的临床资料,所有患者病理分类按照神经系统肿瘤WHO(2000)分类标准进行统计,总结不同类型肿瘤的影像学特点及手术策略,并根据病变位置将患者分为髓内及髓外肿瘤两组,依据术后1周及术后6个月日本骨科学会(Japanese Orthopaedic Association,JOA)评分,对患者的症状改善进行评估,分析高颈段肿瘤生长部位对预后的影响。 [结果] 1.本组135例患者术前均行颈椎MRI平扫和强化检查,明确肿瘤位置。其中105例(77.78%)患者采用颈后正中入路,颈外侧入路17例(12.59%),远外侧入路5例(3.71%),颈前入路6例(4.44%),颈前及颈后联合入路2例(1.48%)。肿瘤全切124例(占91.85%),次全切除10例(占7.41%),部分切除1例(占0.74%)。 2.肿瘤位于髓外硬膜下96例,髓内35例,硬膜外4例,其中哑铃形肿瘤42例。病理类型主要为神经鞘瘤56例(41.48%)和脊膜瘤39例(28.89%),其他类型共占29.63%。术后2周内常规复查MRI,可见脊髓均有不同程度的水肿。 3.本组5例患者术后出现单纯性脑脊液漏；1例高龄患者,术后出现肺部感染,术后第16天死于呼吸衰竭。术后随访110例患者2个月～3年,无颈椎不稳定情况。 [结论] 1.高颈段椎管肿瘤早期不容易确诊,患者就诊时肿瘤体积较大,手术风险高,颈椎MRI是首选影像学检查方法；患者诊断明确后应积极手术治疗,颈后正中入路适合绝大部分高颈段椎管肿瘤的切除,颈外侧入路及远外侧入路对于暴露颈椎管外肿瘤或累及延髓腹侧肿瘤有一定优势,但手术创伤较大。 2.肿瘤病理类型以神经鞘瘤和脊膜瘤最常见,脊髓髓内肿瘤以良性及低恶性度肿瘤多见,术后常有不同程度脊髓肿胀,术中可预防性应用脱水药物及激素治疗,避免术后临床症状加重。 3.若高颈段病变患者术前只有轻度肌力下降、肢体麻木且病程较短者,术后症状、体征基本同术前或较术前明显改善；而术前已出现明显肢体无力、肌张力增高及二便功能障碍的患者,术后临床症状改善缓慢,考虑其原因是术前肿瘤长期压迫脊髓,术中肿瘤切除后,脊髓发生缺血再灌注损伤,加重临床症状。 4.髓内室管膜瘤与正常脊髓有分界面,无浸润性生长,手术全切除率高,肿瘤切除后的复发率低；而髓内星形细胞瘤呈浸润性生长,肿瘤与正常脊髓组织分界不清,如果强调手术切除率,常常会导致严重的并发症。 二、神经电生理监测技术在高颈段椎管肿瘤术中的应用 [目的]探讨神经电生理监测技术在高颈段椎管肿瘤显微切除术中的应用价值及其影响因素。 [方法]回顾性分析我院神经外科2008年1月至2013年12月期间,在神经电生理技术监测下,经显微手术治疗的64例高颈段椎管内肿瘤患者临床资料。 [结果]本组64例患者术中在体感诱发电位(SEP)和运动诱发电位(MEP)辅助监测下,行显微手术切除肿瘤。肿瘤全切除54例(84.38%),次全切除8例(12.50%),部分切除2例(3.12%)。术前McCormick脊髓功能分级Ⅰ级42例,Ⅱ级22例；术后2周McCormick脊髓功能分级Ⅰ级48例,Ⅱ级15例,Ⅲ级1例。其中30例患者SEP监测出现波幅变化,48例患者术中出现MEP电生理波幅变化,在采取相应措施后电生理信号均恢复正常且术后未出现神经功能障碍加重。术中出现假阴性监测结果1例,患者术前双上肢活动正常,术后出现双上肢活动障碍,肌力Ⅱ级。 [结论] l.显微手术辅以神经电生理监测可提高手术安全性,最大程度保护神经功能,改善病人预后。但监测结果若出现假阳性,容易误导术者,延长手术时间；若出现假阴性,术者未能及时终止操作,导致脊髓损伤,遗留神经功能障碍。同时术中监测易受外界因素影响,使电生理监测的准确性下降。 2.术前诊断为脊膜瘤的患者,在经后正中入路切除椎板的过程中,SEP/MEP的波幅可一过性降低,考虑其原因可能是脊髓压迫明显,在椎板切除过程中存在损伤脊髓及脊神经的可能,因此对于脊髓张力较高的病变在暴露肿瘤的过程中动作应轻柔。 3.在高颈段髓内肿瘤术中,切开脊髓时可有神经电生理波幅的改变,如果在肿瘤切除的过程中出现神经电生理警报,则应暂停手术操作,评估肿瘤切除范围,并减少术中双极电凝的使用。我们在切除髓内室管膜瘤的过程中发现大部分患者在肿瘤切除后SEP/MEP的波幅都出现了逐渐恢复的趋势,而对于髓内边界不清的肿瘤应在神经电生理监测的指导下以部分切除肿瘤达到减压目的为主,不应追求肿瘤全切,避免损伤脊髓。
[Abstract]:The microsurgical treatment of high cervical spinal canal tumors

Objective : To investigate the clinical manifestation and imaging characteristics of different pathological types of tumors in high cervical spinal canal , and to analyze the effects of high cervical spinal canal tumor on the prognosis and prognosis .

Methods The clinical data of 135 patients with high cervical spinal canal tumors were analyzed retrospectively . All patients were divided into two groups according to WHO ( 2000 ) classification standard , and the patients were divided into two groups according to WHO ( 2000 ) classification standard . According to the position of lesion , the patients were divided into two groups : intramedullary and extramedullary tumors . According to the score of the Japanese Society of Osteological Association ( JOA ) at 1 week and 6 months after operation , the improvement of symptoms of patients was assessed , and the influence of tumor growth sites on prognosis was analyzed .

The result is not valid .

1 . All 135 patients underwent MRI plain scan and intensive examination before operation . Among them , 105 patients ( 77.78 % ) underwent cervical posterior median approach , lateral cervical approach in 17 cases ( 12.59 % ) , distal lateral approach in 5 cases ( 3.71 % ) , anterior cervical approach 6 cases ( 4.44 % ) , anterior cervical and posterior joint approach in 2 cases ( 1.48 % ) , total resection in 124 cases ( 91.85 % ) , subtotal removal in 10 cases ( 7.41 % ) , partial resection in 1 case ( 0.74 % ) .

2 . The tumor was located in 96 cases of extramedullary hard membrane , 35 cases of intramedullary nail and 4 cases of epidural hematoma . Among them , there were 42 cases of dumbbell - shaped tumors . The pathological types were 56 cases ( 41.48 % ) and 39 cases ( 28.89 % ) of neurilemmoma , and 29.63 % of other types . MRI was routinely reviewed within 2 weeks postoperatively .

3 . Simple cerebrospinal fluid leakage occurred in 5 patients after operation .
One elderly patient with pulmonary infection after operation died of respiratory failure on day 16 . Follow - up was performed in 110 patients for 2 months to 3 years without cervical instability .

Conclusion

1 . The early stage of cervical spinal canal tumor is not easy to be diagnosed , the tumor volume is larger at the time of visit , the operation risk is high , cervical vertebra MRI is the preferred imaging examination method ;
After the diagnosis of the patient is clear , the patient should be treated actively , and the posterior median approach is suitable for the removal of most of the high cervical spinal canal tumors . The lateral approach and the distal approach of the neck have some advantages to the exposure of the tumors in the cervical canal and the ventral tumors of the medulla . However , the surgical trauma is greater .

2 . The pathological types of tumors are most common in neurilemmoma and spinal meningoma , and the intramedullary tumor of the spinal cord is most common in benign and low malignant degree tumors .

3 . In patients with high cervical segment disease , only slight muscle strength was decreased before operation , and the symptoms and signs were significantly improved before or before operation .
The clinical symptoms were improved slowly before the operation , and the clinical symptoms were improved slowly after operation . The reason was that the spinal cord was compressed for a long time after the operation , and the spinal cord developed ischemia - reperfusion injury after operation , and the clinical symptoms were aggravated .

4 . The intermedullary dymoma and normal spinal cord had sub - interface , no invasive growth , high operation total resection rate and low recurrence rate after tumor resection .
In contrast to normal spinal cord tissue , tumor and normal spinal cord tissue are not clear . If the resection rate is emphasized , serious complications are often caused .

Application of nerve electrophysiology monitoring technique in high cervical spinal canal tumor

Objective : To investigate the value of neuroelectrophysiological monitoring in the treatment of high cervical spinal canal tumors and its influencing factors .

Methods : The clinical data of 64 patients with high cervical spinal canal tumors treated by microsurgical treatment were retrospectively analyzed from January 2008 to December 2013 in our hospital .

Results Among 64 patients , 64 patients underwent micro - surgical resection of tumors . Total resection of tumor was performed in 54 cases ( 84.38 % ) , subtotal removal in 8 cases ( 12.50 % ) , partial resection in 2 cases ( 3.12 % ) . The preoperative McCormick spinal cord function was grade 鈪，

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