椎管内外哑铃状神经鞘瘤的临床特点及治疗方式探讨
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摘要
目的:探讨椎管内外哑铃状神经鞘瘤的临床特点及治疗方式,为临床治疗提供依据。方法:回顾性分析2012年1月-2017年6月广元市中心医院神经外科收治的30例椎管内外哑铃状神经鞘瘤的临床资料。手术均采用侧卧位后正中入路显微镜下病变切除术,其中行单侧钉棒系统固定13例,双侧钉棒系统固定15例,椎板部分切除未行内固定2例。术中常规采用神经电生理监测,避免神经功能损伤,同时将穿过肿瘤的部分神经切除。结果:30例椎管内外哑铃状肿瘤,SimpsonⅠ级和Ⅱ级切除9例,Ⅳ级切除1例。术后患者痊愈28例,好转2例,术后病理结果显示WHOⅠ级神经鞘瘤27例(其中4例伴有囊肿及出血),神经纤维瘤3例。随访1～5年,未见复发,所有患者均未行放疗及化疗。结论:椎管内外哑铃状神经鞘瘤在脊柱并不少见,该肿瘤通常都由神经根发出,临床由椎管内波及椎管外,病变椎间孔扩大部分,部分波及椎体部分,如椎体波及超过1/3及同侧上下关节突影响较大的需行植骨融合及钉棒系统固定,避免术后脊柱变形,因此术前应全面检查需行MRI、CT、X线等全面检查,术前做好准备,在保护神经完整及功能安全情况下,尽量如肿瘤切除后易导致脊柱不稳定,术中需同时行椎体融合及钉棒系统固定,防止术后脊柱畸形,术中争取全切除肿瘤,切除程度对预后是否复发影响较大。
Objective:To investigate the clinical characteristics and treatment methods of dumbbell shaped neurinoma in and outside the spinal canal,and to provide evidence for clinical treatment.Method:The clinical data of 30 cases of dumbbell shaped neurinoma in and outside the spinal canal were retrospectively analyzed from January 2012 to June 2017 in Department of Neurosurgery,Guangyuan central hospital.All the operations were performed by lateral position and median approach microscope.Among them,13 cases were treated with unilateral nail and bar system,15 cases with bilateral nail bar system,2 cases with laminectomy.Intraoperative electrophysiological monitoring was performed to avoid neurologic impairment and to remove part of the nerve through the tumor.Result:10 cases of dumbbell shaped tumors in the spinal canal were treated with Simpson,grade I and grade II resection in 9 cases,grade IV resection in 1 case.After operation,28 cases were cured,2 cases improved.Postoperative pathological findings showed WHO grade I schwannoma(3 cases with cyst and bleeding).Follow up for 1-5 years,no recurrence,all patients were not treated with radiotherapy and chemotherapy.Conclusion:the dumbbell shaped schwannoma is not uncommon in the spine,the tumor usually consists of nerve root canal by a clinical spread of spinal lesions,intervertebral foramen enlargement section,part of affected vertebral body part,such as the need for more than 1/3 of affected vertebral interbody fusion and pedicle screw system fixation,avoid spinal deformity after operation,so the operation before should check the check for MRI,CT,X-ray,prepared before operation,in the protection of nerve integrity and function of safety situation,as far as tumor resection can cause spinal instability,and vertebral fusion and pedicle screw fixation in preventing postoperative spinal deformity surgery,strive for the whole resection of the tumor,extent of resection on the prognosis of recurrence of large.
Objective:To investigate the clinical characteristics and treatment methods of dumbbell shaped neurinoma in and outside the spinal canal,and to provide evidence for clinical treatment.Method:The clinical data of 30 cases of dumbbell shaped neurinoma in and outside the spinal canal were retrospectively analyzed from January 2012 to June 2017 in Department of Neurosurgery,Guangyuan central hospital.All the operations were performed by lateral position and median approach microscope.Among them,13 cases were treated with unilateral nail and bar system,15 cases with bilateral nail bar system,2 cases with laminectomy.Intraoperative electrophysiological monitoring was performed to avoid neurologic impairment and to remove part of the nerve through the tumor.Result:10 cases of dumbbell shaped tumors in the spinal canal were treated with Simpson,grade I and grade II resection in 9 cases,grade IV resection in 1 case.After operation,28 cases were cured,2 cases improved.Postoperative pathological findings showed WHO grade I schwannoma(3 cases with cyst and bleeding).Follow up for 1-5 years,no recurrence,all patients were not treated with radiotherapy and chemotherapy.Conclusion:the dumbbell shaped schwannoma is not uncommon in the spine,the tumor usually consists of nerve root canal by a clinical spread of spinal lesions,intervertebral foramen enlargement section,part of affected vertebral body part,such as the need for more than 1/3 of affected vertebral interbody fusion and pedicle screw system fixation,avoid spinal deformity after operation,so the operation before should check the check for MRI,CT,X-ray,prepared before operation,in the protection of nerve integrity and function of safety situation,as far as tumor resection can cause spinal instability,and vertebral fusion and pedicle screw fixation in preventing postoperative spinal deformity surgery,strive for the whole resection of the tumor,extent of resection on the prognosis of recurrence of large.
引文
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[15]Gerszten P C,Quader M J.Radiosurgery for benign tumors of the spine:clinical experience and current trends[J].Neuro Oncol,2011,13(9):983-999.
[16]卜博,章文斌.神经外科手术核心技术[M].北京:人民卫生出版社,2014:345-622.
[17]Tomii M.Itoh Y,Numazawa S,et al.Surgical consideration of cervical dumbbell tumors[J].Acta Neurochir(Wien),2013,155(10):1907.
[18]范涛.脊髓脊柱肿瘤外科手术图谱[M].沈阳:辽宁科学技术出版社,2009:1-9.
[19]菅凤增.简明脊柱内固定图谱[M].北京:人民军医出版社,2014:7-35.
[20]Nishimura Y,Hara M.Natsume A,et al.Intra-extradural dumbbell.shaped hemangioblasloma manifesting as subarachnoid hemorrhage in the cauda equina[J].Neurol Med Chir(Tokyo),2012,52(9):659-665.
[2]Chen S L,Liu C,Liu B,et al.Schwannomatosis:a new member of neurofibromatosis family[J].Chin Med J(Engl),2013,126(14):2656-2660.
[3]王书中.椎管内神经鞘瘤的MRI诊断[J].实用医学杂志,2006,22(18):2149-2150.
[4]Kshettry V R,Hsieh J K,Ostrom Q T,et al.Descriptive Epidemiology of Spinal Meningiomas in the United States[J].Spine(Phila Pa 1976),015,40(15):E886-889.
[5]Wiemels J,Wrensch M,Claus E B.Epidemiology and etiology of meningioma[J].J Neurooncol,2010,99(3):307-314.
[6]刘通,刘辉,张建宁,等.椎管哑铃形肿瘤的显微外科治疗[J].中华神经外科杂志,2016,32(6):551-555.
[7]陈良,庞清江,张前法,等.微型钛板腰椎管成形术在腰椎管狭窄症的应用[J].中国修复重建外科杂志,2006,20(4):410-412.
[8]Sachdev S,Dodd R L,Chang S D,et al.Stereotactic radiosurgery yields long-term control for benign intradural,extramedullary spinal tumors[J].Neurosurgery,2011,69(3):533-539.
[9]Li Y,Si R,Feng Y,et al.Myocardial ischemia activates an injurious innate immune signaling via cardiac heat shock protein60 and TOLL-like receptor 4[J].J Biol Chem,2011,286(36):31308-31319.
[10]Temiz C,Solmaz I,Tehli O,et al.The effects of splenectomy on lipid peroxide and neuronal loss in experimental spinal cord ischemia reperfusion injury[J].Turk Neurosurg,2013,23(1):67-74.
[11]Kertmen H,Gttrer B,Yulmaz E R,et al.The protective effect of low-dose methotrexate on ischemia-reperfusion injury of the rabbit spinal cord[J].EUR J Pharmacol,2013,714(1-3):148-156.
[12]Xu W B,Lv C,Wang Y F,et al.Combination of dexamethasone and aminobuanidine reduces secondary danage in compression spinal cord injury[J].Cell Mol Neurobiol,2009,29(5):683-689.
[13]皮国富,刘宏建,王卫东主译.脊柱外科手术学[M].郑州:河南科学技术出版社,2017:339-345.
[14]Schuhhess R,Gullotta C.Resection of relevant nerve roots in surgery of spinal neurinomas without persisting neurological deficit[J],1993,122(1-2):91-96.
[15]Gerszten P C,Quader M J.Radiosurgery for benign tumors of the spine:clinical experience and current trends[J].Neuro Oncol,2011,13(9):983-999.
[16]卜博,章文斌.神经外科手术核心技术[M].北京:人民卫生出版社,2014:345-622.
[17]Tomii M.Itoh Y,Numazawa S,et al.Surgical consideration of cervical dumbbell tumors[J].Acta Neurochir(Wien),2013,155(10):1907.
[18]范涛.脊髓脊柱肿瘤外科手术图谱[M].沈阳:辽宁科学技术出版社,2009:1-9.
[19]菅凤增.简明脊柱内固定图谱[M].北京:人民军医出版社,2014:7-35.
[20]Nishimura Y,Hara M.Natsume A,et al.Intra-extradural dumbbell.shaped hemangioblasloma manifesting as subarachnoid hemorrhage in the cauda equina[J].Neurol Med Chir(Tokyo),2012,52(9):659-665.