本文選題：高頸段 + 椎管腫瘤　； 參考：《天津醫(yī)科大學(xué)》2014年碩士論文

【摘要】：一、高頸段椎管腫瘤的顯微外科治療 [目的]探討高頸段椎管內(nèi)不同病理類型腫瘤的臨床表現(xiàn)及影像學(xué)特點,分析高頸段椎管內(nèi)腫瘤顯微手術(shù)治療效果及預(yù)后相關(guān)因素。 [方法]回顧性分析天津醫(yī)科大學(xué)總醫(yī)院神經(jīng)外科2003年1月至2013年12月期間,經(jīng)手術(shù)治療的135例高頸段椎管內(nèi)腫瘤患者的臨床資料,所有患者病理分類按照神經(jīng)系統(tǒng)腫瘤WHO(2000)分類標(biāo)準(zhǔn)進(jìn)行統(tǒng)計,總結(jié)不同類型腫瘤的影像學(xué)特點及手術(shù)策略,并根據(jù)病變位置將患者分為髓內(nèi)及髓外腫瘤兩組,依據(jù)術(shù)后1周及術(shù)后6個月日本骨科學(xué)會(Japanese Orthopaedic Association,JOA)評分,對患者的癥狀改善進(jìn)行評估,分析高頸段腫瘤生長部位對預(yù)后的影響。 [結(jié)果] 1.本組135例患者術(shù)前均行頸椎MRI平掃和強化檢查,明確腫瘤位置。其中105例(77.78%)患者采用頸后正中入路,頸外側(cè)入路17例(12.59%),遠(yuǎn)外側(cè)入路5例(3.71%),頸前入路6例(4.44%),頸前及頸后聯(lián)合入路2例(1.48%)。腫瘤全切124例(占91.85%),次全切除10例(占7.41%),部分切除1例(占0.74%)。 2.腫瘤位于髓外硬膜下96例,髓內(nèi)35例,硬膜外4例,其中啞鈴形腫瘤42例。病理類型主要為神經(jīng)鞘瘤56例(41.48%)和脊膜瘤39例(28.89%),其他類型共占29.63%。術(shù)后2周內(nèi)常規(guī)復(fù)查MRI,可見脊髓均有不同程度的水腫。 3.本組5例患者術(shù)后出現(xiàn)單純性腦脊液漏；1例高齡患者,術(shù)后出現(xiàn)肺部感染,術(shù)后第16天死于呼吸衰竭。術(shù)后隨訪110例患者2個月～3年,無頸椎不穩(wěn)定情況。 [結(jié)論] 1.高頸段椎管腫瘤早期不容易確診,患者就診時腫瘤體積較大,手術(shù)風(fēng)險高,頸椎MRI是首選影像學(xué)檢查方法；患者診斷明確后應(yīng)積極手術(shù)治療,頸后正中入路適合絕大部分高頸段椎管腫瘤的切除,頸外側(cè)入路及遠(yuǎn)外側(cè)入路對于暴露頸椎管外腫瘤或累及延髓腹側(cè)腫瘤有一定優(yōu)勢,但手術(shù)創(chuàng)傷較大。 2.腫瘤病理類型以神經(jīng)鞘瘤和脊膜瘤最常見,脊髓髓內(nèi)腫瘤以良性及低惡性度腫瘤多見,術(shù)后常有不同程度脊髓腫脹,術(shù)中可預(yù)防性應(yīng)用脫水藥物及激素治療,避免術(shù)后臨床癥狀加重。 3.若高頸段病變患者術(shù)前只有輕度肌力下降、肢體麻木且病程較短者,術(shù)后癥狀、體征基本同術(shù)前或較術(shù)前明顯改善；而術(shù)前已出現(xiàn)明顯肢體無力、肌張力增高及二便功能障礙的患者,術(shù)后臨床癥狀改善緩慢,考慮其原因是術(shù)前腫瘤長期壓迫脊髓,術(shù)中腫瘤切除后,脊髓發(fā)生缺血再灌注損傷,加重臨床癥狀。 4.髓內(nèi)室管膜瘤與正常脊髓有分界面,無浸潤性生長,手術(shù)全切除率高,腫瘤切除后的復(fù)發(fā)率低；而髓內(nèi)星形細(xì)胞瘤呈浸潤性生長,腫瘤與正常脊髓組織分界不清,如果強調(diào)手術(shù)切除率,常常會導(dǎo)致嚴(yán)重的并發(fā)癥。 二、神經(jīng)電生理監(jiān)測技術(shù)在高頸段椎管腫瘤術(shù)中的應(yīng)用 [目的]探討神經(jīng)電生理監(jiān)測技術(shù)在高頸段椎管腫瘤顯微切除術(shù)中的應(yīng)用價值及其影響因素。 [方法]回顧性分析我院神經(jīng)外科2008年1月至2013年12月期間,在神經(jīng)電生理技術(shù)監(jiān)測下,經(jīng)顯微手術(shù)治療的64例高頸段椎管內(nèi)腫瘤患者臨床資料。 [結(jié)果]本組64例患者術(shù)中在體感誘發(fā)電位(SEP)和運動誘發(fā)電位(MEP)輔助監(jiān)測下,行顯微手術(shù)切除腫瘤。腫瘤全切除54例(84.38%),次全切除8例(12.50%),部分切除2例(3.12%)。術(shù)前McCormick脊髓功能分級Ⅰ級42例,Ⅱ級22例；術(shù)后2周McCormick脊髓功能分級Ⅰ級48例,Ⅱ級15例,Ⅲ級1例。其中30例患者SEP監(jiān)測出現(xiàn)波幅變化,48例患者術(shù)中出現(xiàn)MEP電生理波幅變化,在采取相應(yīng)措施后電生理信號均恢復(fù)正常且術(shù)后未出現(xiàn)神經(jīng)功能障礙加重。術(shù)中出現(xiàn)假陰性監(jiān)測結(jié)果1例,患者術(shù)前雙上肢活動正常,術(shù)后出現(xiàn)雙上肢活動障礙,肌力Ⅱ級。 [結(jié)論] l.顯微手術(shù)輔以神經(jīng)電生理監(jiān)測可提高手術(shù)安全性,最大程度保護(hù)神經(jīng)功能,改善病人預(yù)后。但監(jiān)測結(jié)果若出現(xiàn)假陽性,容易誤導(dǎo)術(shù)者,延長手術(shù)時間；若出現(xiàn)假陰性,術(shù)者未能及時終止操作,導(dǎo)致脊髓損傷,遺留神經(jīng)功能障礙。同時術(shù)中監(jiān)測易受外界因素影響,使電生理監(jiān)測的準(zhǔn)確性下降。 2.術(shù)前診斷為脊膜瘤的患者,在經(jīng)后正中入路切除椎板的過程中,SEP/MEP的波幅可一過性降低,考慮其原因可能是脊髓壓迫明顯,在椎板切除過程中存在損傷脊髓及脊神經(jīng)的可能,因此對于脊髓張力較高的病變在暴露腫瘤的過程中動作應(yīng)輕柔。 3.在高頸段髓內(nèi)腫瘤術(shù)中,切開脊髓時可有神經(jīng)電生理波幅的改變,如果在腫瘤切除的過程中出現(xiàn)神經(jīng)電生理警報,則應(yīng)暫停手術(shù)操作,評估腫瘤切除范圍,并減少術(shù)中雙極電凝的使用。我們在切除髓內(nèi)室管膜瘤的過程中發(fā)現(xiàn)大部分患者在腫瘤切除后SEP/MEP的波幅都出現(xiàn)了逐漸恢復(fù)的趨勢,而對于髓內(nèi)邊界不清的腫瘤應(yīng)在神經(jīng)電生理監(jiān)測的指導(dǎo)下以部分切除腫瘤達(dá)到減壓目的為主,不應(yīng)追求腫瘤全切,避免損傷脊髓。
[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，

本文編號：1991379