显微手术治疗骶管囊肿43例临床分析

Microsurgical Treatment of Sacral Canal Cyst: an Analysis of 43 Cases

目的探讨骶管囊肿的手术方式及疗效。方法 2015年1月~2017年1月,显微外科治疗骶管囊肿43例,后正中切口行椎板切除或椎板切开保留回置,显微镜下行囊肿漏口修补、神经根松解、神经根袖状成形缝合或漏口缝扎、切断外终丝,小囊肿在神经电生理监测下电凝塑形,明胶海绵、止血纱与人工硬脊膜材料或椎旁肌肌肉瓣填充骶管内残腔。结果行神经根袖状成形25例,其中合并小囊肿予以囊壁电凝塑形2例;囊肿漏口缝扎17例,其中9例行外终丝切断;臀大肌肌皮瓣填充1例。椎板切除28例,椎板回置15例。手术时间82~300 min,中位数161 min,术中出血10~300 ml,中位数50 ml。随访6~27个月,中位时间15个月。与术前相比,末次随访时疼痛视觉模拟评分(VAS)显著降低[中位数6分(0~10分)vs.0分(0~8分),Z=-5.230,P=0.000],JOA评分显著升高[21分(4~28分)vs.28分(20~29分),Z=-5.314,P=0.000]。治愈19例(44.2%),显效12例(27.9%),有效4例(9.3%),无效8例(18.6%),总有效率81.4%(35/43)。结论依据囊肿类型采取分类显微外科手术治疗骶管囊肿微创、安全,能够明显改善疼痛症状及神经功能,囊肿漏口的处理和神经根松解是治疗的关键,应早期治疗以恢复骶管正常解剖学形态。

Objective To discuss the surgical treatment and curative effect of sacral canal cyst. Methods A total of 43 cases of sacral canal cyst received microsurgical treatment from January 2015 to January 2017. They were given laminectomy or laminoplasty under general anesthesia. The ventages between cyst and dura sac were repaired and a nerve root sleeve plasty was performed, or ventages were closed by suture without nerve root in the cyst and the filum was cut off if seen. The small cysts were shaped by bipolar coagulation under electrophysiological monitoring. The gelatin sponge, hemostatic yarn with artificial dura materials or paravertebral muscle flap were used to fill residual cavity in the sacral canal. Results There were 25 cases receiving nerve root sleeve plasty （2 of which were complicated with small cysts and treated by electric coagulation） , 17 cases had cyst fistula and suture （including 9 cases of external end wire cut） , and 1 case filled with gluteus maximus myocutaneous flap. Laminectomy was performed in 28 cases and laminoplasty in 15 cases. The operation time was 82 - 300 min （ median, 161 min） and the intraoperative bleeding was 10 - 300 ml （ median, 50 ml） . The follow-up period was 6-27 months, with a median of 15 months. The median postoperative VAS score was 0 （ range, 0 - 8 ） , which was significantly lower than the preoperative level [ 6 （ range, 0 - 10 ） , Z = -5. 230,P = 0. 000 ]. The postoperative JOA score was 28 （range,20 - 29）,which was significantly higher than the preoperative level [21 （range,4 - 28）, Z - - 5.314, P = 0. 000 ] . There were 19 cured cases （44. 2% ） , 12 excellent cases （ 27. 9% ） , 4 effective cases （9.3%）, and 8 invalid cases （18.6% ）. The total efficiency was 81.4% （35/43）. Conclusions Individualized microsurgery for sacral canal cyst is minimally invasive and safe, and can improve the pain symptoms and neurological function. The treatment of ventages of the cysts and release of the nerve root are important. Surgical indications should be taken and early treatment should be performed to restore sacral canal morphology.