显微手术治疗小儿腰骶部脊髓脊膜膨出35例报告

Microsurgical treatment of myelomeningocele in the lumbar and sacral region in children:Report of 35 cases

目的总结显微手术治疗小儿腰骶部脊髓脊膜膨出的经验及近期效果。方法2005年10月-2006年11月显微手术治疗35例先天性脊髓脊膜膨出患儿,均行脊髓和马尾神经的松解,硬膜成形,8例患儿同时进行终丝切断,10例脑积水行脑室-腹腔分流术。结果35例均成功实施了脊膜膨出切除修补术、脊髓和马尾神经松解。10例术前存在膀胱直肠功能障碍中,术后3例直肠功能好转,余7例大小便情况同前。术前足部畸形9例,术后4例足内翻张力减低,余5例无明显功能变化。2例术后发生切口脑脊液漏,余切口一期愈合。10例合并明显脑积水患儿进行了脑室-腹腔分流术,其中二期进行分流术的9例治愈,1例一期进行分流术的患儿术后发生感染,二次行脑室-腹腔分流术。结论小儿腰骶部脊髓脊膜膨出及早采取手术治疗可改善神经功能障碍;合并脑积水的患儿,二期脑室-腹腔分流术安全有效;硬膜修补成形和皮下组织的处理是预防术后脑脊液漏的关键。

Objective To summarize and evaluate the experience and near-term outcomes of microsurgical treatment of myelomeningocele in the lumbar and sacral region in children.Methods Clinical data of 35 cases of myelomeningocele from October 2005 to November 2006 were analyzed retrospectively.The spinal cord and the cauda equine nerves were dissected microsurgically from the surrounding tissues.The duraplasty was performed and the thecal sac was reconstructed.The tight filums were released simultaneously in 8 cases and a ventriculoperitoneal shunt was placed in 10 children with severe hydrocephalus. Results The microsurgical repair was implemented and the spinal cord was released successfully in all the 35 cases.Among 10 cases of vesicorectal dysfunction,there were 3 cases of improvement of rectal sphincter functions after operation.Out of 9 cases of equinovarus,the tension of varus was decreased in 4 cases and no obvious functional improvement was observed in the rest of 5 cases.Leakage of cerebrospinal fluid from the incision occurred in 2 cases,and in the remaining cases the incision healed by first intention.The 10 cases of severe hydrocephalus were cured with ventriculoperitoneal shunting,including a delayed shunt insertion in 9 cases and a single-stage insertion in 1 case,in which a postoperative infection was encountered and a re-operation of ventriculoperitoneal shunting was given. Conclusions For children with myelomeningocele,a surgical treatment should be given as early as possible.A delayed shunt insertion 1~2 weeks after myelomeningocele repair is safe and effective.The duraplasty and optimized closure of the subcutaneous tissue are important for preventing cerebrospinal fluid leakage.