脊髓栓系伴神经原性膀胱的治疗策略

Treatment of Tethered cord Syndrome Accompanied with Neurogenic Bladder

目的 探讨脊髓栓系综合征伴有神经原性膀胱的跨学科协作治疗。方法 本组脊髓栓系综合征患者24例，年龄4-47岁．平均35．1岁．男10例，女14例。手术前后行尿流动力学测定，神经外科手术分离粘连、松解脊髓，修补缺损及硬脊膜重建。排尿障碍改善不佳者行尿道支架置入及骶神经调控器植入术。结果 术前24例患者均诊断为神经原性膀胱，包括逼尿肌无力9例，扩约肌-逼尿肌共济失衡15例。病理诊断包括脂肪瘤8例，表皮样囊肿5例，先天性脊髓脊膜膨出11例。随访8-36月，19例患者术后尿流动力学检查有显著改善：3例放置尿道支架，2例行骶神经调控后改善。所有患者均无神经系统症状加重。结论 伴有神经原性膀胱的脊髓栓系综合征应早期行栓系松解术，排尿障碍改善不明显者放置尿道支架或行骶神经调控术。早期诊断及成立医疗协作小组是积极有效的，治疗的最终目的是阻止神经病变加重及预防可能发生的上尿路系统损害。

Objective To explore the cooperative treatment of the patients with tethered cord syndrome （TCS） accompanied neurogenic bladders （NB）. Methods Of 24 patients with TCS, 10 were male and 14 female. They were averagely 35.1 years old. The pre-and postoperative urodynamics was determined by urologic surgeons. The surgery for relaxing the tethered conus medullaris which included lipomas, or epidermoid cyst removing, separation of adhesion and terminal ilium cutting off, and the reconstruction of the dura mate of the spinal cord were performed by neurosurgeons. The urethral stents or sacral neuro-modulations implantation were performed in the patients with dysuria after the relaxing the tethered conus medularis. Results The neurogenic bladders were definitely diagnosed in all the patients before the operation, including detrusor urinae adynamia in 9 patients and sphincter-detrusor urinae dyssynergia in 15 patients. The pathological examination showed 8 cases of lipomas, 5 cases of epidermoid cysts and 11 cases of meningomyelocele. The following up from 8 to 36 months showed that the postperative urodynamics became significantly better than preoperative that in 19 patients. Three patients receiving urethred stents implantation and 2 patients receiving sacral neuro-modulation implantation were improved in dysuria. Conclusions The tethered cord relaxation should be early performed in the patients with TCS accompanied with NB. The urethral stents or sacral neuro-modulation implantation should be performed in the patients with dysuria after the tethered cord relaxation. The early diagnosis and cooperative treatment are helpful to the increase in the curative effect in the patients with TCS accompanied with NB. The major objective of treatment is to prevent further neurological deterioration and to protect kidney function in the patients with TCS accompanied with NB.