颈椎管哑铃形肿瘤的外科分期及手术策略

The surgical staging and strategy of cervical dumbbell intra-extradural tumors

目的探讨颈椎管内外哑铃形肿瘤的临床特点、外科分期、手术入路、切除方法及内固定重建技术。方法回顾性分析1999年1月至2005年12月收治的37例颈椎管内外哑铃形肿瘤患者。年龄18～80岁,平均39岁;男18例,女19例。肿瘤性质:神经鞘瘤25例,神经纤维瘤3例,多发性神经纤维瘤5例,恶性神经鞘瘤4例。根据肿瘤侵袭的范围和区域自行设计外科分期系统:Ⅰ期8例,Ⅱ期9例,Ⅲ期13例,Ⅳ期5例,Ⅴ期2例。经颈后外侧入路行肿瘤切除术20例,前后联合入路(后外侧+前外侧)行肿瘤切除术17例;26例采用后路钉棒/钉板内固定系统重建,5例采用前后联合固定,6例未行内固定。结果术后随访3个月～7年,平均39个月。术后出现单侧上肢一过性肌力减弱1例,单侧颈后部感觉麻木1例,霍纳征1例,1例术中因一侧椎动脉损伤而行椎动脉结扎,2例恶性神经鞘瘤者术后1～2年因局部复发而再次行手术治疗。多数患者术后疗效较满意,局部疼痛和神经症状均有改善或缓解,19例患者脊髓神经功能完全恢复,2例未行内固定术的患者于术后1～2年出现不同程度的颈椎反屈畸形。结论根据肿瘤的部位、性质及外科分期制定手术治疗策略能显著提高肿瘤切除率,降低术后局部复发率和手术并发症的发生率。内固定重建对维持颈椎的稳定性具有重要价值,术中应准确判断肿瘤与神经根、椎动脉和颈髓的关系并注意保护。

Objective To investigate the clinical characteristic, surgical stage, operative approach, resection and stability reconstruction of dumbbell intra-extradural tumor of cervical spine. Methods From January 1999 to December 2005, 37 consecutive cases with cervical dumbbell intra-extradural tumor were retrospectively studied. 18 males and 19 females ranged from 18 to 80 years old were involved in this study, including 25 schwannomas, 3 neurofibromas, 5 muhi-neurofibromas and 4 malignant schwannomas. According to tumor location and involved range, all tumors were divided into five stages： 8 cases in Ⅰ stage, 9 cases in Ⅱ stage, 13 cases in Ⅲ stage, 5 cases in Ⅳ stage and 2 cases in Ⅴ stage. Resection and reconstruction were performed at 20 patients through posterior-lateral approach, 17 patients through anterior-lateral combined with posterior-lateral approach. Lateral mass screw internal fixation system were used in 26 cases, while anterior combined posterior fixation were performed in 5 cases and none fixation in 6 cases. Results The follow-up period was from 3 months to 7 years. 1 case developed a transient weakening of upper limb, 1 case developed anesthesia in posterior neck, and 1 case developed Homer＇s sign. Vertebral artery ligation was performed in 1 case because of vertebral artery injury. 2 cases with malignant schwannoma occurred local recurrence in 1-2 years postoperation and received second operation. The recent effects after operation were satisfactory in majority cases ,with complete recovery of spinal cord function in 19 cases. 2 cases without fixation appeared recuration deformity in cervical spine in 1-2 years postoperation. Conclusion The surgical approach and operative methods must be selected according to the location, surgical staging, characters of tumors. Stability reconstruction plays important roles in maintaining stability of cervical spine. More care should be taken in procedure for protecting vertebral artery, cervical nerve and spinal cord.