经乳突下-颌下联合入路行寰椎侧块肿瘤切除术

Resection of tumors at lateral mass of the atlas through a combined sub-mamillary process and sublower mandible approach

目的探讨经乳突下一颌下联合人路行寰椎侧块肿瘤切除术及疗效。方法2003年1月至2008年5月，采用乳突下-颌下联合入路行肿瘤切除术治疗8例寰椎侧块肿瘤患者，男4例，女4例；年龄19～61岁，平均40_3岁；肿瘤位于左侧侧块6例，右侧侧块2例。患者均出现不同程度的枕颈部疼痛，7例伴头颈歪斜、颈部旋转活动受限，3例伴眩晕，3例伴吞咽不适或吞咽异物感，2例伴四肢麻木、乏力，1例伴患侧肢体乏力。肿瘤类型：骨软骨瘤3例，骨母细胞瘤、骨巨细胞瘤、浆细胞瘤、软骨肉瘤、嗜酸性肉芽肿各1例。肿瘤切除后所有病例均一期行后路枕颈内固定。浆细胞瘤、骨巨细胞瘤、软骨肉瘤患者术后4-8周接受局部放疗。结果手术显露良好，肿瘤顺利切除，无椎动脉损伤、神经损伤及感染并发症。术后局部疼痛缓解，3例伴咽部不适症状者均有不同程度改善。术后随访8-72个月，平均46个月。1例软骨肉瘤患者于术后14个月局部复发，术后39个月死于高位瘫痪、呼吸及循环衰竭；1例浆细胞瘤患者定期行骨髓穿刺，未发现异常改变；其余患者未见复发。结论手术切除治疗单侧寰椎侧块肿瘤，采用经乳突下一颌下联合入路较为理想，该入路显露充分，可游离保护患侧椎动脉，有助于寰椎侧块肿瘤的彻底切除，并可避免经口腔入路相关并发症。

Objective To investigate procedure and therapeutic effect of combined sub-mamillary process and sub-lower mandible approach for resection of tumors at lateral mass of the atlas. Methods Eight patients with neoplasm at lateral mass of the atlas were surgically treated by combined sub-mamillary process and sub-lower mandible approach. Tumor lesions involved in left lateral mass for 6 cases and in right for 2 cases. Pathological type of tumors included osteochondroma in 3 cases, osteoblastoma, giant cell tumor, plasmocytoma, chondrosarcoma and eosinophilic granuloma in 1 case respectively. All patients underwent oc- cipitocervical fusion through posterior approach after tumor resection. Patients with plasmocytoma, giant cell tumor or chondrosarcoma received radiotherapy after surgery. Results This combined approach bought a good surgical field exposure so that tumor resection was performed successfully without vertebral artery and nerve injury nor infection. Postoperative outcomes were satisfactory in all patients, with pain at the occiput and discomfort in pharyngeal portion alleviated. At the follow-up of 8-72 months, 1 patient with chondrosar- coma recurred locally 14 months after operation and died of respiratory and circulation failure in 39 months after operation. No evidence of local recurrence was found in other patients. Conclusion Comparing with other approaches reported previously, the combined sub-mamillary process and sub-lower mandible approach is an ideal approach for the treatment of tumor lesions at lateral mass of the atlas, through which a wide ex- posure with well protect of vertebral artery benefiting to radical excision could be obtained without complications related to traMs-oral surgery.