上颈段哑铃形肿瘤的外科治疗策略

The surgical strategy of upper cervical dumbbell tumors

目的探讨上颈段哑铃形肿瘤的外科治疗策略及预后。方法回顾2000年1月至2009年12月收治的46例上颈段哑铃形肿瘤患者,分析其临床特点、外科分期、手术入路、切除方法、内固定重建技术及疗效。肿瘤性质包括神经鞘瘤33例,神经纤维瘤9例,恶性神经鞘瘤4例。依据前期设计的颈椎管哑铃形肿瘤的外科分期方法,Ⅰ期8例,Ⅱ期24例,Ⅲ期9例,Ⅳ期3例,Ⅴ期2例。经后外侧入路行肿瘤切除36例,前后联合入路行肿瘤切除10例。39例采用颈椎后路钉棒内固定系统重建,3例采用前后联合固定,4例未行内固定。结果 1例术中发生椎动脉损伤,压迫止血。术后发生脑脊液漏19例,2例继发颅内感染,经相关处理后痊愈。术后随访6～125个月,2例恶性神经鞘瘤患者于术后8个月、14个月出现局部复发,再次行手术治疗,分别于术后21个月、38个月因肺部转移导致全身衰竭死亡。其余患者未见复发,随访仍在持续进行中。结论上颈段哑铃形肿瘤的外科治疗具有相当的难度与风险,外科分期系统有助于合理制定手术方案。经后外侧入路或联合前方入路可实现肿瘤切除与重建,应注意相关并发症的处理与预防,以提高疗效。

Objective To investigate the surgical strategy and prognosis of upper cervical dumbbell tumors. Methods From January 2001 to December 2009, 46 consecutive cases with upper cervical dumbbell tumor were retrospectively studied on clinical characteristics, surgical staging, operative approach, resection, stability reconstruction and therapeutic effect. This series consisted of 33 cases of schwannomas, 9 neurofibromas and 4 malignant schwannomas. According to the surgical staging of cervical dumbbell tumors we designed previously, 46 patients were assessed with 8 cases in stageⅠ, 24 cases in stageⅡ, 9 cases in stage Ⅲ, 3 cases in stage Ⅳ and 2 cases in stage Ⅴ. Resection and reconstruction were performed for 36 patients through posteriolateral approach, and 10 patients through combined posteroanterior approaches. Posterior cervical screw-rod systems were used in 39 cases, while combined anterior and posterior fixation were performed in 3 cases and no fixation were carried out in 4 cases. Results Vertebral artery injury occurred in one patient during operation. Nineteen patients experienced cerebral spinal fluid leakage, 2 of them developed intracranial infection and recovered after corresponding management. The following up period ranged from 6 to 125 months. Two cases with malignant schwannoma relapsed at 8 and 14 months after surgery, and received revision surgery later. Both patients deceased due to systemic failure from pulmonary metastasis at 21 and 38 months respectively. No evidence of local recurrence was found in other patients and follow-up was continued. Conclusions The surgical management for upper cervical dumbbell tumors has many difficulties and risks, and the surgical staging is useful in the decision making process. Tumor resection and reconstruction could be accomplished through posterolateral or combined posteroanterior approach. Much care should be taken in prevention and management for complications, so as to improve curative effect.