听神经瘤的显微外科治疗和面神经功能保护的探讨

Microsurgical management of acoustic neuroma and protection of facial nerve

目的探讨听神经瘤的显微外科手术技巧及保留面神经的技术。方法福建医科大学附属第一医院神经外科自2002年8月至2010年12月经枕下乙状窦后（骨瓣成型、锁孔）入路显微手术治疗听神经瘤患者168例，术中在面肌肌电图监测下采取囊内切除与囊壁切除交替进行、双向会合、锐性分离面神经等技术切除肿瘤，并回顾性分析显微手术的技巧和疗效。结果肿瘤全切149例（88．69％），部分切除19例（11.31％）；面神经解剖学保留146例（86．9％1；死亡2例（1．19％）。术后6个月按House Blackmann标准评估面神经功能：Ⅰ、Ⅱ级91例（54．16％）。Ⅲ、Ⅳ级52例（30．95％），Ⅴ、Ⅵ级25例（14．89％）。结论经枕下乙状窦后（骨瓣成型、锁孔）入路显微手术治疗听神经瘤安全有效；利用术中面肌肌电图监测可以提高面神经解剖保留率；熟练掌握显微手术技巧是全切肿瘤、解剖保留面神经的关键。

Objective To discuss the microsurgical skills of management of acoustic neuroma and the protection of facial nerve. Methods One hundred and sixty-eight patients with acoustic neuroma, admitted to our hospital from August 2002 to December 2010, received microsurgery through suboccipital retrosigmoid approach. Under intraoperative electromyography （EMG） monitoring, the facial nerve was separated sharply from both sides, and the tumors were removed by alternate intracapsular excision and capsule wall excision. The microsurgical skill and the method of protection of facial nerve were evaluated retrospectively. Results Total resection was performed in 149 cases （88.69%）, partial resection in 19 cases （11.31%）. Facial nerve was protected in 146 cases （86.9%） during the operation. Two patients were dead shortly after the surgery. The facial nerve functions were evaluated 6 months after the surgery： 91 （54.26%） belonged to grade I and grade II, and 52 （30.95%） belonged to grade III and grade IV, while 52 （14.89%） belonged to grade V and grade VI according to House-Brackmann grade. Conclusion The microsurgical removal of acoustic neuroma through suboccipital retrosigmoid approach is safe and effective. The intraoperative electromyography monitoring could improve the reservation rate of facial nerve. Skilled microsurgical technique is the key to the total removal of acoustic tumor and the protection of facial nerve.