晚期腰骶部巨大脊髓脊膜膨出的显微外科治疗

Microsurgical treatment for huge lumbosacral myelomeningocele of advanced stage

目的探讨晚期腰骶部巨大脊髓脊膜膨出的显微外科手术治疗策略及其疗效。方法2004年4月至2009年8月间采用显微神经外科手术共治疗17例晚期腰骶部巨大脊髓脊膜膨出患者，平均病程21．5年，膨出囊平均大小20．6cm×22．4cm×19．3cm。均在显微镜下切除囊肿、解剖与囊壁粘连的神经组织并还纳入椎管、强化修补硬膜囊、局部软组织及椎板缺损，并行皮肤成形术，7例患者同时行脊髓栓系松解、终丝切断术。结果所有患者中失访2例，术后随访33—95个月，平均63．3个月。术前有下肢肌力下降的10例患者中有5例术后下肢肌力改善，改善率50％；术前下肢疼痛和／或感觉障碍的6例患者中有2例感觉障碍部分恢复，1例双下肢疼痛消失，改善率50％；术前6例单纯小便功能障碍者，3例有改善，2例情况同前，1例出现尿潴留，改善率为50％；术前7例大小便功能障碍者，术后4例二便控制力有提高，3例无明显改善，改善率为57％；二便障碍总体改善率为54％。全部随访病例生活质量较术前均有改善：术前平卧受限或完全不能平卧，术后可完全或间断平卧。并发症：术后并发脑积水而行脑室一腹腔分流术1例，伤口延迟愈合3例，感觉障碍加重（平面上升）1例，小便障碍加重1例。结论对于晚期腰骶部巨大脊髓脊膜膨出患者，积极的显微神经外科手术干预亦能明显改善其生活质量，并可能恢复部分神经功能，长期随访效果满意。

Objective To study the strategy and effects of microsurgical treatment for patients with huge lumbosacral myelomeningocele （MMC） of advanced stage. Methods 17 patients with huge lumbosacral MMC of advanced stage admitted from April 2004 to August 2009 were involved and retrospectively followed - up in this study. The mean size of cyst was 20.6 cm×22.4 cm×19.3 cm. The mean age of patients was 21.5 years old. Microneurosurgical treatment was performed to all patients. The dissection and resection of cyst, return of the adhesive nerves into spinal canal and complete repair were done. Among all of the patients, 7 cases complicated with TCS were performed ilium terminale - cutting procedure at the same time. Results All patients except 2 were followed - up from 33 to 95 months （63.3 months in average ）. Five patients＇ motor function and two patients＇ sensory function were improved postoperatively. One patient was completely relieved from intermittent pain of his lower limbs. Among all of the six patients with urinary dysfunction and seven patients suffering dysfunction of both urination and defecation, three patients got improved urinary function, while four enhanced their sphrincter function. The quality of life of all 15 patients were improved. The postoperative complications included one case of V - P shunt due to postoperative hydrocephalus, one case of deterioration of urinary function, one case of worse dysfunction of sensation of lower limbs and 3 cases of wound complications. Conclusions For huge lumbosacral MMC of advanced stage, microsurgical intervention is still necessary and effective. It should be adopted promptly for improving the quality of life of patients, and even partly restoring their neurological function.