脑运动区小病变个体化手术治疗

Individualized surgical treatment for small lesions in the cerebral motor area

目的探讨脑运动区小病变（直径〈3 cm）的个体化手术治疗方法及效果。方法回顾性分析44例脑运动区小病变病人的临床资料,术前评估心理状态,检查肢体肌力,分析影像学特点,设计手术方法。根据手术方法分组,单纯手术组包括轴外病变10例,采用导航引导下手术切除;监测组包括轴内病变18例,采用导航引导加神经电生理监测下手术切除;唤醒组包括轴内病变16例,采用导航引导、电生理监测及术中唤醒下手术切除。结果单纯手术组均全切;监测组全切除11例,次全切除7例;唤醒组全切除12例,次全切除4例。监测组和唤醒组的全切率及次全切率无统计学差异（P〉0.05）。单纯手术组中2例术后3 d肌力下降,3周后恢复;监测组6例肌力下降,治疗后1例未恢复;唤醒组5例肌力下降,治疗后2例未恢复;治疗后肌力未恢复病人的病理结果均为Ⅲ～Ⅳ级星形细胞瘤;监测组与唤醒组在肌力下降程度及恢复情况无明显统计学差异（P〉0.05）。结论对于脑运动区小病变病人,根据病人心理状态、病变影像学特点等制定个体化手术方案,可取得满意的治疗效果。

Objective To explore the method and efficacy of individualized surgical treatment for small lesions（diameter 〈3 cm） in the motor cortex. Methods Clinical data of 44 patients with small lesions in the motor area were analyzed retrospectively. The surgical procedures were designed for these patients according to psychological state, muscle strength and radiological features. All the patients were divided into three groups. The surgery-alone group consisted of 10 patients with extra-axial brain lesions, which were removed by surgery under neuronavigation system. The monitoring group consisted of 18 patients with intra-axial brain lesions, which were removed by surgery under neuronavigation guidance combined with electrophysiological monitoring. The awake group consisted of 16 patients with intra-axial brain lesions, which were removed by surgery under neuronavigation, intraoperative electrophysiological monitoring and awake anesthesia. Results The lesion was totally resected in surgery-alone group. The lesion was totally resected in 11 patients and subtotally resected in 7 of monitoring group. The lesion was totally resected in 12 patients and subtotally in 4 of awake group. There was no difference in the total or subtotal resection rates between monitoring and awake groups（P 〉0.05）. For patients in surgery-alone group, 2 patients had decreased muscle strength 3 days after and recovered well 3 weeks after the surgery. In monitoring group, 6 patients had decreased muscle strength, and 1 of whom did not recover after therapy. In awake group, 5 patients experienced decrease of muscle strength and 2 did not recover at last. The pathological diagnosis was high grade（ grade Ⅲ to Ⅳ） gliomas in the patients with unrecovered muscle strength after treatment. And there was no statistically significant difference in the extent of muscle strength reduction and recovery condition between monitoring and awake groups（P〉0.05）. Conclusions For the patients with small lesions in the motor area, the individualized surgery treatment can be chosen according to the psychological state and radiological features, and good outcome can be obtained.