椎管哑铃形肿瘤的显微外科治疗

Microsurgery for spinal dumbbell tumors

目的探讨椎管哑铃形肿瘤的临床分型及显微外科手术治疗策略。方法回顾性分析2008年1月至2014年12月天津医科大学总医院神经外科经显微手术切除的124例椎管内外沟通性肿瘤的临床表现及影像学特点，建立“四区肿瘤分型法”指导手术入路的选择。采取单纯后正中全椎板入路53例、半椎板入路47例、前后路联合入路11例、颈外侧入路8例、远外侧入路5例，其中89例行一期脊柱内固定术或椎板成形术。结果124例椎管内外沟通性肿瘤中，全切除121例，近全切除2例，部分切除1例。术后病理提示：神经鞘瘤77例，神经纤维瘤15例，血管脂肪瘤11例，淋巴瘤8例，血管瘤5例，脊膜瘤3例，节细胞神经瘤3例，海绵状血管畸形1例，小细胞恶性肿瘤1例。颈部肿瘤主体位于C区31例，CB区8例，CD区13例，CBA区6例，CDA区3例，CABD区1例，胸腰部肿瘤均位于C区共62例。无手术感染、脑脊液漏及截瘫的患者。术后随访6个月至3年，平均随访（32．6±4．8）个月。患者术后肢体运动功能及感觉障碍明显改善88例，无明显变化6例，术后新发或感觉障碍区域扩大者3例。结论椎管哑铃形肿瘤的临床分型对手术入路的选择具有重要的指导意义，根据肿瘤的分型采用相应的术式可行一期全切肿瘤，术前因骨质破坏或术中切除小关节的患者，应同时行脊柱内固定，以维持脊柱稳定性。

Objective To investigate the clinical classification and microsurgical treatment strategies of spinal dumbbell tumors. Methods From January 2008 to December 2014, the clinical manifestations and imaging features of 124 patients with intra-and extra-spinal tumors resected by microsurgery at the Department of Neurosurgery, Tianjin Medical University General Hospital were analyzed retrospectively. ＂ Four-zone tumor typing method＂ was established to guide the choice of surgical approaches. Fifty-three patients were treated via the simple posterior midline laminectomy approach, 47 via the semi-laminectomy approach, 11 via the combined anterior and posterior approach, 8 via the lateral cervical approach, and 5 via the far lateral approach, in which 89 patients were treated with stage 1 spinal internal fixation or laminoplasty. Results In 124 patients with intra-and extra-spinal tumors, 121 were removed totally, 2 were removed near totally, and 1 was removed partially. Postoperative pathology suggested that 77 patients had neurilemmoma, 15 had neurofibroma, 11 had angiolipoma, 8 had lymphoma, 5 had angioma, 3 had meningioma, 3 had ganglioneuroma, 1 had cavernous hemangioma, and 1 small cell malignant tumor. The main bodies of the cervical tumors were located in the C area in 31 cases, in CB area in 8 cases, in CD area in 13 cases, in CBA area in 6 cases, in CDA area in 3 cases, in CABD area in 1 case, and the thoracic and lumbar tumors were located in C area in 62 cases. No surgical infection, cerebrospinal fluid leakage, and paraplegia patients were observed. They were followed up for 6 months to 3 years after procedure （ mean 32.6 ＋ 4.8 months）. Postoperative limb motor function and sensory disturbance were improved significantly in 88 cases. There were no significant changes in 6 cases. The patients with new tumor after operation or regional expansion of sensory disturbance were in 3 cases. Conclusions The clinical classification of spinal dumbbell tumors has an important guiding significance for the selection of operative approaches. According to the classification of tumors, using the corresponding operation method may conduct tumor stage 1 total resection. Patients with bone destruction or intraoperative resection of small joints should perform spinal fixation simultaneously in order to maintain the stability of spines.