骶骨巨大良性神经源性肿瘤的手术治疗策略

Surgical strategy for benign sacral neurogenic tumor

目的：探讨骶骨巨大良性神经源性肿瘤的手术治疗策略。方法：2000年6月～2015年12月，共收治骶骨良性巨大神经源性肿瘤188例，其中神经纤维瘤137例，神经鞘瘤51例。男93例，女95例；年龄17-75岁（42.3±10．4岁）。初次手术患者167例，外院术后复发21例。术前影像学诊断为神经源性肿瘤，均未行穿刺活检。肿瘤局限于骶管内或巨大相对低位（S1以下）的骶前神经源性肿瘤采用单纯经后路分块切除方式完整切除肿瘤；对于巨大相对高位（S1以上）的骶前神经源性肿瘤采用前后联合入路手术切除；肿瘤下界高于S2水平的骶前神经源性肿瘤采用前路手术切除。术后均经病理证实。结果：手术时间75．420min（185±61min），出血量500-5000ml（1600±908m1）。行单纯后路手术切除肿瘤165例，前后路联合手术切除肿瘤16例，单纯前路手术切除肿瘤7例；除9例体积较小的肿瘤整块切除外。其余病例均行分块完整切除。1例死于围手术期失血性休克、弥散性血管内凝血（DIC）；3例因累及骶骨范围太大，出血较多，未能保留S2以下神经根，术后出现大小便困难，但均未行膀胱、直肠造瘘。其余病例均保留了双侧S3以上神经根，术后患者均未出现大小便功能障碍。随访10～126个月（59±23个月）．16例术后局部复发，局部复发率8．5％。结论：对骶部神经源性肿瘤应根据肿瘤生长的部位及大小来决定手术入路，整块或分块完整切除肿瘤可取得较好的临床疗效。

Objectives： To discuss the most appropriate surgical strategy for sacral benign neurogenic tumor. Methods： Between June 2000 and December 2015, 188 cases（neurofibromas 137 cases, schwannomas 51 cases） with sacral neurogenic tumors were admitted and treated. There were 93 males and 95 females, with an average age of 42.3±10.4 years old（range, 17-75 years old）. Among them, 167 patients were firstly treated in our hospital, and 21 patients were treated because of local recurrence after treatment in other institations. The diagnoses of sacral benign neurogenic tumors were made by imaging studies without biopsy before surgery. Giant presacral neurogenic tumors confined to the sacral canal or located below the S1 level were piecemeal removed in a posterior-only approach. Giant tumors above S1 level were removed in a anterior-posterior surgical approach. Giant presacral neurogenic tumors above S2 level could be resected in an anterior-only approach. The diagnosis of benign neurogenic tumor was confirmed by postoperative pathologic examination. Resuits： Surgeries lasted a mean of 185±61 minutes（range, 75-420 minutes）. The mean estimated blood loss was 1600±908ml（range, 500-5000ml）. Depending on the location and size of tumor, posterior-only approach was used in 165 cases, anterior-posterior surgical approach in 16 cases, and anterior-only approach in 7 cases. 9 cases with small tumors received en bloc resection, and the remaining cases received piecemeal resection. Among the 188 patients, one patient died in the perioperation period, 3 patients with huge tumor received the resection of nerve roots below the S2 level because of too much bleeding, which resulted in incontinence of feces and urine but without vesicostomy or rectostomy, all the other patients were operated with preservation of nerve roots above S3 level. The average period of follow-up was 59±21 months （range, 10-126 months）. There were 16 patients suffered from local recurrence（8.5%）. Conclusions： In surgical resection of sacral neurogenic tumors, surgical approach depends on the location and size of the tumors. Both en bloc and piece-meal resection can achieve satisfying clinical outcome.