延颈髓髓内室管膜瘤的手术策略（附120例报告）

Surgical strategies of intramedullary medullocervical ependymomas： a report of 120 cases

目的探讨延髓和颈髓髓内室管膜瘤的临床特征及显微操作技巧，以提高全切除率和降低致残率。方法回顾性分析2001年1月至2016年11月第二军医大学附属长征医院神经外科收治的120例位于延髓和颈髓髓内室管膜瘤患者的临床表现、影像学特征、显微手术操作、切除程度和术后随访资料。患者均采用枕下后正中入路切除肿瘤。结果120例患者中，111例肿瘤全切除（92．5％），9例大部分切除（7．5％）。肿瘤体积最大为25．0cm×2．0cm×2．0cm，最小为1．0cm×1．0cm×0．6cm，最长累及颈椎全部节段。其中106例患者（95．5％）获得随访，随访时间为3～108个月，平均（23．0±18．5）个月。83例（78．3％）术后感觉和运动功能较术前改善或与术前相同，加重22例（20．8％），死亡1例（0．9％）；因肿瘤复发再次手术者4例（3．8％）。McCormick分级Ⅰ级60例（56．6％），Ⅱ级28例（26．4％），Ⅲ级16例（15．1％），Ⅳ级1例（0．9％）。结论对于多数延颈髓髓内室管膜瘤患者，结合影像学技术和神经电生理监测技术，应用正确的手术策略和娴熟的显微操作技术能够全切除肿瘤并保留神经功能。

Objective To explore the clinical characteristics and microsurgical skills of intramedullary medullocervical ependymomas for increasing the rate of gross total resection （GTR） and decreasing the disabling rate. Methods A total of 120 patients with medullocervical ependymomas were admitted to Department of Neurosurgery, Changzheng Hospital, the Second Military Medical University of PLA, from January 2001 to November 2016. A retrospective analysis was conducted regarding their clinical manifestations, imaging characteristics, microsurgical manipulations, extent of resection and postoperative follow-up data. In all cases, the tumor resection was performed using posterior suboccipital midline approach. Results Among the 120 patients, GTR was achieved in 111 （92.5%） cases and subtotal resection was performed in 9 （7.5%） cases. The maximal tumor size was 25.0×2.0×2.0 cm and affected all cervical levels, and the minimal size of the tumor was 1.0×1.0×0.6 cm. Follow-up was successfully conducted in 106 （95.5%） patients and for 3 to 108 months with an average of （23.0±18.5 ） months. The patient＇s sensory and motor functions were relieved or remained unchanged post surgery in 83 （ 78.3% ） cases and aggravated in 22 （20.8%） cases. One （0.9%） death occurred. Four patients （3.8%） were reoperated on due to tumor recurrence. The neurological function was graded based on the McCormick system as 60 （56.6%） cases in grade I, 28 （26.4%） cases in grade II, 16 cases （15.1%） in grade III and 1 （0.9%） case in grade IV. Conclusion For most intramedullary medullocervical ependymomas, proper surgical strategies and qualified operational skills, combined with imaging and neuroelectrophysiological technologies could be applied to realize the GTR of tumors and preservation of neurological functions.