经皮穿刺斜置显微通道下keyhole手术切除胸椎管内脊膜瘤

Microscopic keyhole technique for surgical resection of thoracic spinal meningioma via an oblique placing tube

目的报告显微镜下应用keyhole手术切除胸椎管内脊膜瘤的方法与疗效。方法2013年5月至2017年6月福建省立医院脊柱外科应用keyhole手术切除胸椎管内脊膜瘤39例。采用在棘突中线旁2.0~3.5 cm经皮穿刺斜放置直径为1.8 cm的工作套管,对于胸脊髓背侧的脊膜瘤,采用半椎板开窗锁孔手术切除;对位于脊髓侧方的脊膜瘤,采用半椎板加部分关节突磨除开窗手术切除;对位于脊髓腹侧的脊膜瘤,采用半椎板加半关节突磨除,在硬脊膜侧前方切开进入脊髓腹侧切除肿瘤。所有病例均无进行内固定。分别采用视觉模拟评分法(VAS)和美国脊髓损伤协会分级(ASIA)来评估患者手术前后疼痛程度和脊髓功能恢复情况。手术前后数据比较采用配对t检验。结果本组肿瘤位于颈胸段(C7~T1)3例,胸段36例,均显露充分,获得完全切除。手术时间120~185 min,平均(148±21)min;术中出血量50~200 ml,平均(101±27)ml。3例发生术后脑脊液漏,经保守治疗后痊愈,其余无感染或术后脊髓损伤加重等并发症。住院时间5~9 d,平均(6.1±0.8)d。手术后随访9~57个月,平均(29±13)个月。术前VAS评分(7.38±1.71),术后末次随访为(0.31±0.63)分(t=-24.228,P<0.05)。ASIA分级除2例不变外(5.1%),其余均得到改善,其中24例提高1级(61.5%),9例提高2级(23.1%),4例提高3级(10.3%)。随访期间无肿瘤复发或出现脊柱失稳的并发症。结论显微镜下微创keyhole手术可用来治疗胸椎管内脊膜瘤,可获得完全切除,临床疗效确切,且很好保护脊柱稳定性。

Objective To report the methods and clinical outcomes of microscopic minimally invasive keyhole technique for surgical resection of thoracic spinal meningiomas. Methods Thirty-nine patients with thoracic spinal meningiomas received keyhole surgery from May 2013 to June 2017 in the Department of Spine Surgery, Fujian Provincial Hospital. A working channel with a diameter of 1.8 cm was inserted percutaneously about 2.0 to 3.5 cm away from the mid-line. Dorsally attached tumors were resected with hemilaminectomy fenestration;for the spinal meningiomas located in the lateral side of the spinal cord, hemilaminectomy combined with partial facetectomy were used;hemilaminectomy combined with hemifacetectomy fenestration were used for spinal meningiomas located ventrally. No internal fixation was performed in all cases. Clinical outcome was assessed using the visual analog scale (VAS) for pain relief and the American Spinal Injury Association (ASIA) scale for evaluation of the function of the spinal cord after surgery. The pre-and post-operative data were compared by paired t test. Results Among the 39 patients, the tumors in 36 cases located in the thoracic spine and 3 in the cervicothoracic junction. Complete resection was achieved in all patients. Mean operative time was (148±21) min (range, 120-185 min). Mean blood loss during surgery was (101±27) ml (range, 50-200 ml). No infection or aggravation of spinal cord injury occurred after operation, except for 3 patients who had postoperative cerebrospinal fluid leakage that recovered after conservative treatment. The mean hospital stay was (6.1±0.8) days (range, 5-9 days). Patients were followed-up for a period of 9 to 57 months, with a mean follow-up time of (29±13) months. At the last follow-up, all patients had a reduced level of pain as suggested by an average VAS score that improved from (7.38±1.71) to (0.31±0.63), the ASIA grade improved in all patients except for 2 cases (5.1%), 24 cases (61.5%) improved by 1 grade, 9 cases (23.1%) improved by 2 grades, and 4 cases (10.3%) improved by 3 grades. No evidence of tumor recurrence or secondary spinal instability was observed in any patients during the postoperative follow-up. ConclusionMicroscopic minimally invasive keyhole technique can be used to completely resect the thoracic spinal meningiomas;such surgical procedures convey reliable clinical outcomes and good postoperative spinal stability.