儿童髓母细胞瘤的显微手术治疗

Microsurgical treatment of medulloblastoma in children

目的探讨经小脑延髓裂(CMF)入路手术切除儿童髓母细胞瘤(MDB)的显微手术方法和技巧。方法回顾性分析笔者自2011年1月至2019年12月采用经CMF入路微创显微手术治疗32例MDB患儿的临床资料,对显微外科手术技巧进行总结。28例患儿采用单侧CMF入路,4例患儿采用双侧CMF入路。结果肿瘤全切除者29例(90.6%),次全切除者3例(9.4%),无手术相关死亡病例,无永久性脑脊液漏。1例患儿术后并发小脑性缄默症,1个月后完全恢复。所有患儿均打通导水管,除2例患儿术后因脑积水未解除或加重需行脑室-腹腔分流术外,其余患儿术后原有颅高压症状和体征均得到改善。术后2例患儿出现后组颅神经麻痹,5例患儿有幕上、幕下硬脑膜下积液,经皮下置管和加压包扎后治愈;颅内感染3例,共济运动障碍加重3例,脑膜脑膨出和呼吸障碍各1例,经对症处理后痊愈。术后均经影像学随访,中位随访时间为37个月(3~81个月),27例患儿恢复正常生活,5例患儿仍有不同程度的神经功能障碍。结论经CMF入路是一种显露充分、方便实用、安全有效的切除MDB的微创手术入路。掌握CMF入路和MDB显微手术方法和技巧,采用精湛的微创神经外科手术技术,有利于提高MDB的全切除率和提高手术疗效。

Objective To explore the microsurgical methods and techniques for the resection of medulloblastoma(MDB)in children with cerebellomedullary fissure(CMF)approach.Methods The clinical data of 32 children with MDB treated by minimally invasive microsurgery with CMF approach from January 2011 to December 2019 were retrospectively analyzed.Unilateral CMF approach was used in 28 patients and bilateral CMF approach was used in 4 patients.Results There were 29 cases(90.6%)with total resection and 3 cases(9.4%)with subtotal resection.There was no operation related death and no permanent cerebrospinal fluid leakage.One patient suffered from cerebellar mutism and recovered completely 1 month later.All patients had their aqueduct opened,except for 2 patients who needed ventriculoperitoneal shunt because hydrocephalus was not relieved or aggravated,the symptoms and signs of intracranial hypertension were improved.After operation,2 patients developed posterior cranial nerve palsy,5 patients had supratentorial and inferior subdural effusion,which were cured by subcutaneous catheterization and pressure bandage;3 patients had intracranial infection,3 patients had ataxia aggravation,1 patient had meningocele and 1 patient had dyspnea,which were cured by symptomatic treatment.The median follow-up time was 37 months(3-81 months),27 patients returned to normal life,and 5 patients still had different degrees of neurological dysfunction.Conclusion The CMF approach is a safe and effective minimally invasive surgical approach for the removal of MDB.Mastering the methods and skills of CMF approach and MDB microsurgery,and adopting exquisite minimally invasive neurosurgical techniques are helpful to improve the total resection rate and surgical efficacy of MDB.