高压氧联合显微外科松解术治疗脂肪瘤型脊髓栓系综合征33例疗效观察

Clinical efficacy of hyperbaric oxygen combined with microsurgical lysis in 33 cases of lipoma-type tethered cord syndrome

目的探讨高压氧(HBO)联合显微外科松解术治疗脂肪瘤型脊髓栓系综合征(脊髓栓系)(TCS)的临床疗效及其作用机制。方法回顾性分析2015年1月至2020年1月烟台山医院骨科和毓璜顶医院骨科收治的脂肪瘤型TCS 59例患者的临床资料。按照治疗方法分为观察组(n=33)和对照组(n=26)。对照组予以常规显微外科松解术治疗,观察组在显微外科松解术的基础上联合HBO治疗。按照术后TCS松解分级标准评定其临床疗效。松解前及治疗3个疗程后采用分光光度计检测脑脊液中丙二醛(MDA)、超氧化物歧化酶(SOD)的光密度(D)值。采用体感诱发电位(SEP)监测并判断手术效果及治疗后神经功能恢复情况,主要包括胫后神经诱发电位波幅、潜伏期及传导速度3个指标。按照脊柱裂神经量表(SBNS)评定神经反射功能、肌力、大小便情况。采用多功能尿动力学测压仪检测术后患者膀胱顺应性、逼尿肌反射、逼尿肌力量。评估患者治疗后头痛、神经损害、脑脊液漏和假性囊肿、再栓系等发生情况。结果观察组患者治疗后的总有效率(87.88%)明显高于对照组(73.08%),差异有统计学意义(χ2=4.991,P<0.05)。2组患者治疗后逼尿肌反射亢进、膀胱顺应性下降和逼尿肌无力的发生情况比较差异有统计学意义(F=6.534,P<0.05)。治疗3个疗程后,与治疗前比较,2组患者脑脊液MDA水平明显降低,SOD水平明显升高,且观察组患者治疗后脑脊液MDA水平显著低于对照组,SOD水平高于对照组,差异均有统计学意义(P<0.05)。与治疗前比较,2组患者治疗后胫神经传导速度、诱发电位波幅明显升高,潜伏期明显缩短,且观察组患者治疗后胫神经传导速度、诱发电位波幅明显高于对照组,潜伏期明显短于对照组,差异均有统计学意义(P<0.05)。治疗后6个月随访,观察组患者SBNS评分[(14.49±1.76)分]明显高于对照组[(10.86±1.44)分],差异有统计学意义(χ^(2)=5.782,P<0.05)。观察组患者治疗后出现头痛、脑脊液漏和假性囊肿、神经损害、再栓系的例数明显小于对照组,差异有统计学意义(F=6.395,P<0.05)。结论HBO联合显微外科松解术治疗脂肪瘤型TCS疗效显著,脊髓神经元缺血缺氧状态得到改善,胫神经传导速度加快,SBNS综合评分明显提高,术后并发症明显减少,值得临床推广应用。

Objective To investigate the clinical efficacy and action mechanism of hyperbaric oxygen(HBO)combined with microsurgical lysis in the treatment of lipoma-type tethered cord syndrome(TCS).Methods The clinical data of 59 patients with lipoma-type TCS treated in the Department of Orthopedics of Yantai Mountain Hospital and the Department of Orthopedics of Yantai Yuhuangding Hospital from January 2015 to January 2020 were retrospectively analyzed.According to the treatment,they were divided into observation group(n=33)and control group(n=26).The control group was treated with conventional microsurgical lysis,while the observation group was treated with HBO on the basis of the treatment in the control group.The clinical efficacy was evaluated according to the Kirollos grading system of postoperative TCS lysis.The optical densities(D)of malondialdehyde(MDA)and superoxide dismutase(SOD)in cerebrospinal fluid were measured by spectrophotometer before microsurgical lysis and after 3 courses of treatment.Somatosensory evoked potential(SEP)was used to monitor and judge the efficacy of operation and the recovery of neurological function after treatment,including the amplitude,latency,and conduction velocity of posterior tibial nerve sensory evoked potential(PTNSEP).The reflexes,motor function,and the bladder and bowel function were evaluated according to the spina bifida neurological scale(SBNS).The bladder compliance,detrusor reflex,and detrusor strength after operation were measured by multifunctional urodynamic manometry.Postoperative complications,such as headache,nerve damage,cerebrospinal fluid leakage pseudocyst,and re-tethering were evaluated.Results The total effective rate of the observation group(87.88%)was significantly higher than that of the control group(73.08%)(χ^(2)=4.991,P<0.05).There were significant differences in detrusor hyperreflexia,decreased bladder compliance,and detrusor weakness between the two groups after treatment(F=6.534,P<0.05).After three weeks of treatment,compared with those before treatment,the levels of MDA in cerebrospinal fluid of the two groups were significantly decreased,and the levels of SOD of the two groups were significantly increased than those before treatment;the level of MDA in cerebrospinal fluid in the observation group was significantly lower than that of the control group,and the level of SOD in the observation group was significantly higher than that in the control group(P<0.05).After 3 courses of treatment,compared with those before treatment,the conduction velocity and evoked potential amplitude of the two groups were significantly increased,and the latency was significantly shortened in the two groups;and the conduction velocity and evoked potential amplitude of the observation group were significantly increased than those in the control group,and the latency of the observation group was significantly lower than that of the control group(P<0.05).In the six-month follow-up after operation,the total SBNS score of the observation group[(14.49±1.76)points]was significantly higher than that of the control group[(10.86±1.44)points],with a statistically significant difference(χ^(2)=5.782,P<0.05).The incidences of headache,cerebrospinal fluid leakage pseudocyst,nerve damage,and re-tethering in the observation groups were significantly lower than those in the control group(F=6.395,P<0.05).Conclusion HBO combined with microsurgical lysis is effective in the treatment of lipoma-type TCS,which can improve the anoxic-ischemic state of spinal cord neurons,accelerate the tibial nerve conduction velocity,significantly improve the comprehensive score of SBNS,and significantly reduce the incidence of postoperative complications.Thus,it is worthy of clinical application.