经锁孔入路显微外科切除腰椎管肿瘤54例临床研究

Microscopic resection of lumbar intraspinal tumor through keyhole approach:A clinical study of 54 cases

目的:探讨经微通道锁孔显微手术切除腰椎管肿瘤的可行性和关键技术。方法:回顾性分析2017年2月至2019年9月纳入研究的54例腰椎管肿瘤患者的临床资料,包括硬膜外肿瘤8例,硬膜内外肿瘤3例,髓外硬膜下肿瘤43例(脊髓圆锥腹侧肿瘤3例),肿瘤长径0.5~3.0 cm。患者的临床症状包括:相应神经支配区疼痛49例,肿瘤所在节段及以下感觉障碍(麻木)5例,肢体无力7例,大小便功能障碍2例。患者均采用显微镜下微通道锁孔技术进行手术。结果:微通道下半椎板切除37例,半侧椎板间开窗14例,半椎板切除或半侧椎板间开窗+小关节内侧1/4切除3例,所有患者的肿瘤均得以全切除。手术时间75~135 min,平均93.3 min;术后住院时间4~7 d,平均5.7 d。术后组织病理检查结果为神经鞘瘤34例,脊膜瘤4例,室管膜瘤9例,肠源性囊肿1例,畸胎瘤/皮样囊肿/表皮样囊肿5例,副神经节瘤1例。所有患者术后无感染,无脑脊液漏,4例患者出现相应神经支配区的麻木感,1例患者出现排尿困难,其余患者无神经功能障碍加重。术后随访3~33个月,平均14.4个月,5例术后症状加重的患者均恢复正常,49例术前有疼痛症状者均完全缓解,7例术前肌力减退者和2例术前大小便功能障碍者均恢复正常,5例术前感觉减退者中有4例完全恢复,1例仍残余轻度感觉减退。未见脊柱不稳定或畸形,未见肿瘤复发或残留。按McCormick分级,均为Ⅰ级。结论:经微通道锁孔显微手术切除腰椎管肿瘤应适当选择病例,两个节段以下的腰椎管髓外肿瘤(包括部分脊髓圆锥腹侧肿瘤)通过微通道技术可Ⅰ期全切除。微通道技术有利于保留腰椎的正常结构和肌肉附着,有利于保持腰椎的完整性及稳定性。

Objective:To explore the feasibility and key technology of microscopic resection of lumbar intraspinal tumor through microchannel keyhole approach.Methods:The clinical features,imaging characteristics and surgical methods of 54 cases of lumbar intraspinal tumor which were microscopically operated by microchannel from February 2017 to September 2019 were reviewed and analyzed.There were 8 cases of extradural tumor,3 cases of extra-and intradural tumor and 43 cases of subdural extramedullary tumor(including 3 cases of ventral spinal tumor).The tumors were 0.5-3.0 cm in diameter.The clinical symptoms included 49 cases of pain in the corresponding innervation area,5 cases of sensory disturbance(numbness)at or below the tumor segment,7 cases of limb weakness and 2 cases of urination and defecation dysfunction.Results:In the study,37 tumors were resected through hemilaminectomy,14 tumors were resected through interlaminar fenestration,3 tumors were resected through hemilaminectomy or interlaminar fenestration combined with facetectomy of medial 1/4 facet.All of the 54 tumors were totally resected.The operation time was 75-135 min,with an average of 93.3 min.The postoperative hospital stay was 4-7 days,with an average of 5.7 days.Postoperative pathology included 34 cases of schwannoma,4 cases of meningioma,9 cases of ependymoma,1 case of enterogenous cyst,5 cases of teratoma/epidermoid/dermoid cyst,and 1 case of paraganglioma.No infection or cerebrospinal fluid leakage was found after operation.No neurological dysfunction occurred except 1 case of urination dysfunction and 4 cases of limb numbness.The follow-up period ranged from 3 to 33 months with an average of 14.4 months.Five patients with new onset symptoms returned to normal.The pain symptoms of 49 patients were completely relieved;4 of 5 patients with hypoesthesia recovered completely,the other 1 patient had residual mild hypoesthesia;7 patients with limb weakness,and 2 patients with urination and defecation dysfunction recovered to normal.No spinal instability or deformity was found,and no recurrence or residual tumors were found.According to McCormick classification,they were of all gradeⅠ.Conclusion:The lumbar intraspinal extramedullary tumors within two segments(including the ventral spinal tumors)can be totally resected at stageⅠthrough microchannel keyhole approach with appropriate selection of the cases.Microchannel technique is beneficial to preserve the normal structure and muscle attachment of lumbar spine,and to maintain the integrity and stability of lumbar spine.