颈侧后联合入路在颈椎管沟通性肿瘤一期切除手术中的应用

Application of multidisciplinary cooperation in one-stage resection of cervical spinal canal communicating tumors via combined lateral and posterior median cervical approaches

目的探讨经颈侧后联合入路手术一期切除颈椎管沟通性肿瘤的临床疗效。方法病例系列报告。纳入2015年7月—2022年8月南通大学附属医院12例颈椎管沟通性肿瘤患者,其中男3例、女9例,年龄33~74(51.2±11.9)岁;ToyamaⅡb型2例、Ⅱc型7例、Ⅲb型3例;肿瘤位于C2节段以上4例、C2~4节段3例、C4~7节段5例。患者均采用颈侧后联合入路一期切除手术治疗:神经外科采用经典后正中入路,磨除病变节段半椎板,切除位于椎管内和椎间孔处的肿瘤;头颈外科对于肿瘤完全位于下颌骨平面以上者采用颈腮腺入路,其余采用单纯颈侧入路切除向椎旁颈部间隙延伸的肿瘤组织,并与后正中入路会师,切除顺序为先椎管内、后椎管外。观察肿瘤一次性全切率、手术时间、术中出血量、手术并发症及术后神经症状改善情况,术后6个月颈椎X线摄片评估脊柱稳定性。结果本组患者肿瘤均一期彻底切除,肿瘤一次性全切率为12/12。术后病理诊断:神经鞘瘤10例,软骨瘤和神经纤维瘤各1例。手术时间215(183,315)min,术中出血120(85,188)mL。术后并发脑脊液漏1例、局部感染1例,均经对症处理痊愈后出院。5例患者因切除2个节段半椎板术后佩戴颈托6~12周。术后随访6~90个月,12例患者均恢复正常生活,无一例肿瘤复发;12例中,有1例患者术后手部麻木缓解不明显、运动功能正常,其余患者原神经受累症状改善。所有患者术后复查颈椎X线片,随访期内未见脊柱畸形,脊柱稳定性良好。结论对于累及颈椎管内外的沟通性肿瘤,采用耳鼻咽喉头颈外科和神经外科协作颈侧后联合入路手术,不仅可以一期彻底切除肿瘤,还能最大限度地减少对头颈部重要血管神经的损伤以及术后颈椎不稳,体现了多学科合作的优势。

Objective This study aimed to investigate the clinical efficacy of one-stage resection of cervical spinal canal communicating tumor via combined posterior lateral cervical approaches.Methods Case series study.Twelve patients(three males and nine females)with cervical spinal canal communicating tumor were included.They were admitted to Affiliated Hospital of Nantong University from July 2015 to August 2022.The patients aged 33-74(51.2±11.9).Two patients had Toyama typeⅡb,seven had typeⅡc,and three had typeⅢb.Four patients had tumors above the C2segment,three in the C2−4 segments,and five in the C4−7 segments.All patients accepted combined posterior lateral cervical surgery.A classical posterior median approach was adopted in neurosurgery,and tumors located in the spinal canal and intervertebral foramen were excised after the corresponding vertebral plate was treated.In otolaryngology head and neck surgery,the cervical parotid gland approach was used for tumors located completely above the mandibular plane.A simple lateral cervical approach was performed for the other tumors.Tumors extending to the paravertebral cervical space were removed in the following sequence:first intraspinal canal and extraspinal canal,and then knocked together.The one-time full-resection rate,surgery time,intraoperative blood loss,postoperative neurological symptoms were observed,and spinal stability were evaluated by X-ray filmat 6 months after operation.Results The one-time total tumor resection rate was 12/12.Postoperative pathological diagnosis was schwannoma in 10 patients,chondroma in one patient,and neurofibroma in one patient.The surgery time was 215(183,315)min,and the hemorrhage volume was 120(85,188)mL.One patient suffered from leakage of cerebrospinal fluid after surgery,one patient suffered from local infection,and both were discharged after symptomatic treatment.Five patients wore cervical supports for 6-12 weeks after treatment of two segments and semi-lamina.After 6-90 months of follow-up,all patients returned to normal life without tumor recurrence.One of the 12 patients had no obvious relief of hand numbness,but their motion was normal after surgery,whereas other patients showed improvement in the symptoms of original nerve involvement.All patients were reexamined using the films of cervical spine after surgery,and no spinal deformity was found during the follow-up period.All patients had good spinal stability.Conclusion For communicating tumors involving the intraspinal and extraspinal cervical spinal canal,the approach combining otorhinolaryngology head and neck surgery and neurosurgery not only completely removes tumors in one stage but also minimizes damage to the important blood vessels and nerves of the head and neck and the instability of the cervical spine,demonstrating the advantages of multidisciplinary cooperation.