儿童脊髓髓内胶质瘤的显微外科治疗

摘要

目的 总结儿童脊髓髓内胶质瘤显微神经外科治疗的经验.方法 1999-2005年共手术治疗儿童脊髓髓内胶质瘤52例,男30例,女22例,年龄2～14岁(平均7.8岁),病程2个月-3年;肿瘤直径占脊髓横断面的60%～90%,长度跨越4～11个椎体;临床表现按McCormick神经功能分级:Ⅰ级8例,Ⅱ级35例,Ⅲ级7例,Ⅳ级2例.早期采用传统椎板切除术、后期采用整块切除棘突及椎板后再回植重建的方法进入椎管,在显微镜下沿脊髓后正中裂切开脊髓显露肿瘤并分块切除.结果 星形细胞瘤35例(67%),其中全切26例(74%),部分切除9例(26%);室管膜瘤15例(29%),均全部切除;节细胞瘤2例(4%),其中1例全切,1例部分切除.术后近期症状较术前加重或出现新神经损害症状者29例(56%),症状改善或无变化者23例(44%);随访6个月-6年,38例恢复正常生活或学习,10例可自理生活,4例不能自理生活.肿瘤复发2例.患儿功能预后与术前神经功能分级密切相关,术前神经损害症状越轻,术后恢复越好.结论 显微神经外科手术切除脊髓髓内胶质瘤是目前最有效的治疗措施,最佳手术时机是在患儿尚未发生严重神经损害症状之前.%Objective To summarize the experience of microsurgcial management of intramedullary spinal cord gliomas. Method Between 1999 and 2005, consecutive series of 52 patients were referred to the department of neurosurgery in Xijing Hospital and underwent surgical treatment. There were 30 male and 22 female patients. Mean age was 7.8 years (2 to 14 years). The diameter of the tumors was occupied 60%～90% of the spinal cord in transverse sections. The tumor extension of involved spinal segments was 4 to 11. According to the McCormick clinical/functional classification scheme, grade Ⅰ 8 patients, grade Ⅱ 35 patients, grade Ⅲ 7 patients, and grade Ⅳ 2 patients. Bone exposure at the early time was performed by traditional laminotomy, later by osteoplastic laminotomy so that the laminar roof can be removed in one piece and replaced. Under the microscope, the myelotomy can be performed from the posterior median raphe, and the tumor can be exposed and removed piecemeally. Results Thirty-five patients with astrocytomas (67%), complete tumor removal was achieved in 26 patients (74%), and subtotal resection in 9 cases (26%); 15 ependymonas were all totally removed; 2 gangliocytoma, one was completely removed, the other one subtotally removed. Postoperative neurological state was improved or unchanged in 29 patients (56%) and worsened in 23 cases (44%). Neurological function at a 0.5-6 years of follow-up was improved to normal in 38 patients, independent with aid in 10 cases and aid-dependent in 4 cases. Recurrences within 4 years in 2 patients. The postoperative outcome is directly related to preoperative neurologic status. In other words, recovery from a severe and long-standing deficit rarely occurs. Conclusions The best option for the intramedullary spinal cord glioma is radical surgery. The microsurgical resection of these tumors shoud be taken before neurologic deterioration because poor-grade patients rarely recover function, whereas good-grade patients remain as they are or improve.