上颈椎哑铃形椎管内神经鞘瘤的外科治疗

摘要

目的 探讨上颈椎椎管内哑铃形神经鞘瘤的手术及稳定性重建的方法和技巧. 方法 回顾性分析2002年1月—2007年1月收治的19例枕骨大孔区至C2水平哑铃形椎管内神经鞘瘤患者的临床资料.术前完善颈椎正侧位X线、MRI、CT平扫及三维重建检查以明确肿瘤部位和范围,其中病变位于枕骨大孔至C1水平5例,C1,2水平14例.均在神经电生理监测下行手术治疗.肿瘤位于枕骨大孔至C1水平者,先部分切除枕骨大孔后缘,依据情况切除寰椎后弓;肿瘤位于C1,2水平者切除C2肿瘤侧椎板.肿瘤切除先切除椎管内部分,再切除椎管外部分.根据情况对脊柱稳定性进行重建. 结果 所有患者均顺利完成手术,19例肿瘤均完全切除,其中恢复良好13例,改善4例,无明显改善1例,恶化1例.术后6个月所有患者均获得骨性融合.随访12 ~ 72个月,MRI检查均未见肿瘤复发. 结论 上颈椎哑铃形椎管内神经鞘瘤发生率低,手术风险大.手术显露及脊柱稳定性重建范围应根据肿瘤分布、脊柱结构缺如、功能需要等因素综合决定.术中神经电生理监测能有效减少神经损伤并发症.%Objective To explore the surgical techniques for intraspinal dumbbell-shaped schwannoma and methods for reconstruction the stability of the upper cervical spine. Methods From January 2002 to January 2007,clinical data of 19 patients with intraspinal dumbbell-shaped schwannoma of the upper cervical spine were collected and analyzed. Roentgenograph,MRI,CT scan and three-dimensional reconstruction were performed to clarify the tumor site and extent. The tumor from the foramen magnum to C1 level was seen in 5,and C1,2 level in 14. All surgeries were performed under the neurophysiological monitoring. The posterior edge of the foramen magnum or C1 posterior arch was removed when the tumor located at the foramen magnum to C1 level. The partial laminectomy of C2 was performed when the tumor located at C1,2 level. Intraspinal part of the tumor was cut first and then the extraspinal part. And spinal stability was reconstructed according to the situation. Results All the operations were successfully completed. The tumor was completely resected in 19 patients. Among them,13 recovered well,and 4 were improved,and 1 had no significant improvement and 1 became deteriorated. All the patients received bone fusion at postoperative 6 months. The follow-up period was 12 - 72 months. No recurrence was observed by MRI. Conclusion The upper cervical dumbbell-shaped schwannoma is rarely seen and the operative risk is high. The exposure range and spinal stability reconstruction should be determined by the tumor segment and the functional requirements. The neurophysiological monitoring can reduce complication as nerve injury.