【摘要】 目的探讨C₁～C₂硬膜内外神经鞘瘤的显微微创手术方法和疗效。方法回顾性分析2010年7月～2019年5月57例C₁～C₂硬膜内外神经鞘瘤的临床特点、影像学特征和手术方法。临床症状包括枕颈部疼痛53例、麻木26例,对侧肢体无力6例。首发症状为枕颈部疼痛50例,麻木7例。肿瘤在MRI上表现为等T1或稍长T1、等T2或稍长T2信号,增强扫描明显强化,部分肿瘤有囊性变,长径1～4 cm,平均1.8 cm。根据肿瘤部位及大小进行个体化椎板切开,尽可能保留C₂棘突。先切除硬膜外肿瘤,严格在包膜内切除;切除硬膜下肿瘤时注意轻柔分离粘连,保护脊髓。结果 57例肿瘤均获全切除,无椎动脉损伤。手术时间60～180 min,平均93.4 min;术后住院时间3～9 d,平均6.0 d。病理均证实为神经鞘瘤。术后无感染、脑脊液漏。7例载瘤神经支配区麻木,无其他新发神经功能障碍。术后随访6个月～9年,中位数3.5年,其中<3年18例,3～5年22例,>5年17例。术后新出现的症状均恢复正常。53例枕颈部疼痛者疼痛均消失;26例麻木者中24例完全恢复,2例残余轻度麻木;6例肢体无力者均恢复正常。按McCormick分级,均为Ⅰ级。复查MRI均未见肿瘤复发,X线未见颈椎不稳或畸形。结论充分利用C₁～C₂的解剖间隙,进行个体化椎板切开,行C₁～C₂硬膜内外神经鞘瘤切除是可行的,中长期结果良好。尽量减少C₂骨质破坏,保留C₂棘突的正常肌肉附着,有利于防止颈椎不稳定或畸形的发生。切除硬膜外部分肿瘤时严格包膜内切除可有效防止椎动脉损伤。切除硬膜下肿瘤时应尽量避免损伤脊髓。更多还原

【Abstract】 Objective To explore the minimally invasive microsurgical method and effect for C₁-C₂ extra-and intradural schwannoma. Methods The clinical features, imaging characteristics and surgical methods of 57 cases of C₁-C₂ extra-and intradural schwannoma from July 2010 to May 2019 were reviewed and analyzed. Pain and numbness in occipitocervical region were the common clinical symptoms. There were 53 cases with pain, 26 cases with numbness and 6 cases with limb weakness. MRI showed that the tumors located in the C₁-C₂ extra-and intradural space with long diameter of 1-4 cm（mean, 1.8 cm）. The equal or slightly lower T1 and equal or slightly higher T2 signals were found on MRI. The tumors had obvious enhancement. Some tumors have cysts which had no enhancement. Individualized laminotomy was performed according to the location and size of the tumors, and axis spinous processes were preserved as far as possible. The extradural tumor was resected at first, which was performed strictly within the capsule. After that the subdural tumor was removed. The adhesion between tumor and spinal cord should be separated gently to avoid damage to the spinal cord. Results Total resection of tumor was achieved in all the 57 cases. No vertebral artery injury was found. The operation time ranged from 60 to 180 minutes, with an average of 93.4 minutes. The hospitalization time ranged from 3 to 9 days, with an average of 6.0 days. All tumors were confirmed as schwannoma by pathology. There was no postoperative infection or cerebrospinal fluid leakage. There was no new-onset dysfunction except for 7 cases of numbness in the nerve innervation area. The period of follow-up ranged from 6 months to 9 years（median, 3.5 years）, including 18 cases for less than 3 years, 22 cases for 3-5 years, and 17 cases for more than 5 years. All the new-onset dysfunction recovered completely. Pain disappeared in all of the 53 patients with pain. Numbness recovered completely in 24 patients while slight numbness remained in another 2 patients. 6 patients with muscle weakness recovered completely. The spinal function of all patients restored to McCormick grade Ⅰ. No recurrence was found on MRI. No cervical spine instability or deformity was found on X-ray. Conclusions It is feasible to resect C₁-C₂ extra-and intradural schwannoma by full use of the anatomical space between atlas and axis and individualized laminotomy. Result of meddle and long term follow-up is favorable. It is helpful to prevent cervical instability or deformity by minimizing the destruction of C₂ bone and preserving normal muscle attachment to C₂ spinous process. Strict intracapsular resection can effectively prevent vertebral artery injury when extradural tumor was resected. The injury of spinal cord should be avoided as far as possible when the subdural tumor is removed.更多还原