显微手术切除颈段脊髓侧前方和前方大型肿瘤(附48例分析)

目的探讨应用显微手术切除颈段脊髓侧前方和前方肿瘤的手术技巧、脊髓保护方法和术后处理。方法回顾性分析48例颈段脊髓侧前方和前方肿瘤的手术经验。本组以神经鞘瘤和脊膜瘤为主,占85.4%（41例）。肿瘤最大径3～13cm。病变长入颅内13例,向椎管外生长10例。根据肿瘤生长特性及大小采用三种手术入路切除肿瘤,大多行分块切除。结果肿瘤全切除44例（91.7%）。随访0.5～8.8年,恢复基本生活和工作能力40例（83.3%）。结论采用颈后改良手术入路和显微手术能明显提高颈段脊髓侧前方和前方肿瘤的全切除率,同时降低致残率。     

电生理监测下显微手术切除胸段脊髓腹侧脊膜瘤

目的探讨在电生理监测下显微手术切除胸椎腹侧脊膜瘤的效果。方法回顾性分析2009年12月至2012年12月收治的68例胸段脊髓腹侧脊膜瘤患者临床资料。采用后正中入路手术切除肿瘤,所有手术均在电生理监测下进行。结果肿瘤全切62例（91．2％）,大部分切除6例（8．8％）。术后1周神经功能障碍改善46例,无变化10例,加重8例。术后64例（94．2％）随访4个月。2年,神经功能均较术前改善,其中完全正常者55例;无肿瘤复发。结论采用显微手术切除胸段脊段腹侧脊膜瘤是治疗该病有效的方法,术中电生理监测有助于手术的安全进行。     

单侧部分半椎板入路显微手术治疗脊柱脊髓肿瘤

目的探讨采用单侧部分半椎板入路显微手术切除脊髓肿瘤。方法回顾性分析45例单侧部分半椎板入路显微手术切除脊髓肿瘤病人的临床资料,术中均行运动和体感诱发电位监测。结果 45例肿瘤均达全切除,术后病理:神经鞘瘤15例,脊膜瘤17例,神经纤维瘤9例,肠源性囊肿3例,海绵状血管瘤1例。术后随访6～24个月,无肿瘤复发,无脊柱失稳病例。结论偏向一侧的椎板节段间脊髓肿瘤及部分椎管内外沟通性肿瘤可选用单侧部分半椎板入路手术,该术式能够充分显露肿瘤,且保留椎板后弓的完整性,对脊柱稳定性影响较小。     

脊膜瘤的显微手术治疗

目的总结脊膜瘤的显微手术技巧。方法回顾性分析经病理证实的97例脊膜瘤的显微手术经验。肿瘤位于颈段31例,胸段59例,腰段5例,腰骶段2例。采用后正中入路91例,旁正中T字形皮肤切口1例,远外侧入路5例。结果肿瘤全切除85例,次全切除8例,大部切除4例。术后症状好转86例;无变化8例;恶化3例,与压迫解除后继发水肿、缺血有关。无手术并发症。结论采用正确的手术入路、手术步骤和显微手术技巧是全切除脊膜瘤的关键。     

神经纤维瘤病-Ⅱ型显微手术治疗策略

目的探讨神经纤维瘤病-Ⅱ型(NF-2)显微手术切除的治疗策略。方法回顾性分析2000年1月至2015年12月期间16例NF2经显微手术切除的临床资料。其中双侧听神经瘤11例,另5例为Segmental型(不完全型) NF-2。均采用乙状窦后入路切除听神经瘤,术中采用面神经、三叉神经和听性脑干反应(ABR)监测。根据肿瘤大小、听力损伤程度选择手术切除时机和侧别。结果分期分侧切除双侧听神经瘤9例,单侧听神经瘤切除7例,共切除听神经瘤25侧。肿瘤全切除22侧(22/25,88%),近全切除3侧(为唯一存在听力耳)。椎管内神经鞘瘤切除3例,颅内脑膜瘤切除1例,均获得肿瘤全切除。大部分切除的3侧肿瘤和尚未行肿瘤切除的2侧听神经瘤(尚存有效听力),以及颅内1例多发性神经鞘瘤和多发性脑膜瘤1例,术后3个月内行伽玛刀治疗。术前有残余听力的11侧耳,术后5侧耳保留不同程度听力,听力保留率为45. 5%(5/11)。23侧肿瘤术中均解剖保留面神经(23/25,92%),术后半年复查面神经功能采用House-Brackmann(H-B)评分I～Ⅲ23侧,H-BⅣ级2侧。随访11～78个月,平均随访38. 4个月,肿瘤均得到有效控制,未见肿瘤复发或增大。结论 NF-2应根据肿瘤的大小、听力水平、解除脑干压迫的必要性、肿瘤的生长速度,制定恰当的手术方案。对于伴发的脑膜瘤或脊膜瘤、椎管内和颅内其它神经鞘瘤,根据是否引起临床症状来决定是否需要切除肿瘤。     

老年椎管内脊膜瘤患者的临床特点及手术治疗

目的探讨脊膜瘤老年患者的临床和病理特点及显微手术技巧。方法回顾性分析2001年3月至2011年10月显微手术治疗的56例经病理学检查证实的脊膜瘤老年患者(年龄60~84岁)的临床资料;按McCormick神经功能分级,56例患者中术前McCormickⅠ级6例,Ⅱ级11例,Ⅲ级22例,Ⅳ级14例,Ⅴ级3例。结果肿瘤位于硬膜下髓外55例(98.2%),完全位于硬膜外1例(1.8%);56例患者中38例(67.9%)肿瘤位于胸段。55例(98.2%)肿瘤全切除,1例大部分切除。无手术死亡病例。术后、McCormick分级改善者31例(55.4%),不变者19例(33.9%),恶化者6例(10.7%)。术后随访3个月至7年,肿瘤无复发。结论老年脊膜瘤患者中女性发病率明显高于男性。老年患者术前脊膜瘤误诊率高,术前大多数患者有中、重度神经功能障碍。肿瘤多位于胸段及脊髓腹侧及腹外侧,且部分质地坚硬,显微手术应精细操作,尽量避免脊髓及神经损伤。     

枕下乙状窦后锁孔入路显微手术切除大型听神经鞘瘤

目的 探讨经枕下乙状窦后锁孔入路显微手术切除大型听神经鞘瘤的手术技巧和临床疗效.方法 采用该入路对59例大型(≥3 cm)听神经鞘瘤行显微手术切除,术中通过调节显微镜角度和手术床位置充分显露肿瘤并切除,然后严密缝合硬脑膜,骨瓣复位固定.结果 肿瘤全切除53例(89.8%),次全切除6例(10.2%),全组无死亡患者,面神经均获解剖保留.术后出现轻、中度面瘫者45例(76.3%),部分听力残存15例,无切口局部脑脊液漏或皮下积液.结论 枕下乙状窦后锁孔入路显微手术是切除大型听神经鞘瘤的较好方法,死亡率和病残率低,并能有效保留面、听神经的功能.     

枕下乙状窦后锁孔入路显微手术切除大型听神经瘤

目的总结枕下乙状窦后锁孔人路切除听神经瘤的临床经验.方法对42例大型听神经瘤行乙状窦后锁孔入路,在耳后发际内1 cm作6 cm小弧形切口,骨窗2.5～3.0 cm,显微手术切除肿瘤.结果肿瘤全切除40例(95.2%),近全切除2例;面神经解剖保留37例(88%),功能保留30例(71.4%);耳蜗神经解剖保留3例,有效听力保留1例;无手术死亡.结论经乙状窦后锁孔入路同样能获得对听神经瘤及桥小脑角神经、血管的良好显露.     

脊膜瘤的诊断与显微手术治疗

目的探讨脊膜瘤的诊断及显微手术治疗效果。方法回顾性分析28例经病理学证实的脊膜瘤患者的MRI影像学资料、临床表现、手术方式及预后。28例均行显微手术治疗,其中5例采用后路锥板切除肿瘤摘除术,17例采用后路半椎板切除肿瘤摘除术,6例采用后路椎板棘突截取原位回植术。结果MRI示肿瘤位于枕骨大孔区2例、颈椎5例、胸椎14例、腰椎7例,肿瘤直径1．1～3．4cm,T1WI及T2WI呈等或稍低信号,增强后肿瘤明显强化,常有脊膜尾征。肿瘤全切除25例,大部分切除3例。随访11月～5年,症状改善25例,症状未改善或加重3例,其中2例复发后再次手术。结论MRI检查能清楚地显示脊膜瘤与周边组织关系,利于手术方式的选择;采用显微手术切除脊膜瘤治愈率高,术后并发症少。     

接触式激光刀辅助显微手术治疗椎管内脊膜瘤病15例临床分析

目的探讨接触式激光刀辅助显微手术治疗椎管内脊膜瘤的疗效。方法 2010年2月~2013年6月我院神经外科收治椎管内脊膜瘤15例,采用接触式激光刀辅助显微手术,对肿瘤切除程度、术后肌力恢复情况进行回顾性分析。结果肿瘤全切除14例(93.3%),次全切除1例(6.7%),术后肌力较术前改善1级7例,改善2级3例,改善3级1例,无改善1例,感觉障碍好转3例,所有患者术后病理证实均为脊膜瘤。结论采用接触式激光刀辅助显微手术切除椎管内脊膜瘤彻底,术后神经功能恢复效果好,能提高手术疗效,降低术后并发症。     

Ganglioglioma of the spinal cord

Summary A case of ganglioglioma or neuroastrocytoma of the spinal cord in a 78-year-old man is reported. Diagnosis was based on the histological identification of the neoplastic cells and on the study of the architecture of the tumour. The presence of cellular anaplasia, sometimes of marked degree, and of small nests of infiltration suggested an initial malignant behaviour regarding both cellular types. A survey of the five reported cases of spinal ganglioglioma is presented.     

Spinal hamartoma associated with spinal dysraphism

Objects The aims of the study were (1) to review the pathological findings of spinal lipomatous masses associated with congenital spinal dysraphism and (2) to discuss the pathological diagnosis.Methods The pathological records of 47 patients at our institution were reviewed, and three illustrative cases were presented.Conclusion Spinal tumorous lesions associated with spinal dysraphism have been traditionally described as lipoma since they are composed mostly of fatty tissue. However, they are different from lipomas arising in other part of the body in that they often contain various tissues of ecto- and mesodermal origin. In our study, we detected such heterotopic components in 24 out of 47 cases. Although they are also similar to teratoma, it is generally accepted that they are malformative lesions which lack neoplastic potential. We therefore should diagnose them as hamartoma rather than lipoma or teratoma.     

Spinal meningioma: Chronicles of contemporary neurosurgical diagnosis and management

Spinal meningiomas are uncommon entities that fortunately burden only a small minority of patients. Notwithstanding their overwhelmingly benign propensity, the occurrence of extramedullary meningioma may nonetheless cause significant morbidity and possible mortality. The consideration therefore, of spinal meningioma in the differential of patients presenting with radiculopathy or complaints of chronic back or neck pain should not be disregarded. The rapidity of diagnosis and the first neurosurgical encounter are cornerstones in patient longevity and neurological preservation. The advent of microsurgical techniques and magnetic resonance imaging and surgical techniques has notably improved clinical outcomes over the past two decades. However, surgical candidacy may be limited, particularly in those patients with significant preexisting medical comorbidities, aggressive or recurring tumors, or multiple lesions. Alternative management strategies such as stereotactic radiosurgery or less invasive surgical techniques are currently underway in clinical practice. A review on neurosurgical diagnosis and treatment modalities in the management of spinal meningioma is therefore pertinent.     

Contralaterally projecting lamina VIII interneurones in middle lumbar segments in the cat

Peripheral input to lamina VIII interneurones was investigated by using extracellular and/or intracellular records from them. The interneurones were located in the L4-L5 spinal segments and projected to contralateral motor nuclei in the L7 segment. They constituted a non-homogeneous population but their input from muscle afferents (mainly group II afferents of quadriceps, flexor digitorum longus and pretibial flexors and group I afferents of triceps surae and hamstring nerves) and from cutaneous and joint afferents resembled the input to ipsilaterally projecting laminae V-VII interneurones of the same segments rather than the input to more caudally located lamina VIII interneurones. Since the ipsilaterally projecting laminae V-VII interneurones with such an input might be involved in locomotion, it is proposed that this is also the case for the contralaterally projecting lamina VIII midlumbar interneurones, especially those excited by stimuli applied in the cuneiform nucleus (mesencephalic locomotor region).     

An unusual sequelae of an infected persistent dermal sinus tract

Case report We present a case of a child born with a birthmark over the lumbar spine, which harbored a pinhole-sized opening. At 6 months of age the child presented with fever of unknown origin. Subsequent lower extremity pain resulted in imaging studies that revealed a spinal mass with extension into the posterior mediastinum. At operation, the child was found to have an infected dermal sinus tract. Discussion This case highlights the importance of a thorough examination of the midline craniospinal axis in children with fever of unknown origin. To our knowledge, this is the first reported case of an infected dermal sinus tract with extension into the posterior mediastinum.     

Glucose utilization and reflex activity of the transected rat spinal cord

Spinal cord glucose utilization (SCGU) of gray and white matter was studied with the quantitative autoradiography [¹⁴C]2-deoxyglucose methodology, below and above a complete low thoracic transection. One day after transection, a generalized decrease in SCGU was observed in gray matter, particularly marked in the dorsal horn of the lumbar cord. A progressive increase in SCGU was observed thereafter. Values reached levels greater than those of non-transected controls by 2 and 4 weeks after the intervention in ventral horn of the lumbar cord, and ventral and dorsal horn of the cervical cord. A similar behavior of SCGU was observed in white matter of transected animals. The development of 17 lumbar reflex modalities was quantified between days 1 and 28 after spinal transection. The delay in emergence of these reflexes was related to their complexity. Correlation of reflex scores with SCGU was significant for all lumbar cord regions but linearity of this relationship was only observed in white matter. These results uncover a close relationship between SCGU and reflex activity of the spinal cord below a complete transection, particularly striking in white matter and suggests a role of the fasciculi proprii of the spinal cord in this phenomenon.     

A Comparison of the Clinical Outcomes of Decompression Alone and Fusion in Elderly Patients with Two-Level or More Lumbar Spinal Stenosis

Objective

We compared the results of two surgical techniques by retrospective study of 60 elderly patients (65 years or older) who underwent either decompression alone or fusion for the treatment of two-level or more lumbar spinal stenosis.

Methods

During the period of 2003 and 2008, two-level or more decompression alone or fusion was performed for lumbar spinal stenosis by three surgeons at our institution. Patients were allocated to two groups by surgical modality, namely, to a decompression group (31 patients) or a fusion group (29 patients). Overall mean age was 71.1 years (range, 65-84) and mean follow-up was 5.5 years (range, 3-9). A retrospective review of clinical, radiological, and surgical data was conducted.

Results

No significant difference between the two groups was found with respect to age, follow-up period, surgical levels, or preoperative condition. At the last follow-up, correction of lumbar lordotic angle (determined radiologically) was better in the fusion group. However, clinical outcomes including visual analogue scale, Oswestry Disability Index, and the Odom''s criteria were not significantly different in the two groups. On the other hand, surgical outcomes, such as, operation time, estimated blood loss, and surgical complications were significantly better in the decompression alone group.

Conclusion

Our findings suggest that decompressive laminectomy alone achieves good outcomes in patients with two-level or more lumbar spinal stenosis, associated with an advanced age, poor general condition, or osteoporosis.     

Are “Unstable” Burst Fractures Really Unstable?

ObjectiveThe stability is an important factor to decide the treatment plan in thoracolumbar burst fracture patients. Patients with an unstable burst fracture generally need operative management. Decrease in vertebral body height, local kyphosis, involvement of posterior column, and/or canal compromise are considered important factors to determine the treatment plan. On the other hand, in thoracolumbar injury classification system (TLICS), surgery is recommended in patients with TLICS of more than 5 points. The purpose of this study was to apply the TLICS score in patients with thoracolumbar burst fractures and to distinguish the differences of treatment plan on burst fracture. MethodsAll patients, diagnosed as a thoracolumbar burst fracture between January 2006 and February 2019 were included in this study. Unstable thoracolumbar burst fracture was defined as burst fracture with neurologic deficit, three-column injury, kyphosis over 30 degrees, decrease of anterior body height over 40 percent and canal comprise more than 50%. TLICS score was measured with morphology, neurological involvement and posterior ligamentous complex integrity. The existence of instability was compared with TLICS score. ResultsTotal 233 patients (131 men, 102 women) were included in this study. In Denis classification, 51 patients (21.9%) diagnosed as stable burst fracture while 182 patients (78.1%) had unstable burst fracture. According to TLICS, 72 patients (30.9%) scored less than 4, while 161 patients (69.1%) scored 4 or more. All the patients with stable burst fracture scored 2 in TLICS. Twenty-one patients (9.0) scored 2 in TLICS but diagnosed as unstable burst fracture. Thirteen patients had over 40% of vertebra body compression, four patients had more than 50% of canal compromise, three patients had both body compression over 40% and kyphosis over 30 degrees, one patients had both body compression and canal compromise. Fifteen patients presented kyphosis over 30 degrees, and three (20%) of them scored 2 in TLICS. Seventy-three patients presented vertebral body compression over 40% and 17 (23.3%) of them scored 2 in TLICS. Fifty-three patients presented spinal canal compromise more than 50%, and five (9.4%) of them scored 2 in TLICS. ConclusionAlthough the instability of thoracolumbar burst fracture was regarded as a critical factor for operability, therapeutic strategies by TLICS do not exactly match with the concept of instability. According to the concept of TLICS, it should be reconsidered whether the unstable burst fracture truly unstable to do operation.     

Acute thoracic epidural hematoma following spinal manipulative therapy: case report and review of the literature

Spinal epidural hematoma is a rare complication of chiropractic manipulation. This study reports a case of thoracic spinal epidural hematoma following spinal manipulative therapy in the absence of predisposing factors. The effectiveness and safety of chiropractic treatment in chronic spinal pain and a literature review are also presented.