脊髓室管膜瘤的诊断与治疗

目的：探讨脊髓髓内室管膜瘤的诊断和治疗方法。方法：总结分析16例脊髓髓内室管膜瘤患者的MRI表现特点,应用显微外科手术治疗,评价手术前,后神经功能状态。结果：肿瘤位于颈髓（包括颈延髓）7例,颈胸髓5例,胸髓1例,圆锥3例,肿瘤长度2．5－18cm,肿瘤一端或两端有囊肿者14例,11例合并脊髓空洞,手术全切除15次,次全切除1例,无手术死亡,随访6－38个月未见肿瘤复发,2例术前McComick分级IV级者术后神经功能无恢复。结论：MRI是诊断脊髓室管膜瘤的可靠方法,早期显微外科全切除是治疗髓内室管膜瘤有效的措施,术前神经功能状态与预后有密切关系。     

Postoperative spinal cord herniation with pseudomeningocele in the cervical spine: a case report

Background context

Postoperative spinal cord herniation with pseudomeningocele is a rare disease, with only five cases reported before the present study.

Purpose

To describe the clinical features and radiologic findings of postoperative spinal cord herniation with pseudomeningocele.

Study design

Case report.

Methods

A case of a 51-year-old man who suffered from postoperative spinal cord herniation with pseudomeningocele was reported, and previous reports on this subject are reviewed.

Results

He had undergone excision of a spinal cord tumor in the cervical spine 10 years previously. He had progressive paraparesis and urinary disturbance 10 years later. The Computed Tomography Multi Planner Reconstruction myelogram showed dilation of the ventral subarachnoid space with left deviation of the spinal cord into the pseudomeningocele at C7. On observation at surgery, the spinal cord appeared displaced dorsally and herniated through the defect of the dorsal dura mater. The spinal cord was tightly adhesive around the dural defect. We released the adhesion of the spinal cord and the dural defect under the spinal cord, and the dural defect was repaired using an artificial dura mater.

Conclusions

The release of adhesion around dural defect and repair of dural defect under spinal cord monitoring resulted in a satisfactory neurologic recovery. Surgical repair of the dural defect with a dural substitute was necessary.     

颈椎椎板成形术后脊髓后移的相关因素分析

 目的 探讨颈后路单开门椎板成形术后脊髓后移的影响因素及其规律。方法 2008年2月至2010年10月收治的压迫性颈脊髓病患者经筛选后43例纳入本研究,均接受C₃～C₇后路单开门椎板成形术,男32例,女11例;年龄33～78岁,平均57.9岁。脊髓型颈椎病伴发育性颈椎管狭窄30例,颈椎后纵韧带骨化症13例。门轴侧关节突螺钉锚定法21例,保留门轴侧肌肉韧带复合体的钛缆悬吊法22例。术前、术后3个月颈椎中立位MRI正中矢状面测量各节段代表脊髓及硬膜囊后移的参数：脊髓前缘后移,脊髓后缘后移,硬膜囊前缘后移,硬膜囊后缘后移;将齿突与T₁椎体后下角的连线定义为E线,其长度为E值,从每个基准点向E线作垂线,每个垂线段的长度为Px(x=1~6),得到代表每个节段局部曲度的参数(100×Px/E);以颈椎曲度指数 (curvature index, CI) 表示颈椎整体曲度。对以上参数进行线性相关分析。结果 硬膜囊前缘后移在不同水平无明显变化,脊髓前缘后移、脊髓后缘后移与硬膜囊后缘后移则随所处节段不同而相应发生变化,且三者的变化具有一致性。脊髓后缘后移最大值位于C_5,6水平,但C_5,6水平脊髓后缘后移与CI无相关性。相关分析表明脊髓后缘后移与硬膜囊后缘后移呈高度线性相关,与(100×Px/D)具有较低的相关性 。结论 颈椎单开门椎管扩大成形术后脊髓的后移程度与同水平硬膜囊的后移程度高度相关,与局部曲度相关性较弱,与颈椎整体曲度无相关性。     

无骨折脱位颈髓损伤的临床治疗

1996—2001年，我院在颈髓损伤的治疗中，收治无骨折脱位的颈髓损伤患者24例。由于此类患者X线检查无明显骨折脱位以及对该病的认识和经验不足，较易造成漏诊、误诊，治疗效果常不够理想。本文就对该病的临床诊断、治疗和发病机制作一探讨，报告如下。     

Paralysis of the arm after posterior decompression of the cervical spinal cord

Summary Paralysis of the arm with radicular distribution occurring after posterior decompression of the cervical spinal cord included C5, C6, C7 and C8 roots, in isolation or combined. The most frequent patterns of paralysis were C5 and C6 root involvements of the motor-dominant type. The overall frequency of occurrence in our series was 11% (20 cases of postoperative paralysis in 188 surgical cases), but the frequency varied with the posterior decompression method. The higher frequency of postoperative paralysis was noted in the group in which the surgical procedures selected were considered as enabling the expanded dura to exert its traction power more easily on the extradural portion of the roots. Radiographical analyses showed that C5 roots which satisfied the following two conditions were more prone to sustain postoperative paralysis: first, location at the level of the highly expanded dural tube and, second, lying in the foramina with a higher degree of anterior protrusion of the superior process. In the majority of cases with C5 motor-dominant paralysis, the postoperative cord-root pouch distances of the C5 anterior roots were unchanged or even decreased compared with the preoperative ones, but the extradural portions of the C5 roots were elongated in all cases. These findings support the validity of mechanisms of postoperative paralysis which were deduced from the anatomical investigations.     

多节段颈髓室管膜瘤的手术治疗

目的探讨多节段颈髓室管膜瘤显微外科手术治疗可能性和疗效。方法回顾性分析1990年10月至2006年10月,我们治疗的26例多节段颈髓室管膜瘤的临床资料、影像学特点、手术中、术后注意要点。结果肿瘤完全在颈髓内14例、主要位于颈髓累及胸髓者12例,平均累及4．5个节段。双下肢不完全截瘫18例,不完全高位截瘫8例,呼吸困难6例,括约肌功能障碍10例。MRI显示脊髓空洞形成24例。20例采用椎板复位固定,6例未采用,其中1例为二次手术无法复位固定者。术后患者肌力恢复21例,无改变4例,1例手术后临床症状较术前加重。术后呼吸困难1例。MRI均未见术后肿瘤残留,1例未固定者脊柱不稳定。结论显微外科手术可以全切除多节段颈髓室管膜瘤,术后患者症状多有明显改善;手术后应进行椎板复位固定以保持脊柱稳定性,提高患者生活质量。     

外伤性无骨折脱位型颈髓损伤的误诊及对疗效的影响

目的 探讨外伤性无骨折脱位型颈脊髓损伤的误诊原因及其对疗效的影响. 方法 回顾1998年10月至2005年10月52例无骨折脱位型颈脊髓损伤患者病例资料,分析18例被漏诊或误诊患者其被漏诊或误诊的原因,并分别于入院时及治疗后随访时对脊髓损伤程度按ASIA标准分级进行评定与比较. 结果 所有患者获得6～67个月(平均29个月),患者入院时及治疗后随访时采用ASIA标准分级比较,34例无漏诊或误诊患者平均提高1.06级,18例被漏诊或误诊患者平均提高0.50级,采用等级资料Ridit分析,两组差异有统计学意义(u=2.0739,P=0.0381). 结论 无骨折脱位型颈脊髓损伤易被漏诊或误诊,早期确诊并合理治疗具有较好的疗效.     

早期手术治疗急性颈脊髓损伤

目的 探讨早期手术治疗急性严重颈脊髓损伤的临床效果。方法 自1999～2002年对24例急性颈脊髓损伤的患者进行早期手术治疗，受伤到手术的平均时间为67h，手术方式包括颈椎前路手术、后路手术及前后路联合手术，对损伤的颈椎节段实施复位、减压、固定和融合。结果 22例获得12．38个月(平均18个月)的随访，除11例全瘫者中的2例无恢复外，其他病例均有不同程度的恢复，ASIA分级平均提高1．8个等级，无并发症发生。结论 对急性严重颈脊髓损伤，早期实施手术治疗可取得满意的治疗效果。     

急性无骨折脱位型颈脊髓损伤的治疗与预后

我院自1996-2002年收治无骨折脱位颈脊髓损伤24例，全部手术治疗，术后恢复满意。     

脊髓线预测颈椎后路开门术后脊髓减压效果的临床研究

目的 探讨颈椎后路开门手术后脊髓减压程度的预测及方法.方法 收集2008年3月至2009年8月25例行颈椎单开门椎管成形术患者术前、术后的MRI图像.根据脊髓前方的压迫程度可分为0～4分;其中＞3分(3和4分)表明有脊髓压迫,＜3分表明脊髓无压迫.在开门节段上位椎体下终板做一水平线与脊髓前方成一交点,在开门节段下位椎体...     

无颈椎骨折脱位的急性颈髓损伤

目的探讨无颈椎骨折脱位的急性颈髓损伤的特征和机制.方法对33例无颈椎骨折脱位的急性颈髓损伤病例进行回顾性研究,分析其神经学、X线和MRI检查结果.结果颈髓完全性损伤者8例,不完全性损伤者25例;21例患者有颈椎变性改变(椎间盘间隙狭窄伴有骨赘形成者15例,后纵韧带骨化者6例),3例C5颈椎管Pavlov率小于0.8;30例可见颈髓受压,25例表现为椎旁软组织损伤.结论无颈椎骨折脱位的急性颈髓损伤的重要诱因为颈椎变性改变和发育性颈椎管狭窄,致病原因主要为颈髓受压;MRI检查有利于查明脊髓损伤的部位和机制.     

无骨折脱位型颈髓损伤的临床研究进展

无骨折脱位型颈髓损伤是指没有骨折或脱位的颈部创伤所导致的急性颈脊髓损伤。通常多见于儿童,具体损伤机制至今仍不明了。X线、CT检查提示颈椎无骨折脱位,MRI检查有脊髓损伤的表现。临床表现多种多样,以脊髓中央型损伤综合征常见。临床治疗可分为保守治疗和手术治疗,如何选择合适的治疗方法仍存在争议。本文就无骨折脱位型颈髓损伤的病因、损伤机制、临床治疗等方面的研究进展作一综述。     

Imaging diagnosis of cervical spine and spinal cord injuries in children

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颈椎骨折合并急性颈髓损伤的手术时机探讨

目的：探讨颈椎骨折合并急性颈髓损伤的手术时机。 方法：回顾性分析2000年1月~2011年1月我科治疗的颈髓损伤患者42例,其中急诊手术组（≤24h）18例,延期手术组（>24h）24例,对比分析手术前后神经功能变化、术后并发症和住院时间等临床资料,并进行统计学分析。 结果：急诊手术组感觉和运动功能改善明显,并发症发生率、重症监护时间和住院时间均低于延期手术组。 结论：颈椎骨折合并急性颈髓损伤的急诊手术减压是可行的,对神经功能的恢复有积极作用,并减少围手术期并发症。     

颈髓挥鞭样损伤的回顾性研究

目的通过对临床资料的回顾性分析,探讨颈髓挥鞭样损伤病例手术的必要性。方法根据治疗方式和损伤后MR I所示脊髓受压程度的不同,将2004年4月～2006年4月收治的36例过伸性颈椎损伤患者分成3组：非手术治疗组（8例）、受压不明显者手术组（10例）、受压明显者手术组（18例）;比较3组间治疗前后的ASIA评分及Frankel分级改变。结果所有患者获得12～24个月随访,神经功能行ASIA评分及Frankel分级,手术组均高于非手术治疗组（P〈0.05）。结论过伸性颈脊髓损伤尽早手术减压是最大限度恢复神经功能的关键。凡存在明显神经功能障碍、MR I提示有颈髓损伤,无论是否有明显脊髓受压者都应早期手术。手术可避免因颈椎管高压和颈椎不稳造成的继发性脊髓损伤,保证其远期疗效。     

陈旧性颈髓损伤的外科治疗

目的：观察颈椎减压融合手术对陈旧性颈椎骨折脱位引起的颈脊髓或神经根损伤的治疗效果。方法：1999年1月～2003年12月手术治疗因颈椎骨折脱位合并不同程度颈脊髓损伤后1个月以上的患者58例，总结临床资料，比较手术前后感觉运动功能的改善程度。结果：平均随访27个月。术前ASIA分级A级的7例患者术后上肢有1～2个神经根功能改善者3例，下肢出现肌肉活动功能改善者2例：术前B级的11例患者术后8例上肢活动有改善，6例出现下肢功能改善；术前C级6例患者术后达D级3例，E级3例：术前D级34例患者术后达到E级24例，10例仍为D级。所有患者术后ASIA的感觉及运动评分较术前明显提高（P〈0．05）。结论：减压融合手术对陈旧性颈椎骨折脱位引起的颈脊髓损伤或神经根损伤仍是有效的治疗方法，脊髓功能的恢复与脊髓损伤程度有关。     

Adult spinal cord injury with no radiographic bone lesion: analysis of nine consecutive patients

Background

Spinal cord injury with no radiographic bone lesion described as spinal cord injury without radiographic abnormality (SCIWORA) in childhood is less often reported in adults than in children. This study was undertaken to report our experience in the management of nine cases over 25 years.

Patients and methods

This was a retrospective study from 1985 to 2009 concerning nine adult patients who sustained spinal cord injury with no radiographic abnormality. The ratio among all cervical spine traumas for the same period was 2.21%. Magnetic resonance imaging (MRI) was performed in all the patients. The patients’ clinical status at the time of admission and discharge was evaluated using the Frankel's grading system. We report the results based on the clinical, epidemiologic and radiological findings and outcomes.

Results

The mean age of our population was 37.43 years, ranging from 18 to 60 years. All the patients were men. The main etiology was falls (5/9) followed by road traffic accidents (4/9). According to the Frankel's grading system, four patients (44.45%) were grade A, four were grade B (44.45%), and one was grade C (11.11%). On MRI, medullar lesions were: contusion, non-compressive cervical disc herniation, cervical spine stenosis, and two cases of normal cervical spine. Four patients were operated on via the posterior cervical spine approach (laminectomy, C3-C7 in three cases and C1-C3 in one case). The other five patients were treated orthopaedically for 6 to 8 weeks. Three patients (3/9), who were Frankel's grade B and C with no demonstrable injury on MRI, improved to Frankel a useful neurological grade (Frankel's grades D or E) at the time of discharge. One patient evaluated as Frankel's grade A died from cardiovascular disturbance.

Conclusion

Spinal cord injury with no radiographic abnormality accounted for 2.21% of cases of spinal cord injury in our series. MRI is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to identify surgically correctable abnormalities.     

急性颈脊髓损伤并发低钠血症的机制及治疗分析

目的 :探讨急性颈脊髓损伤患者并发低钠血症的病因、发病机制和治疗方法。方法 :自2005年1月至2010年7月收治严重创伤导致急性颈脊髓损伤伴高位截瘫并发低钠血症患者57例,男46例,女11例;年龄26～69岁,平均39.5岁;颈椎骨折或脱位55例,无骨折或脱位型脊髓损伤2例;完全性损伤28例,不完全性损伤29例。神经功能损害按ASIA分级:A级28例,B级25例,C级4例。每日监测心率、血压、尿量、血钠,诊断低钠血症后即开始静脉补液、补钠,每隔2 d检测尿钠、血浆渗透压、尿渗透压,根据监测结果及治疗反应判断低钠原因是由脑性盐耗综合征(CSWS)还是由抗利尿激素不适当分泌综合征(SIADH)引起,前者继续静脉补液、补钠,后者严格限水同时静脉补钠直至低钠纠正。对治疗前后血钠等指标进行统计学分析。结果:57例中诊断CSWS者42例,SIADH者15例。治疗3周后所有患者的心率、血钠、血渗透压有明显回升(P<0.01),血压、尿渗透压升高,尿钠减少(均P<0.05),尿量未见明显减少(P>0.05)。出院时与治疗3周比较,心率、血浆渗透压、尿渗透压进一步回升,尿量减少,尿钠进一步减少(P<0.05),血压无明显改变(P>0.05)。结论:急性颈脊髓损伤后并发低钠血症受多因素影响,发病机制主要为脑性盐耗综合征(SCWS)及抗利尿激素不适当分泌综合征(SIADH),治疗时应注意鉴别,根据不同病因采取补液或限液治疗。     

Exophytic ependymomas of the spinal cord

Summary Intramedullary ependymomas of the spinal cord with exophytic components are rare outside the filum or conus region. Two cases of combined intradural intramedullary and extramedullary ependymomas of the spinal cord are presented. At operation, the tumours proved to be primarily intramedullary but had a contiguous exophytic component that extruded either through a defect in the ventral pia to encase the anterior spinal artery in one patient, or through the dorsal root entry zone in the second patient. When removing intramedullary spinal tumours with an exophytic component, separate removal of the intramedullary and extramedullary components is recommended, rather than en bloc resection, to prevent possible injury to the vascular supply of the spinal cord.