颈椎管内外哑铃形肿瘤Tovama分型及手术治疗策略

目的:探讨颈椎管内外哑铃形肿瘤的临床特点、Toyama分型及手术治疗策略.方法:回顾分析我院2004年1月～2008年1月期间治疗的21例颈椎哑铃形肿瘤患者,肿瘤节段位于C1/2 6例,C2/3 4例,C3/4 3例,C4/5 3例,C5/6 2例,C6/7 1例,C1/2伴C2/3 1例,C4/5伴C5/6 1例.神经鞘瘤14例,神经纤维瘤4例,多发性神经纤维瘤2例,恶性神经鞘瘤1例.采用Toyama方法分型,Ⅰ型1例,Ⅱ a型4例,Ⅱ b型2例,ⅡC型1例,Ⅲa型10例,Ⅲb型2例,日Ⅴ型1例;IF分期Ⅰ期19例,Ⅱ期2例;TF分期Ⅰ期19例,Ⅱ期2例.术前JOA评分4～15分,平均8.7分;ASIA分级B级1例,C级5例,D级11例,E级4例.对15例肿瘤主要位于后方和椎管内且向前生长不超过椎问孔的Ⅰ型和Ⅱ a型、Ⅴ型及几乎所有Ⅲa型肿瘤选择后路手术;早期有1例C1/2Ⅲa型肿瘤行寰枢椎侧方入路;对4例肿瘤侵及椎管内并且在颈前方存在肿块的Ⅱb型和Ⅲb型选择前后路联合手术;对1例瘤体位于颈椎前方的Ⅱ C型肿瘤选择单纯前方入路.1例Ⅲb型及3例TF或IF分期Ⅱ期者因切除较多骨质而行内固定重建,单侧固定3例,双侧固定1例.术后行JOA评分及ASIA残损分级评估神经功能.结果:手术均顺利完成,术中肿瘤均完全切除,无椎动脉损伤,无神经功能障碍加重.患者局部疼痛和神经症状均有明显改善或缓解,术后即刻出现单侧上肢-过性瘫痪1例,经激素及脱水药物治疗3d后缓解;脑脊液漏1例,保守治疗后闭合;术后颅内感染1例,经持续腰大池引流和抗感染治疗后治愈;未见颈椎反屈畸形.随访6个月～4年,平均23个月.所有患者神经功能均有不同程度恢复,其中14例患者神经功能完全恢复.术后半年时JOA评分10～17分,平均13.2分,ASIA分级C级1例,D级2例,E级18例.1例Ⅲa型患者后路手术后1年椎间孔外部分局部复发,其余病例均未见局部复发.结论:Toyama分型较完善,对于手术方式和入路的选择具有较大的指导意义,有助于提高肿瘤切除率,降低术后局部复发率.

Three-dimensional classification and surgical strategy of inner and outer cervical spinal canal dumbbell tumors

Objective:To analyze the clinical features,surgical strategy of inner and outer cervical spinal canal dumbbell tumors as well as the effect of three-dimensional classification on surgical strategy.Method:Twenty one patients with inner and outer cervical spinal canal dumbbell tumors from January 2004 to January 2008 were reviewed retrospectively.Based on the tumor site,there were 6 cases in C1/2,4 in C2/3,3 in C3/4,3 in C4/5,2 in C5/6,1 in C6/7,1 in C1/2 and C2/3,1 in C4/5 and C5/6.Of all tumors,there were 14 neurinoms,4 neurofibroma, 2 yon Recklingbausen disease, 1 malignant schwannoma.Based on Toyama classification,there were 1 ease of type Ⅰ ,4 of type Ⅱa ,2 of type Ⅱb,1 of Ⅱc,10 of type Ⅲa,2 of type Ⅲb,1 of type V;19 ease of IF stage Ⅰ ,2 of IF stage Ⅱ,19 of TF Ⅰ ,2 of TF Ⅱ .The operative strategy were determined upon Toyama classification.The mean JOA score was 8.7 for all patients.There were 1 ease of B grade,5 of C grade,11 of D grade,4 of E grade based on ASIA scale.Patients with tumors mainly locating in posterior side of spinal canal and not progressing into the intervertebral foramen consisted all type Ⅰ , Ⅱa,V and almost all Ⅲa with tumors removed by posterior approach alone in 15 patients except of one patient with type Ⅲ a tumor at C1-2 experiencing lateral approach on early stnge.4 cases of type Ⅱb and Ⅲb witth tumor involving the spinal canal and paravertebral region experienced combined posterior and anterior approach, 1 case of type Ⅱe with tumor located anteriorly to the cervical spine canal underwent the anterior approach.Reconstruction was performed in 4 patients with bone defect,3 of TF underwent unilateral spinal instrumentation and 1 of IF stage 2 underwent bilateral instrumentation.Neurological fimction was evaluated by JOA score and AIS grade after operation.Result:The mean follow-up period was 23 months (ranged,6 months to 4 years).All tumors were removed successfully.There were no injury to vertebral artery and deteriorate of neurological function.Pain and neurological deficit relieved significantly.There were 1 ease developing transient weakening of upper limb which recovered after 3 days of use of corticosteroids and dehydration.1 ease com-plicating eerebrospinal fluid leakage recovered after conservative management.1 case complicating intracranial infection was cured by simple drainage and anti-infective therapy with no secondary to cervical misalignment.Recurrence were found progressing out of intervertebral foramen in 1 ease with type Ⅲa tumor.The mean score of postoperative JOA was 13.2.After operation,there were no case of grade B,1 of grade C,2 of grade D,18 of grade E based on ASIA scale.Complete neurological recovery was noted in 14 cases.Conclusion:Sys-tematic three-dimensional classification is essential for determining surgical strategy and approach,which is beneficial for tumor en bloc removal rate so as to decrease recurrence rate.