胸腰椎神经鞘瘤手术治疗的临床分析

目的　探讨胸腰椎神经鞘瘤应用后正中入路实施一期肿瘤切除手术的疗效及并发症。方法　２００１年至２０１０年我科收治胸腰椎椎管内神经鞘瘤患者３９例，其中男性２５例，女性１４例；年龄１４～７２岁，平均年龄４１.５岁；发病部位：胸段椎管１７例，胸腰段椎管４例，腰段椎管１５例，腰骶段椎管３例，均为单发。手术均取后正中切口，切除相应节段的小关节突和椎板，一期切除椎管内外的神经鞘瘤，部分患者行椎弓根螺钉内固定。结果　３９例手术均完整切除肿瘤。随访时间为１０～６９个月，平均３５个月。１例良性神经鞘瘤术后局部复发，１例恶性神经鞘瘤患者术后１７个月因复发及肺转移死亡。２２例存在感觉障碍的患者术后ＡＳＩＡ感觉评分平均提高１.６分。１０例存在运动障碍的患者术后ＡＳＩＡ运动评分提高７例，平均提高２.５分。未行内固定的６例患者中术后有２例发生脊柱失稳。结论　胸腰椎神经鞘瘤切除术中需确保术野足够显露，必要时可切除一侧的横突和肋骨头，为勉强保留神经根而忽略肿瘤切除的彻底性可能带来较高的局部复发率和相应增高的再次手术率。除肿瘤位于中段胸椎管外，术中均应通过确切的内固定和植骨融合来维持远期的脊柱稳定性。

Analysis of surgical treatment for schwannomas of thoracic and lumbar spines

Objective To study retrospectively the efficacy and complications of complete tumor resection via a posterior midline approach used to treat primary spinal schwannomas.Methods The patients＇ clinical presentations,operative findings and follow-up were reviewed in 39 patients,over the period from 2001 to 2010.There were 25 males and 14 females with a mean age of 41.5 years（range 14-72 years）.Affected segments included thoracic vertebral canal in 17 cases,thoracolumbar vertebral canal in 4 case,lumbar vertebral canal in 15 cases,and lumbosacral vertebral canal in 3 cases.A posterior midline incision approach with laminectomy and facetectomy for single-stage complete resection of intraspinal and paraspinal components of tumor were used.Spine reconstruction with pedicle screw system was also carried out in relevant cases.Results Total excision was achieved in all patients.The patients were followed up for a mean of 35 months（range 10-69 months）.Local recurrence was observed in one case of benign schwannoma.One patient with malignant nerve sheath tumor had local recurrent and lung metastasis,who died in 17 months after operation.ASIA sensory scores increased 1.6 in average after operation in 22 patients with paresthesia and ASIA motor scores increased 2.5 in average in 7 of 10 patients with paraparesis.Segmental instability occurred in 2 of 6 cases without spinal instrumentation after surgery.Conclusion Optimizing operative exposure is an important prerequisite for a safe and complete resection of thoracic and lumbar spinal schwannoma.This surgical exposure allows for facetectomy and costotransversectomy when necessary.Leaving the affected nerve root behind can result in a potential recurrence with the attendant difficult problems of reoperation.Spinal instrumentation was required except for patinets with the tumor mass located in midthoracic region.