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1 995 椎管内肿瘤神经外科临床研究显微外科手术联合胸腔镜切除胸椎椎管哑铃形肿瘤段波郭家龙秦军陈亮赵洪洋摘要研究背景椎管哑铃形肿瘤因向椎管内及椎旁生长, 压迫脊髓, 侵犯椎管椎间孔和椎旁结构而引起相应临床症状位于胸椎的哑铃形肿瘤可突入胸腔生长, 引起胸膜刺激症状如胸痛气急咳嗽等, 由于侵犯广泛而难以 Ⅰ 期手术完整切除, 存在分期手术损伤大并发症多等缺点, 随着显微外科手术联合胸腔镜技术的临床应用, 使手术损伤及并发症发生率极大地降低方法与结果 4 例胸椎椎管内哑铃形肿瘤患者中 3 例 Ⅱ 型患者先经胸腔镜切除后纵隔肿瘤, 再经脊柱后正中入路行半椎板切除术, 显微镜下肿瘤显露良好, 完整切除肿瘤 ;1 例 Ⅲ 型患者先切除椎管内肿瘤, 后经胸腔镜完整切除胸腔内病灶术后 2 例患者早期症状加重,6 个月后好转 ;1 例双下肢无力胸痛咳嗽症状明显改善 ; 1 例干咳消失随访期间无一例出现严重并发症或死亡,MRI 检查显示肿瘤完整切除无复发结论经脊柱后正中入路行半椎板切除联合胸腔镜切除胸椎椎管内肿瘤具有创伤小并发症少疗效佳患者恢复快等优点, 可以作为治疗胸椎椎管哑铃形肿瘤的首选外科手术方式关键词脊髓肿瘤 ; 椎管 ; 胸椎 ; 椎板切除术 ; 胸腔镜检查 ; 显微外科手术 Microsurgical procedure combined with thoracoscopic resection for thoracic spinal canal dumbbell shaped tumors DUAN Bo 1, GUO Jia long 2, QIN Jun 1, CHEN Liang 1, ZHAO Hong yang 3 1 Department of Neurosurgery, 2 Department of Cardiothoracic Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan , Hubei, China 3 Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei, China Corresponding author: ZHAO Hong yang ( [email protected]) Abstract Background Spinal canal dumbbell shaped tumor growing to spinal canal and paravertebral, may compress the spinal cord and invade the spinal canal, intervertebral foramen and spinal structures, and cause clinical symptoms. The dumbbell shaped tumor in the thoracic vertebrae can penetrate thorax to cause pleural irritation symptoms, such as chest pain, short breath, cough and so on. As the microsurgical technique and video assisted thoracoscopic surgery can remarkably reduce the harm, retrospective analysis was performed in order to explore the combined treatment of microsurgical proceduse and thoracoscopic resection for spinal canal dumbbell shaped tumor and to summarize the surgical experience. Methods and Results There were 4 cases with thoracic spinal canal dumbbell shaped tumors, among them 3 were type Ⅱ and one was type Ⅲ. In the surgery, 3 patients with type Ⅱ underwent posterior mediastinal tumor resection under thoracoscope, and then underwent hemilaminectomy through posterior median approach. Under microscope, the tumors were entirely excised with excellent exporsure. The patient with type Ⅲ was firstly subjected to spinal canal tumor excision, and then entirely excisied intrathoracic tumor under thoracoscope. In 2 cases, the uncommon feelings became worse after surgery, but became better after half a year. In one case, the weakness of two legs, chest pain and cough were remarkably relieved, and in one case dry cough obliterated. During the follow up period, there was no serious complication or death, and MRI revealed that the tumors were entirely excised without relapse. Conclusion The posterior median hemilaminectomy combined with video assisted thoracoscopic surgery to doi: /j.issn 作者单位 : 十堰, 湖北医药学院附属太和医院神经外科 ( 段波秦军陈亮 ), 心胸外科 ( 郭家龙 ); 武汉, 华中科技大学同济医学院附属协和医院神经外科 ( 赵洪洋 ) 通讯作者 : 赵洪洋 ( [email protected])

2 996 中国现代神经疾病杂志 2013 年 12 月第 13 卷第 12 期 Chin J Contemp Neurol Neurosurg, December 2013, Vol. 13, No. 12 treat spinal canal dumbbell shaped tumors has following advantages: small trauma, few complication, good effectiveness and rapid recovery, which can be used as preferred treatment for spinal canal dumbbell shaped tumor. Key words Spinal cord neoplasms; Spinal canal; Thoracic vertebrae; Laminectomy; Thoracoscopy; Microsurgery 椎管哑铃形肿瘤生长于椎管内外, 以椎间孔相连, 形似哑铃状, 占椎管肿瘤的 5% ~ 10% [1], 颈段多见, 胸段少见胸椎椎管哑铃形肿瘤生长于椎管内的部分可压迫脊髓和神经根, 产生相应临床症状与体征, 位于胸腔的部分可压迫椎旁血管 ( 如主动脉腔静脉 ) 和神经, 并刺激或压迫肺叶致胸痛咳嗽等由于肿瘤侵犯周围组织, 实施外科手术时难以同期完整切除, 传统外科手术方案多采用 [2] 分期手术, 创伤大, 术后并发症多为减少损伤改善预后, 湖北医药学院附属太和医院神经外科自 [3] 2009 年以来, 在总结前人经验基础上, 据此类肿瘤生长特点, 与心胸外科协作, 采用侧卧位半椎板切除联合胸腔镜同期切除 4 例患者的胸椎椎管哑铃形肿瘤, 效果满意, 预后良好, 结果报告如下资料与方法一一般资料本组 4 例胸椎椎管哑铃形肿瘤患者 ( 表 1), 男性 3 例, 女性 1 例 ; 年龄 19 ~ 48 岁, 平均岁 ; 病程 6 ~ 18 个月, 平均个月其中肿瘤位于上胸段 (T1 ~ 4) 者 2 例, 经 T3-4 椎间孔向椎旁生长 ; 位于中胸段 (T5 ~ 8) 者 2 例, 经 T6-7 椎间孔突入胸腔肿瘤直径 1.30 ~ 6.00 cm, 平均 2.54 cm (1) 临床表现 : 以胸部不适和麻木疼痛为主,1 例肿瘤突入胸腔且体积较大患者伴干咳 1 例伴下肢活动障碍和感觉异常 (2) 影像学表现 : 胸椎 MRI 检查 ( 平扫及增强扫描 ) 显示, 胸椎椎管内占位性病变, 脊髓受压, 肿瘤经椎间孔向椎旁生长并突入胸腔,T1WI 呈等低或混杂信号,T2WI 呈高或混杂信号 ; 增强扫描病灶呈不同程度强化 ( 图 1) (3) 肿瘤分型 : 根据肿瘤生长方式 [4] 可分为 4 种类型 Ⅰ 型, 椎管内肿瘤体积较大而椎管外较小 ;Ⅱ 型, 椎管内肿瘤体积较小而椎管外较大 ;Ⅲ 型, 椎管内外肿瘤体积均较大 ;Ⅳ 型, 肿瘤广泛侵犯椎管及胸腔本组 4 例患者中 3 例肿瘤生长方式呈 Ⅱ 型 1 例为 Ⅲ 型二手术方法手术分期进行,4 例患者均于全身麻醉下行双表 1 4 例患者临床资料 Table 1. Clinical features of 4 cases with thoracic spinal canal dumbbell shaped tumors Case Sex Female Age (year) Lesion segment T2-3 T2-4 T5-6 T6-7 Symptom Right upper limb pain, chest numbness Double lower limbs numbness, weakness Chest pain Chest pain, cough Operation situation 侧支气管插管, 全侧卧位, 病灶一侧朝上于术前 X 线检查定位病变相应椎体节段椎板, 确定椎板切除术的皮肤正中纵行切口位置, 切口大小依据肿瘤大小而定 ; 胸腔镜手术切口采取常规切口, 同时消毒所有手术区域并铺巾 1. 胸腔镜下肿瘤切除常规选择患侧腋中线第 7 肋间长为 1.50 cm 的切口, 作为胸腔镜探查孔, 操作方法与胸腔闭式引流术相同 ; 插入胸腔镜并进行初步探查, 寻找突入胸腔的肿瘤, 探查肿瘤部位大小与周围组织结构之间的关系及与胸腔之间有无粘连等依据肿瘤位置选择操作孔, 伸入无齿卵圆钳, 进一步确定肿瘤及其与周围组织结构有无粘连 ; 电凝肿瘤所在部位壁层胸膜并切开, 电凝钩与圆头吸引器结合分块切除肿瘤直至椎间孔 ( 图 2) 探查突入胸腔部分的肿瘤, 以确认无残留 ; 探查胸腔无活动性出血后取出胸腔镜, 暂不缝合胸腔镜探查孔, 以备必要时再次进行胸腔探查 2. 椎管内肿瘤切除依据术前定位的切口, 切开皮肤至棘上韧带, 向外侧分离患侧骨膜, 显露病变节段椎板 ( 不超过关节突外侧缘 ), 以受累椎间孔为中心, 依据肿瘤大小咬除椎板, 尽量保留各韧带及椎板外侧小关节突 ; 显露硬脊膜, 仔细辨认肿瘤及其与周围组织结构的解剖关系, 进行分离肿瘤体积较大者采用分块切除, 先行肿瘤囊内部分切除, 待肿瘤体积缩小后再仔细分离肿瘤包膜与周围组织结构的粘连手术操作过程中需注意保护被肿瘤压迫变形的神经根, 尽量使神经根完全从肿瘤

997 图 1 术前胸椎 MRI 检查所见 1a 横断面增强 T1WI 扫描, 肿瘤位于椎管内椎间孔和右侧椎旁, 呈哑铃状, 明显强化 ( 箭头所示 ) 1b 旁正中矢状位增强 T1WI 扫描, 肿瘤位于 T3 ~ 4 节段, 呈哑铃状, 明显强化 (

Axial enhanced T1WI revealed the dumbbell shaped tumor was located in intraspinal, intervertebral foramen and right paravertebral

Paramedian sagittal enhanced T1WI showed the dumbbell shaped tumor was located in segment T3-4 with obvious enhancement (arrow

图 2 术中胸腔镜观察所见 2a 可见椎旁部分肿瘤凸出 ( 箭头所示 ) 2b 于胸腔镜下切除纵隔旁肿瘤, 约 3 cm 4 cm 2 cm 大小 Figure 2 Thoracoscopic findings in the surgery.

Mediastinal tumor with the size of about 3 cm 4 cm 2 cm was removed under thoracoscope (Panel 2b).

tumor residual or relapse, and the tumor was completely removed. Axial enhanced T1WI (Panel 3a). Sagittal enhanced T1WI (Panel 3b).

3 997 图 1 术前胸椎 MRI 检查所见 1a 横断面增强 T1WI 扫描, 肿瘤位于椎管内椎间孔和右侧椎旁, 呈哑铃状, 明显强化 ( 箭头所示 ) 1b 旁正中矢状位增强 T1WI 扫描, 肿瘤位于 T3 ~ 4 节段, 呈哑铃状, 明显强化 ( 箭头所示 ) Figure 1 Preoperative MRI examination findings. Axial enhanced T1WI revealed the dumbbell shaped tumor was located in intraspinal, intervertebral foramen and right paravertebral with obvious enhancement (arrow indicates, Panel 1a). Paramedian sagittal enhanced T1WI showed the dumbbell shaped tumor was located in segment T3-4 with obvious enhancement (arrow indicates, Panel 1b). 图 2 术中胸腔镜观察所见 2a 可见椎旁部分肿瘤凸出 ( 箭头所示 ) 2b 于胸腔镜下切除纵隔旁肿瘤, 约 3 cm 4 cm 2 cm 大小 Figure 2 Thoracoscopic findings in the surgery. Part of tumor in paraspinal protruded (arrow indicates, Panel 2a). Mediastinal tumor with the size of about 3 cm 4 cm 2 cm was removed under thoracoscope (Panel 2b). 图 3 术后 4 个月时, 胸椎 MRI 检查未见肿瘤残留及复发, 肿瘤完全切除 3a 横断面增强 T1WI 3b 矢状位增强 T1WI Figure 3 MRI examination 4 months after operation showed no tumor residual or relapse, and the tumor was completely removed. Axial enhanced T1WI (Panel 3a). Sagittal enhanced T1WI (Panel 3b). 表面分离, 确实无法完整分离时可切断 1 ~ 2 根椎管内肿瘤切除后继续向椎旁探查, 切除椎间孔内肿瘤, 此时由于突入胸腔的肿瘤已切除, 即可完整切除残留肿瘤并可见胸腔内肺叶, 精确止血观察胸腔肺复张情况, 取切口旁肌肉加生物蛋白胶封闭胸腔开口, 逐层关闭可再次经胸腔镜探查孔检查有无活动性出血及肺复张情况, 放置胸腔闭式引流管关闭切口术后严密监护, 预防感染及对症支持治疗结果本组 3 例 Ⅱ 型肿瘤先于胸腔镜下切除后纵隔部分, 再经后正中入路切除椎管内及椎间孔部分 ;1 例 Ⅲ 型肿瘤先经后正中入路切除椎管内部分, 再于胸腔镜下切除后纵隔部分本组 4 例患者均获肿瘤完全切除 ( 图 3), 术后组织病理学检查显示, 神经鞘瘤 2 例脊膜瘤 1 例海绵状血管瘤 1 例术后随访 3 ~ 36 月, 平均 21 个月, 无明显运动障碍脊柱畸形或失稳, 无一例出现严重并发症及死亡 ;2 例肿瘤侵犯神经根分布区域感觉异常 ( 以麻木感和酸胀感为主 ) 者, 术后早期症状加重,6 个月后明显好转 ;1 例下肢无力者, 术后下肢肌力恢复正常, 所伴胸痛和咳嗽症状亦明显好转 ;1 例干咳症状明显者, 术后干咳症状消失

4 998 中国现代神经疾病杂志 2013 年 12 月第 13 卷第 12 期 Chin J Contemp Neurol Neurosurg, December 2013, Vol. 13, No. 12 讨椎管哑铃形肿瘤因向椎管内及椎旁生长, 形似哑铃状而得名 [5] 主要位于颈胸椎, 肿瘤可压迫脊髓, 侵犯椎管椎间孔及椎旁结构而引起相应临床症状, 表现为局部不适和麻木疼痛, 椎管内肿瘤体积较大者可因压迫脊髓而引起肢体功能障碍或括约肌功能障碍等位于胸椎的哑铃形肿瘤, 由于椎旁部分的肿瘤位于后纵隔, 也被归为纵隔肿 [6] 瘤, 可引起胸膜刺激症状, 如气急咳嗽等外科手术切除是治疗椎管哑铃形肿瘤唯一有效的方法此类肿瘤由于累及椎管椎旁结构, 以及后纵隔胸腔等多个部位, 牵涉范围广泛, 手术过程中肿瘤显露十分困难, 操作难度较大, 特别是 Ⅳ 型肿瘤, 需分期或联合入路施行手术 1978 年, [7] Akwari 等采用椎板联合肋骨椎体横突切除术治疗 [8] 胸椎椎管哑铃形肿瘤 ;1983 年,Grillo 等采用同一切口后外侧开胸先切除胸腔内肿瘤, 再行神经外科手术上述方法均由于手术切口大损伤范围广术中需切除较多的椎管及附件结构, 而易使脊柱稳定性下降显微外科技术及腔镜技术的发展为手术治疗椎管哑铃形肿瘤提供了新的思路和方法为治疗术后脊柱稳定性下降而采用的脊柱半椎板切除及椎板成形术, 可以在保证切除肿瘤的前提下最大 [9 10] 程度地保留椎管结构, 而胸腔镜的临床应用可 [11] 微创切除胸腔后纵隔肿瘤我们根据胸椎椎管哑铃形肿瘤的生长特点, 为本组 4 例患者制定手术方案 : 生长于椎管内的肿瘤采用单侧半椎板切除, 先于手术显微镜下切除椎管内肿瘤, 再通过胸腔镜切除后纵隔肿瘤, 取得了良好的治疗效果, 极大地降低了术后并发症发生率, 减轻患者痛苦, 缩短手术时间单侧半椎板切除术适用于偏向一侧生长的椎管内肿瘤, 哑铃形肿瘤的椎管内部分主要位于椎管一侧且通过椎间孔生长采用单侧半椎板切除术可以充分显露肿瘤和受累的椎间孔, 有助于肿瘤的切除, 由于保留了对侧椎板及其附件结构, 故对 [12] 椎管稳定性无明显影响手术显微镜可保证术中操作的精细性, 减少对脊髓及神经根的损伤, 同时亦利于辨认肿瘤胸腔镜下胸腔内肿瘤切除术已是一项十分成熟的胸外科手术技术, 可以充分显露肿瘤, 而且微创, 避免了开胸及切除部分肋骨, 减论 [11] 少创伤, 有利于患者术后恢复与此同时, 手术可在一种体位下完成, 避免术中变换体位, 降低感染风险, 减少手术时间对于先行神经外科手术还是胸腔镜手术, 目前尚未达成共识一般认为, 先行神经外科手术切除椎管内肿瘤, 可减少对脊髓的 [13] 牵拉和损伤我们的体会是: 由于胸腔镜操作具有一定限制, 若椎间孔肿瘤残留则难以通过胸腔镜彻底切除且止血困难因此, 若胸腔内肿瘤体积较大而椎管内较小者可先通过胸腔镜切除肿瘤, 然后再行神经外科手术, 有利于全切除肿瘤和止血 ; 但若椎管内肿瘤体积较大时则应先行椎管内肿瘤切除, 甚至可以直接切除较小的椎旁部分本组 3 例 Ⅱ 型患者椎管内肿瘤体积均较小, 因此我们采取先行胸腔镜手术切除椎旁部分, 再行显微外科手术切除椎管内及椎间孔部分的方案 ;1 例 Ⅲ 型患者则先切除椎管内部分, 再行胸腔镜切除椎旁部分, 术后均未发生明显并发症, 临床疗效良好无论是显微外科手术还是胸腔镜手术, 均需熟练的操作技术, 而且需要神经外科医师与胸外科医师的密切协作, 方能减少手术创伤, 有利于患者术后恢复本组患者肿瘤体积均较小, 因此适宜此类手术, 对于病变范围更加广泛的 Ⅳ 型肿瘤, 半椎板切除联合胸腔镜下操作可能会受限制, 尚待进一步积累临床经验参考文献 [1] Jinnai T, Koyama T. Clinical characteristics of spinal nerve sheath tumors: analysis of 149 cases. Neurosurgery, 2005, 56: [2] Sridhar K, Ramamurthi R, Vasudevan MC, Ramamurthi B. Giant invasive spinal schwannomas: definition and surgical management. J Neurosurg, 2001, 94(2 Suppl): [3] Ishikawa E, Matsumura A, Ishikawa S, Nakamura K, Nose T. Combined minimally invasive approach using microsurgery and thoracoscopic surgery for resecting a dumbbell type thoracic schwannoma. Minim Invasive Neurosurg, 2002, 45: [4] Gao L, Xu QW, Xu W, Yu J, Yao YQ, Pang LW. Classification and surgical management of thoracic spinal tumors with both intracanalicular and extracanalicular extension. Zhongguo Ji Zhu Ji Sui Za Zhi, 2000, 10: [ 高亮, 徐启武, 徐伟, 于佶, 姚亚琪, 庞烈文. 胸椎椎管内外肿瘤的分型和外科治疗. 中国脊柱脊髓杂志, 2000, 10: ] [5] Love JG, Dodge HW Jr. Dumbbell (hourglass) neurofibromas affecting the spinal cord. Surg Gynecol Obstet, 1952, 94: [6] Grillo HC, Ojemann RG. Mediastinal and intraspinal "dumbbell" neurogenic tumors//martini N, Vogt Moykopf I. International trends in general thoracic surgery. St. Louis: Mosby, 1989: [7] Akwari OE, Payne WS, Onofrio BM, Dines DE, Muhm JR. Dumbbell neurogenic tumors of the mediastinum: diagnosis and

999 management. Mayo Clin Proc, 1978, 53:353 358. [8] Grillo HC, Ojemann RG, Scannell JG, Zervas NT. Combined approach to "dumbbell" intrathoracic and intraspinal neurogenic tumors.

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5 999 management. Mayo Clin Proc, 1978, 53: [8] Grillo HC, Ojemann RG, Scannell JG, Zervas NT. Combined approach to "dumbbell" intrathoracic and intraspinal neurogenic tumors. Ann Thorac Surg, 1983, 36: [9] Yeo DK, Im SB, Park KW, Shin DS, Kim BT, Shin WH. Profiles of spinal cord tumors removed through a unilateral hemilaminectomy. J Korean Neurosurg Soc, 2011, 50: [10] Nie QB, Jian FZ. Ten year advance in the clinical study on disease of spinal column and spinal cord. Zhongguo Xian Dai Shen Jing Ji Bing Za Zhi, 2010, 10: [ 聂庆彬, 菅凤增. 脊柱脊髓疾病临床研究十年进展. 中国现代神经疾病杂志, 2010, 10: ] [11] Yang L, Jiang JQ, Zheng YF, Yu YK, Li W, Zheng XS. Clinical curative effect analysis of video assisted thoracoscopic surgery on thoracic bulky lesions. Xi Nan Jun Yi, 2012, 14: [ 杨 [12] [13] 列, 姜建青, 郑轶峰, 俞永康, 李卫, 郑秀山. 全胸腔镜下胸腔内巨大包块切除的临床疗效分析. 西南军医, 2012, 14: ] Hu YZ, Wang DH, Li GZ, Li JW, Gong HD,Chu M, Zhong ZY, Xu K. Application of hemilaminectomy approach for intraspinal neoplasms. Zhongguo Wei Qin Xi Shen Jing Wai Ke Za Zhi, 2013, 18: [ 胡永珍, 王殿洪, 李国忠, 李敬文, 龚海东, 初明, 钟震宇, 徐坤. 半椎板入路切除椎管内肿瘤. 中国微侵袭神经外科杂志, 2013, 18: ] Tanaka T, Kato N, Aoki K, Nakamura A, Watanabe M, Tochigi S, Marushima H, Akiba T, Hasegawa Y, Abe T. Combined unilateral hemilaminectomy and thoracoscopic resection of the dumbbell shaped thoracic neurinoma: a case report. Case Rep Neurol Med, 2012:ID ( 收稿日期 : ) 临床医学图像节细胞胶质瘤和神经节细胞瘤 doi: /j.issn Ganglioglioma and gangliocytoma YAN Xiao ling Department of Pathology, Tianjin Huanhu Hospital, Tianjin , China ( [email protected]) 图 1 光学显微镜观察, 纤细的神经毡背景中可见呈簇状的非典型多形性神经节细胞 HE 染色低倍放大图 2 光学显微镜观察显示大的非典型呈无序排列的神经节细胞和肿瘤性星形胶质成分混杂排列 HE 染色低倍放大 Figure 1 Optical microscopy findings. Clusters of atypical, pleomorphic ganglion cells were embeded within a delicate neuropil matrix. HE staining low power magnified Figure 2 Optical microscopy findings. Large, atypical and unoriented ganglion cells were seen admixed with neoplastic, mildly astrocytic glial element. HE staining low power magnified 节细胞胶质瘤和神经节细胞瘤均分化良好, 为生长缓慢的神经上皮组织肿瘤由肿瘤性成熟神经节细胞单独 ( 神经节细胞瘤 ) 或与肿瘤性星形胶质细胞混合 ( 节细胞胶质瘤 ) 构成, 是长期癫发作患者中最常见的中枢神经系统肿瘤神经节细胞瘤由不规则簇状发育不良的多极神经元组成 ( 图 1), 神经元有大的泡状胞核明显的中心性核仁, 胞质丰富, 多极突起节细胞胶质瘤的组织病理学特征为神经元和星形胶质成分混合 ( 图 2), 可呈明显异质性 ( 天津市环湖医院病理科阎晓玲供稿 )

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<4D6963726F736F667420576F7264202D20ECFAD0C0D0C0C2DBCEC4CCE1BDBB6F7665722E646F63> 硕士专业学位论文论文题目鲍温病临床病理特征和几种治疗方法比较的分析研究研究生姓名指导教师姓名禚欣欣康定华专业名称皮肤性病学研究方向皮肤肿瘤与皮肤病理论文提交日期 2013 年 4 月 I 鲍温病临床病理特征和几种治疗