摘要是原来发表时已经翻译好的!

1、摘要是原来发表时已经翻译好的！后路椎板切除、钉棒系统内固定治疗上颈椎椎管内肿瘤Treatment of canal tumors of the upper cervical spine by posterior laminectomy and fixation screw rod system【摘要】目的探讨后路椎板切除、钉棒系统内固定及自体髂骨植骨融合术治疗上颈椎椎管内肿瘤的方法及疗效。方法2003年1月至2008年6月，共收治上颈椎椎管内肿瘤患者16例，男10例，女6例；年龄33-68岁，平均44.7岁。硬膜外肿瘤2例，硬脊膜下脊髓外肿瘤13例，髓内肿瘤1例。肿瘤位于延髓-C1，3例，C1

2、,2 8例，C2水平2例，C1-3 2例，C2,3 l例；其中4例肿瘤位于颈髓腹侧。15例患者行CT或MR检查示肿瘤组织压迫脊髓。Frankel分级：C级5例，D级10例，E级1例。采用后路椎板切除肿瘤，同时行钉棒系统内固定及自体髂骨植骨融合术。结果所有患者术后均获得随访，随访时间8个月，平均27.4个月。根据JOA 17分法评分，术前争6-17分，平均88分；术后6个月14-17分，平均16分，平均改善率881。术后影像学检查示植骨融合良好。Frankel分级：7例由术前的D级恢复至E级，5例由C级恢复至D级，3例D级及l例E级的患者术后未改变。结论后路椎板切除肿瘤、钉棒系统内固定及植骨融合

3、治疗上颈椎椎管内肿瘤，可彻底切除肿瘤病灶，解除颈脊髓及神经根压迫，重建上颈椎的稳定。【关键词】颈椎；椎管；肿瘤；内固定器【Abstract】Objective To investigate the methods and curative effects of posterior laminectomy and fixation screw rod system in treatment of canal tumors of the upper cervical spineMethods Between January 2003 and June 2008，16 patients(10 mal

4、es and 6 females，average age 44.7 years，range 33-68 years)with canal tumor of the upper cervical spine were treated，including epidural neoplasms in 2 cases,intradural extramedullary tumors in 13, and intramedullary tumor in l caseThe tumors were located between medulla oblongata and C1 in 3 cases，C1

5、,2 in 8，C2 in 2，Cl-3 in 2，C2,3 in l；4 cases were located at ventralis of cervical cordSpinal cord was pressed by tissue of tumor in Fifteen patients which were diagnosed by MRI and computerized tomographic(CT)scansAccording to the Frankel grading system，there Was C in 5 eases，D in 10 casesE in l cas

6、eThey were treated by posterior approach to remove of tumors after laminectomy，fixation with pedicle screw rod system and fusion with autogenous bone graftsResults The follow up was obtained for 6-58 months(mean 27.4 months)According to the JOA grading system，the preoperative average score was 8.8，1

7、6 at 6 months postoperatively, and the average improvement rate was 88.1According to the Frankel grading system，7 cases improved from D to E，5 from C to D，but none in 3 cases with Frankel D and l with EThe good fusion of bone graft Was found in iconography examinationConclusion The treatment by post

8、erior approach to remove of tumors after lamineetomy，and fixation with pedicle screw system and fuIsion with autogenous bone grafts，can relive compression of cervical cord，nerve root，remove of tumor lesion thoroughly，reconstruct stabilization of the upper cervical spine and improve life quality of p

9、atients【Key words】Cervical vertebrae；Spinal canal；Neoplasms；Internal fixators上颈椎椎管内肿瘤一般指位于C1-3水平节段的肿瘤，可造成上颈髓及延髓受压，引起呼吸循环障碍，导致高位截瘫，甚至死亡。早期症状不明显，常表现为单纯枕颈部疼痛或不适、头颈歪斜、头颈部旋转活动受限，早期若无锥体束征等脊髓受压的表现，无明显的神经定位体征，易误诊或漏诊。目前，外科手术切除肿瘤病灶，解除对颈脊髓、神经根、椎动脉的压迫，内固定重建颈椎结构的稳定性，仍然是上颈椎肿瘤最有效、最主要的治疗方法。A tumor located at C1-3 c

10、alled canal tumors of the upper cervical spine. It may compress the upper cervical cord or the medulla oblongata which can cause respiratory and circulatory disorder, high paraplegia and even death. The early symptoms were not manifest, often simple occipital and neck pain or discomfort, neck tilted

11、, neck rotate limited. There was no neurological sign without spinal cord compression symptoms such as pyramid sign and often misdiagnosis or missed diagnosis. At present, surgical resection of the tumor lesion to relieved the compression of spinal cord, nerve root and vertebral artery, fixation sta

12、bility of cervical structure, reconstruct stabilization of the cervical spine with fixation is still the most effective and most important therapy of canal tumors of the upper cervical spine.资料与方法Material and methods一、一般资料1. Physical data 2003年1月至2008年6月，采用颈椎后路经椎板切除肿瘤、钉棒系统内固定及髂骨植骨融合治疗上颈椎椎管内肿瘤患者16例，男

13、10例，女6例；年龄33-68岁，平均44.7岁(表1)。硬膜外肿瘤2例(均为神经鞘瘤)，硬膜内髓外肿瘤13例(神经鞘瘤7例，脊膜瘤3例，脂肪瘤2例，神经纤维瘤1例)，髓内肿瘤1例(室管膜瘤)。肿瘤位于延髓C1 3例，C1，2 8例，C2水平2例，C1-3 2例，C2，3 l例；其中4例肿瘤位于颈髓腹侧。Between January 2003 and June 2008，16 patients(10 males and 6 females，average age 44.7 years, range 33-68 years) with canal tumor of the upper cerv

14、ical spine were treated by posterior laminectomy, fixation screw rod system and graft with autogenous iliac crest (table 1), including epidural neoplasms in 2 cases (Schwannoma)，intradural extramedullary tumors in 13 cases(Schwannoma in 7 cases, meningioma in 3 cases; lipoma in 2 cases; neurofibroma

15、 in 1 case)and intramedullary tumor in l case(ependymoma)The tumors were located between medulla oblongata and C1 in 3 eases，C1-2 in 8，C2 in 2，Cl-3 in 2，C2-3 in l；4 cases were located at ventralis of cervical cordTable 1 16 patients generally data and resultsCaseAge(y)GenderEtipathologyTumor located

16、Following-up time(Mo)Frankel gradingJOA gradingimprovement ratePreo6 Mo postoPreo6 Mo posto146FSchwannomaC28DE81688.9239MSchwannomaC1,226DD81577.8368FSchwannomaC1-312DE717100.0446MSchwannomamedulla oblongata to C118CD71580.0533MSchwannomaC1,26DE1117100.0648FSchwannomaC1,258CD61581.8741MSchwannomaC1,

17、226DD141666.7834MSchwannomaC1,235CD61472.7936MSchwannomamedulla oblongata to C19DE1017100.01052FMeningiomaC1,218DE1017100.01147FMeningiomaC1,244DE917100.01244MMeningiomaC1,217DE917100.01337MLipomaC225EE1717-1449MLipomaC1-349CD61472.71540MNeurofibromaC2,321DD81688.91655MEpendymomamedulla oblongata to

18、 C127CD71681.8Average44.724.98.81688.1JOA Improvement rate (%) = ×100Case 13 was asymptomatic preoperative and postoperative and no evaluate the improvement rate.二、病程及临床表现2. The history and clinical manifestation本组患者9例病程为10个月4年，7例为6一10个月。除l例患者因肿瘤较小而无神经受损及脊髓压迫症状外，余15例患者均表现为不同程度的颈部疼痛、头部旋转活动受限、上肢酸

19、痛麻木，其中7例存在神经根受压症状，表现为一侧上肢麻木、肩臂放射性疼痛、肌力45级，2例双上肢肌力约3级，5例伴胸部束带感及下肢酸痛麻木，有踩棉花感；1例伴双下肢无力，行走困难。根据JOA 17分法评分1，术前6-17分，平均8.8分。按Frankel分级2：C级5例，D级10例，E级1例。肱二头肌反射、肱三头肌反射活跃6例，膝、跟腱反射活跃7例，髌、踝阵挛阳性7例，12例Hoffmann征阳性，Babinski征阳性。15例CT或MR检查提示肿瘤组织压迫脊髓。In the study, 9 cases of patients with course for 10 months to 4 ye

20、ars, 7 cases 6 to 10 months. In one case, the tumor was smaller and without Symptoms of nerve injury and spinal cord compression. The other 15 patients had various degrees of neck pain, neck rotate limited, upper extremities aching pain and anaesthesia, and 7 of them had nerve root compression sympt

21、oms such as one side of upper extremity anaesthesia, shoulder and arm radiated pain, muscle strength 4-5/5; 2 cases muscle strength was 3/5; 5 cases together with chest band lower extremities aching pain and anaesthesia and has a sense of Step on Cotton; 1 case together with both lower extremities a

22、dynamia and dys-walks. According to the JOA grading system1, the preoperative average score was 8.8(range from 6 to 17). According to the Frankel grading system2，there was 5 cases with Frankel C, l0 with D and 1 with E6 cases biceps jerk and triceps reflex activity, 7 cases quadriceps reflex and ach

23、illes jerk activity, 7 cases trepidation sign and ankle-clonus positive, 12 cases Hoffmann sign and Babinski sign positive. Spinal cord was pressed by tissue of tumor in Fifteen patients which were diagnosed by MRI and computerized tomographic(CT)scans三、辅助检查3. The auxiliary examination (一)X线及CT扫描：16

24、例均行颈椎正、侧位X线检查及CT扫描，6例表现为椎弓根变形，椎弓根间距增宽，3例见椎间孔扩大，2例椎体后部有弧形压迹改变，椎体骨质吸收(图1)。a. X-rays and CT scans. 16 cases were performed cervical anteroposterior, lateral x-rays and CT scans. 6 of them with pediculus arcus vertebrae deformation, interpedicular distance widen; 3 cases intervertebral foramina dilatati

25、on, posterior centrum comma impression and vertebral bone absorption could found in 2 cases.Figure 1 Female, 68 years. CT scans showed the left margin of C2 vertebral has tumor notch, sclerotin oppressed and absorbed, osseous canal broaden.(二)MR检查：16例均行MR检查，3例表现为哑铃形肿块，在T1WI呈等信号，在T2WI呈高信号，伴一侧椎间孔扩大。9例

26、神经鞘瘤、3例脊膜瘤及2例脂肪瘤示椎管硬膜内及脊髓外圆形或椭圆形占位，边界清晰，T1WI呈等信号，T2WI呈高信号，部分病灶T2WI呈低信号(病灶出血)，信号均匀或不均匀改变，上颈髓受压移位，3例延髓C1水平患者均无延髓受压。1例(例16)室管膜瘤增强MRI显示信号增强，轮廓尚清晰。1例(例15)神经纤维瘤T1WI呈等信号，T2WI呈不均匀高信号，边界稍模糊。b. MR examination. All 16 cases performed MR examination, 3 cases with dumbbell shaped mass, isointensity in T1WI signa

27、l, high-intensity in T2WI and one side of intervertebral foramina dilatation. 14 cases(Schwannoma in 9 cases, meningioma in 3 cases; lipoma in 2 cases) showed intradural extramedullary has round or oval occupied and bouncary were clear, isointensity in T1WI signal, high-intensity in T2WI, some of th

28、e lesions which with bleeding had uniformity or uneven low-intensity in T2WI, the upper cervical spine compressed and displaced. 3 cases whos tumors were located between medulla oblongata and C1 without medulla compression. Enhanced MRI showed signal enhancement and circumsciption clear in 1 case (c

29、ase 16) which with ependymoma. 1 case (case 15) with neurofibromatosis had isointensity in T1WI signal, uneven high-intensity in T2WI and bouncary was obfuscation.四、手术方法4. Surgical(一)术前准备A Preoperative preparation1手术前的影像学检查，特别是MR检查对于确定肿瘤组织的范围、椎动脉的走行、椎动脉是否迂曲受压、肿瘤组织与脊髓神经的关系等非常重要。a. Preoperative imagin

30、g examination especially MR imaging examination is very important to determine the circumsciption of tumors, the tendency of vertebral artery, whether the vertebral artery circuitous and compression or not and the relationship of the tumor and spinal nerves.2术前准备大剂量的甲基泼尼松龙，待术中切除肿瘤时，应用冲击疗法，以保护脊髓，减少炎症

31、反应3，同时静滴抑制胃酸药物，以防应激性溃疡。b. Preparation high-dose methyllprednisolone preoperative and stosstherapy when resection the tumor to protect the spinal cord and reduce inflammation 3, and intravenous drip infusion acid-inhibitory drugs to avoid stress ulcer at the same time.3术前右侧股静脉穿刺，在透视引导下将心脏临时起搏器导线置入右心室

32、，接心脏起搏器，预防术中及术后的心脏骤停。c. Right femoral venous puncture preoperative and isertion temporary cardiac pacemakers guideline into right ventricular with fluoroscopy guided to prevent cardiac arrest intraoperative and postoperative.(二)手术过程B. Operations全麻气管内插管，俯卧位，“U”形枕垫起胸腹部，头部置于头架上。经后正中入路切开皮肤及皮下组织，充分显露枕骨后侧

33、及寰枢椎棘突、椎板和小关节突。因肿瘤切除后，寰枢椎后方结构缺如，故先置入椎弓根螺钉，并于远离肿瘤一侧置人棒并旋紧，维持上颈椎稳定。切除椎板显露肿瘤，切除的椎板以能显露肿瘤上下极为界，尽量行假膜外切除肿瘤；除2例硬膜外肿瘤无须切开硬膜外，14例硬膜内肿瘤均切开硬脊膜，切开硬脊膜，以细丝线将硬脊膜悬吊于四周，沿脊髓外侧并分离蛛网膜显露脊髓和神经根。充分暴露肿瘤，一手用神经剥离子轻轻抵住肿瘤，另一手用另一神经剥离子分离脊髓与肿瘤的界面，沿肿瘤的上下极分离切除肿瘤。位于腹侧的肿瘤，可用丝线先将肿瘤固定，然后小心剥离，尽量向肿瘤一侧轻轻提起，分离时尽量将神经剥离子稳定脊髓侧，避免过度牵拉脊髓，另一侧置入

34、棒并旋紧螺钉。最后取大块髂骨植骨。General anaesthesia by intratracheal insufflation, prone posture, and “U" shaped pillow underlay the chest and abdomen and the head keep in spindle stock. Incise skin and hypodermis by posteromedian approach, revealed the posterior aspect of the occipital, acanthi of the atlant

35、oaxial, vertabral lamina and facets. Because rear structure of atlantoaxial vertebral absence after tumor resection, so we inserted the pedicle screws and the bar away from the tumor and tighten the bar first to maintain the upper cervical stability. Laminectomy to reveal the upper pole and perineum

36、 of the tumor and removed the tumor within false memebrane as possible as we can. Except two cases who suffered by epidural neoplasms without incise the meninx fibrosa. 14 cases who suffered by intradural neoplasms incise the meninx fibrosa. Hang on the meninx fibrasa with silk after incise it. Disa

37、ssociate arachnoid outsid spinal cord to expose spinal cord and nerve root. A nerve dissector resists the tumor; the other one disassociates tumor and spinal cord and resects the tumor. If the tumor located at ventralis of cervical cord, fix the tumor by silk first and then disassociate the tumor. S

38、table the spinal cord as far as possible when disassociate and avoid over-stretching the spinal cord. Insert the other bar and tight the screw. Finally, autogeneous iliac bone grafting.五、术后处理5. Postoperative treatment术后床边常规准备气管切开包及呼吸机。复查血气分析、血常规、电解质，以防内环境紊乱。术后常规激素治疗：术后第1天给予静脉滴注地塞米松10mg，2次；第2天5 mg，2次

39、；第3天5 mg，1次；第4天停药4。同时应用抗生素、神经营养剂、脱水剂。术后9-12 d，可在颈围保护下下床活动。卧床3周，颈托保护36个月。常规行放射学检查明确内固定位置及植骨融合情况。根据患者的肿瘤病理类型选择化疗或放疗。Postoperative, prepared tracheotomy instruments set and breathing machine routinely. Reexamined blood gas analysis, routine blood test and electrolysis to prevent internal environment di

40、sorder. Therapy with hormone regularly: intravenous drip dexamethasone 10mg twice in the first day after surgery, 5mg twice in the second day, 5mg once in the third day, stop in the forth day4. Intravenous drip antibiotics, nerve nutritional agent and dehydrater at the same time. 9-12 days after sur

41、gery, the patient cans out-of-bed activity with neck collar. Bed ridden 3 weeks and protect by neck collar 3- 6 months. Radiological examination to identify fixation position and bone fusion status. Choose chemotherapy or radiotherapy according to the pathological of tumor.结果Results本组16例患者，除l例(例14)肿

42、瘤较大位于颈髓腹侧和椎间孔行次全切除外，其余肿瘤均全部切除。手术时间165280 min，平均218.7 min。术中出血8002300 ml，平均1324.4 ml。15 patients tumor performed total excision, 1 case (case 14) which tumor was located at ventralis of cervical cord and intervertebral foramina performed subtotal ectomy. Average operative time was 218.7min (range fro

43、m 165 to 280min). Average intraoperative hemorrhage was 1324.4ml (range from 800 to 2300ml). 术后所有病例均未出现与内固定有关的神经脊髓损伤和脑脊液漏等并发症。无一例发生切口感染及出现眩晕、颈痛、头痛等颈椎不稳的表现。术后3周左右脊髓功能恢复至最终水平，枕颈部疼痛或眩晕较术前减轻，甚至恢复正常，四肢麻木感一般较术前好转，但持续时间较长。Postoperative all cases had not complications which related with internal fixation su

44、ch as spinal cord injury and leakage of cerebrospinal fluid. No wound infection and cervical instability symptoms such as giddiness, neck pain and headache. About 3 weeks after surgery, the spinal functional recoveries come to the final level. Compare with the preoperative, neck pain or giddiness le

45、ssen even became normal, limbs anesthesia reduced generality but last a longer time.全部患者均获得随访，随访时间6-58个月，平均24.9个月。术后X线片和CT扫描显示植骨融合良好，颈脊髓、神经根压迫均解除。骨性融合时间35个月，平均36个月；无一例发生内固定松动、移位和断裂(图2)。脊髓神经功能均有不同程度恢复，术后6个月JOA评分14-17分，平均16分，平均改善率881。根据Frankel分级，7例由术前的D级恢复至E级，5例由术前的C级恢复至D级，3例术前D级及l例术前E级的患者术后未改变(表1)。l例

46、(例3)硬膜外肿瘤累及C2椎体左后方，因肿瘤与C2神经根粘连，将C2神经根一侧切断后摘除肿瘤，术后患者未出现任何明显不适。本组5例患者至末次随访时躯干或四肢仍存在麻木感。1例(例7)神经鞘瘤患者于术后24个月复发，再次行手术切除。本组无一例死亡病例。All patients follow-up 6-58 months(mean 27.9 months)Postoperative X-ray and CT scan showed bone grafts were good fusion; cervical spinal cord and nerve root compression were r

47、elieved. The solid fusion time was about 3-5 months (mean 3.6months). There were no fixation loosening, displace and disrupt (figure 2). Spinal nerves function recovered in various degrees. According to the JOA grading system，at 6 months postoperatively, the average score was 16(range from 14 to 17)

48、 and the average improvement rate was 88.1According to the Frankel grading system，7 cases improved from D to E，5 from C to D，but none in 3 cases with Frankel D and l with E(table 1)1 epidural neoplasm (case 13) involved left-back part of the C2 centrum and the tumor was adhering to the C2 nerve root

49、. The nerve root has been cut off when removed the tumor and patient didnt suffer any discomfortable postoperative. 5 cases has trunk and limbs anesthesia at last follow-up.1 patient (case 7) who suffer from schwannoma recurrent in 24 months after resection and exairesis one more time. No deaths in

50、our study. Figure 2, female, 52 years, a,b Preoperative sagittal and coronal MRI showing the tumor is located in front of the spinal cord; deflected to the left, spinal cord compressed and displaced to the right side. c Postoperative MRI showed it decompressed to the C3 vertebral level, spinal cord

51、compression has been completely lifted. d 18 months postoperative, cervical spine radiogram showed implanted bone fusion and internal fixation no loosening, displacement and disruption. e,f 18 months postoperative the patient can fasten button and use chopsticks.讨论Discussion上颈椎椎管内肿瘤好发于为青壮年，肿瘤一般巨大。本组

52、患者平均年龄为44.7岁，16例患者中12例肿瘤至少跨过两个节段。大多数患者病程较长，本组l例(例14)病程长达4年。Chevrot等5认为，局部肿瘤是颈部疼痛的可能原因之一，应对此类患者行影像学检查，CT及MRI能提供更多的信息。我们认为，对怀疑上颈椎椎管内肿瘤的患者，应及早进行相应检查。上颈椎椎管内肿瘤的典型X线表现为椎间孔扩大，椎弓间距增宽等，但这些特征出现的比例不高6。CT、MR检查能清晰显示肿瘤侵犯的部位、范围及椎管的完整性、与脊髓的关系、脊髓的受压程度及椎旁软组织的侵及范围，诊断正确率较高7；特别是MR检查，可清晰显示肿瘤与周围结构尤其是椎动脉被压迫、移位等情况8。Canal tu

53、mors of the upper cervical spine often occur in teenager and the tumor size is huge. In our study, the average age was 44.7 years, and the tumor across two section at least in 12/16 cases. Most of the patients had a long history, 1 case (case 14) in our study was 4 years. Chevrot etc. 5 consider tha

54、t local tumor is one of the possible reasons of neck pain, so the patients who have neck pain should perform imaging examination, CT and MRI imaging can provide more information. In our opinion, the patients who suspect suffer from canal tumors of the upper cervical spine should perform correspondin

55、g check early. The typical characters of the canal tumors of the upper cervical spine in X-rays were intervertebral foramina dilatation, the distance of vertebral arch broaden and so on, but the frequency of those characters occurrences was low6. CT and MRI scan can display the location and extent o

56、f the tumor, completeness of the canal, the relationship of the tumor and spinal cord, the degree of compressed spinal cord and the extent encroach on paravertebral soft tissue, and the diagnostic accuracy is higher 7. Particularly, MR examination can show the relationship between the tumor and surr

57、ounding structure, especially the vertebral artery oppressed, displacement 8.一、手术入路的选择1. Operation approach治疗位于脊髓腹侧的上颈椎椎管内肿瘤的手术入路存在争议。由于肿瘤位于上颈椎脊髓腹侧，所以术中可能影响呼吸和心跳的机能，甚至危及生命。有学者采用前方入路，行前方椎体次全切进入椎管后再行肿瘤切除。肖建如等6认为，切除位于上颈椎腹侧的肿瘤时，可选择后侧人路；切断偏肿瘤一侧的脊神经后根9，在背外侧分离瘤体，挂线牵引方法将肿瘤切除。Acosta等10采用后侧旁正中经椎弓根入路，游离椎动脉及神经根

58、，亦可安全切除位于脊髓腹侧的肿瘤。我们认为，只要掌握颈椎解剖特点、术前明确肿瘤大小以及肿瘤与脊髓关系、术中仔细操作，后方入路行上颈椎椎管内肿瘤切除一般不会发生严重脊髓干扰，可完全切除大多数肿瘤。Operative approach of canal tumors of the upper cervical spine which located at ventralis of cervical cord is controversial. Because the tumors located at ventralis of cervical cord, so the breathing and heartbeat function may be affec