摘要目的 探讨经皮套管椎旁入路显微治疗腰椎椎管内肿瘤的疗效.方法 自2011年11月至2014年2月福建医科大学附属协和医院神经外科收治的21例腰椎椎管内肿瘤,其中神经鞘瘤19例,室管膜瘤2例,肿瘤纵向长径0.6～2.0 cm,术前影像检查未见肿瘤破坏关节突,腰椎无失稳.气管插管全麻后在神经电生理监测下采用经皮手术套管经椎旁入路显微切除椎管内肿瘤,分析手术时间、出血量和住院时间;记录术前1d和术后1、3、5d肌酸磷酸激酶(CPK-MM)水平;于术前1d和术后1、3、5d和6个月采用日本骨科学会(JOA)评分和疼痛视觉模拟量表(VAS)评估临床疗效;术后1周行腰椎CT三维重建;术前、术后1周、术后6个月腰椎MRI平扫加增强.结果 本组椎管内肿瘤均完全切除,无神经损伤和脑脊液漏等并发症,JOA评分及VAS评分较术前改善[(11.6±1.3)分比(23.3±1.3)分,P＜0.05];术后第1天CPK-MM升高,术后第5天下降至术前1d水平,差异无统计学意义[(140.2±10.5)IU/ml比(143.7±12.1)IU/ml,P＞0.05];随访6～28个月,MRI检查未见肿瘤残留及复发,CT三维重建示单侧椎板开窗范围,随访期间未见腰椎畸形和不稳.结论 经皮套管椎旁入路显微切除腰椎椎管内肿瘤,既能最大程度避免损伤椎旁肌肉、关节突、棘突和韧带,也能达到完全显露并切除椎管内肿瘤的目的,具有创伤小、恢复快、并发症少和腰椎稳定性好等特点.

abstractsObjective To evaluate the clinical outcomes and operative techniques of microsurgical resection of lumbar intraspinal tumors through paraspinal approach by percutaneous tubular retractor system.Methods A retrospective study was conducted to analyze 21 patients with lumbar intraspinal tumors between November 2011 and February 2014,including Schwannoma (n =19) and meningioma (n =2)without lumbar instability on preoperative images.The length of tumors was 0.6-2.0 cm.Tracheal intubation anesthesia was performed prior to microsurgery using percutaneous tubular retractor system through paraspinal approach.Operative duration,blood loss volume,postoperative wound pain duration and hospital stay were analyzed.Creatine phosphokinase (CPK-MM) level was recorded at 1 day preoperatively,1 day,3 days and 5 days postoperatively.The scores of Japanese Orthopedic Association (JOA) and visual analog scale (VAS) were analyzed at 1 day preoperatively,1,3,5 days and 6 months postoperatively to evaluate the function status of spinal cord.Computed tomography (CT) three-dimensional reconstruction of lumbar vertebrae was performed at 1 week postoperatively.Magnetic resonance imaging (MRI) plain scan and enhanced scan of lumbar vertebrae were conducted preoperatively,1 week and 6 months postoperatively.Results Complete removal of tumors was achieved in all patients without the injuries of spinal cord or nerve root.Postoperative scores of JOA and VAS improved versus preoperative ones (P ＜ 0.05).Level of CPK-MM increased 1 day postoperatively and declined to preoperative level at 5 days postoperatively.And the difference was not statistically significant (P ＜ 0.05).Neither residual tumor nor tumor recurrence was detected by MRI plain and enhanced scans.No postoperative spinal instability was identified by CT three-dimensional reconstruction.And no spinal deformity occurred during a follow-up period of 6-28 months.Conclusion Microsurgical resection of lumbar intraspinal tumors using percutaneous tubular retractor system through paraspinal approach minimizes the injuries of paraspinal muscles,facet joint,spinous process and ligaments.This technique offers the advantages of mini-invasiveness,shorter hospital stay,rapid recovery and preserved postoperative spinal stability.