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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C1/26例,C2/34例,C3/43例,C4/53例,C5/62例,C6/71例,C1/2伴C2/31例,C4/5伴C5/61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,Ⅱa型4例,Ⅱb型2例,Ⅱc型1例,Ⅲa型10例,Ⅲb型2例,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间孔的Ⅰ型和Ⅱa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Ⅱc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一过性瘫痪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。
Objective: To investigate the clinical features, Toyama classification and surgical treatment strategy of dumbbell tumors in and outside the cervical canal. Methods: Twenty-one patients with cervical dumbbell-shaped tumors treated in our hospital from January 2004 to January 2008 were retrospectively analyzed. The tumor segments were located in C1 / 26 cases, C2 / 34 cases, C3 / 43 cases, C4 / 53 cases, C5 / 62 cases, C6 / 71 cases, C1 / 2 with C2 / 31 cases, C4 / 5 with C5 / 61 cases. Schwannoma in 14 cases, 4 cases of neurofibroma, multiple neurofibromatosis in 2 cases, 1 case of malignant schwannoma. According to the Toyama method, there were 1 type Ⅰ, 4 type Ⅱa, 2 type Ⅱ b, 1 type Ⅱc, 10 type Ⅲa, 2 type Ⅲ b and 1 type Ⅴ. 2 cases; TF staging stage Ⅰ 19 cases, Ⅱ period 2 cases. Preoperative JOA score 4 to 15 points, an average of 8.7 points; ASIA grade B grade in 1 case, C grade in 5 cases, D grade in 11 cases, E grade in 4 cases. 15 cases of tumors mainly located in the posterior and spinal canal and not more than forward foraminoplasty type Ⅰ and Ⅱ a, V-type and almost all type Ⅲ a tumor selected posterior surgery; early in 1 cases of type C1 / 2 Ⅲ a tumor Atlantoaxial lateral approach; 4 cases of invasion of the spinal canal and the presence of lumps in front of the neck of Ⅱ b and Ⅲ b type anterior and posterior joint surgery; on a tumor located in front of the cervical type Ⅱ c tumor selection simple front Into the road. One case of type IIIb and three cases of stage II of TF or IF staged reconstruction due to more bone removal. Three cases were fixed on one side and one case was fixed on both sides. Postoperative JOA score and ASIA impairment rating of neurological function. Results: All the operations were successfully completed. All the tumors were completely resected, no vertebral artery injury and no neurological dysfunction. Patients with local pain and neurological symptoms were significantly improved or alleviated, immediately after the unilateral upper limb paralysis occurred in 1 case, hormone and dehydration after 3 days of treatment to ease; one case of cerebrospinal fluid leakage, closed after conservative treatment; postoperative cranial 1 case of internal infection, sustained by the lumbar drainage and anti-infective therapy cured; no cervical deformity. Follow-up 6 months to 4 years, an average of 23 months. All patients had different degrees of nerve function recovery, of which 14 patients with complete recovery of nerve function. Six months after operation, JOA score ranged from 10 to 17, with an average of 13.2 points. There were 1 case of ASIA grade C, 2 cases of grade D and 18 cases of grade E. One case of type IIIa patients had local recurrence of the external foramen partially at 1 year after posterior surgery, and no other cases had local recurrence. Conclusion: The classification of Toyama is more perfect, which has great guiding significance for the choice of surgical approach and approach, which helps to improve the tumor resection rate and reduce the local recurrence rate.