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Xiao Jianru Yang Xinghai Chen Huajiang Yang Cheng Ma Junming Wei Haifeng Yang Lili Shi Jiangang Zhao Bizeng Liu Tielong Yan Wangjun Li Yusong Yuan Wen Jia Lianshun Reconstruction Technology. Methods A retrospective analysis was performed on 37 patients with internal and external dumbbell tumors treated from January 1999 to December 2005. Age 1840 years old, average 39 years old; 18 males and 19 females. Tumor properties: 25 cases of schwannomas, 3 cases of neurofibromas, 5 cases of multiple neurofibromas, and 4 cases of malignant schwannomas. According to the scope and area of ​​tumor invasion, the surgical staging system was designed on its own: 8 cases in stage I, 9 cases in period, 13 cases in stage I, 5 cases in W stage, and 2 cases in V stage. Twenty patients underwent tumor resection through the posterolateral approach of the neck, and 17 patients underwent anterior and posterior approach (postolateral and anterolateral) tumor resection. Twenty-six patients were reconstructed with a posterior screw/plate internal fixation system. Joint fixation, 6 cases were not internal fixation. The results were followed up for 3 months and 7 years, with an average of 39 months. Unilateral upper extremity muscle weakness decreased in 1 case, unilateral numbness in the back of the neck, 1 case in Horner's sign, 1 case of vertebral artery ligation during one-sided vertebral artery injury, and 2 cases of malignancy. Schwannoma was treated surgically for local recurrence 14 years after surgery. The majority of patients had satisfactory postoperative results, and local pain and neurological symptoms improved or relieved. Nineteen patients had complete recovery of spinal nerve function. Two patients without internal fixation had different degrees of cervical flexion deformity at 14 years after surgery. Conclusion According to the location, nature and surgical staging of the tumor, the surgical treatment strategy can significantly improve the rate of tumor resection, reduce the local recurrence rate and the incidence of surgical complications. The fixation of internal fixation is of great value in maintaining the stability of the neck. The relationship between the tumor and the nerve root, vertebral artery and cervical cord should be accurately judged during surgery and protection should be taken care of. Cervical and external cervical tumors are special types of cervical spinal canal tumors. Compared with simple cervical spinal canal tumors, they are difficult and risky to operate. The residual tumors and local recurrence rate are high after surgery. They are considered to be difficult problems for spinal surgery and neurosurgery. Although there are a few case reports in China, analysis and surgical staging of a group of dumbbells inside and outside the cervical canal has not been reported. From January 1999 to December 2005, 37 cases of patients with dumbbells in the cervical spinal canal were treated and treated. The surgical staging, surgical methods and efficacy were reported. Materials and methods 18 cases, 19 females. Tumor sites: Ci, 29 cases, C2, 35 cases, C3, 44 cases, C457 cases, C5, 68 cases, C6, 72 cases, C1, 2 cases with C451, Cl, 2 with C5" 1 case. Tumor properties: 25 cases of schwannomas, 3 cases of neurofibromas, 5 cases of multiple neurofibromas, and 4 cases of malignant schwannomas. We divided the spine into six anatomical regions: (1) Intraspinal region; (2) Pedicle and intervertebral foramen; (3) Lamina and spinous process; (4) Vertebral body area; ) Posterior lateral area of ​​the foramen; (6) Front and outer area of ​​the foramen exit. Any tumor originating in the spinal canal is located in these areas (). Divided into the scope of a tumor: Phase I: The tumor is confined to the spinal canal and intervertebral foramen (1+2 area); Period: The tumor invades the lamina posteriorly or protrudes into the lamina space (1+2+3) Area) or across the posterolateral lamina (1+2+3+5 area); Stage I: The tumor penetrates the intervertebral foramen and expands to the paravertebral soft tissue area (1+2+6 area); Stage IV: lesions involving the vertebrae Body (1+2+4 zone); V phase: Lesions involve two or more intervertebral foramen. The group I 8 cases, 9 cases, 13 cases of I, V 5 cases, V 2 cases (). The division of the cervical anatomical region III. Clinical manifestations 5 cases of pure occipital neck pain or discomfort only, 1 case of sudden vertigo, 13 cases of unilateral upper limb numbness or pain, 3 cases of numbness or pain in the upper extremities, 7 Unilateral limb numbness or fatigue occurred in 9 cases, and numbness or weakness occurred in 9 cases. Ipsilateral limb muscle strength in 2 cases in 6 cases, 3, 14 cases, 5 - 5 cases, 5 cases in 12 cases. Unilateral or bilateral Hoffmann sign was positive in 10 patients, upper extremity reflex was hyperactive or hyperactive in 11 patients, chest banding was felt in 5 patients, and sphincter dysfunction was found in 3 patients. Fourth, surgical approach and methods (A) cervical posterior lateral approach: take posterior occipitocervical or posterior cervical posterior incision, conventional incision revealed posterior arch, axial spinous process, lamina and its lateral mass. According to the location of the involved spinal canal and intervertebral foramen, bite the corresponding segmental lamina and the affected lateral mass, fully expose the dural sac and the ipsilateral nerve root, cut the dura longitudinally and follow the direction of the nerve root. Open nerve sheath membrane, dumbbell-shaped tumor can be seen. 2.5 times under the surgical magnifier carefully stripped of the tumor, bipolar electrocoagulation to stop bleeding, pay attention to protect the cervical and cervical nerve roots, according to the size of the tumor and the adhesion with the surrounding tissue using block-by-block or block resection method, in the separation of vertebrae The vertebral artery and vertebral vein should be protected when the tumor is located on the medial side wall and at the outlet. After the tumor is resected, the dura mater is sutured. The residual cavity of the intervertebral foramen can be sprayed with hemostatic glue and covered with artificial dura mater to prevent cerebrospinal fluid leakage. In this group, 5 cases of epidural tumors located in the cervical spinal canal were directly detached from the epidural space without cutting the dura. After tumor resection, bone grafting and posterior occipitocervical fixation were performed in 4 patients with C1,2 tumors, and adjacent vertebral pedicles and lateral blocks Cervifix/AXIS/SUM-MT/Vertax were performed in 27 patients. Internal fixation was performed in 6 patients without internal fixation. This group of 17 patients with stage I, stage 2 and stage 2 patients completed the tumor resection using the above approach (). (B) Cervical combined anterior and posterior approach: after the completion of the cervical anterolateral approach by resection and reconstruction of the spinal canal and intervertebral foramen, the lateral anterolateral approach of the ipsilateral cervical foramen invades and invades the surrounding soft tissue. Tumor resection. For CU, G, and 3 extracanal outlet tumors, take the medial margin of the lateral sternocleidomastoid muscle incision C3, 4 and the tumor below the exit of the segmental intervertebral foramen to remove the cervical sternocleidomastoid Muscle medial edge oblique incision, avoid common carotid artery, internal jugular vein, to avoid damage to the cervical plexus and brachial plexus, cut off the corresponding segment of the longissimus dorsi, revealed the tumor and enlarged intervertebral foramen exit, careful stripping of the tumor along the capsule Body and to be removed to protect the vertebral artery. In this group, 11 patients with stage I and 2 patients with V stage were treated with this procedure. For the fourth stage IV patients who invaded the vertebral body and caused vertebral collapse, destruction, and instability of the spine, we performed a lesion vertebral body resection, a titanium mesh graft plus Orion (or Zephir, Codman) based on the above method. Plate fixation (). Routinely preventing infections, 3 of 4 patients with malignant schwannomas received local radiotherapy at 46 weeks postoperatively. The results were followed up for 3 months and 7 years, with an average of 39 months. One patient experienced transient unilateral upper limb weakness, one patient experienced unilateral numbness of the neck, one had Horner's sign, and one patient had vertebral artery ligation during one-sided vertebral artery injury. 2 Cases of cerebrospinal fluid leakage occurred, and 2 cases of malignant schwannoma underwent surgical treatment again due to local recurrence 14 years after surgery. The majority of patients had satisfactory postoperative effects, and local pain and neurological symptoms all had improvement or remission in different degrees. Twenty patients had complete recovery of spinal nerve function. Two patients who had not undergone internal fixation had different levels of cervical vertebrae at 14 years after surgery. Qu deformed. Dumbbell tumors inside and outside the cervical canal are mainly neurogenic tumors. They grow along the nerve root sheath or nerve root fibers of the interforaminal space. Most of them are benign schwannoma or neurofibromas. Only a few are low-grade schwannomas. The clinical features and tumor spectrum are different from those of spinal tumors; their early clinical symptoms are not obvious, and most of them are neck pain or discomfort. Because the tumor easily leads to compression or destruction of the cervical spinal cord, nerve roots, and blood vessels, it is potentially very harmful and has a high morbidity and mortality rate. According to the origin and nature of the tumor, it is often divided into primary benign schwannomas, neurofibromas, multiple neurofibromas, and malignant schwannomas and neurofibrosarcomas. However, due to the relatively complex anatomical structures of dumbbell-shaped tumors inside and outside the cervical canal, most of the tumors grow expansively or invasively along the intervertebral foramen. The blood supply is abundant, and it involves the nerve roots and accompanying roots in the intervertebral foramen. Arteries, root venous plexuses, and adjacent vertebral arteries, veins, etc., are easily bleed locally. The operative field and lesions are unclear. As a result, most doctors are limited to resection of intraspinal tumors or partial removal of tumors in the intervertebral foramen. Often with tumor survival, easy to relapse or accelerate tumor tissue growth. Therefore, it is difficult and risky to completely remove the tumor under the naked eye, and it requires the surgeon's precise surgical skills and experience. Because of the particularity of the cervical spinal canal and its adjacent anatomical structures, dumbbell-shaped tumors are rare, and only a few cases have been reported in China. Surgical approaches and resections of cervical and intraspinal tumors are divergent. Foreign scholars have tried to establish staging methods for internal and external tumors of the cervical spinal canal to guide surgical treatment strategies. The spine dumbbell-shaped tumor classification method proposed by Eden in 1958 was popular for a time. With the gradual deepening of the understanding of this tumor and the advancement of surgical techniques, Takashi et al. proposed the method of classification according to the anatomical position and shape of the tumor in 2004. However, this classification method is cumbersome, and it is not practical to guide the development of surgical treatment strategies. . The development of imaging, especially MRI for clinical examination, makes spine surgeons more comprehensive and profound understanding of the tumors inside and outside the cervical canal, and also provides an opportunity for the development of a more reasonable method of preoperative surgical staging. According to the MRI performance of various dumbbells inside and outside the cervical canal, combined with the experience of surgery, we proposed its surgical staging system in order to standardize the surgical approach and improve the tumor resection rate. First, the clinical significance of surgical staging (a) surgical staging and surgical approach, the choice of resection 1. I: due to dumbbell-shaped tumor is limited to the spinal canal and a foramen, the choice of transaxial cervical surgery After completion of the tumor resection, the dural sac and ipsilateral nerve root should be fully revealed during the operation. The excision and removal of the tumor should be performed under a 2.5x surgical magnifier to protect the cervical spinal cord and cervical nerve roots. Care should be taken to protect the vertebral arteries and vertebral veins when operating adjacent to the internal wall of the foramen and the outlet. 2. Period: The tumor invades into the intervertebral foramen, and involves the lamina, lamina space and posterolateral soft tissue. It is a common type of tumor inside and outside the Cu spinal canal. The tumor can be removed through the posterolateral cervical approach. Due to the involvement of the lamina and its interspaces, care should be taken when the ipsilateral lamina and the lateral masses are exposed, so that the instrument does not protrude into the damaged lamina or the enlarged intervertebral space causes cervical spinal cord injury. 3. Phase I: The tumor penetrates the intervertebral foramen and expands to the anterolateral paravertebral soft tissue area. The cervical anterior or posterior approach or the posterolateral approach can be used to complete the tumor resection. Intraoperative posterior lateral approach to remove the tumor, bite off the ipsilateral vertebral plate and lateral mass, longitudinally cut the dura mater, incised the sheath along the direction of the nerve root, exposed the dumbbell-shaped tumor body, in 2.5 times surgical loupes Peel off and remove. The tumor penetrates the intervertebral foramen, and is adjacent to or around the vertebral artery and vein. Attention should be paid to the identification and protection of the vertebral artery and vein. Some patients can complete the tumor resection through the posterolateral approach, no need for anterior surgery, if the posterolateral approach can not completely remove the tumor, the tumor stump suture or hemostatic gauze packing, in order to facilitate the anterolateral approach surgery Confirm that the tumor has been completely removed. After the ipsilateral cervical anterolateral approach, a tumor resection of the intervertebral foramen and the surrounding soft tissue was performed. Care should be taken to avoid injury to the carotid artery, internal jugular vein, cervical plexus, and brachial plexus. Stage IV: The tumor invades the intervertebral foramen and involves the vertebral body. The tumor can be removed by combining the anterior and posterior approaches. Due to the destruction of the vertebral body, after the resection and reconstruction of the spinal canal and the intervertebral foramen by the posterolateral approach of the cervical spine, the total corpectomy of the affected segment via the anterior cervical approach is performed. The surgical approach and the resection method are the same as the cervical vertebrae. Full vertebral body resection, surgery should pay attention to protect the vertebral artery, vein. 5. V period: dumbbell-shaped tumor involving two or more intervertebral foramen, according to the involvement of different segments of the I-IV phase of the method to select the appropriate surgical approach. If the tumor is confined to the intervertebral foramen or involves the lamina and its space, the tumor is removed through the posterolateral approach of the cervical spine in this segment; if the tumor penetrates the intervertebral foramen and expands to the paravertebral soft tissue area or vertebral body Involvement, then in this segment choose the joint approach before and after complete tumor resection. (II) Surgical staging and reconstructive strategy Patients with stage I4 patients undergoing a posterolateral approach through the cervical spine to complete a tumor resection can choose to perform stability reconstruction of the ipsilateral or bilateral lateral mass screw internal fixation system according to the laminectomy and lateral block bite removal. The screws were implanted with bone fragments or bone cement around them, taking care to prevent the broken bones from falling into the spinal canal to cause secondary compression. Because the stability in the front was not affected, the patients with stage I had no need to reconstruct the stability of the posterior side after the tumor was removed via the anterolateral approach of the ipsilateral cervical foramen and the surrounding soft tissue. Patients with stage IV complete the tumor resection through the posterior lateral approach of the cervical spine. The same method is used for the I-I stage. After the total corpectomy through the anterior cervical approach, the anterior cervical locking plate and the titanium mesh graft (or bone) are used. Cement) to complete the stability reconstruction. In patients with stage V, after complete resection of the tumor through the posterolateral approach of the cervical spine, the ipsilateral or bilateral lateral mass screw internal fixation system was selected for stability reconstruction, and the anterior cervical plate and titanium mesh graft were selected according to the segment of vertebral involvement. Or bone cement) to rebuild the stability of the front. (1) Treatment of vertebral artery: Dumbbell-shaped tumors inside and outside the cervical canal are closely related to the vertebral artery. Special attention should be paid to the treatment of the vertebral artery. Especially for patients with stage I and stage V, if the relationship between the vertebral artery and the tumor lesion is not clear before surgery, routine vertebral artery MRA or DSA imaging should be performed to understand the relationship between the orientation of the vertebral artery and the lesion. For patients with tumor surrounding the vertebral artery, it is considered that the vertebral artery can be easily damaged during the resection of the tumor. During the operation, the initial segment of the vertebral artery should be exposed and rubber sheets should be reserved so that the vertebral artery injury can be blocked or ligated in time. (B) the treatment of cervical nerve root: As the dumbbell-shaped tumor inside and outside the spinal cord often from the cervical nerve root or along the cervical nerve root through the surgery is very easy to damage, preoperative should be through clinical symptoms, signs and imaging findings of nerve root In relation to the tumor, the tumor should be carefully discriminated and resected under 2.5x or 5x magnification during the operation to avoid the ganglion being mistaken for resection of the tumor resulting in sensory and motor dysfunction in the corresponding segment. For tumors invading the cervical roots, if the Cl, C2 nerve roots and lesion adhesion can not be separated, can be considered together with the removal of the cervical nerve root to completely remove the tumor, and the nerve root below C3 due to neck and upper limb movements Should avoid accidental injury as far as possible and it should not be removed. (C) treatment of dural defects: after removal of tumors inside and outside the cervical spinal canal, it will cause local dural defect, artificial dural or auto fascia repair should be used in time, combined with the use of bioprotein glue to avoid postoperative The occurrence of cerebrospinal fluid leakage. Third, the factors that affect the efficacy and prognosis of the tumor's nature, location and extent, thorough tumor resection and postoperative radiotherapy and chemotherapy convergence directly affect the efficacy and prognosis of surgery. In this group, except for 2 cases of malignant schwannoma who underwent surgical resection for local recurrence 14 years after surgery, the prognosis of the other patients was satisfactory. In tumors of the same nature, the prognosis in the period of training and V is poor, followed by stage I, and the prognosis of stage I and stage is better. For malignant neurogenic tumors, standard chemotherapy and radiotherapy should be given promptly after surgery to reduce the recurrence rate.
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Surgical staging and surgical strategy of dumbbells for cervical spinal canal
Surgical staging and surgical strategy of cervical spinal canal dumbbell tumors Date:2015-10-29 16:54