小脑延髓裂入路在第四脑室和脑干背侧肿瘤手术中的临床应用

摘要

目的 探讨枕下后正中-经小脑延髓裂入路显微手术切除第四脑室和脑干背侧肿瘤的手术方法、手术技巧,及其疗效.方法 回顾性分析2006年1月~2015年12月采用小脑延髓裂入路手术治疗的106例第四脑室和脑干背侧肿瘤患者的临床资料.其中83例患者采用双侧小脑延髓裂入路,23例明显偏侧的第四脑室区、脑干肿瘤或小型肿瘤患者经单侧小脑延髓裂入路.结果 肿瘤全切除者97例,次全切除者9例;全切除率达91.5%,次全切除率8.5%.术后并发脑积水1例,经脑室-腹腔分流术后治愈;无症状性颅内积气13例,皮下积液2例,吞咽障碍、一过性复视、短暂性消化道出血和呼吸障碍各1例,均经保守治疗后痊愈.术后无出现共济失调、平衡障碍和小脑性缄默综合征、脑脊液漏、颅内出血和感染等并发症,无死亡病例.结论 经小脑延髓裂入路显微手术切除第四脑室和脑干背侧的肿瘤是一种微创、安全、有效,且显露充分、方便实用的手术方法.熟练的显微外科技术有助于提高手术的疗效.%Objective To explore the microsurgical method and the surgical technique of a trans cerebellomedullary fissure approach to resect the tumor located in the fourth ventricle and the dorsal brainstem , in order to improve the operative effect .Methods The clinical data of 106 patients with tumors in the fourth ventricle and the dorsal brainstem underwent microsurgical resection by the trans cerebellomedullary fissure approach from January 2004 to December 2012 , were analyzed retrospectively .There were 83 cases in a bilateral approach and 23 in a unilateral approach.Results Of 106 cases,tumor total resection was achieved in 97 and subtotal resection in 9 .Total and subtotal resection rate was 91 .5% and 8 .5% respectively .One case suffered from postoperative symptomatic hydrocephalus cured by ventricle-abdomen ventricular peritoneum shunt , 2 with suboccipital hydrops ,13 with asymptomatic intracranial pneumatocele ,1 with transient upper gastrointestinal hemorrhage ,1 with respiration disorders recovered well by mechanical ventilation , and 1 with transient diplopia , all patients are recovery well at discharge .No patient died and no approach complications , such as ataxia , cerebellar mutism , leakage of cerebrospinal fluid , cranial hemorrhage and infection .Conclusions The transcerebellomedullary fissure approach provided a minimal,safe and effective surgical exposure ,sufficient,convenient and practical operative approach to fourth ventricle and dorsolateral region of pons and medulla through normal anatomic spaces with facility without splitting the vermis .Therapeutic effect could be improved by consummate microsurgical techniques .