收稿日期:2009-04-28;修回日期:2009-08-13作者简介:乔栎(1969-),男,兰州市人,硕士,主治医师,从事显微神经外科研究。通讯作者:张新定,男,硕士生导师,主任医师,教授。·论著·小脑延髓裂入路的临床应用评价乔栎1张新定23陈天立1郭小红1韩广21.甘肃省人民医院神经外科,甘肃兰州730000;2.兰州大学第二医院神经外科,甘肃兰州730030摘要:目的探索不同方式分离小脑延髓裂(CMF)切除小脑延髓裂区、桥脑及第四脑室周围病变的方法,并评价其临床应用结果。方法采用不同方法(广泛型、外侧壁型和外侧隐窝型),对小脑延髓裂区、四脑室周围及桥脑占位病变20例进行手术,术中评价病变显露及切除情况,术后评价近期临床预后及并发症。结果广泛型CMF切开11例,外侧壁型切开7例,外侧隐窝切开2例。显露良好者16例(80%),显露受限和显露困难者各2例(10%)。全切除10例(50%),次全切除6例(30%),部分切除4例(20%)。出院时GOS5分者12例(60%),4分者8例(40%)。结论广泛型切开可暴露从导水管下口至闩的病变,外侧壁型和外侧隐窝型切开可显露外侧隐窝区、小脑中脚及桥延部背外侧区病变。关键词:小脑延髓裂入路;临床应用EvaluationoftranscerebellomedullaryfissureapproachanditsclinicalapplicationQIAOLi,ZHANGXinding,CHENTianliGUOXiaohong,HANGuang.DepartmentofNeurosurgery,LanzhouUniversitySecondHospi2tal,Lanzhou730030,ChinaAbstract:ObjectiveToexploredifferenttypesoftrans2CMFapproachesinremovingthelesionslocatedinthecerebellomedullaryfis2sure(CMF),ponsandthefourthventricle,andevaluatetheclinicaloutcomeoftheirapplication.MethodsThedifferenttypesoftrans2CMFapproach(extensivetype,lateralwalltype,lateralrecesstype)wereadoptinremovingthelesionslocatedintheCMF、fourthventricle、dorsolateraltotheponsandmedullain20patients.Thedegreeofresectionandthesufficiencyofexposurewerecom2paredduringtheoperation.Inaddition,theshort2termprognosisandthecomplicationrelatedtotheoperationwerealsoevaluated.ResultsThelesionswereremovedbyextensivetype(11cases),lateralwalltype(7cases)andlateralrecesstype(2cases).Suffi2cientexposureofthelesionswereachievedin16cases,lesssufficientin2casesandexposingwithdifficultyin2cases.Completeexci2sionwereachievedin10cases,sub2totalremovalin6casesandpartialremovalin4cases.GOSsofthepatientsatdischargeare5pointsin12casesand4pointsin8cases.ConclusionsExtensivetypeoftrans2CMFapproachprovidessufficientexposureforremo2vinglesionsoftheareafromtheaqueducttoobex,whilelateralwalltypeandlateralrecesstypeoftrans2CMPapproachesaremoreap2propriateinremovingthelesionsofthelateralrecess,middlecerebellarpeduncleanddorsolateralpartoftheponsandmedulla.Keywords:transcerebellomedullaryfissureapproach;clinicalapplication为了暴露四脑室和蚓部脑室面,常需要切开下蚓部,然而儿童患者切开下蚓部,牵拉齿状核和齿状核皮层束都可以产生“小脑缄默综合征”和共济失调等严重并发症,同时经蚓部入路即使切除下蚓部后对四脑室侧部也不能完全暴露。随着微创神经外科理念和技术的发展,经脑的自然沟裂进行神经外科手术已经成为共识。小脑延髓裂(cere2bellomedullaryfissure,CMF)作为天幕下最重要的自然裂隙之一,同样引起了广泛的重视[1-3]。1对象与方法1.1临床资料1.1.1一般资料本组患者男13例,女7例,年龄11～60岁,平均年龄31岁。病程20天～9年,平均病程30.6月。·413·JournalofInternationalNeurologyandNeurosurgery2009,36(4)1.1.2症状及体征间歇头痛伴眩晕14例,单纯眩晕3例,行走不稳12例,听力减退6例,进食水呛咳5例,视力下降1例,半身麻木7例,肢体肌力减退9例,外展神经麻痹13例,三叉神经麻痹9例,眼球水平震颤11例,共济失调11例。1.1.3神经影像资料本组病例全部经术前MRI+增强扫描或数字减影脑血管造影证实,病变位于第四脑室7例、小脑蚓部3例、小脑延髓裂6例、桥脑和延髓背侧4例。1.2手术方法1.2.1麻醉与体位采取...
