上海新華醫院神經外科腰骶神經中心
原文:Microsurgical treatment of sacral perineural (Tarlov) cysts: case series and review of the literature
作者:John F. Burke, MD, PhD, Jayesh P. Thawani, MD, Ian Berger, BS, Nikhil R. Nayak, MD, James H. Stephen, MD, Tunde Farkas, MD, Hovik John Aschyan, BA, John Pierce, MS, Suhail Kanchwala, MD, Donlin M. Long, MD, PhD, and William C. Welch, MD (美國 賓夕法尼亞)
編譯:楊敏沈霖審校:鄭學勝
Tarlov cysts (TCs) occur most commonly on extradural components of the sacral and coccygeal nerve roots. These lesions are often found incidentally, with an estimated prevalence of 4%–9%. Given the low estimated rates of symptomatic TC and the fact that symptoms can overlap with other common causes of low-back pain, optimal management of this entity is a matter of ongoing debate. Here, the authors investigate the effects of surgical intervention on symptomatic TCs and aim to solidify the surgical criteria for this disease process.
Tarlov囊腫(TCs)最常見於骶尾部神經根的硬膜外病變。這些病變通常是偶然發現的,患病率約為4%-9%。考慮到症狀性骶管囊腫的患病率較低,而且症狀可能與其他常見的腰部疼痛病因重疊,因此,對該疾病的最佳治療是一個持續爭論的問題。本文作者調查了外科幹預治療症狀性骶管囊腫的預後,目的是建立這一疾病過程的外科治療標準。
Twenty-three adults (4 males, 19 females) who had been symptomatic for a mean of 47.4 months were treated with laminectomy, microsurgical exposure and/or imbrication, and paraspinous muscle flap closure. Eighteen patients (78.3%) had undergone prior interventions without sustained improvement. Thirteen patients (56.5%) underwent lumbar drainage for an average of 8.7 days following surgery. The mean follow-up was 14.4 months. Univariate analyses demonstrated that an advanced age (p = 0.045), the number of noted perineural cysts on preoperative imaging (p = 0.02), and the duration of preoperative symptoms (p = 0.03) were associated with a poor postoperative outcome. Although 47.8% of the patients were able to return to normal activities, 93.8% of those surveyed reported that they would undergo the operation again if given the choice.
23名成人(4名男性,19名女性)平均47.4個月出現症狀,接受椎板切除術、顯微手術暴露後摺疊縫合術,以及棘旁肌瓣閉合術。18例患者(78.3%)術前曾接受過早期幹預治療,但沒有持續改善。13例(56.5%)術後平均8.7d行腰椎引流術。平均隨訪14.4個月。單因素分析顯示高齡(p=0.045)、術前影像學上發現的神經周囊腫數量(p=0.02)和術前症狀持續時間(p=0.03)與術後不良預後相關。雖然47.8%的患者能夠恢復正常活動,但93.8%的受訪患者表示,如果再次選擇,他們還是會選擇接受手術。
Diagnosis and Surgical Intervention
All patients underwent imaging studies demonstrating TC. Magnetic resonance imaging of the lumbar spine delineated 1 or many cystic masses consistent with a diagnosis of TC (Fig. 1). Computed tomography scanning was also performed to reveal any possible bony erosion adjacent to the TC.
所有患者都接受了顯示囊腫的影像學檢查。腰椎磁共振成像顯示1個或多個囊性腫塊,符合骶管囊腫的診斷(圖1)。電腦斷層掃描也顯示出任何可能的骨侵蝕鄰近的囊腫。
Given symptoms refractory to medication and/or prior intervention as well as radiological evidence of TC, patients were offered the option of surgery. Other causes of pain were ruled out before patients were presented with a surgical option. All patients elected to undergo microsurgical treatment performed by the study’s senior author. Surgery entails a lumbosacral incision, subperiosteal dissection, and an osteoplastic laminotomy that is performed over the level of the cyst. Incision and exposure are conducted using anatomical landmarks. Following incision into the cyst wall, a 4-0 Nurolon suture is placed lateral to the opening on either side to bring the dural edges inward and under the closure. Autologous muscle patches can be used to augment the dural closure and decrease the overall volume of the cyst. The resulting defect requires watertight tension-free closure. Sharp lateral dissection is used to free the paraspinous musculature. If necessary, the fascial insertion can be detached medially along the posterior iliac spine, taking care not to injure the superior cluneal nerves, the dorsal sacroiliac ligaments, or the iliolumbar ligament. The midline incision is closed in several layers, including deep and more superficial subcutaneous tissues as well the skin, by using a simple, running absorbable suture reinforced with nonabsorbable verticalmattress sutures. Patients with cysts larger than 2.5 cm in the largest dimension and/or a history of prior interventions have lumbar drains placed at the time of surgery. The lumbar drain is used in the event of large cysts, when a significant amount of dura mater is excised during excision of the cyst wall. Methods of the surgical approach are visually summarized in Fig. 2
對於藥物或先前保守治療無效的骶管囊腫患者,放射學明確有骶管囊腫,此類患者可以選擇手術。術前因排除其他的疼痛原因。所有病人都選擇接受顯微外科治療,由本研究的資深術者進行。手術包括腰骶部切口,骨膜下剝離,以及在囊腫上方進行的骨塑形椎板切開術。使用解剖標誌進行切口和暴露。切開囊腫壁後,將4-0 Nurolon縫合線置於兩側開口的側面,使硬腦膜邊緣向內並位於閉合處。自體肌肉補片可以用來加強硬腦膜閉合,減少囊腫的總體積。由此產生的缺陷需要水密無張力閉合。側切除術用於松解棘旁肌層。如有必要,可沿髂後棘內側分離筋膜止點,注意不要損傷上臀神經、骶髂背韌帶或髂腰韌帶。中線切口分幾層閉合,包括較深和更淺的皮下組織以及皮膚,方法是使用一種簡單的可吸收縫線,並輔以不可吸收的垂直床墊縫合線。最大直徑大於2.5釐米的囊腫和/或有既往手術史的患者在手術時放置了腰椎引流管。當囊腫壁切除時,大量硬腦膜被切除,腰椎引流用於治療大囊腫。手術入路的方法如圖2所示。
Conclusions
Although TCs were described more than 75 years ago, there is still no consensus on their origin or treatment. Most are benign, but about 1% are symptomatic and can be managed effectively with surgery. A few studies have been conducted on the surgical management of TCs, and much of this literature shows positive outcomes (Table 1). Here, we described a cohort of patients with symptomatic TCs that was successfully treated with surgery. Age, extent of disease, and duration of symptoms were related to outcome. The overall long-term outcome for this patient group was positive.
儘管骶管囊腫在75年前就被描述過了,但是對於它們的起源和治療方法仍然沒有達成共識。大多數是良性的,但約1%是有症狀的,可以通過手術有效地處理。對骶管囊腫的外科治療已經進行了一些研究,並且大部分文獻顯示了積極的結果(表1)。本文描述了一組成功通過手術治療的症狀性骶管囊腫患者。年齡、疾病程度和症狀持續時間與預後相關。該患者組的總體長期預後是積極的。
總結:
同意本文關於手術指針的觀點。我們亦認為有症狀的骶管囊腫患者,影像學明確診斷,在排除其他疾病後有明確手術指針。本文主要採取後椎板切開術+囊腫摺疊縫合術+肌瓣囊腫閉合術。我們的觀點是漏口封堵術是骶管囊腫手術中的關鍵,無論囊腫大小,都應行漏口封堵術,提高手術預後,減少術後復發。對於較大的骶管囊腫可以在漏口封堵的基礎上行肌瓣囊腫內封堵+囊腫摺疊縫合術。我們術中應用顯微鏡和神經電生理術中監測,這兩項措施可以提高手術預後並有效減少術中神經損傷併發症。