成人原发性脊髓拴系综合征的分型及显微外科手术治疗

doi:10.19723/j.issn.1671-167X.2023.04.012

摘要/Abstract

摘要：

目的: 总结成人原发性脊髓拴系综合征(tethered cord syndrome, TCS)的临床特点、分型及手术治疗经验。方法: 回顾性分析2007年3月至2019年10月北京大学第三医院手术治疗的171例成人原发性TCS患者的临床资料，男性61例，女性110例，年龄18~65岁，平均年龄(39.02±11.81)岁，主要症状为腰腿痛、双下肢麻木无力和大小便功能障碍。按照临床特点及医学影像学分为5型：终丝牵张型(69例)、脊髓纵裂型(21例)、脊髓脊膜膨出型(20例)、脂肪脊髓脊膜膨出型(36例)、皮窦道型(25例)。对不同类型的TCS采取相应的显微手术治疗，以Kirollos分级评定手术拴系松解程度，以视觉模拟疼痛评分(visual analogue scale, VAS)评估疼痛情况，采用关键肌肉力量0~5级评分评价下肢运动功能，用日本骨科协会(Japanese Orthopaedic Association，JOA)括约肌功能评分评价膀胱功能。结果: 171例患者均经显微手术松解粘连，切断终丝，其中61例将伴随病灶也分离切除。脊髓拴系均达到Kirollos Ⅰ级松解，均重建硬膜囊。除5例脑脊液漏切口愈合不良外，其余无手术并发症，经过再次缝合加俯卧位，伤口均愈合。患者术后疼痛缓解或消失，双下肢无力和大小便功能障碍症状也逐渐恢复。随访时间6个月至12.5年，平均(5.62±2.31)年，153例患者的脊髓功能状态好转，18例稳定，无恶化病例，随访期间未见再拴系。结论: 成人原发性TCS按临床特点及医学影像学分为5种类型，按照分型制定手术策略，手术解除脊髓牵张及压迫，恢复正常的解剖结构，预防再粘连，相应的显微手术治疗效果满意。

关键词: 脊髓拴系综合征, 终丝, 脊柱裂, 显微外科手术

Abstract:

Objective: To summarize the clinical manifestation, classification, and experience of surgical treatment of primary tethered cord syndrome (TCS) in adults. Methods: The authors retrospectively analyzed a series of 171 adult patients with primary TCS who were surgically treated under microscope from March 2007 to October 2019. There were 61 males and 110 females whose ages were 18-65 years, with an average age of (39.02±11.81) years. Clinically, the patients presented with various neurological symptoms and signs including lower back and legs pain, reflex changes, sensory disturbances, muscle weakness, and sphincter problems. They were divided into 5 types by clinical manifestations and neuro-imaging features: (1) filum terminale traction in 69 cases, (2) split cord malformation in 21 cases, (3) myelomeningocele in 20 cases, (4) lipomyelomeningocele in 36 cases, and (5) dermal sinus traction in 25 cases. All the patients underwent microsurgery to untether the spinal cord. The patients kept prone position 7 days postoperatively. The Kirollos grading was used to evaluate the outcome of intraoperative untethering. The visual analogue scale (VAS) was used to evaluate the pain, the score of critical muscle strength was used to evaluate the lower extremity motor function, and the Japanese Orthopaedic Association (JOA) sphincter function score was used to evaluate the bladder function. Results: All of the 171 patients were treated with microsurgery to release the adhesion and cut off the filum terminalis. 61 cases of them received resection of the lesions according to the etiology. All the tethered spinal cord reached Kirollos grade Ⅰ untethering and the dural sac was reconstructed. Other than 5 patients had cerebrospinal fluid leakage and incision laceration and underwent re-suture, there was no surgical complication. The local pain was relieved, the lower limbs weakness or bowel and bladder dysfunction gradually recovered postoperatively. The period of follow-up ranged from 6 months to 12.5 years with an average of (5.62±2.31) years. The neurological function was improved in 153 cases and stable in 18 cases. There was no recurrence of tethered cord be found during the follow-up period. Conclusion: The primary TCS in adulthood could be classified into 5 types by clinical manifestations and neuro-imaging features and surgical treatment should be undertaken in regard to the classifications including dissection and resection of the lesion detethering the spinal cord and reconstruction of the dura sac under microscope. The outcome of surgical treatment is satisfactory.

Key words: Tethered cord syndrome, Filum terminale, Spina bifida, Microsurgery

中图分类号:

R651.2

林国中,谢京城,陈晓东,杨军. 成人原发性脊髓拴系综合征的分型及显微外科手术治疗[J]. 北京大学学报（医学版）, 2023, 55(4): 641-645.

Guo-zhong LIN,Jing-cheng XIE,Xiao-dong CHEN,Jun YANG. Classification and microsurgical treatment of primary tethered cord syndrome in adults[J]. Journal of Peking University (Health Sciences), 2023, 55(4): 641-645.

图/表 1

图1

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