经乙状窦后-内听道入路微创手术治疗听神经瘤

doi:10.3877/cma.j.issn.2095-9141.2018.03.002

目的

探讨听神经瘤微创显微手术切除听神经瘤的手术方法和技巧，以提高肿瘤的全切除率和面神经的功能保护率。

方法

回顾性分析陆军总医院附属八一脑科医院自2000年1月至2017年12月应用多模态技术辅助经枕下乙状窦后-内听道入路微创手术治疗的887例听神经瘤患者的临床资料。术后3个月常规复查增强MRI明确肿瘤切除程度，评估面神经功能。

结果

肿瘤全切841例，全切除率为94.8%。术中面神经解剖保留832例，面神经解剖保留率为93.7%；解剖未能保留的55例，其中16例术中行面神经端-端吻合，另有3例术后行面神经移植。肿瘤切除3个月后复查，面神经功能Ⅰ~Ⅱ级695例(78.4%），Ⅲ~Ⅳ级176例(19.8%），Ⅴ级16例(1.8%）。

结论

听神经瘤微创显微手术有助于提高肿瘤切除的安全性和手术疗效，熟练掌握显微手术技巧是提高肿瘤全切除、面神经解剖和功能保护率的关键。

关键词: 听神经瘤, 面神经, 电生理监测, 显微外科技术

Objective

To explore surgical methods and techniques of minimally invasive microsurgical resection of acoustic neuroma, in order to improve the total resection rate of tumor and the protective rate of facial nerve.

Methods

Eight hundred and eighty-seven patients suffering from acoustic neuromas treated microsurgically by suboccipital retrosigmoid transmeatus approach were analyzed retrospectively between January 2000 and December 2017. Routine reexamination of enhanced MRI and assessment of facial nerve function were performed in 3 months after operation.

Results

Total resection of the tumor was achieved microsurgically in 841 cases, the total removal rate was 94.8%. The facial nerve was preserved anatomically in 832 cases during the operation, the facial nerve anatomic reservation rate was 93.7%. Fifty-five cases were not preserved in the anatomy, 16 of them received end to end anastomosis of facial nerve, and 3 cases underwent facial nerve grafting after operation. After 3 months of tumor resection, 695 cases (78.4%) of facial nerve function were restored to House-Brackmann (H-B) grade I to Ⅱ, 176 cases(19.8%) H-B grade III to Ⅳ and 16 cases (1.8%) H-B grade V.

Conclusion

Minimally invasive microsurgery for acoustic neuroma is helpful to improve the safety and surgical effect of tumor resection. Mastery of microsurgical skills is the key to the improvement of total tumor resection, facial nerve anatomy and function protection.

Key words: Acoustic neuroma, Facial nerve, Electrophysiologic monitoring, Microsurgical technique

图1 左侧听神经瘤术前增强MR资料

图2 经乙状窦后-内听道入路微创手术术中图像

图3 经乙状窦后-内听道入路微创手术术后复查增强MRI

表1 听神经瘤大小与面神经位置的关系[例（%）]

肿瘤大小(cm)	例数	前中央	前上方	前下方	上极	下极	不详
小型(≤2.0)	82	63(76.8)	9	8	1	1	0
中型(2.1~3.9)	554	226(40.8)	131	107	48	37	5
大型(≥4.0)	251	85(33.9)	58	54	16	17	21
总计	887	374(42.2)	198(22.3)	169 (19.1)	65(7.3)	55(6.2)	26(2.9)

表1 听神经瘤大小与面神经位置的关系[例（%）]

肿瘤大小(cm)	例数	前中央	前上方	前下方	上极	下极	不详
小型(≤2.0)	82	63(76.8)	9	8	1	1	0
中型(2.1~3.9)	554	226(40.8)	131	107	48	37	5
大型(≥4.0)	251	85(33.9)	58	54	16	17	21
总计	887	374(42.2)	198(22.3)	169 (19.1)	65(7.3)	55(6.2)	26(2.9)

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Minimally invasive treatment for acoustic neuromas by retrosigmoid transmeatus approach

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Minimally invasive treatment for acoustic neuromas by retrosigmoid transmeatus approach