骶管囊肿文献导读：两种不同手术方法治疗骶管囊肿的疗效比较：一项前瞻性临床研究

原文：Comparative Outcomes of the Two Types of Sacral Extradural Spinal Meningeal Cysts Using Different Operation Methods: A Prospective Clinical Study

作者：Jian-jun Sun, Zhen-yu Wang, Mario Teo, Zhen-dong Li, Hai-bo Wu , Ru-yu Yen , Mei Zheng , Qing Chang , Isabelle Yisha Liu

Department of Head and Neck Surgery, UCLA Medical Center, Los Angeles, California, United States of America （美国 洛杉矶）

编译：杨敏、沈霖 校对：郑学胜

摘要：

This prospective study compares different clinical characteristics and outcomes of patients with two types of sacral extradural spinal meningeal cysts (SESMC) undergoing different means of surgical excision. Using the relationship between the cysts and spinal nerve roots fibers (SNRF) as seen under microscope, SESMCs were divided into two types: cysts with SNRF known as Tarlov cysts and cysts without. The surgical methods were tailored to the different types of SESMCs. The improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological function of the patients. Preoperative IJOA scores were 18.5±1.73, and postoperative IJOA scores were 19.6±0.78. The difference between preoperative and postoperative IJOA scores was statistically significant (t = -4.52, p = 0.0001), with a significant improvement in neurological function after surgery. Among the improvements in neurological functions, the most significant was sensation (z=-2.74, p=0.006), followed by bowel/bladder function (z=-2.50, p=0.01). There was a statistically significant association between the types of SESMC and the number (F=12.57, p=0.001) and maximum diameter (F=8.08, p=0.006) of the cysts. SESMC with SNRF are often multiple and small, while cysts without SNRF tend to be solitary and large. We advocate early surgical intervention for symptomatic SESMCs in view of significant clinical improvement postoperatively.

这项前瞻性研究比较了两种不同类型骶管囊肿（SESMC），经过不同手术方式治疗后的不同临床特征和预后。根据囊肿与脊神经根纤维（SNRF）在显微镜下的关系，将骶管囊肿分为两种类型：一种是有脊神经根纤维的囊肿，称为Tarlov’s囊肿，另一种是没有脊神经根纤维的囊肿。根据不同类型的骶管囊肿，采用不同的手术方法。采用改良的日本骨科协会（IJOA）评分系统进行评价，患者手术前后神经功能状况。术前IJOA评分为18.5±1.73，术后IJOA评分为19.6±0.78。手术前后IJOA评分的差异有统计学意义（t=-4.52，p=0.0001），术后神经功能显著改善。其中神经功能改善最为显著（z=-2.74,p=0.006），其次是肠道/膀胱功能（z=-2.50，p=0.01）。骶管囊肿的类型、数量（F=12.57，p=0.001）和最大直径（F=8.08，p=0.006），在统计学上有显著的相关性。有脊神经根纤维的囊肿通常是多发的小囊肿，而没有脊神经根纤维的囊肿往往是孤立的和大的。鉴于术后临床显著改善，我们提倡对有症状的骶管囊肿进行早期手术干预。

手术时机：

When neural irritation symptoms occurred in patients with sacral extradural spinal meningeal cysts (SESMCs), and when bone erosion was found in the neuroimaging, surgical intervention was highly recommended for these patients. When sacral extradural spinal meningeal cyst was discovered incidentally, the patient would be kept under yearly surveillance. Surgical intervention would only be carried out if the cyst progressively enlarged, or patient became symptomatic.

骶管囊肿患者出现神经刺激症状时，当神经影像学发现骶骨被囊肿侵蚀时，强烈建议这两类患者进行外科手术治疗。当体检偶然发现骶管囊肿时，患者应进行每年的复查。当囊肿逐渐增大或病人出现症状时，即应进行手术治疗。

手术方式：

Our operative technique followed the standard procedures for SESMCs surgery. An incision was made from L5 to S3, and the sacral laminae were completely exposed according to the location of SESMCs. Laminectomy was performed with a rongeur, while carefully preserving the integrity of the underlying cyst. The surgical microscope was then brought into the field. The terminal thecal sac was identified and dissected free from the overlying cysts. Each cyst was dissected from surrounding structures to reveal its origin and relationships with SNRFs by the senior authors (ZY Wang, JJ Sun). If the SESMCs were identified as those with SNRFs (Figure 1), the cysts were partially resected and the defect oversewn to prevent CSF leakage from the subarachnoid space and the nerve root sheath reconstructed. Redundant cyst wall was shrunk using bipolar cautery. If the SESMCs were identified as those without SNRFs, which originated in the armpit of SNRFs (Figure 2) or extremity of terminal pool (Figure 3), the neck of cyst was transfixed, ligated and the remaining cyst wall resected distal to the ligation. If the cysts were associated with a tethered cord, then untethering would be performed during the same procedure. Intraoperative neurophysiological monitoring was used to differentiate SNRFs from other tissues. Electrical stimulation was used to verify that no motor nerve fibers were involved. The closure was reinforced with a local muscle flap.

我们的手术技术遵循硬膜外脊膜囊肿手术的标准程序。从L5至S3切口，根据囊肿的位置完全暴露骶骨椎板。椎板切除术是用咬骨钳进行的，同时小心地保护下一层囊肿的完整性。在手术显微镜下操作。确认硬脊膜囊的终末端，并解剖出囊肿。最后的鞘囊被确定和解剖没有覆盖的囊肿。每一个囊肿都从周围结构中解剖出来的，以揭示其起源和与神经根纤维的关系。如果囊肿被鉴定为神经根纤维型（图1），囊肿部分切除，缺损部分闭合，以防止脑脊液漏，重建神经根鞘。用双极烧灼法缩小多余的囊壁。如果确定囊肿是不含神经根纤维的，起源于神经根的腋窝（图2）或终末期池的末端（图3），则将囊肿颈部缝合、结扎，并切除结扎远端的剩余囊壁。如果囊肿与系带有关，则在同一程序中进行解除栓系。术中神经生理监测用于区分神经根纤维与其他组织。用电刺激证实没有运动神经纤维参与。局部肌肉瓣加强闭合。

专家点评：

新华医院神经外科郑学胜主任指出，关于手术时机，新华的观点和本文观点一致，当有神经刺激症状时，或当神经影像学发现骶骨被侵蚀时，强烈建议这些患者进行外科手术治疗。当偶然发现骶骨硬膜外脊膜囊肿时，建议患者应每年进行核磁共振的复查。当发现囊肿逐渐有增大或病人出现症状时，即应进行手术治疗。

2、本文发现有神经根纤维的囊肿通常是多发的小囊肿，而没有神经根纤维的囊肿往往是孤立的和大的。根据新华的经验，囊肿的大小通常与漏口的大小有正相关性。有神经根纤维的囊肿，当漏口大、流量高时，亦可形成较大的囊肿，甚至有个别成为突入盆腔的巨大囊肿。我们发现终丝性囊肿（文中的图3），此类囊肿往往较大并伴有栓系，对于此类囊肿，我们的经验是在硬脊膜下切断终丝，在囊肿内切断终丝并缝合结扎漏口。

3、有些患者在囊肿存在的同时，合并有脊柱裂、脊髓栓系，在处理囊肿的同时，一定要解除栓系，对提高术后疗效有必要的作用。

4、本文中提到有神经纤维通过的囊肿，新华主张骶管囊肿漏口封堵 + 神经根袖重建的微创手术，可以有效降低复发率。

5、我们同意本文中关于显微镜和神经电生理术中检测的应用，这两项措施可以有效减少术中神经损伤并发症。