CAJ | 학술논문

目的探讨在保护运动功能的前提下,最大程度地切除运动区低级别胶质瘤的手术策略和方法.方法总结分析首都医科大学附属北京天坛医院2011年12月至2013年5月收治的30例运动区低级别胶质瘤患者的手术计划及治疗经过.所有患者术前均行头MRI检查,以“ω”形或倒“Ω”形“手结”为标识定位中央前回(初级运动区,M1);术中应用体感诱发电位(SEP)位相倒置(波形翻转)技术确认中央沟、初级运动区和运动前区,应用运动诱发电位(MEP)技术监测运动传导通路的功能,同时应用B超实时监测肿瘤切除情况;术后72h内复查头颅MRI,了解肿瘤切除程度,分别于术后清醒时、术后2周和术后3个月评价患者病变对侧肢体肌力变化.结果头颅MRI检查结果显示肿瘤主体位于M1者3例,辅助运动区(SMA)者3例,运动前区(PMA)者11例,同时侵及SMA和PMA者13例.肿瘤近全切除27例(90％),部分切除3例(10％).病理结果:少突胶质细胞瘤2例,星形细胞瘤9例,少突-星形细胞瘤19例.患者术前肌力Ⅳ级者5例;肌力正常者25例,其中4例伴有一侧手指欠灵活、及物不准确,2例走路伴有踩空感.术后部分患者曾一度出现肌力障碍,术后3个月检查肌力正常者23例,其中9例伴有手指欠灵活、及物不准确,3例伴有走路踩空感;其余7例上(下)肢遗留有不同程度瘫痪(肌力Ⅲ～Ⅳ级).结论运动区主要由M1、PMA、SMA三个部分和由此发出的皮质核束及皮质脊髓束组成,运动区低级别胶质瘤的切除要求术前准确判定肿瘤在运动区的具体位置,术中辅助应用电生理监测技术和B超等手段,依靠娴熟的显微操作技能,可以做到肿瘤近全切除而不造成永久性瘫痪.
목적 탐토재보호운동공능적전제하,최대정도지절제운동구저급별효질류적수술책략화방법.방법 총결분석수도의과대학부속북경천단의원2011년12월지2013년5월수치적30례운동구저급별효질류환자적수술계화급치료경과.소유환자술전균행두MRI검사,이“ω”형혹도“Ω”형“수결”위표식정위중앙전회(초급운동구,M1);술중응용체감유발전위(SEP)위상도치(파형번전)기술학인중앙구、초급운동구화운동전구,응용운동유발전위(MEP)기술감측운동전도통로적공능,동시응용B초실시감측종류절제정황;술후72h내복사두로MRI,료해종류절제정도,분별우술후청성시、술후2주화술후3개월평개환자병변대측지체기력변화.결과 두로MRI검사결과현시종류주체위우M1자3례,보조운동구(SMA)자3례,운동전구(PMA)자11례,동시침급SMA화PMA자13례.종류근전절제27례(90％),부분절제3례(10％).병리결과:소돌효질세포류2례,성형세포류9례,소돌-성형세포류19례.환자술전기력Ⅳ급자5례;기력정상자25례,기중4례반유일측수지흠령활、급물불준학,2례주로반유채공감.술후부분환자증일도출현기력장애,술후3개월검사기력정상자23례,기중9례반유수지흠령활、급물불준학,3례반유주로채공감;기여7례상(하)지유류유불동정도탄탄(기력Ⅲ～Ⅳ급).결론 운동구주요유M1、PMA、SMA삼개부분화유차발출적피질핵속급피질척수속조성,운동구저급별효질류적절제요구술전준학판정종류재운동구적구체위치,술중보조응용전생리감측기술화B초등수단,의고한숙적현미조작기능,가이주도종류근전절제이불조성영구성탄탄.
Objective To explore the possibility and strategy of maximally removal of low-grade gliomas which involved the motor areas on the premise of protecting the patient' motor function.Methods The neurosurgical plans and procedures of 30 patients with low-grade gliomas involving the motor areas in Beijing Tiantan Hospital from December 2011 to May 2013 were analyzed retrospectively.Preoperative head magnetic resonance imaging (MRI) was performed in all patients.A ω-shaped or inverted Ω-shaped hand-knob as a logo was used to confirm the precentral gyrus (primary motor area,M1).Intraoperative somatosensory evoked potential (SEP) was used to confirm the central sulcus,M1 and premotor area (PMA).MEP was used to monitor the function of motor pathway.The extent of tumor resection was evaluated by intraoperative B-mode ultrasound at the same time.Postoperative head MRI within 72 hours was used to evaluate the extent of tumor resection.The muscular power was determined instantly after waking up,2 weeks and 3 months following operation separately.Results The M1 was involved in 3 cases,the supplementary motor area (SMA) in 3,the PMA in 11,and the SMA and PMA were simultaneously involved in 13.Subtotal resection was achieved in 27 cases (90％) while partial resection in 3 (10％).The histological results of all patients revealed oligodendroglioma in 2 cases,astrocytoma in 9 and oligo-astrocytoma in 19.Preoperative muscle power was normal in 25 cases,4 of them had one hand less flexible and could not perform accurately,and 2 of them felt trample empty while walking,and 5 cases had grade Ⅳ muscle power.After the surgery,part of patients had transient muscle disorders.Three months after the surgery,muscle power was normal in 23 cases,9 of them had one hand less flexible and could not perform accurately,3 of them felt trample empty while walking.7 cases had grade Ⅲ-Ⅳ muscle power of upper or lower limbs.Conclusions Motor area is consisted of M1,PMA,SMA,corticonuclear tract and corticospinal tract started from them.The position of low-grade gliomas involving the motor areas should be confirmed accurately before surgery.Under the use of some technologies such as intraoperative electrophysiology,B-mode ultrasonography and delicate microneurosurgical techniques,subtotal resection of tumors without causing permanent motor deficits might be achieved.