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核磁共振檢查:
左為打對比劑後C1橫切面,右為矢狀切面,可見邊緣清楚的腫瘤壓迫第一及第二頸髓神經,腫瘤並延伸至後腦枕部大孔。
2002.02.10 2002.02.10
 

  History
This 56-year-old male patient was well before. However, about 6 months ago, L't neck soreness, numbness and pinprick pain started to attack. When it attacked, it radiated to L't shoulder and ascending up to L't occipaital area. In addition, he also noted his numbness and weakness at his L't upper extremities latter. About 4 months ago, he also noted the area of numbness went downward to L't side of trunk and to L't lower extremity. About 2 months ago, he noted his L't leg weakness after he walked about 10+ meters long. He came to our orthopedical OPD for help and MRI was arranged on 2001/12/10 and it showed a neurologic tumor at L't C1-2 level. Therefore, he was admitted at our ward for further managements.
 
   
 

 

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診 斷:. Intraspinal tumor, (Neurilemmoma) C1~2 and foramen magnum with cord compression
手 術:. Total laminectomy C1& C2 and parital suboccipital craniecomy with total excision of tumor
  教學重點:
1.Neurilemmoma(Schwannoma)在脊髓大多是良性的腫瘤。如果就位置來說,neurilemmoma可發生在(一)硬腦膜外 (二)硬腦膜內脊髓外 (三)脊髓內三種,就比例上而言,最多的是)硬腦膜內脊髓外這一類型的。如果是發生在脊髓內的腫瘤,一般常見的有,神經膠質瘤(glioma)或室管膜細胞瘤(ependymoma)。此病例為發生在硬腦膜內脊髓外的神經鞘膜瘤。

2.術前:
a. 高位的脊髓神經腫瘤,譬如在第三第四頸椎以上,如此例,最擔心患者的呼吸功能,而且若頸髓受傷也會造成四肢癱瘓。像這個案例,雖然頸髓已受到明顯的壓迫80%以上,但病人入院時仍然可自行行走,還可以正常生活,像這類病人在開刀時須特別小心,且必須事先跟家屬說明手術危險性。
b. 為了避免術後組織的swelling,術前可先給類固醇藥物(Corticosteroids)來預防。

3.術中:
a. 手術中在取出腫瘤時小心不能壓迫正常的地方,可用central debulking、devasculization、且特殊器械使用(ex:CUSA, Cubitron Ultrasonic Surgical Aspirator、SSEP, SomatoSensory Evoked Potentials)等方式來避免正常神經受到傷害。
b. 為了避免CSF從縫線的縫隙漏出,需用non-absorbable縫線以不漏水的方式來縫合開刀傷口。

4.術後:
a. CSF leakage會造成頭痛(spinal headache)的情形,此時應盡快將把drain拔除,並鼓勵病人多喝水補足CSF、或再打上IV灌水,並且多bed rest。
b. 為什麼把rootlet去除後,motor很少會有影響?大部份的tumor都是從dorsal rootlet來的,從ventral rootlet來的較少,所以常是以sensory dysfunction(dermatome)來表現,而motor很少有變化(myotone)。

結論:
此案例經本院神經外科以上述方式小心處理,將腫瘤完全拿掉後,患者可自行行走,且手腳無力功能逐漸回復,在約兩週後出院。