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1、 硬脊膜动静脉瘘论文：神经内镜辅助手术治疗硬脊膜动静脉瘘【中文摘要】探讨神经内镜辅助手术治疗硬脊膜动静脉瘘的方法,分析治疗前后脊髓功能以及脊髓血管造影的改变,比较神经内镜辅助手术治疗与以往治疗方式的差异,以期最大限度地减少手术创伤,提高患者的生存质量。方法：本文回顾性分析了山东大学齐鲁医院神经外科2008年11月2010年7月采用神经内镜辅助手术治疗硬脊膜动静脉瘘的6例病例资料,对其临床表现、影像学资料、手术方法、术后恢复以及随访情况进行分析。6例SDAVF患者均为初次发病,男5例(83.3%),女1例(16.7%),男女比例5：1；年龄4867岁,平均58.3岁；病史6个月36个月,平均16
2、.5个月。6例病例均有脊髓功能障碍的表现,其中3例以下肢进行性无力、行走困难为首发症状,2例以下肢麻木,1例以阳痿为首发症状。随着病情的进展,6例病例均出现下肢运动及感觉障碍,4例出现小便功能障碍。本组病例术前均行脊髓MRI以及DSA检查,MRI检查中T2加权像可见相应脊髓节段髓内高信号,T2矢状位于脊髓背侧可见迂曲增粗的血管流空影；DSA检查明确供血动脉及瘘口位置。术前X线骨窗平片定位相应脊髓节段的棘突,术中切除半椎板后神经内镜辅助切断引流静脉并电灼瘘口。术后第2天开始口服华法林抗凝3个月,并监测凝血酶原活动度。结果：6例患者均为单瘘口病变,术中神经内镜辅助下发现瘘口并行引流静脉切断术,出院
3、前行DSA检查,均未见瘘口及引流静脉显影,达到影像学治愈。术后至出院,5例下肢运动及感觉有明显改善,1例无明显变化。1例术后括约肌功能较术前有改善,3例基本无变化。随访335个月,平均13.8个月。2例痊愈,改良Aminoff-Logue评分为0分；3例好转,随访与出院时症状无变化,但较术前有明显改善,改良Aminoff-Logue评分提高12分;1例无变化,术前、出院及随访时改良Aminoff-Logue评分均为3分。结论：随着影像学技术的发展以及对此病认识的加深,SDAVF的检出率较以往有很大的提高。神经内镜辅助手术治疗SDAVF作为一种新的手术治疗方式,在疗效确定的前提下,减少手术创伤,
4、降低医疗费用,缩短住院时间,符合神经外科“微侵袭”发展的趋势。随着神经内镜技术在各级医院中的逐步开展,内镜辅助手术治疗将以其独特的优势在SDAVF的治疗中发挥重要的作用。【英文摘要】:To explore the neuroendoscope-assisted surgical treatment to spinal dural arteriovenous fistulas, and analyse the changes of spinal function and spinal DSA before and after treatment. Comparing the neuroendos
5、cope-assisted and traditional surgical treatment, in order to minimize the surgical trauma and improve the quality of life.Methods:From November 2008 to July 2010,6 cases of spinal dural arteriovenous fistulas underwent neuroendoscope-assisted surgical treatment by hemilaminectomy approach in neuros
6、urgery department of Qilu hospital. Retrospectively analyzed the 6 casesclinical manifestations, imaging data, surgical methods, postoperative recovery and follow-up data. The 6 cases were all first attack, included 5 males(83.3%) and 1 female(16.7%),male to female ratio 5:1. The patientsage ranged
7、from 48 to 67 years(mean age 58.3 years). The diagnostic time ranged from 6-36 months(mean 16.6 months). All cases had the spinal dysfunctions,3 casesfirst symptom was the lower limbsprogressive powerless and had difficulty in walking,2 caseslower limbs numb and 1 case had impotence. With the develo
8、pment of the disease, all 6 cases had lower limbsmotor and sense dysfunction,4 cases had sphicteric dysfunction. Spinal cords magnetic resonance imaging and selective spinal cord angiography were performed before preoperation. The T2-weighted sequences showed mass effect, the vessels on the back of
9、spinal cord were dilated, coiled and flew voids. The selective spinal cord angiography showed the segment artery which harboring the fistula. Before the operation, all patients received routinely x-rays radiographs to mark the spinal processposition to guide the hemilaminectomy. In operation, after
10、hemilaminectomy, found the draining vein and the fistula with the assistance of neuroendoscope. Fulgerized and cut the draining vein, the vein obviously collapsed and the colour turned into dull-red. Then fulgerized the fistula repeatly. Taking warfarin orally the next day after operation to anticoa
11、gulate for 3 months, and survived the prothrombin activity regularly.Results:6 cases were all single fistula, fulgerized the draining vein and fistla during the operation. The angiography before leaved the hospital showed all fistulas and draining veins were disappeared, achieved imaging cure.5 case
12、slower limbs motor and sensory function had obviously improved,1 case had no chang.1 cases sphicteric function improved obviously,3 caseshad no change. After 3 months to 35 monthsfollow-up,13.8 months on average.2 casessymptoms were disappeared, the score of Aminoff-Logue was 0,3 cases were obviousl
13、y improved, the score of Aminoff-Logue had raised 1-2 points.1 case had no change, the score of Aminoff-Logue was still 3.Conclusion:With the development of the image technology and the understanding of SDAVF, the diagnostic rate has improved visibly. The neuroendoscope-assisted surgery can minimize
14、 the surgical injury, cut down the cost, reduce the hospital stays, according with the trends of “minimally invasive surgery”. With the neuroendoscopes development in various hospitals, the neuroendoscope-assisted surgery can play important role in the treatment of spinal dural arteriovenous fistula.【关键词】硬脊膜动静脉瘘 神经内镜 手术治疗【英文关键词】Spinal dural arteriovenous fistulas Neuroendoscope Surgery【目录】神经内镜辅助手术治疗硬脊膜动静脉瘘中文摘要6-8英文摘要8-9符号说明10-11前言11-13材料与方法13-15结果15-16讨论16-26结论26-27附表27-28附图28-29参考文献29-34综述34-44参考文献40-44致谢44-45攻读学位期间发表的学术论文目录45-46学位论文评阅及答辩情况表46
