Spinner Robert J, Endo Toshiki, Amrami Kimberly K, Dozois Eric J, Babovic-Vuksanovic Dusica, Sim Franklin H
Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
J Neurosurg. 2006 Dec;105(6):873-80. doi: 10.3171/jns.2006.105.6.873.
The operative management of combined intrapelvic and extrapelvic sciatic notch dumbbell-shaped tumors is challenging. The relatively rare occurrence of these tumors and the varied extent of disease have made it difficult for surgeons to establish definitive surgical indications or predict favorable neurological outcomes based on preoperative imaging data.
In the past 3 years, the authors treated five patients presenting with radiating leg pain as a result of benign sciatic notch dumbbell-shaped tumors. These tumors in three patients with unilateral leg symptoms were considered unresectable by other neurosurgeons because of presumed direct intrinsic neural involvement. After high-resolution magnetic resonance (MR) imaging demonstrated that the extensive tumors were separate from the sciatic nerve and the lumbosacral plexus, however, these patients underwent a combined one-stage transabdominal and posterior transgluteal complete resection. Normal neurological status was maintained postoperatively in these three patients, and after more than 1 year of postoperative follow up, there were no tumor recurrences. In two patients with bilateral symptoms and extensive tumor burden, serial MR images showed that innumerable tumors directly involved the entire cross-sectional area of the sciatic nerves and extended longitudinally to the lumbosacral plexuses. Tumor debulking or resection in these patients would have resulted in neurological deficits and would not have addressed their neuropathic pain, and therefore no surgery was performed. These two patients were treated pharmacologically and advised to monitor their tumor status over the course of their lifetimes in case of malignant transformation of the tumor.
A combined one-stage transabdominal and transgluteal approach allows safe resection of selected benign but extensive sciatic notch tumors. High-resolution MR imaging is a useful tool in the management of these tumors because it allows the surgeon to visualize the anatomical relationships of the tumor to the sciatic nerve. The authors believe that as this imaging technology advances, it will provide surgeons with a method to predict definitively which sciatic notch tumors displace rather than directly involve the sciatic nerve, and therefore indicate which tumors can be resected safely and completely.
盆腔内和盆腔外坐骨切迹哑铃形肿瘤的手术治疗具有挑战性。这些肿瘤相对罕见，且疾病范围各异，这使得外科医生难以根据术前影像学数据确定明确的手术指征或预测良好的神经功能预后。
在过去3年中，作者治疗了5例因良性坐骨切迹哑铃形肿瘤导致腿部放射性疼痛的患者。其他神经外科医生认为，3例单侧腿部症状患者的这些肿瘤因推测直接累及神经内部而无法切除。然而，高分辨率磁共振（MR）成像显示广泛的肿瘤与坐骨神经和腰骶丛分离后，这3例患者接受了经腹和经臀后联合一期完整切除。这3例患者术后神经功能状态正常，术后随访1年以上无肿瘤复发。2例双侧症状且肿瘤负荷广泛的患者，系列MR图像显示无数肿瘤直接累及坐骨神经的整个横截面积，并纵向延伸至腰骶丛。对这些患者进行肿瘤减瘤或切除会导致神经功能缺损，且无法解决其神经性疼痛，因此未进行手术。这2例患者接受了药物治疗，并被建议在有生之年监测肿瘤状态，以防肿瘤恶变。
经腹和经臀联合一期入路可安全切除部分良性但广泛的坐骨切迹肿瘤。高分辨率MR成像是管理这些肿瘤的有用工具，因为它能让外科医生看清肿瘤与坐骨神经的解剖关系。作者认为，随着这种成像技术的进步，它将为外科医生提供一种方法，以明确预测哪些坐骨切迹肿瘤是移位而非直接累及坐骨神经，从而指明哪些肿瘤可以安全、完整地切除。
