Columbia University College of Physicians and Surgeons, Department of Neurological Surgery, New York, New York, USA.
J Neurosurg Spine. 2011 Jul;15(1):28-37. doi: 10.3171/2011.3.SPINE1095. Epub 2011 Apr 15.
Access to the ventral intradural spinal canal may be required for treatment of a variety of lesions affecting the spinal cord and adjacent intradural structures. Adequate exposure is usually achieved through a standard posterior laminectomy or posterolateral approaches, although formal anterior approaches are used to access lesions in the subaxial cervical spine. Modifications of the standard posterior exposure as well as ventral or ventrolateral approaches are increasingly being used for treating intradural spinal pathologies. In this study, the authors review their experience with 35 consecutive cases of ventral intradural spinal lesions.
Only patients with intradural lesions located completely ventral to the dentate ligament attachments were included in this retrospective study. Patients with the following lesions were excluded from the study: lesions at the level of the filum terminale/cauda equina, lesions with any component that extended dorsally to the dentate ligament, or lesions with extradural extension (that is, dumbbell tumors) below the C-2 level. Between January 2000 and September 2009, a total of 35 patients (age range 17-72 years, mean 42.6 years) with ventral intradural spinal pathology underwent surgery at the authors' institution.
There were 28 intradural extramedullary mass lesions: 15 meningiomas, 12 solitary schwannomas, and 1 neuroenteric cyst. Surgical approaches to these lesions included 23 posterior or posterolateral approaches, 4 anterior approaches with corpectomy followed by tumor resection and reconstruction, and 1 lateral transforaminal resection. No patient had evidence of instability at follow-up, which ranged from 6 months to 8 years in duration. One patient had worsened spinal cord function following surgery. There were 7 patients with intramedullary lesions: 2 hemangioblastomas, 2 cavernous malformations, 2 perimedullary fistulas, and 1 astrocytoma. All but 1 were superficial pia-based lesions arising ventral to the dentate ligament. Five of the 6 pia-based lesions were successfully resected via a standard posterior laminectomy, partial facetectomy with dentate section, and spinal cord rotation. One midline pial lesion was successfully removed with a minimally invasive retropleural thoracotomy. The astrocytoma was resected through an anterior cervical corpectomy, which was followed by instrumented reconstruction. There were no significant complications or neurological morbidity at follow-up (range 9 months-6 years).
Most intradural spinal lesions can be treated with contemporary microsurgical techniques with long-term control or cure of the lesion and preservation of neurological function. Standard posterior approaches provide adequate exposure to safely remove the vast majority of these lesions without the need for a potentially destabilizing resection of the facet or pedicle. Posterior exposures with varying degrees of lateral bone resection, dentate ligament division, and gentle cord rotation may also provide adequate exposure for safe removal of nonmidline ventrolateral superficial pial presenting spinal cord lesions. Nevertheless, in certain cases of ventral intradural lesions, anterior approaches are necessary and should be considered under appropriate circumstances.
治疗影响脊髓和邻近硬脊膜结构的各种病变可能需要进入椎管腹侧。通常通过标准的后路椎板切除术或后外侧入路来实现充分暴露，尽管正式的前路入路用于治疗颈段下颈椎的病变。标准后路暴露的改进以及腹侧或腹外侧入路越来越多地用于治疗硬脊膜内脊髓病变。在这项研究中，作者回顾了他们对 35 例连续的腹侧硬脊膜内脊髓病变的经验。
只有完全位于齿状韧带附着处腹侧的硬脊膜内病变的患者才被纳入本回顾性研究。有以下病变的患者被排除在研究之外：终丝末端/马尾病变，病变的任何部分向齿状韧带背侧延伸，或病变在 C-2 以下有硬膜外延伸（即哑铃状肿瘤）。2000 年 1 月至 2009 年 9 月，作者所在机构共对 35 例腹侧硬脊膜内脊髓病变患者进行了手术。
共有 28 例硬脊膜外髓内肿块病变：15 例脑膜瘤，12 例单发神经鞘瘤和 1 例神经肠囊肿。这些病变的手术入路包括 23 例后路或后外侧入路，4 例前路伴椎体切除术、肿瘤切除和重建，1 例侧方经椎间孔切除术。随访时无患者出现不稳定证据，随访时间为 6 个月至 8 年。1 例患者术后脊髓功能恶化。7 例为髓内病变：2 例血管母细胞瘤，2 例海绵状畸形，2 例脊髓旁瘘管和 1 例星形细胞瘤。除 1 例外，所有病变均为位于齿状韧带腹侧的浅性软脊膜病变。6 例基于软脊膜的病变中，除 1 例外，其余 5 例均通过标准后路椎板切除术、部分关节突切除术和齿状韧带节段切除以及脊髓旋转成功切除。1 例中线软脊膜病变通过微创经胸膜后胸入路成功切除。星形细胞瘤通过前路颈椎椎体切除术切除，随后进行器械重建。随访时无明显并发症或神经功能障碍（9 个月至 6 年）。
大多数硬脊膜内脊髓病变可以通过现代显微外科技术治疗，长期控制或治愈病变，同时保持神经功能。标准后路入路可提供充分的暴露，安全切除大多数病变，而无需对关节突或椎弓根进行潜在不稳定的切除。后路暴露时可进行不同程度的侧方骨切除、齿状韧带切开和轻柔的脊髓旋转，也可为非中线腹外侧浅性软脊膜脊髓病变的安全切除提供充分的暴露。然而，在某些情况下，需要采用前路入路，并且应在适当的情况下考虑使用前路入路。
