Lusk M D, Kline D G, Garcia C A
Department of Neurosurgery, Louisiana State University Medical Center, Charity Hospital, New Orleans.
Neurosurgery. 1987 Oct;21(4):439-53. doi: 10.1227/00006123-198710000-00001.
Over a 17-year period, 56 patients with 57 tumors involving the brachial plexus were operated upon. The 40 neural sheath tumors included 26 neurofibromas, 8 schwannomas, 4 malignant neural sheath tumors, 1 fibrosarcoma, and 1 meningioma. Nine of the neurofibromas were associated with von Recklinghausen's disease (VRD), and 2 others were what was termed regionalized neurofibromatosis characterized by involvement of one limb with extension along the course of one or more plexus elements. Seventeen tumors were not of neural sheath origin; 7 were benign and 10 were metastatic malignant tumors compressing or invading the plexus. Benign neurofibromas and malignant sheath tumors almost always presented with pain or functional neural deficit, whereas schwannomas often presented with a palpable mass as their only initial symptom. Patients with solitary neurofibromas were significantly older, often female, and more likely to have tumor on the right side than patients with schwannomas, malignant neural sheath tumors, or neurofibromas associated with VRD. Solitary neurofibromas could often be totally resected without added deficit by sacrificing fascicles entering and leaving tumor that were determined to be "nonfunctional" by intraoperative nerve action potential recordings. Resection of neurofibromas associated with VRD sometimes but not always resulted in significant loss. Operation is nonetheless recommended, especially when malignancy is suspected because of rapidly increasing size, when severe pain or neural deficit is present, or when compression of adjacent plexus elements is a concern. Schwannomas and benign non-neural sheath tumors can usually be extirpated without damage to plexus elements. Forequarter amputation is advised for malignant intrinsic tumors involving distal plexus elements even though gross total resection seems feasible.
在17年的时间里,对56例患有57个累及臂丛神经肿瘤的患者进行了手术。40例神经鞘瘤包括26例神经纤维瘤、8例施万细胞瘤、4例恶性神经鞘瘤、1例纤维肉瘤和1例脑膜瘤。其中9例神经纤维瘤与冯雷克林霍增氏病(VRD)相关,另外2例为所谓的局限性神经纤维瘤病,其特征是一个肢体受累并沿一个或多个神经丛成分的走行扩展。17个肿瘤并非神经鞘起源;7个为良性,10个为转移性恶性肿瘤,压迫或侵犯神经丛。良性神经纤维瘤和恶性鞘瘤几乎总是表现为疼痛或功能性神经功能缺损,而施万细胞瘤通常仅以可触及肿块作为首发症状。与施万细胞瘤、恶性神经鞘瘤或与VRD相关的神经纤维瘤患者相比,孤立性神经纤维瘤患者年龄明显更大,多为女性,且右侧发生肿瘤的可能性更高。通过牺牲术中神经动作电位记录确定为“无功能”的进出肿瘤的束支,孤立性神经纤维瘤通常可以完全切除而不增加功能缺损。与VRD相关的神经纤维瘤切除有时但并非总是导致明显的功能丧失。尽管如此,仍建议进行手术,特别是当因肿瘤迅速增大怀疑有恶变、出现严重疼痛或神经功能缺损或担心相邻神经丛成分受压时。施万细胞瘤和良性非神经鞘肿瘤通常可以切除而不损伤神经丛成分。对于累及远端神经丛成分的恶性原发性肿瘤,即使似乎可行根治性切除,也建议进行上肢截肢。