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坐骨神经恶性神经鞘膜瘤复发一例

2018-05-25 曹慧 陈雷 张亚楠 中国修复重建外科杂志

患者 男,41岁。因“左足外侧疼痛、麻木1年,发现左大腿肿物1个月”于2016年8月入院。

【一般资料】

患者 男,41岁。

【主诉】

因“左足外侧疼痛、麻木1年,发现左大腿肿物1个月”于2016年8月入院。

【体格检查】

左大腿后方中段可触及鹌鹑蛋大小质韧肿物,横向活动度可、纵向活动度差,压之轻度疼痛伴放射痛,Tinel征(+);左足外侧及足背皮肤刺痛觉减退;膝、踝及足部各关节屈伸正常。左下肢各肌肌力未见明显异常。

【辅助检查】

MRI显示左大腿中下份后部肌间隙间见结节状长T1长T2信号影,大小2.8CM×2.1CM,长径2.5CM。

【初步诊断

左大腿坐骨神经恶性神经鞘膜瘤。

【治疗】

行左侧股后侧肿物切除术。术中见坐骨神经上肿物、触之质韧,于显微镜下纵行切开神经外膜,见肿物为实性,包绕神经纤维束存在,剥离肿物,尽量保持各纤维束完整性。止血后关闭切口。术后病理检查显示为恶性周围性神经鞘膜瘤,免疫组织化学染色示S-100(+)。术后患者左下肢感觉障碍明显减轻,未行放化疗。2个月后原手术瘢痕处再次发现肿物,超声检查提示可疑神经来源(坐骨神经)性肿物,临床诊断为左大腿坐骨神经恶性神经鞘膜瘤术后复发。MRI显示左大腿后肌群团块状异常信号影,大小3.9CM×2.0CM×2.9CM,T1低信号、T2压脂呈高信号。胸腹CT未见明显异常。全麻下行肿瘤扩大切除、神经移植术。术中沿原手术切口入路,见肿物位于坐骨神经中下段,质韧、呈实性、分叶状,直径约5CM,与周围组织轻度粘连,包绕神经纤维束存在,无法分离肿物。于肿物边缘近、远侧约2CM处将坐骨神经切断。切除肿物经术中快速病理检查显示为坐骨神经恶性神经鞘膜瘤,周围切缘未见肿瘤浸润。取同侧小腿全长腓肠神经,多股合并行电缆式神经移植桥接坐骨神经缺损。术后待切口愈合后行放疗治疗。随访9个月,未见肿物局部复发,患者可穿戴足底支撑托板行走,无足底溃疡发生。见图1。



【讨论】

恶性周围性神经鞘膜瘤(MPNST)是一种神经源性恶性肿瘤,起源于具有多向分化潜能的原始神经脊细胞,占全身软组织恶性肿瘤的5%~10%,发病率约0.001%,无明显性别差异。该病约半数继发于Ⅰ型神经纤维瘤病,少数由神经鞘瘤恶变所致;好发于四肢近端,局部发现肿块为常见症状。首选影像学检查是MRI,确诊依赖于病理学检查。MPNST组织形态学多样,需行免疫组织化学与其他软组织肉瘤相鉴别,S-100蛋白为较敏感的特异性标志物。我们认为如果患者出现难以解释的足部麻木和疼痛,应考虑下肢神经鞘瘤,需沿下肢神经干检查有无包块或Tinel征。MRI检查示如存在沿神经干走行的梭形肿块,中央有坏死灶,增强扫描呈不均匀强化,可考虑该病可能性。MPNST是一种高度恶性肿物,较其他软组织肉瘤更易复发,尤其是原位复发。外科手术是主要治疗方法,术后放疗是减少手术次数以及降低复发风险的重要手段,但对远期预后无明显影响,该病对化疗不敏感。一般认为,伴有Ⅰ型神经纤维瘤病、肿瘤直径>5CM、手术切除范围是影响MPNST预后的重要因素。手术广泛切除是改善预后的唯一治疗方法。对于重要神经必须切除患者,可应用显微外科技术行神经移植重建功能。

原始出处:

曹慧,陈雷,张亚楠, 等. 坐骨神经恶性神经鞘膜瘤复发一例[J]. 中国修复重建外科杂志 2018年03期

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1801968, encodeId=2a62180196838, content=<a href='/topic/show?id=2d4de4617eb' target=_blank style='color:#2F92EE;'>#神经鞘膜瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74617, encryptionId=2d4de4617eb, topicName=神经鞘膜瘤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=62e4433, createdName=zz12341234, createdTime=Sat Sep 29 18:13:00 CST 2018, time=2018-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319140, encodeId=afeb31914024, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun May 27 22:15:33 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319076, encodeId=14a73190e61e, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Sun May 27 14:43:24 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1571810, encodeId=872f15e181013, content=<a href='/topic/show?id=9e40414e44c' target=_blank style='color:#2F92EE;'>#坐骨神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=106, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=41474, encryptionId=9e40414e44c, topicName=坐骨神经)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4cdc15767871, createdName=ycmayy, createdTime=Sun May 27 08:13:00 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318513, encodeId=942d318513a8, content=学习了.好详细-, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Fri May 25 17:48:09 CST 2018, time=2018-05-25, status=1, ipAttribution=)]
    2018-05-27 天地飞扬

    了解一下.谢谢分享!

    0

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    2018-05-27 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0

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    2018-05-25 虈亣靌

    学习了.好详细-

    0

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坐骨神经盆腔出口狭窄症与梨状肌症候群,是发生在坐骨神经自骶丛神经分开后,在走经骨纤维管道离开骨盆达臀部之前,因局部病变所引起的嵌压综合征。前者病变主要位于盆腔出口周围,而后者主要是梨状肌本身病变所致。本研究为了通过报道横断面影像学表现、影像学研究和治疗结果对临床的影响增加临床对梨状肌综合征(PMs)认识的重要性,并将结果发表在Eur Radiol上。

原发性坐骨神经淋巴瘤一例

      患者 男,42岁。因右下肢麻木、疼痛1年,加重半年,于2011年4月20日在山东大学齐鲁医院血液科治疗。患者1年前无明显诱因出现右小腿屈侧疼痛,行走时疼痛明显伴右足麻木,逐渐出现右侧腓肠肌下垂无力,在当地医院诊断为腰椎间盘突出,行手术治疗,术后足部麻木感消失。术后1个月患者出现右腿短缩感;术后5个月出现右大腿背侧阵发性疼痛,触诊有电击感,屈足活动受限,肌肉僵硬,平卧

Neural Regen Res:黄芪甲苷促进坐骨神经再生的机制

黄芪甲苷是中药黄芪的主要活性成分,以往研究表明,具有抗炎、抗氧化、抗病毒、抗细胞凋亡、免疫调节,尤其对神经缺血有保护作用。那么,神经损伤后黄芪甲苷的保护作用是通过何种途径产生的呢? 吉林大学药学院张晓红所在课题组进行的一项关于“The mechanism of astragaloside IV promoting sciatic nerve regeneration”

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