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糖尿病合并椎管内马尾神经鞘瘤一例

2018-05-21 段霖 陈璐 许光 中国糖尿病杂志

患者男,65岁,因“双下肢麻木6个月,加重伴疼痛、乏力1个月”来我院。

【一般资料】

患者男,65岁,

【主诉】

因“双下肢麻木6个月,加重伴疼痛、乏力1个月”来我院。

【既往史】

既往了2DM病史5年,平素口服“磺脲类”“二甲双胍”等降糖药治疗,血糖控制欠佳。

【现病史】

2014年7月2日行走时觉腰部伴左大腿内侧疼痛,休息后症状未减轻,于当地某医院行腰椎CT(L3-S1),诊断为“腰椎间盘突出症”,给予止痛、理疗等处理,症状减轻但时有反复。2014年9月上旬出现双下肢足部及小腿发凉、麻木,左侧明显,夜间休息更甚,当地医院拟诊为糖尿病周围神经病变(DPN),予营养神经、改善微循环等措施效果不明显,症状反复。此后逐渐出现双下肢麻木加重,夜间明显,行走乏力,左侧更明显,一直按DPN处理。于2015年1月20日因下肢麻木疼痛,乏力行走困难转至我院诊治。入院时轮椅推入病房,搀扶行走至病床。近2个月来神志精神可、饮食、睡眠正常,大便正常,间断有小便失禁现象。

【体格检查】

血压150/100mmHg,神志清,言语流利,心肺阴性,脊柱无压痛,4字试验(+),直腿抬高试验(一)。双足背动脉搏动正常。颅神经检查阴性,脊柱无压痛。双下肢针刺觉减退及双足底音叉振动觉减退,左侧较右侧明显,远端较近端明显。双上肢感觉未见异常。双上肢肌力正常,双下肢肌力左侧III(+)级,右侧IV(—)级,双侧膝腱反射、跟腱反射减弱,病理征(一)。入院初步诊断:T2DM;DPN;腰椎间盘突出症;高血压病2级很高危组。初步治疗给予控制血糖、血压、营养神经、改善微循环等治疗措施。

【辅助检查】

入院后各项检查示:血尿粪常规、肝肾功、电解质、凝血、甲功、血脂未见异常,自身抗体谱、肿瘤全项及传染病检查均未见异常,FPG74mmol/L,HbA1C6.8%。双足底振动感觉阈值(VPT)检查,左侧28V,右侧25V为中度风险,报告有DPN可能。下肢神经传导速度(NCV)测定:左右腓总运动神经分别为22m/s、35m/s,F波缺失;左右胫神经分别为13m/s、25m/s,F波缺失;左右腓感觉神经分别为27.3m/s、36.4m/s;左右腓浅神经分别为8.5m/s、12.2m/s,NCV减慢。影像检查:腰椎MRI示腰2~3椎管内占位,考虑神经源性肿瘤(图1~2);腰3~4、腰4~5、腰5~骶1椎间盘膨出;腰椎退行性改变。


图1  腰椎2~3椎管内占位术前MIR影像


图2  腰椎2~3椎管内占位术后MIR影像

【治疗】

经内科治疗,下肢麻木、疼痛、乏力症状无明显变化,血糖、血压稳定后,2015年1月24日转入神经外科。于2015年1月26日在插管全麻下行“腰2~3椎管内占位切除术”。手术过程顺利,术中切开硬脊膜即见3条马尾神经下方一黄白色肿瘤,边界清,包膜完整,起源于马尾神经一支,与周围神经黏连,肿瘤腹外侧端与硬脊膜黏连紧密,大小约3cm×2cm×2cm,质韧,血供丰富。手术由包膜内分块切除肿瘤,术后病理见肉眼结节性肿物1个,大小2.3cm×2.0cm×1.3cm;镜下A区瘤细胞丰富,呈现栅栏状排列;B区细胞稀疏,有黏液基质。特殊染色:黏液染色(AB)、糖原染色(PAS)阴性;免疫组化:S-100蛋白(+)、PGP9.5(+)、CD34分子(+)、髓磷脂碱性蛋白(MBP)(+)、胶质纤维酸性蛋白(GFAP)、神经纤维细丝蛋白(NF)、上皮膜抗原(EMA)均为阴性。病理诊断:(L2~3椎管内)神经鞘瘤,中央伴出血、嚢性变(图3~4)。最后诊断为糖尿病合并腰2~3椎管内马尾神经鞘瘤。术后给予补液、止血、消炎等治疗,于2015年2月6日康复出院。出院时其下肢麻木、疼痛、乏力症状消失,下肢肌力V级。半年后随访其症状无反复,复查周围神经传导正常。


图3  L2-3椎管内神经鞘瘤,中央伴出血、嚢性变病理HE染色(40×)


图4  L2-3椎管内神经鞘瘤,中央伴出血、嚢性变病理HE染色(100×)

原始出处:

段霖, 陈璐, 许光. 糖尿病合并椎管内马尾神经鞘瘤一例[J]. 中国糖尿病杂志, 2017, 25(1):81-84.

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topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Fri May 25 13:13:50 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318302, encodeId=8af731830206, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri May 25 06:21:15 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317947, encodeId=aaf931e947ec, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Wed May 23 23:07:15 CST 2018, time=2018-05-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340170, encodeId=417013401e061, content=<a href='/topic/show?id=d0c3e4615f2' target=_blank style='color:#2F92EE;'>#神经鞘瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74615, encryptionId=d0c3e4615f2, topicName=神经鞘瘤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=48732500158, createdName=12498c32m68暂无昵称, createdTime=Wed May 23 09:52:00 CST 2018, time=2018-05-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317608, encodeId=219431e608b4, content=好医生!, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=41962298363, createdName=121ff658m46暂无昵称, createdTime=Tue May 22 22:14:59 CST 2018, time=2018-05-22, status=1, ipAttribution=)]
    2018-10-02 bugit
  4. 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objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=41962298363, createdName=121ff658m46暂无昵称, createdTime=Tue May 22 22:14:59 CST 2018, time=2018-05-22, status=1, ipAttribution=)]
    2018-07-10 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  5. 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attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Wed May 23 23:07:15 CST 2018, time=2018-05-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340170, encodeId=417013401e061, content=<a href='/topic/show?id=d0c3e4615f2' target=_blank style='color:#2F92EE;'>#神经鞘瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74615, encryptionId=d0c3e4615f2, topicName=神经鞘瘤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=48732500158, createdName=12498c32m68暂无昵称, createdTime=Wed May 23 09:52:00 CST 2018, time=2018-05-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317608, encodeId=219431e608b4, content=好医生!, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=41962298363, createdName=121ff658m46暂无昵称, createdTime=Tue May 22 22:14:59 CST 2018, time=2018-05-22, status=1, ipAttribution=)]
    2018-06-17 jyzxjiangqin

    糖尿病的治疗.

    0

  6. 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objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=41962298363, createdName=121ff658m46暂无昵称, createdTime=Tue May 22 22:14:59 CST 2018, time=2018-05-22, status=1, ipAttribution=)]
    2018-05-25 清风拂面

    谢谢分享学习

    0

  7. 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topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Fri May 25 13:13:50 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318302, encodeId=8af731830206, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri May 25 06:21:15 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317947, encodeId=aaf931e947ec, content=学习了.谢谢分享., beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/xkvRjYnJzzRJ2R0y7VhicibvkjPWHjIMmu4ZpKnE9cWAu4lVicS3uDUCfF4M4JWvrkrYfpb2KehPV0Ee29tPqyPEebBUibiaKhnvD/0, createdBy=f8412001184, createdName=惠映实验室, createdTime=Wed May 23 23:07:15 CST 2018, time=2018-05-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340170, encodeId=417013401e061, content=<a href='/topic/show?id=d0c3e4615f2' target=_blank style='color:#2F92EE;'>#神经鞘瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74615, encryptionId=d0c3e4615f2, topicName=神经鞘瘤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=48732500158, createdName=12498c32m68暂无昵称, createdTime=Wed May 23 09:52:00 CST 2018, time=2018-05-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317608, encodeId=219431e608b4, content=好医生!, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=41962298363, createdName=121ff658m46暂无昵称, createdTime=Tue May 22 22:14:59 CST 2018, time=2018-05-22, status=1, ipAttribution=)]
    2018-05-25 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0

  8. 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objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=41962298363, createdName=121ff658m46暂无昵称, createdTime=Tue May 22 22:14:59 CST 2018, time=2018-05-22, status=1, ipAttribution=)]
    2018-05-23 惠映实验室

    学习了.谢谢分享.

    0

  9. 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  10. 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    2018-05-22 121ff658m46暂无昵称

    好医生!

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