聽神經(jīng)瘤術(shù)后面神經(jīng)功能恢復(fù)規(guī)律及腫瘤大小對(duì)其的影響

丁維亮，蒲珂，王宏

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聽神經(jīng)瘤術(shù)后面神經(jīng)功能恢復(fù)規(guī)律及腫瘤大小對(duì)其的影響

丁維亮1，蒲珂2，王宏2

摘要:目的探討聽神經(jīng)瘤術(shù)后面神經(jīng)功能恢復(fù)的規(guī)律以及腫瘤大小對(duì)術(shù)后面神經(jīng)功能的影響。方法89例聽神經(jīng)瘤患者均采用顯微外科乙狀竇后入路開顱聽神經(jīng)瘤切除術(shù)，術(shù)中行神經(jīng)電生理檢測(cè)，均達(dá)到面神經(jīng)的完整解剖保留。于術(shù)后即刻、術(shù)后15 d、45 d、3個(gè)月、6個(gè)月、12個(gè)月及12個(gè)月后等不同時(shí)點(diǎn)采用面神經(jīng)功能分級(jí)標(biāo)準(zhǔn)（HB分級(jí)）對(duì)患者的面神經(jīng)功能級(jí)別進(jìn)行評(píng)估，分析術(shù)后面神經(jīng)功能的恢復(fù)規(guī)律。并根據(jù)瘤體最大直徑分為＜30 mm（23例）、30～40 mm（31例）和 40 mm組（35例），比較各組術(shù)后早期（15 d）和遠(yuǎn)期（12個(gè)月后）的面神經(jīng)功能分級(jí)。結(jié)果本組89例患者，聽神經(jīng)瘤術(shù)后15 d面神經(jīng)功能最差（優(yōu)秀率為52.81%），3個(gè)月內(nèi)逐漸恢復(fù)（優(yōu)秀率為80.90%），12個(gè)月內(nèi)絕大部分可恢復(fù)至優(yōu)秀水平（優(yōu)秀率為91.01%），12個(gè)月后面神經(jīng)恢復(fù)較平穩(wěn)（優(yōu)秀率為92.13%）。不同瘤體直徑組術(shù)后早、遠(yuǎn)期HB分級(jí)差異均有統(tǒng)計(jì)學(xué)意義（χ2分別為23.34、14.46，P＜0.05）；瘤體直徑與術(shù)后早、遠(yuǎn)期HB分級(jí)均呈正相關(guān)（r分別為0.476、0.379，P＜0.05），面神經(jīng)功能優(yōu)秀率均隨瘤體直徑增加而降低。結(jié)論聽神經(jīng)瘤術(shù)后早期（15 d內(nèi)）患者面神經(jīng)功能可能出現(xiàn)明顯惡化，術(shù)后12個(gè)月絕大部分可恢復(fù)至優(yōu)秀水平。瘤體直徑是影響術(shù)后早、遠(yuǎn)期面神經(jīng)功能預(yù)后的因素之一。

關(guān)鍵詞：神經(jīng)瘤,聽；手術(shù)后期間；面神經(jīng)；顯微外科手術(shù)；功能恢復(fù)；隨訪研究

作者單位：1天津醫(yī)科大學(xué)研究生院（郵編300070）；2天津市環(huán)湖醫(yī)院神經(jīng)外科

聽神經(jīng)瘤是一種常見的顱內(nèi)神經(jīng)鞘瘤，約占顱內(nèi)腫瘤的8.4%，橋小腦角區(qū)腫瘤的80%～90%，好發(fā)于中年人，發(fā)病高峰為30～50歲[1]。手術(shù)是目前治療聽神經(jīng)瘤的最有效手段，面神經(jīng)功能障礙是術(shù)后常見的并發(fā)癥之一。隨著臨床顯微外科手術(shù)技術(shù)、解剖技術(shù)和術(shù)中神經(jīng)電生理檢測(cè)技術(shù)的發(fā)展，術(shù)中面神經(jīng)的解剖保留率顯著提高，但要真正意義上提高術(shù)后面神經(jīng)功能，最大限度地減少術(shù)后面癱的發(fā)生，提高聽神經(jīng)瘤患者術(shù)后生活質(zhì)量，仍然是當(dāng)前聽神經(jīng)瘤手術(shù)面臨的重要難題之一。以往研究大多針對(duì)手術(shù)治療與術(shù)后遠(yuǎn)期面神經(jīng)功能狀態(tài)的關(guān)系，而忽視了術(shù)后面神經(jīng)功能的變化規(guī)律。本研究旨在探討術(shù)后面神經(jīng)功能的變化規(guī)律以及腫瘤大小對(duì)術(shù)后面神經(jīng)功能的影響。

1　對(duì)象與方法

1.1患者資料選取2009年4月—2014年6月我院神經(jīng)外科由同一術(shù)者主刀的聽神經(jīng)瘤患者89例，男34例，女55例；年齡24～82歲，平均（43.0±8.5）歲。所有病例術(shù)前均行頭CT和MRI檢查符合聽神經(jīng)瘤影像學(xué)特點(diǎn)，且經(jīng)術(shù)后病理證實(shí)為神經(jīng)鞘瘤；均為單側(cè)，其中左側(cè)43例，右側(cè)46例；癥狀以耳鳴、聽力下降73例，面部麻木18例，頭痛10例，走路不穩(wěn)21例，飲水嗆咳6例。納入標(biāo)準(zhǔn)：首次行該手術(shù)，術(shù)前面神經(jīng)功能未受明顯影響，術(shù)后無復(fù)發(fā)，隨訪資料完整。

1.2術(shù)后面神經(jīng)功能級(jí)別評(píng)估89例患者均采用顯微外科乙狀竇后入路開顱聽神經(jīng)瘤切除術(shù)，術(shù)中行神經(jīng)電生理檢測(cè)，均達(dá)到面神經(jīng)的完整解剖保留。術(shù)后常規(guī)應(yīng)用脫水、營養(yǎng)神經(jīng)藥物，并配合自身的面肌訓(xùn)練。于術(shù)后即刻、術(shù)后15 d、45 d、3個(gè)月、6個(gè)月、12個(gè)月及12個(gè)月后等不同時(shí)點(diǎn)，通過門診復(fù)查并輔以電話隨訪的方式對(duì)患者的面神經(jīng)功能級(jí)別進(jìn)行評(píng)估，隨訪截止時(shí)間為2015年6月。面神經(jīng)功能評(píng)估采用House等[2]的面神經(jīng)功能分級(jí)標(biāo)準(zhǔn)（HB分級(jí)）：Ⅰ級(jí)為正常；Ⅱ級(jí)，輕度面癱，仔細(xì)檢查可見輕微面肌無力和連帶動(dòng)作；Ⅲ級(jí)，中度面癱，有明顯的面肌無力和連帶動(dòng)作；Ⅳ級(jí)，中重度面癱，可見明顯的面肌無力和面部不對(duì)稱；Ⅴ級(jí)，重度面癱，面部不對(duì)稱和面部幾乎不能運(yùn)動(dòng)；Ⅵ級(jí)，面肌完全癱瘓。HBⅠ級(jí)、Ⅱ級(jí)為面神經(jīng)功能優(yōu)秀，HBⅢ級(jí)、Ⅳ級(jí)為較差，HBⅤ級(jí)、Ⅵ級(jí)為很差。

1.3腫瘤大小對(duì)術(shù)后面神經(jīng)功能的影響根據(jù)東京共識(shí)會(huì)議制定的腫瘤大小標(biāo)準(zhǔn)[3]將89例患者分為3組，瘤體最大直徑＜30 mm組23例，30～40 mm組31例， 40 mm組35例。比較各組術(shù)后早期（15 d）和遠(yuǎn)期（12個(gè)月后）的面神經(jīng)功能。1.4統(tǒng)計(jì)學(xué)方法采用SPSS 17.0軟件進(jìn)行統(tǒng)計(jì)學(xué)處理。計(jì)數(shù)資料組間比較采用χ2檢驗(yàn)，相關(guān)性分析采用Spearman相關(guān)，P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2　結(jié)果

2.1術(shù)后面神經(jīng)功能恢復(fù)規(guī)律術(shù)后15 d面神經(jīng)功能最差，面神經(jīng)功能優(yōu)秀率最低，之后面神經(jīng)功能優(yōu)秀率呈上升趨勢(shì)，面神經(jīng)功能較差和很差所占比例逐漸下降，術(shù)后12個(gè)月后面神經(jīng)恢復(fù)較平穩(wěn)，90%以上可恢復(fù)至優(yōu)秀水平。見圖1。

Fig. 1 The changingcurves of facial nerve function recovery in different time points圖1術(shù)后不同時(shí)點(diǎn)面神經(jīng)功能級(jí)別的變化曲線

2.2腫瘤大小對(duì)術(shù)后早、遠(yuǎn)期面神經(jīng)功能的影響

2.2.1腫瘤大小對(duì)術(shù)后早期面神經(jīng)功能的影響不同瘤體直徑組的術(shù)后早期HB分級(jí)差異有統(tǒng)計(jì)學(xué)意義（χ2=23.34，P＜0.05）；瘤體直徑與術(shù)后早期HB分級(jí)呈正相關(guān)（r=0.476，P＜0.05）；面神經(jīng)功能優(yōu)秀率隨瘤體直徑的增加明顯降低，見表1。

Tab. 1 Comparison of early postoperative nerve function results between different tumor size groups表1不同腫瘤大小患者術(shù)后早期面神經(jīng)功能比較

2.2.2腫瘤大小對(duì)術(shù)后遠(yuǎn)期面神經(jīng)功能的影響不同瘤體直徑組的術(shù)后遠(yuǎn)期HB分級(jí)差異有統(tǒng)計(jì)學(xué)意義（χ2=14.46，P＜0.05）；瘤體直徑與術(shù)后遠(yuǎn)期HB分級(jí)呈正相關(guān)（r=0.379，P＜0.05）；面神經(jīng)功能優(yōu)秀率隨瘤體直徑的增加逐漸降低，見表2。

Tab. 2 Comparison of long-term facial nerve functional outcome between different tumor size groups表2不同腫瘤大小患者術(shù)后遠(yuǎn)期面神經(jīng)功能比較

3　討論

臨床上聽神經(jīng)瘤術(shù)后早期（一般在術(shù)后3 d內(nèi)）經(jīng)常出現(xiàn)面神經(jīng)功能惡化的現(xiàn)象。有研究指出，這種現(xiàn)象的出現(xiàn)主要是由術(shù)后神經(jīng)組織水腫引起，尤其是內(nèi)耳道局部的水腫。水腫產(chǎn)生的主要原因是局部血管痙攣造成的組織缺血、靜脈淤血、手術(shù)操作對(duì)周圍組織的牽拉和損傷或術(shù)后無菌性腦膜炎[4-6]。術(shù)后72 h以后出現(xiàn)的面神經(jīng)功能惡化被定義為遲發(fā)型面癱，有文獻(xiàn)報(bào)道其發(fā)生率為11%～41%[7]。但Grant等[5]研究顯示314例聽神經(jīng)瘤患者術(shù)后僅15例（4.8%）發(fā)生遲發(fā)型面癱，平均發(fā)生時(shí)間為（10.9± 7.3）d，且80%的患者面神經(jīng)功能于3個(gè)月內(nèi)恢復(fù)到優(yōu)秀水平。Gianoli等[7]認(rèn)為遲發(fā)型面癱的病因除水腫以外，手術(shù)操作激活了神經(jīng)根部的皰疹病毒也可能導(dǎo)致術(shù)后面神經(jīng)功能惡化。由于遲發(fā)型面癱的發(fā)生時(shí)間和發(fā)生率尚存在爭議，本研究將術(shù)后15 d內(nèi)一并統(tǒng)計(jì)為術(shù)后早期。結(jié)果顯示，術(shù)后即刻面神經(jīng)功能優(yōu)秀率為94.38%，但術(shù)后15 d內(nèi)部分患者出現(xiàn)面神經(jīng)功能惡化，面神經(jīng)功能優(yōu)秀率僅為52.81%，但具體惡化時(shí)間點(diǎn)尚不明確；至術(shù)后3個(gè)月80.9%的患者面神經(jīng)功能可恢復(fù)到優(yōu)秀水平，術(shù)后12個(gè)月后面神經(jīng)恢復(fù)較平穩(wěn)，90%以上可恢復(fù)至優(yōu)秀水平，提示對(duì)于患者術(shù)后早期出現(xiàn)的面神經(jīng)惡化，常規(guī)應(yīng)用脫水、營養(yǎng)神經(jīng)藥物，加強(qiáng)面肌鍛煉，絕大部分可獲得良好預(yù)后，無需采取面神經(jīng)修復(fù)治療。

目前多項(xiàng)研究認(rèn)為聽神經(jīng)瘤術(shù)后面神經(jīng)功能狀態(tài)與腫瘤最大直徑相關(guān)，瘤體直徑越大術(shù)后面神經(jīng)功能越差[6, 8-9]。與本研究結(jié)果一致，其原因可能是腫瘤越大，對(duì)面神經(jīng)和周圍組織血管推擠、壓迫和粘連程度越大，以致術(shù)中操作對(duì)周圍組織牽拉越明顯，手術(shù)難度越大，手術(shù)操作時(shí)間延長，這些均可能導(dǎo)致術(shù)后神經(jīng)組織水腫的發(fā)生率增高，水腫程度加重[10]。另外，本研究結(jié)果顯示，瘤體直徑對(duì)術(shù)后早期面神經(jīng)功能惡化的影響較遠(yuǎn)期明顯，與以往研究結(jié)果一致[8-9,11-12]。瘤體最大直徑＜30 mm者，術(shù)后早期和遠(yuǎn)期面神經(jīng)功能預(yù)后良好；而直徑 40 mm者，術(shù)后早期可能會(huì)出現(xiàn)面神經(jīng)功能惡化明顯，且部分持續(xù)時(shí)間較長，遠(yuǎn)期預(yù)后較差，應(yīng)于術(shù)后及時(shí)給予有效的干預(yù)措施。

有研究指出，術(shù)后面神經(jīng)功能的恢復(fù)情況可能與多種因素有關(guān)，如年齡、術(shù)前病程、術(shù)前癥狀、腫瘤質(zhì)地、術(shù)后并發(fā)癥、術(shù)后伽馬刀治療和術(shù)者經(jīng)驗(yàn)等[11-12]。但也有研究顯示這些因素與術(shù)后面神經(jīng)功能變化無明顯相關(guān)性[4,13]。術(shù)后面神經(jīng)功能的恢復(fù)規(guī)律和影響因素仍有待于進(jìn)一步研究。

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（2015-07-20收稿2015-12-04修回）

（本文編輯陳麗潔）

流行病學(xué)調(diào)查

The facial nerve functional recovery law and tumor size impact after acoustic neuroma surgery DING Weiliang1, PU Ke2, WANG Hong2

1 Graduate School of Tianjin Medical University，Tianjin 300070, China; 2 Department of Neurosurgery, Tianjin Huanhu Hospital Corresponding Author E-mail:dwliang.8758@163.com

Abstract:Objective To explore the facial nerve functional recovery law after resection of acoustic neuroma，and the influence of tumor size on postoperative facial nerve function. Methods According to the House-Brackman (HB) facial nerve function classification method, 89 patients with acoustic neuroma were performed microsurgical resection with the ret?rosigmoid approach and facial nerve preservation. The HB classification method was used to evaluate the facial nerve func?tion at operation, 15 d, 45 d, 3 m, 6 m, 12 m and more than 12 m after surgery. The recovery pattern of neurological function after operation was analyzed. al. According to the tumor size, patients were divided into three groups: diameter＜30 mm group (n=23), 30-40 mm group (n=31) and 40 mm group (n=35). The facial nerve function was compared between different groups with early postoperative (within 15 days) and long-term (more than 12 months). Results The facial nerve function was the worst in 15 days after operation (excellence rate was 52.81%), but the function was returned to normal in postopera?tive 3 months (excellent rate reached 80.90%). After postoperative 12 months, almost all patients returned to normal func?tion (excellent rate was 91.01% ), and the facial nerve recovery was more smoothly (excellent rate was 92.13%). Tumor size had remarkable effect on facial nerve function in the early postoperative period (χ2= 23.34, P＜0.05), and long-term period (χ2= 14.46, P＜0.05). And tumor size was positively correlated with classification of facial nerve function in the early stage (r = 0.476, P＜0.05) and long-term stage (r = 0.379, P＜0.05). The excellent rates of postoperative facial nerve function were decreased with the increased diameters of tumor size. Conclusion The facial nerve function may appear deterioration in early postoperative period (within 15 days) in patients with acoustic neuroma, which can return to the normal level in 12 months. The diameter of tumor is one of important factors influencing the early and long-term prognosis of postoperative fa?cial nerve function.

Key words:neuroma, acoustic; postoperative period; facial nerve; microsurgery; recovery of function; follow-up studies

中圖分類號(hào)：R739.41

文獻(xiàn)標(biāo)志碼：A

DOI：10.11958/20150045

作者簡介：丁維亮(1989)，男，碩士在讀，主要從事神經(jīng)外科基礎(chǔ)和臨床方面的研究

通訊作者E-mail：dwliang.8758@163.com