Management of 1000 vestibular schwannomas (acoustic neuromas): The facial nerve - Preservation and restitution of function
Management of 1000 vestibular schwannomas (acoustic neuromas): The facial nerve - Preservation and restitution of function
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DOI：
10.1097/00006123-199704000-00006
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发表时间：
1997-04-01
期刊：
影响因子：
4.8
通讯作者：
Matthies, C
中科院分区：
文献类型：
--
作者：
Samii, M;Matthies, C
目的：虽然报道的前庭神经鞘瘤术后面神经保留率不断增加，但面神经麻痹或瘫痪是手术后常见的后遗症。这项研究的主要目标是确定正确的适应症、时机和治疗类型的标准，以治疗那些没有解剖神经连续性的瘫痪患者和那些失去解剖连续性的患者。方法：1978年至1993年，诺德施塔特医院神经外科手术治疗了1000例前庭神经鞘瘤。在979例完全切除和21例故意部分切除中，929例(93%)面神经解剖得到保留。保存率正在提高，最近的案例证明了这一点，保存得到了特殊的电生理监测的支持。面神经解剖切断60例(6%)。在以往的手术中有11例(1%)在解剖上丢失。对于神经不连续的患者(42例)，在同一手术环境下，采用三种可供选择的手术方式(桥小脑角内、颅内-颞内、颅内-颅外)中的一种进行即刻神经重建。在脑干近端面神经残端丢失的情况下，大多数患者在肿瘤手术后几周内通过联合舌下神经实现了早期复苏。少数有解剖神经连续性但无神经支配10~12个月的患者，应用了舌下-面联合移植。所有部分或完全性瘫痪的患者每隔3~6个月进行一次定期对照和调整理疗的特殊随访计划。结果：桥小脑角脑神经重建术中，61%~70%的患者恢复了完全闭眼，总体结果相当于House-Brackmann分级3级，79%的患者舌下面部恢复到3级。从瘫痪开始到重建程序之间的时间长短对结果的质量起决定性作用。这些数据针对其他治疗方案和影响结果的某些参数进行了讨论。结论：这种处理包含以下三个主要原则：1)通过术中监测保持面神经功能的连续性，2)在失去连续性的情况下进行早期神经重建，3)为所有不完全或完全瘫痪的患者安排随访计划。
OBJECTIVE: Although the rate of reported facial nerve preservation after surgery for vestibular schwannomas continuously increases, facial nerve paresis or paralysis is a frequent postsurgical sequelae of major concern. The major goal of this study was to define criteria for the right indication, timing, and type of therapy for patients with palsies despite anatomic nerve continuity and those with loss of anatomic continuity,METHODS: One thousand vestibular schwannomas were surgically treated at the Department of Neurosurgery at Nordstadt Hospital from 1978 to 1993. Of 979 cases of complete removal and 21 cases of deliberately partial removal, the facial nerve was anatomically preserved in 929 cases (93%). The rate of preservation is increasing, as is evidenced in the most recent cases, and preservation is supported by special electrophysiological monitoring. The facial nerve was anatomically severed in 60 cases (6%). It was anatomically lost in previous operations that were performed elsewhere in 11 cases (1%). In case of nerve discontinuity (42 cases), immediate nerve reconstruction by one of three available intracranial procedures (within the cerebellopontine angle, intracranial-intratemporal, intracranial-extracranial) was performed in the same surgical setting. In case of loss of the proximal facial nerve stump at the brain stem, early reanimation by combination with the hypoglossal nerve was achieved in most patients within weeks after tumor surgery. In a few patients with anatomic nerve continuity but absence of reinnervation for 10 to 12 months, a hypoglossal-facial combination was applied. All the patients with partial or with complete palsies were treated in a special follow-up program of regular controls and of modulation of physiotherapeutic treatment every 3 to 6 months.RESULTS: In intracranial nerve reconstruction at the cerebellopontine angle, 61 to 70% of patients regained complete eye closure and an overall result equivalent to House-Brackmann Grade 3. Hypoglossal-facial reanimation led to Grade 3 in 79%. The duration between the onset of paralysis and the reconstructive procedure is decisive for the quality of the outcome. These data are discussed in view of other treatment options and certain parameters influencing outcome.CONCLUSIONS: This management contains three major principles as follows: 1) preservation of facial nerve continuity in function by the aid of intraoperative monitoring, 2) early nerve reconstruction in case of lost continuity, and 3) scheduled follow-up program for all patients with incomplete or complete palsies.