orthopedic paper IV
Lipoma under soft spinal membrane complicated with high paraplegia
椎管内肿瘤，虽85%为髓外肿瘤，然软脊膜下脂肪瘤实属罕见。因其位置紧贴脊髓，所造成的病理改变及临床症状易与髓内肿瘤相混。但因其为良性病变，手术处理及其预后均迥然不同。我院收治一例，术后随访半年，现已恢复。兹报告如下:
AAlthough 85% of intraspinal tumors are extramedullary tumors, infraspinal lipoma is rare. Because its location is close to the spinal cord, the resulting pathological changes and clinical symptoms are easy to be mixed with intramedullary tumors. However, due to its benign nature, surgical management and prognosis are quite different. One case was treated in our hospital and has been followed up for half a year after the operation. It has now recovered. This is reported as follows.
患者男性，39岁，本县农民，已婚，病案号1340，于1979年3月28日入院。
两下肢麻木、无力伴右胸带状刺痛半年，大小便困难，不能行走、站立2月，麻痹平面上升至乳头水平伴呼吸不畅2周。
A 39-year-old farmer from our county, married with medical record No.1340, was admitted to our hospital on March 28, 1979.
Numbness and weakness of both lower limbs with band-like stabbing pain in the right chest for half a year, difficulty in urination and defecation, inability to walk and stand for two months, and elevation of the plane of paralysis to the level of nipples with poor breathing for two weeks.
体检: 第二肋间以下浅感觉基本消失，以右侧为重，左侧遗有部分刺痛区。腹壁、提睾反射不能引出，两下肢肌力 8-4 级，无踝阵挛。上胸段脊柱棘突叩击痛，但无畸形。脊柱胸段X线片阴性。奎肯氏试验示蛛网膜下腔完全梗阻，脑脊液化验: 潘氏试验(+)，细胞数10个/立方毫米，呈弗洛因氏征(Froin)。截瘫指数2-4 (感觉2，运动1，括约肌1)。
Physical examination
The superficial sensation under the second intercostal space almost disappeared, with the focus on the right side, and some stabbing pain areas were left. Abdominal wall and cremaster reflex could not be extracted, and the muscle strength of both lower limbs was grade 8–4, with no ankle clonus. The spinous process of the upper thoracic spine was impacted with pain, but there was no deformity. X-rays of the thoracic spine were negative. A Kuiken’s test showed complete obstruction of the subarachnoid space, and cerebrospinal fluid tests: Pan Shi test (+), with 10 cells/mm3 and Froin. Paraplegia index was 2–4 (sensation 2, movement 1, sphincter 1).
手术前诊断: 颈胸段椎管内肿瘤并截瘫，髓外型。
4月4日在局麻下行椎管内探查。后正中入路，胸7-12全椎板切除，切开颈6-胸5椎管。硬膜外脂肪分布匀均，无局部吸收现象，亦未见局部隆起、增粗，扪之未发现硬变区。但术中胸4穿刺奎肯氐试验仍示梗阻，乃切开硬脊膜，见胸1:2脊髓背侧略偏右有35x20x12厘米脂肪样黄色柔软赘生物致使脊髓被压1/2，为蛛网膜下腔阻塞因素。在软脊膜下试行剥离切除，因其相邻紧密，为避免脊髓损伤仅切除赘生物80%，送检病理，银夹标记，冲洗手术野。此时可见脊髓恢复较弱搏动，硬膜未缝，任其敞开减压，常规缝合软组织，未引流。
Pre-operative diagnosis: tumor in cervical and thoracic spinal canal with paraplegia, extramedullary.
On April 4, the spinal canal was explored under local anesthesia. Through posterior midline approach, complete laminectomy was performed for thoracic region 7–12, and cervical region 6–thoracic region 5 spinal canal was cut open. Epidural fat was uniformly distributed and there was no local absorption, nor was there any local bulge or thickening, and no hard degeneration area was found in palpation. However, during the operation, the QUAKENBI test of thoracic 4-puncture still showed obstruction, and the dura mater was incised. It was shown that thoracic 1:2 spinal cord was slightly to the right at the dorsal side, and there were 35x20x12 cm fat-like yellow soft vegetation, which caused the spinal cord to be compressed by 1/2, which was the factor of subarachnoid space obstruction. Stripping resection was performed under the soft spinal membrane. Due to the close proximity, only 80% of the vegetation was removed to avoid spinal cord injury. The pathology was sent for examination, marked with silver clips, and the operation field was rinsed. At this time, the spinal cord recovered to weak pulsation, and the dura mater was not sutured, which was allowed to open for decompression. The soft tissues were routinely sutured, and no drainage was performed.
手术后48小时，两下肢即有烧灼感，尔后运动、感觉渐形恢复。术后19天撤除导尿管自行排尿，此时亦可自行翻身。住院36天，无并发症出院休养。
The burning sensation developed in both lower limbs 48 hours after the operation, and the movement and sensation gradually recovered. The urinary catheter was removed 19 days after surgery to urinate on his own, and he could also turn over on his own at this time. She was hospitalized for 36 days and discharged for rest without complications.
病理报告: 赘性生物为“脂肪组织”，病理号4724。
术后半年，患者可以扶拐下地行走，感觉全部恢复，大便正常，小便射程同正常，食纳佳，营养良好，可做编织类手工劳动。
Pathological report: The neoplastic organism was “adipose tissue”, pathological No.4724.
Half a year after the operation, the patient could walk under the crutch, and all of his feelings recovered. His stool was normal, and his range of urination was the same as normal. He had good food and nutrition, and could do manual work like weaving.
讨 论
软脊膜下肿瘤为加盖在脊髓上的赘生物，造成占位性压迫导致椎管梗阻，而不同于髓内肿瘤直接破坏脊髓结构，除可致占位性病理改变外，还可损害脊髓功能，前者以良性病变居多，后者则恶性为主。但两者均因与脊髓关系密切，可早期出现截瘫，并且病情进展快。此例“脂肪瘤”，当属良性病变，仅半年病程，亦造成椎管完全梗阻的严重情况。
Discussion
Submucosal tumors of spinal cord are vegetations covered on the spinal cord, which cause space-occupying compression and spinal canal obstruction. Unlike intramedullary tumors that directly destroy the spinal cord structure, they can not only cause space-occupying pathological changes, but also damage spinal cord function. The former are mostly benign lesions, while the latter are mainly malignant. However, both of them are closely related to the spinal cord, so the paraplegia can occur early and the disease progresses quickly. The “lipoma” in this case was a benign lesion with a course of only half a year, which also caused a severe case of complete spinal canal obstruction.
髓内恶性肿瘤，如胶质细胞瘤，截瘫出现早而完全。紧邻脊髓的良性病变，往往因赘生物偏于某一侧面出现临床上同侧瘫痪较严重现象，即所谓布朗–色夸(Brown-sequard)氏征。该例两侧瘫痪程度不等，且早期出现右侧“肋间神经痛”，这与术中见赘生物偏于右侧相符合。同时，膀胱、直肠机能障碍亦不完全。
Intramedullary malignancies, such as gliomas, and paraplegia occur early and completely. Benign lesions adjacent to the spinal cord often present with clinically severe ipsilateral paralysis due to the deviation of the neoplasm to one side, the so-called Brown-sequard syndrome. In this case, the degree of bilateral paralysis was different, and the right “intercostal neuralgia” appeared in the early stage, which was consistent with the vegetation leaning to the right during the operation. At the same time, bladder and rectum dysfunction is not complete.
临床上进行性截瘫出现，奎氏试验示梗阻，即表示有机械受压因素，以早期手术探查病损并及时减压为宜。因为即使良性病变，压迫过久亦可造成脊髓之不可逆损害。有谓弛缓性瘫痪，即使数周也难以复元。我们此例，及时予以手术减压，效果良好。
In the clinical practice of progressive paraplegia, the Kwechsler test showed obstruction, which meant that there was mechanical compression factor. It was advisable to carry out early surgical exploration of the lesion and timely decompress. Because even benign lesions, prolonged compression can cause irreversible damage to the spinal cord. It’s called flaccid paralysis, and you can’t recover from it for weeks. In our case, surgical decompression was performed in time with good results.
根据临床上麻痹平面以及奎氏试验、脊髓造影常可了解椎管梗阻情况和指示定位。术中视脊髓恢复搏动情况来判断减压效果。在不能彻底清除赘生物的情况下，硬膜敞开的减压措施是十分必要的。
According to the plane of clinical paralysis and the Quirrell test and myelography, we can often understand the situation of spinal canal obstruction and indicate the location. The decompression effect was judged according to the recovery of spinal cord pulsation during the operation. In cases where the neoplasm cannot be completely removed, decompression with an open dura is necessary.
软脊膜下脂肪瘤，组织柔软，又系良性，在硬膜上不造成脂肪被吸收，又无局部隆起及发硬区，故不能在硬膜外被察出; 当切开硬脊膜，透过软膜，可以清楚地被识出: 一块黄色赘生物盖在脊髓上，血管增多，分布异常，脊髓受压变扁。
The lipoma under the soft spinal membrane has soft tissue and is benign. It does not cause fat absorption on the dura mater, and there is no local uplift and hard area, so it cannot be detected outside the dura mater. When the dura mater was incised and the soft membrane was penetrated, it was clearly recognized that a yellow vegetation covered the spinal cord, with an increase in blood vessels, an abnormal distribution, and the compressed and flattened spinal cord.
小结
本文报告了一例软脊膜下脂肪瘤并截瘫的少见病例及其治疗经过和恢复情况，从病理和临床角度分析了其与髓内肿瘤的鉴别，提出了诊断和治疗意见。指出: 手术宜尽早施行，但不须冒险“彻底”切除肿瘤，而脊髓减压措施十分必要。
Summary
In this paper, we report a rare case of infraspinal lipoma with paraplegia, as well as its treatment and recovery. The differential diagnosis from intramedullary tumor was analyzed from the pathological and clinical aspects, and the diagnosis and treatment were proposed. It was pointed out that the operation should be performed as soon as possible without risking “complete” resection of the tumor, and spinal cord decompression was necessary.
By Mingjie Li, Nanling Hospital Surgery Department
原载
