小脑扁桃体软膜下切除术与硬膜扩大修补术治疗 Chiari Ⅰ型畸形并脊髓空洞的疗效观察

Efficacy observation between subpial cerebellar tonsillectomy and dural expansion repair on Chiari Ⅰ malformation with syringomyelia

中文关键词:  小脑扁桃体下疝切除术  Chiari畸形Ⅰ型  脊髓空洞症  后颅窝减压术

英文关键词:Excision of cerebellar tonsillar hernia  Chiari type Ⅰ malformation  Syringomyelia  Posterior fossa decompression

中文摘要:

  【摘要】 目的：观察小脑扁桃体软膜下切除术与硬膜扩大修补术治疗Chiari Ⅰ型畸形合并脊髓空洞的手术效果及预后，为临床治疗提供决策。方法：回顾性分析2013年11月～2016年11月在我院接受治疗的115例ChiariⅠ畸形患者的临床资料，男34例，女81例；年龄16～60岁（42.3±11.3岁）。患者有脊髓空洞症表现49例次，枕大孔区神经刺激症状58例次，延颈髓受压症状9例次，后组颅神经及小脑功能障碍25例次，高颅压症状24例次。脊髓空洞26例累及颈段，85例累及胸段，4例累及腰段，3例合并有脑积水，2例合并有胸段脊柱侧凸。其中78例采用后颅窝减压+下疝的小脑扁桃体切除+四脑室流出道的膜性结构切除术（A组），37例采用枕骨大孔区减压+硬脑膜成形术（B组）。记录患者的住院时间，术中出血量，术后并发症，术前、术后6个月影像学特征，Klekamp神经评分，临床症状变化情况。结果：A组手术时间为159.32±40.06min，高于B组（134.10±30.76min）（P<0.05）；术后A、B组分别有11例、8例发热，3例、1例皮下积液，3例、2例切口感染，A组术后头晕头痛发生率（25.6％，20/78）高于B组（8.1%，3/37）（P<0.05），总体并发症发生率两组无明显差异（P>0.05）。术后疼痛、感觉障碍、共济失调、运动障碍的Klekamp神经评分较前有改善（P<0.05）；术后A组症状改善69例（88.4%），B组31例（83.8%）；两组神经评分改变、临床表现改善情况差异无统计学意义（P>0.05）；术后空洞闭合或缩小例数分别为54例、29例，无变化例数分别为22例、7例，扩大例数为2例、1例，两组术后空洞变化差异无统计学意义（P>0.05）。结论：小脑扁桃体软膜下切除术治疗Chiari Ⅰ型畸形并脊髓空洞手术效果与硬膜扩大修补术无明显差异，但手术时间长，术后头晕头痛发生率较高。

英文摘要:

  【Abstract】 Objectives: To observe the postoperative effect and prognosis of subpial cerebellar tonsillectomy and dural expansion repair in the treatment of Chiari I malformation with syringomyelia, and to provide clinical evidence for decision making in clinical practice. Methods: From November 2013 to November 2016, the clinical data of 115 cases with Chiari I malformation that treated in our hospital were retrospectively analyzed, including 34 males and 81 females. The mean age was 42.3±11.3 years old(range, 16 to 60 years). There were 49 cases with syringomyelia, 58 cases with nerve stimulation in occipital foramen magnum, 9 cases with compression of cervico-medullary, 25 cases with dysfunction of posterior cranial nerve and cerebella, and 24 cases with high intracranial pressure. There were 26 cases of syringomyelia with cervical segments involvement, 85 cases with thoracic section involvement, 4 cases with waist involvement, 3 cases were associated with hydrocephalus, and 2 cases were combined with scoliosis inthoracic segments. Among them, 78 cases treated with posterior fossa decompression and lower cerebellar hernia tonsillectomy and the mucous membrane excision of the 4th ventricle outflow tract(group A), and 37 cases adopted occipital foramen magnum decompression and dural angioplasty(group B). The hospitalization time, intraoperative blood loss, postoperative complications, 6 months postoperative imaging features, Klekamp nerve score, and clinical symptoms were recorded. Results: The operation time of group A(159.32±40.06min) was higher than that of group B(134.10±30.76min)(P<0.05). Postoperatively, there were 11 and 8 cases respectively in group A and B with fever, 3 cases and 1 case with subcutaneous effusion, and 3 cases and 2 cases with incision infection. The incidence of dizziness and headache in group A postoperatively was 20 cases, which was higher than that of group B, 3 cases(P<0.05). There was no significant difference of overall complication between the two groups (P>0.05). There was 1 point change in postoperative pain, sensory disturbances, ataxia under Klekamp nerve score, and there appeared poor improvement in dyskinesia; a total of 69 patients(88.4%) with alleviated symptoms in group A, and 31(83.8%) in group B. There was no significant difference in neurological score or the improvement of clinical manifestations between the two groups(P>0.05). Also, there were 54 and 29 cases respectively with reduced cavity after operation, 22 and 7 cases without changes, 2 cases and 1 case with expansion, and there was no significant difference between the two groups in the cavity changes after operation(P<0.05). Conclusions: The effect of subpial cerebellar tonsillectomy in the treatment of Chiari I malformation with syringomyelia is not significantly different from that of dural expansion repair, but the operation time is long and the incidence of dizziness and headache after operation is high.