Chiari畸形Ⅰ型并不稳定型颅底凹陷的手术策略

发布时间：2018-05-31 00:01

本文选题：Chiari畸形 + 寰枢关节脱位　；参考：《西南医科大学》2017年硕士论文

【摘要】：目的:探讨后路减压复位内固定术对Chiari畸形I型(ACM I)并不稳定型颅底凹陷的疗效;方法:回顾西南医科大学附属医院2013年4月至2016年1月经后路减压及复位枕颈内固定术治疗的ACMI并不稳定型颅底凹陷患者15例,男性4例,女性11例,年龄19-62岁,平均43.3岁;病程1月-10余年;15例患者术前均行全脊柱/脊髓MRI及头颈部3D-CT检查,并行血管成像检查,了解周围血管走形。所有患者均合并寰枢椎脱位,齿状突陷入颅内,13例合并脊髓空洞。根据术前临床症状及影像学表现是否存在小脑扁桃体下疝超过10mm,明显延髓变性;MRI显示四脑室流出道显著狭窄或合并脑积水者及头颈交界区蛛网膜下腔闭塞,后组颅神经症状严重或呼吸心跳异常考虑与脑干受压相关等情况采取不同减压方式。其中6例采用枕大池成形(包括寰枕减压,下疝小脑扁桃体切除及枕大池硬/脊膜扩大成形),9例采用后颅窝减压术(PFD)。所有患者均采用直接复位内固定术对不稳定型颅底凹陷进行复位、固定。术后1年定期随访了解患者入院自觉症状恢复情况,以日本骨科协会(JOA)评分对患者对神经功能进行评分,通过寰齿间距(ADL),齿状突超过钱氏线距离(CL),延髓颈髓角(CMA)及脊髓空洞最大层面空洞大小等复查指标对手术效果进行综合评价。结果:本组所有患者均采用后路减压及复位内固定术,术后无患者出现神经功能恶化,无死亡病例。患者主要自觉症状头痛消失7例(7/10,70%),3例(3/7,30%)好转;头晕消失6例(6/7,85.7%),好转1例(1/7,14.3%);肢体乏力消失2例(2/11,18.2%),好转8例(8/11,72.7%),无改善1例(1/11,9.1%);肢体麻木消失4例,4/10,40%),好转6例(6/10,60%);10(66.7%)例神经功能预后良好,4(26.7%)例中效,1(6.7%)例无效。JOA评分由术前10.47±2.23分提高到术后13.67±1.54分,差异有统计学意义(P0.05)。齿状突超过Chamberlain线距离术后平均6.07±1.36mm较术前11.19±2.70下降,寰齿间隙术后3.44±1.90mm较术前4.76±2.11mm缩窄,延颈角术后136.94±7.46°较术前126.43±7.90°增大,差异有统计学意义(P0.05)。13例合并脊髓空洞病例中2例(15.4%)脊髓空洞消失,9例(69.2%)较前缩小,2例(15.4%)无明显变化。并发症:1例行枕大池成形术患者术后伤口积液,脑脊液漏,经持续腰池引流及加强换药后伤口愈合出院,随访无复发。结论:1.后路减压复位内固定术在ACM I型并不稳定颅底凹陷症治疗中能改善患者预后;2.直接后路撑开复位内固定能改善患者寰枢椎不稳,有效扩大头颈交界区椎管容积,缓解蛛网膜下腔受压,改善局部脑脊液循环;3.根据ACM I型并不稳定型颅底凹陷患者术前临床症状及影像学表现区别手术方式能在既改善患者预后同时减小手术并发症的发生率;
[Abstract]:Objective: to investigate the effect of posterior decompression and reduction and internal fixation on unstable cranial base depression of type I Chiari malformation. Methods: from April 2013 to January 2016, 15 patients with unstable cranial base depression of ACMI were treated by posterior decompression and occipitocervical internal fixation from April 2013 to January 2016, including 4 males and 11 females, aged 19-62 years with an average of 43.3 years. Fifteen patients with disease course from 1 month to more than 10 years underwent MRI of whole spine / spinal cord and 3D-CT of head and neck before operation. Angiography was performed to understand the shape of peripheral blood vessels. All patients were complicated with atlantoaxial dislocation and 13 cases with syringomyelia. According to the clinical symptoms and imaging findings before operation, there was a cerebellar subtonsillar hernia more than 10 mm. The MRI showed that the outflow tract of the fourth ventricle was significantly narrow or complicated with hydrocephalus and subarachnoid space occlusion in the junction of head and neck. In the posterior group, severe cranial nerve symptoms or abnormal respiration and heartbeat were related to brainstem compression, and different decompression methods were adopted. Among them, 6 cases were treated with occipital cisternoplasty (including atlantooccipital decompression, resection of inferior cerebellar tonsillectomy and enlarged occipital cistern dura / meningoplasty). 9 cases were treated with posterior cranial fossa decompression. All patients were treated with direct reduction and internal fixation. One year after operation, the patients were followed up regularly to find out the recovery of the patients' conscious symptoms, and the neurologic function was evaluated by the Japanese Orthopaedic Association (JOAA) score. The operative results were evaluated comprehensively by means of atlantoid distance (ADL), distance of odontoid process beyond Qian's line (CLA), medullary cervical spinal cord angle (CMA) and the size of syringomyelia. Results: all the patients were treated with posterior decompression and internal fixation. The main symptoms of the patients disappeared. 7 cases had 7 / 10 / 70% of headache disappeared and 3 cases had 3 / 7 / 7 / 30% of the symptoms. Dizziness disappeared in 6 / 7 / 85.7 cases, improvement in 1 / 7 / 714.3C in 1 / 1; loss of limb fatigue in 2 / 1118.2J; improvement in 8 / 8 / 1172.7m; no improvement in 1 / 1 / 1172.7m; loss of limb numbness in 4 / 4 / 10 / 1040m; improvement in 6 / 61066.7m / 61066.7a) in which the neurologic function was good (426.66.7e).) the prognosis of the patients was 10.47 卤2.23 (n = 10.47 卤2.23). (JOA score was 10.47 卤2.23% before operation, and the prognosis of the patients was as follows: 10.47 卤2.23%; 10.47 卤2.23%; 10.47 卤2.23 cases; 10.47 卤2.23 cases) The score increased to 13.67 卤1.54 after operation. The difference was statistically significant (P 0.05). The average distance between odontoid process and Chamberlain line was 6.07 卤1.36mm, 3.44 卤1.90mm, 136.94 卤7.46 掳and 126.43 卤7.90 掳, respectively. The difference was statistically significant (P 0.05. 05%. 13 cases with syringomyelia: 2 cases (15. 4) the syringomyelia disappeared in 9 cases (69.2%), and there was no significant change compared with the former 2 cases (15. 4%). Complications: 1 case of occipital cisternoplasty received wound effusion and cerebrospinal fluid leakage. The wound healed and discharged after continuous lumbar cistern drainage and enhanced dressing change. No recurrence was found during follow-up. Conclusion 1. Posterior decompression and reduction and internal fixation can improve the prognosis of patients with ACM I unstable skull base depression. Direct posterior open reduction and internal fixation can improve the atlantoaxial instability, enlarge the volume of spinal canal effectively, relieve the pressure of subarachnoid space, and improve the circulation of local cerebrospinal fluid (CSF). According to the preoperative clinical symptoms and imaging findings of patients with unstable skull base depression of ACM type I, the operative methods can not only improve the prognosis of patients but also reduce the incidence of surgical complications.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R651.1

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