Chiari Ⅰ畸形颅颈减压手术中的硬膜下显微操作

Intgadural manipulation in decompressive surgery of craniocervical junction for patients with Chiari Ⅰ malformation

目的总结Chiari Ⅰ畸形颅颈减压手术中的硬膜下显微操作的关键步骤，强调硬膜下显微操作内容的重要性。方法12例Chiari Ⅰ畸形患者（8例合并脊髓空洞症）行颅颈减压、硬膜成形、硬膜下探查术。硬膜下显微操作包括部分切除下疝的小脑扁桃体，探查第四脑室正中孔、延髓及高位颈髓外侧。结果术中证实小脑扁桃体与延髓间蛛网膜粘连并松解6例，小脑扁桃体与尾组颅神经间蛛网膜粘连并松解4例。术后近期观察8例患者临床症状有改善，4例无变化。远期随访患者神经功能均有不同程度改善。5例患者（3例合并脊髓空洞症）术后磁共振成像（MRI）复查示小脑扁桃体达正常水平，枕大池成形，脊髓空洞呈不同程度缩小。结论Chiari Ⅰ畸形颅颈减压手术中的硬膜下显微操作是达到手术目的、改善患者临床症状的重要步骤之一。

Objective To summarize key steps of intradural manipulation in decompressive surgery of craniocervical junction for patients with Chiari Ⅰ malformation. Methods A prospective series of 12 patients with Chiari Ⅰ malformation （8 with syringomyelia） underwent decompression of the craniocervical junction （CCJ）,duraplasty and exploration of intradural contents. Different intradural manipulations were performed including resection of part of cerebellar tonsils, exploring median aperture of the fourth ventricle, and lateral region of medulla and upper cervical cord. Results All patients＇ cerebellar tonsils were resected to normal level. The cerebrospinal fluid outflow from the foramen of Magendie was confirmed in all patients. The adhesion of arachnoid between cerebellar tonsils and medulla was found and disconnected in 6 patients. The adhesion of arachnoid between cerebellar tonsils and ultimate class cranial nerve was found and disconnected in 4 patients. Eight of 12 patients had improvement after surgery. The clinical symptoms improved in all patients during long-term follow-up. Five patients （3 with syringomyelia） undertaken follow-up MRI had a decrease in the size of the spinal marrow hollow. Conclusion Some intradural manipulations of decompressive surgery are key steps to improve clinical symptoms of patients with Chiari I malformation which should not be ignored.