改良枕大池重建术治疗Chiari畸形并脊髓空洞症:附35例临床研究

Modified reconstruction of the cistern magna for treatment of syringomyelia with Chiari malformation:clinical analysis of 35 cases

目的探讨改良枕大池重建术治疗Chiari畸形并脊髓空洞症的术式选择、操作技巧及手术效果,探索该病手术治疗的适宜术式。方法回顾性分析我院2001年1月～2006年10月间采取改良枕大池重建手术治疗35例Chiari畸形并脊髓空洞症患者的临床表现,手术前后影像学特征,手术方式及手术疗效。结果35例Chiari畸形并脊髓空洞症患者中Chiari畸形I型18例,II型17例;29例患者术后症状均有不同程度的改善,6例临床症状无改变,3例行脊髓空洞分流术。随访平均2年,32例症状显著改善,25例患者脊髓空洞基本消失。结论改良枕大池重建术避免了小脑下垂的同时又能有效地骨性减压;小脑扁桃体缩小主要采用电灼和软膜下切除相结合的方式,尽量保持局部软膜完整,减少术后粘连和复发;疏通四脑室中孔和侧孔流出道,通畅脑脊液循环;蛛网膜的悬吊和硬脑膜扩大修补是有效重建枕大池的重要措施。改良枕大池重建术是治疗Chiari畸形并脊髓空洞症的相对合理的术式。根据本组数据提出了骨性减压和小脑扁桃体缩减的范围。

Objective To explore the surgical approaches, microsurgical techniques and therapeutic effect of modified cistern magna reconstruction for treating of syringomyelia with Chiari malformations. Methods The clinical data of 35 patients with syringomyelia complicated by Chiari malformations were retrospectively reviewed, and the patients＇ chief complaints, presenting symptoms, neurological and radiographic findings, surgical approaches, outcomes, and complications were analyzed. Results The radiographs revealed type Ⅰ Chiari in 18 and type Ⅱ Chiari malformations in these patients. Surgical treatment resulted in symptomatic improvements in 29 patients, and 6 patients showed no obvious changes in the symptoms after the surgery; 3 patients received subarachnoid shunting for syringomyelia. During the follow-up for a mean of 2 years, 32 patients showed obvious clinical improvement, and magnetic resonance imaging demonstrated complete spontaneous resolution of syringobulbia in 25 patients. Conclusions Modified cistern magnh reconstruction relieves brainstem compression and restores the pulsatile flow of the cerebrospinal fluid at the cervicomedullary junction. Cerebellar tonsil reduction is performed chiefly by electric coagulation and cauterization combined with subpial resection, and the integrity of the pia mater should be maintained as much as possible to avoid potential adhesion and recurrence. The median foramens and Luschka of the fourth ventricle have to be opened to recover normal CSF circulation. Arachnoidal suspension and placement ofa patulous dural graft are also importaht. Modified reconstruction of the cistern magna can be a good option for treatment of syringomyelia complicated by Chiari malformations.