枕骨大孔减压伴硬膜外层切开术在治疗Chiari畸形Ⅰ型中的应用

Application of Foramen Magnum Decompression with Removal of the Outer Layer of the Dura in Chiari Type Ⅰ Malformation Treatment

目的通过临床表现及影像学检查确诊为Chiari畸形的患者,以改善枕大孔区脑脊液循环为目的,采用枕骨大孔减压伴硬膜外层切开的手术方法治疗,随访观察分析手术前后患者临床表现的改善程度,脊髓空洞大小的变化,及其与临床症状改善的相关性。方法收集整理行枕骨大孔减压伴硬膜外层切开术治疗的45名Chiari畸形I型患者的临床症状资料以及MRI检查结果,将患者分为2组,Ⅰ组为不伴有脊髓空洞的Chiari畸形Ⅰ型患者17例,Ⅱ组为伴有脊髓空洞的患者28例,对比手术前后患者临床症状的改善情况,以及手术前后MRI的变化。结果Ⅰ组患者术后主要临床症状获得明显的缓解,术后均未再次出现临床症状,行MRI复查示小脑扁桃体位置上升,枕大池深度扩大,未出现脊髓空洞。而Ⅱ组的28例患者中尽管脊髓空洞的大小有不同程度的缩小甚至消失,但由于脊髓空洞导致的常见症状如肢体麻木、疼痛,感觉缺失虽有不同程度的缓解,而像肌肉萎缩,括约肌功能障碍等临床症状几乎无明显改善。结论枕骨大孔减压伴硬膜外层切除术治疗Chiari畸形Ⅰ型患者有较好疗效;对于Ⅰ组的患者,枕骨大孔减压伴硬膜外层切开术不仅能够使患者得到较高的临床症状缓解率,针对此组患者早期手术极有可能降低脊髓空洞的发生率。

Objective To observe and analyze the change of the clinical manifestation and MRI of ChiariⅠ malformation after the treatment of foremen magnum decompression combined with removal of the outer layer of the dura,and to evaluate the correlation between the them- peutic outcome and the treatment. Methods The patients with Chiari Ⅰ malformation diagnosed according to their chnical manifestations and MRI were treated with foramen magnum decompression with removal of the outer layer of the dura, and were followed up by our neurological center. Clinical and MRI data were researched of 45 patients diagnosed with Chiari Ⅰ malformation, and then the patients were divided into two groups ： group Ⅰ of Chiari Ⅰ malformation without syringomyelia （n = 17 ）, and groupⅡ of Chiari Ⅰ malformation with syringomyelia （n = 28）. Further,clinical and MRI changes pre and post operation were compared. Results Main clinical symptoms of the 17 patients were ob- viously improved after the surgery, no obvious MRI changes after operation were found except for elevated tonsil of cerebellum and deepened cistema magna, and no syringomyelia was developed. The other 28 patients with syringomyelia, whose chnieal symptoms included limb numb- ness and anesthesia, also gained ideal improvement. Their syringomyelia was alleviated, and even disappeared during the follow-up,, mean- while, discomforts like numbness, pain and sensation loss were relieved. However, symptoms such as myatrophy and sphincter disfunction were found no obvious change. Conclusion Foramen magnum decompression with removal of the outer layer of the dura for treatment of Chiari Ⅰ malformation is effective. ChiariⅠ malformation patients without syringomyelia can get greater improvement, and early operational treatment may reduce the incidence rate of syringomyelia in them.