复杂代偿头位眼球震颤的手术治疗

Surgical treatment for correcting abnormal complicated head posture in nystagmus

目的探讨复杂代偿头位即两个及两个以上轴位存在代偿头位的眼球震颤患者的手术治疗方案。方法回顾性系列病例研究。对38例复杂代偿头位同时不合并斜视的眼球震颤患者的临床资料进行分析。代偿头位以水平面向左、右侧转为主的患者29例（76．32％），以下颌上抬或内收为主的3例（7．89％），分别行水平中间带移位术以及垂直中间带移位术；以头向一侧肩倾斜为主2例（5．26％），行垂直肌肉退后联合水平方向移位一个肌肉宽度；水平及垂直方向头位扭转角基本相等4例（10．53％），2例行一组水平配偶肌伴垂直配偶肌退后手术，2例联合减弱双眼协同斜肌。行Parks手术患者术前术后头位扭转角两组比较采用配对t检验，对于改良Parks和Anderson手术患者因样本量小采用非参数秩和检验。结果在29例代偿头位以水平面向左、右侧转为主的患者中，术前头位扭转角25°-30°的15例患者行Parks术后面向左、右侧转消失，术前头位扭转角35°-40°的7例患者Parks术后残余5°-15°面向左、右侧转头位，术前头位扭转角〉40°的3例患者行改良的Parks手术术后残留10°-15°面向左、右侧转头位，术前水平头位扭转角15°-20°的4例患者行Anderson术后面向左、右侧转消失。对术前头位扭转角在25°-40°的22例代偿头位以水平面向左、右侧转为主的患者进行分析，行Parks手术后水平、垂直、旋转3个轴向头位扭转角分别为3．18°±1．01°、4．32°±1．14°、4．55°±1．95°，均较术前减小（t=63．13，3．57，3．95；P〈0．01）。3例代偿头位以下颌上抬或内收为主的患者，行一组垂直肌肉退后5mm或合并斜肌手术，可矫正垂直头位扭转角20°患者的头位，对其他轴向头位改善5°-10°；2例头向一侧肩倾斜合并下颌上抬或内收患者，垂直肌肉退后5mm合并水平移位一个肌肉宽度能矫正10°旋转方向头位以及10°-15°垂直头位；2例各退后一组水平垂直配偶肌手术可矫正20°-25°面向左、右侧转头位以及20°以内的垂直头位。结论复杂代偿头位眼球震颤患者当以水平面向左、右侧转头位为主时，头位扭转角在25°-40°患者，针对水平头位进行手术，可有效改善水平、垂直、旋转3个轴向的异常头位；以垂直或旋转头位为主要头位的患者，个体化设计手术方案，必要时需分次手术。

Objective To demonstrate the surgical choices for patients with complicated head posture associated with nystagmus. Methods It was a retrospective clinical study. Thirty-eight cases of congenital nystagmus with abnormal head posture in all three axes without strabismus were retrospectively analyzed. Twenty-nine（76. 32% ） cases whose dominant head posture were with face turn, 3 cases（7, 89% ） with chin up or down , respectively, were performed horizontal null zone shift as well as vertical null zone transposition; 2 cases （5.26%） with head tilt as the dominant position were underwent one tendon width transposition of all four vertical muscles ;4 cases （ 10. 53% ）basically with the same degree for face turn and chip up or down, 2 cases were profermed with recess a group of horizontal yoke muscles and a group of vertical yoke muscles,the other 2 cases were combined with weaken both synergistic oblique muscles. SPSS 13.0 was used to analyse the difference of them. Results In 29 patients with horizontal head posturedominanted, 15 cases （68.18%） with 25 °-30 ° in horizontal head posture were corrected completely, 5°- 15° was the residue for 7 cases （31.82%） with 35 °-40 °degree in horizontal before surgery. 15 °-20° was residue for 3 eases larger than 40 ° before operation after modified Parks procedure. Anderson procedure can correct the angle of 15°-20° in 4 eases. The horizontal,vertical and torsional components of 22 cases whose predominant head posture were in horizontal with 25°-40°（3.18°±1.01°, 4. 32° ± 1.14°, 4. 55° ± 1.95°） were significantly reduced （ t = 63.13,3.57,3.95 ; P 〈 0. 01 ） after Parks procedure. Recession a group of vertical muscles 5mm or combined with oblique muscles in 3 patients could correct the 20° of vertical head posture, but the improvement of the other two axes was about 5°-10°. One tendon width transposition of all four vertical muscles in 2 cases could correct the 10° of head tilt and 10°-15°of chip up or down. Recession a group of horizontal and vertical muscles can correct 20o-25° of face turn and 20° of vertical head posture. Conclusions When head turn with 25°-40°predominates over the vertical and torsional components,recess the horizontal muscles could be effective way in diminishing the abnormal head position on all three axes. When vertical or torsional head posture predominates for the complicated nystagmus,individual designs should be considered. When necessary, reoperations should be needed.