颅颈交界畸形不恰当后颅窝减压术后的修正治疗

Revision surgery for patients after inappropriate posterior fossa decompression for craniocervical junction malformation

目的探讨颅颈交界畸形患者在不恰当后颅窝减压术后运用术中CT导航下翻修手术的治疗特点。方法2009年3月至2012年3月翻修手术治疗不恰当扩大后颅窝减压术后症状加重的患者12例，回顾性分析12例患者的临床和影像学资料及随访结果。结果8例患者行术中CT导航下后路部分复位固定植骨融合术；4例难以复位仅行后路固定植骨融合术，其中1例二期行经口齿状突磨除术。随访9个月-2年，平均17个月。术后6个月CT、MRI复查显示12例患者固定植骨融合满意，7例脊髓空洞有好转，3例小脑下垂均好转；McCormick分级为I～Ⅲ级；Karnofsky预后评分为80～100分。结论对于ChiariI型畸形、脊髓空洞伴有颅颈交界畸形患者，应行适当范围的后颅窝减压并同时枕颈复位固定植骨融合术；对于不恰当的扩大后颅窝减压术后的患者，行术中cT导航下枕颈复位固定植骨融合翻修手术效果满意。

Objective To evaluate the revision surgical techniques with intraoperative CT navigation system for the treatment of craniocervical junction malformation after inappropriate excessive posterior fossa decompression. Methods 12 patients with Chiari I malformation, basilar invagination and syringomyelia, after extensive posterior fossa decompression received the revision surgery from April 2009 to March 2012. The clinical presentation, treatment and follow- up results of the patients were retrospectively studied. Results The 12 patients included 5 females and 7 males. The mean age was 37. 4 years. The most common symptom was motor deficit in 12 patients. Syringomyelia occurred in 8 patients. Three patients got cerebellar ptosis. 8 patients were performed the posterior fixation and fusion in a reduced position with the intraoperative CT and neuronavigation. 4 patients with irreducible craniovertebral junction were only performed the posterior occipitocervical fixation, whereas 1 patient was performed the posterior occipitocervical fixation, and a transoral odontoidectomy was performed as the second procedure. During 9 - 24 months of follow - up, solid bone fusion was observed between the occipital bone and axis in all patients. The syringomyelia in 7 patients was improved. The cerebellar ptosis of 3 patients was resolved. The range of McCormick grade was I - III and the range of 6 months postoperative KPS score was 80 - 100. Conclusions It was necessary that simultaneous fixation and fusion after an appropriate posterior decompression in patients of basilar invagination associated with Chiari malformation. The revision occipitocervical fixation and fusion with the intraoperative CT and neuronavigation for the treatment of craniocervical junction malformation after inappropriate excessive posterior fossa decompression could be successfully performed.