四脑室-蛛网膜下腔分流术治疗复发性、特发性脊髓空洞症疗效观察

Effect of shunt surgery with four ventricles-subarachnoid shunt on patients with recurrent and idiopathic syringomyelia

目的探讨四脑室-蛛网膜下腔分流术(FVSS)治疗复发性、特发性脊髓空洞症(SM)的临床疗效。方法选择2019年1月至2021年6月郑州大学附属郑州中心医院收治的16例复发性、特发性SM患者为研究对象。所有患者均行FVSS,通过查阅病历资料收集患者手术前后的症状资料。分别于术前1周及术后6个月应用改良日本骨科学会(mJOA)评分评估患者的神经功能。分别于术前1周及术后6个月,采用全脊髓磁共振成像检查患者脊髓空洞直径,相位对比磁共振成像(PC-MRI)测量中脑导水管中段、枕骨大孔收缩期及舒张期脑脊液流速,PC-MRI测量收缩期脑干背侧脑脊液循环情况,Queckensted试验检测患者40、60 mm Hg压力下的脑脊液峰值压力以及达峰时间;于术后6个月,采用芝加哥Chiari畸形预后量表(CCOS)评估患者预后情况。结果术前SM患者出现疼痛14例、节段性感觉分离10例、肢体麻木9例、上肢肌力下降9例、下肢肌力下降5例。术后13例患者疼痛明显改善,1例疼痛无明显改善。手术前后SM患者mJOA评分分别为5~11(9.86±2.20)、10~15(12.67±3.95)分,SM患者术后mJOA评分显著高于术前(P<0.05)。SM患者术后脊髓空洞直径显著低于术前(P<0.05)。SM患者术后收缩期和舒张期枕骨大孔脑脊液流速峰值、中脑导水管脑脊液流速峰值均显著低于术前(P<0.05);PC-MRI显示,与术前相比较,患者术后收缩期脑干背侧脑脊液循环信号更强。SM患者术后40、60 mm Hg压力下脑脊液压力峰值均显著高于术前(P<0.05);SM患者术后40、60 mm Hg压力下脑脊液压力达峰时间与术前比较差异无统计学意义(P>0.05)。SM患者预后良好14例,预后不良2例,患者均未出现神经损伤、脑脊液漏、感染等并发症。术后6个月复查PC-MRI及Queckensted试验显示,SM患者四脑室-蛛网膜下腔置入分流管固定良好,未发现分流管脱落及堵塞情况。结论FVSS可有效改善复发性、特发性SM患者的临床症状,改善神经功能和脑脊液循环情况,且预后良好。

Objective To explore the clinical efficacy of four ventricles-subarachnoid shunt(FVSS)in the treatment of recurrent and idiopathic syringomyelia(SM).Methods A total of 16 patients with recurrent and idiopathic SM admitted to Zhengzhou Central Hospital Affiliated Zhengzhou University from January 2019 to June 2021 were selected as the study subjects.All patients underwent FVSS,and the symptom data before and after surgery were collected by reviewing medical records.At 1 week before surgery and 6 months after surgery,the neurological function of patients was evaluated by the modified Japanese Orthopedic Association(mJOA)score,the diameter of the spinal cord cavity was examined by whole spinal magnetic resonance imaging,the systolic and diastolic flow rates of cerebrospinal fluid in the midbrain aqueduct and foramen magnum were measured by phase-contrast magnetic resonance imaging(PC-MRI),the cerebrospinal fluid circulation on the dorsal side of the brainstem during systole was measured by PC-MRI,the peak cerebrospinal fluid pressure and peak time at 40 mm Hg and 60 mm Hg pressures of patients was detected by using Queckensted test.At 6 months after surgery,the patient′s prognosis was evaluated by the Chicago Chiari outcome scale(CCOS).Results Before surgery,14 SM patients experienced pain,10 patients had segmental sensory separation,9 patients had limb numbness,9 patients had decreased upper limb muscle strength,and 5 patients had decreased lower limb muscle strength.After surgery,13 patients showed significant improvement in pain,while 1 patient reported no significant improvement in pain.The mJOA scores of SM patients before and after surgery were 5-11(9.86±2.20)and 10-15(12.67±3.95),respectively;the mJOA score of SM patients after surgery was significantly higher than that before surgery(P<0.05).The diameter of spinal cord cavity of SM patients after surgery was significantly lower than that before surgery(P<0.05).The peak flow velocity of cerebrospinal fluid in the foramen magnum and midbrain aqueduct of SM patients during postoperative systolic and diastolic periods were significantly lower than those before surgery(P<0.05).Compared with preoperative,postoperative PC-MRI showed stronger high-intensity signals on the dorsal side of the brainstem during systole.The peak cerebrospinal fluid pressure of SM patients under 40 mm Hg and 60 mm Hg pressure after surgery were significantly higher than those before surgery(P<0.05);there was no significant difference in the peak time of cerebrospinal fluid pressure at 40 mm Hg and 60 mm Hg pressure of SM patients after surgery and before surgery(P>0.05).Fourteen SM patients had a good prognosis,while 2 had a poor prognosis.No SM patients experienced complications such as nerve injury,cerebrospinal fluid leakage,or infection after surgery.At 6 months after operation,the PC-MRI and Queckensted test showed that the shunt tube placed in the fourth ventricle subarachnoid space of SM patients was well fixed,and no shedding or blockage of the shunt tube was found.Conclusion FVSS can effectively improve the clinical symptoms of recurrent and idiopathic SM patients,improve neurological function and cerebrospinal fluid circulation,and has a good prognosis.