后颅窝减压术治疗Chiari畸形I型对颅-颈交界区稳定性的影响

doi:10.3877/cma.j.issn.2095-123X.2021.06.005

目的

探讨后颅窝减压术治疗Chiari畸形Ⅰ型（CM-Ⅰ）对颅-颈交界区（CVJ）稳定性的影响，分析CM-Ⅰ的最佳治疗方法。

方法

回顾性分析南昌大学第二附属医院神经外科自2015年1月至2020年1月接受后颅窝减压术+枕大池扩大成形术治疗的CM-Ⅰ患者的临床资料，根据CVJ失稳影像诊断参数将患者分为稳定组和失稳组，根据脊髓空洞、改良日本骨科协会及芝加哥Chiari畸形预后量表评分评估手术疗效，并分析失稳的影响因素。

结果

纳入89例患者作为研究对象，随访3~55个月，有4例患者术前无失稳但在术后3~4年出现寰枕关节失稳纳入失稳组，稳定组85例，2组患者临床症状和体征得到明显改善。

结论

后颅窝减压术治疗CM-Ⅰ安全有效，并且对CVJ稳定性无明显影响，是CM-Ⅰ的首选治疗方式。

关键词: Chiari畸形Ⅰ型, 后颅窝减压术, 颅-颈交界区失稳, 后颅窝容积

Objective

To investigate the effect of posterior fossus decompression for Chiari malformation typeⅠ (CM-Ⅰ) on the stability of craniocervical junction, to analyze the best treatment method of CM-Ⅰ.

Methods

The CM-Ⅰ patients who received cranial fossus decompression + enlarged cisternplasty in in the Neurosurgery Department of the Second Affiliated Hospital of Nanchang University from January 2015 to January 2020 were retrospectively collected. According to the imaging diagnostic parameters of craniocervical junction instability, the patients were divided into the stability group and the instability group. The surgical efficacy was evaluated and the influencing factors of instability were analyzed according to the myelomyelia volume, modified Japanese Orthopedic Association and the Chicago Chiari outcome scale.

Results

Of the 89 subjects who were followed up for 3 to 55 months, 4 had no craniocervical junction instability before surgery and had atlanto-occipitocervical joint instability 3 to 4 years after surgery, 85 in the stability group. The clinical symptoms and function of patients in both groups were significantly improved.

Conclusion

Posterior fossa decompression is safe and effective, and has no significant effect on the stability of craniocervical junction. Therefore, it is the preferred treatment for CM-Ⅰ.

Key words: Chiari malformation typeⅠ, Posterior fossa decompression, Craniovertebral junction instability, Posterior fossa volume

图2 典型病例2术前和随访影像学资料

表1 89例CM-Ⅰ患者的基本情况

基本情况		数据
性别[例（%）]
	男性	34（38.2）
	女性	55（61.8）
年龄（岁，Mean±SD）		45.88±10.37
病程[月，M（P₂₅，P₇₅）]		24（0.25，360）
随访[月，M（P₂₅，P₇₅）]		36（3，55）
术前mJOA评分（分，Mean±SD）		14.80±1.40
术后CCOS（分，Mean±SD）		13.43±1.49
头痛[例（%）]		33（37.08）
颈痛[例（%）]		21（23.60）
肩痛[例（%）]		10（11.24）
肢体痛[例（%）]		8（8.16）
肢体乏力[例（%）]		40（44.94）
肢体麻木[例（%）]		60（67.42）
感觉障碍[例（%）]		5（5.62）
肌肉萎缩[例（%）]		6（6.74）
头晕[例（%）]		21（23.60）
脊髓空洞[例（%）]		63（70.79）
术前脊髓空洞体积[mm³，M（P₂₅，P₇₅）]		1141.60（0，2729.18）
术前CMA（Mean±SD）		149.88°±4.99°
术前小脑扁桃体下疝长度（mm，Mean±SD）		9.19±3.52
术前PFV（mm³，Mean±SD）		175.59±10.20

表1 89例CM-Ⅰ患者的基本情况

基本情况		数据
性别[例（%）]
	男性	34（38.2）
	女性	55（61.8）
年龄（岁，Mean±SD）		45.88±10.37
病程[月，M（P₂₅，P₇₅）]		24（0.25，360）
随访[月，M（P₂₅，P₇₅）]		36（3，55）
术前mJOA评分（分，Mean±SD）		14.80±1.40
术后CCOS（分，Mean±SD）		13.43±1.49
头痛[例（%）]		33（37.08）
颈痛[例（%）]		21（23.60）
肩痛[例（%）]		10（11.24）
肢体痛[例（%）]		8（8.16）
肢体乏力[例（%）]		40（44.94）
肢体麻木[例（%）]		60（67.42）
感觉障碍[例（%）]		5（5.62）
肌肉萎缩[例（%）]		6（6.74）
头晕[例（%）]		21（23.60）
脊髓空洞[例（%）]		63（70.79）
术前脊髓空洞体积[mm³，M（P₂₅，P₇₅）]		1141.60（0，2729.18）
术前CMA（Mean±SD）		149.88°±4.99°
术前小脑扁桃体下疝长度（mm，Mean±SD）		9.19±3.52
术前PFV（mm³，Mean±SD）		175.59±10.20

表2 稳定组患者手术疗效分析

指标	首次住院评估	随访首次评估	t/Z值	P值
mJOA评分（分，Mean±SD）	14.88±1.33	16.76±0.95	7.632	<0.001
CCOS评分（分，Mean±SD）	13.49±1.11	15.12±0.85	7.594	<0.001
脊髓空洞体积[mm³，M（P₂₅，P₇₅）]	1113.8（0，2729.18）	450.9（0，1558.71）	5.627	<0.001
小脑扁桃体下疝长度[mm，M（P₂₅，P₇₅）]	8（7，10）	7（5.4，9.2）	5.266	<0.001
CMA（Mean±SD）	150.07°±4.98°	154.50°±4.33°	7.584	<0.001

表2 稳定组患者手术疗效分析

指标	首次住院评估	随访首次评估	t/Z值	P值
mJOA评分（分，Mean±SD）	14.88±1.33	16.76±0.95	7.632	<0.001
CCOS评分（分，Mean±SD）	13.49±1.11	15.12±0.85	7.594	<0.001
脊髓空洞体积[mm³，M（P₂₅，P₇₅）]	1113.8（0，2729.18）	450.9（0，1558.71）	5.627	<0.001
小脑扁桃体下疝长度[mm，M（P₂₅，P₇₅）]	8（7，10）	7（5.4，9.2）	5.266	<0.001
CMA（Mean±SD）	150.07°±4.98°	154.50°±4.33°	7.584	<0.001

表3 失稳组患者术前及随访指标统计

患者编号	术前							随访
患者编号	CCOS	mJOA	疝体长度（mm）	空洞体积（mm³）	CMA	BDI（mm）	BAI（mm）	CCOS	mJOA	疝体长度（mm）	空洞体积（mm³）	CMA	BDI（mm）	BAI（mm）
1	13	12	10	813.7	148.6°	7.5	5.6	15	15	7.0	455.6	122.3°	7.1	14.6
2	9	15	6	1809.0	142.8°	8.6	7.7	15	17	4.1	756.3	127.1°	5.6	13.5
3	12	11	12.4	3195.0	142.6°	4.3	7.8	16	16	8.8	1463.0	124.0°	6.4	16.0
4	13	14	11.2	1692.0	149.3°	8.4	5.7	15	16	7.2	671.4	123.6°	5.5	13.2

表3 失稳组患者术前及随访指标统计

患者编号	术前							随访
患者编号	CCOS	mJOA	疝体长度（mm）	空洞体积（mm³）	CMA	BDI（mm）	BAI（mm）	CCOS	mJOA	疝体长度（mm）	空洞体积（mm³）	CMA	BDI（mm）	BAI（mm）
1	13	12	10	813.7	148.6°	7.5	5.6	15	15	7.0	455.6	122.3°	7.1	14.6
2	9	15	6	1809.0	142.8°	8.6	7.7	15	17	4.1	756.3	127.1°	5.6	13.5
3	12	11	12.4	3195.0	142.6°	4.3	7.8	16	16	8.8	1463.0	124.0°	6.4	16.0
4	13	14	11.2	1692.0	149.3°	8.4	5.7	15	16	7.2	671.4	123.6°	5.5	13.2

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[1]	吕学明, 段亦然, 赵振宇, 门学忠, 初晨宇, 王天助, 卢培刚, 袁绍纪. 后颅窝枕下减压术治疗大面积小脑梗死的预后分析[J]. 中华神经创伤外科电子杂志, 2018, 04(06): 363-366.
[2]	苏新文, 闫润民. 后颅窝减压术后脊髓空洞无好转再治疗的进展[J]. 中华临床医师杂志(电子版), 2020, 14(11): 937-940.

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Effect of posterior fossa decompression on craniovertebral junction stability in the treatment of Chiari type I malformation

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Effect of posterior fossa decompression on craniovertebral junction stability in the treatment of Chiari type I malformation