Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications.
Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications.
复制标题
DOI：
10.3171/2020.6.peds20376
复制
发表时间：
2021-01-01
期刊：
影响因子：
--
通讯作者：
Ellenbogen RG
中科院分区：
文献类型：
--
作者：
Ene CI;Wang AC;Collins KL;Bonow RH;McGrath LB;Durfy SJ;Barber JK;Ellenbogen RG
虽然一部分患有I型基亚里畸形（CM-I）的儿童患者仍无症状，但一些患者出现咳嗽性头痛、神经功能缺损、进行性脊柱侧凸和其他需要手术干预的衰弱症状。手术需要多种策略来恢复正常的CSF流量，包括仅通过骨减压增加后颅窝体积，或通过硬脑膜成形术进行骨减压，伴或不伴枕骨探查。硬脑膜成形术和枕骨探查骨减压后的适应症仍有争议。本研究的目的是描述一个机构系列的儿科患者接受手术的CM-I，由一个单一的神经外科医生。对于出现空洞的患者，作者比较了仅进行骨减压、仅进行硬脑膜成形术和进行硬脑膜成形术（包括奥贝克斯探查）后的结果。评价的临床结局包括空洞的消退、脊柱侧凸、症状和手术并发症。由资深作者对2001年至2015年期间在一家机构接受CM-I手术的276例连续儿科患者的病历进行了回顾性审查。记录扁桃体下降、相关空洞（脊髓空洞症或脊髓延髓炎）、基底动脉内陷的影像学表现，以及CM-I相关症状和脊柱侧凸的临床评估。在出现空洞的患者中，比较了三个手术组的临床结局，包括空洞消退、症状消退和对脊柱侧凸进展的影响：仅骨/后颅窝减压术（PFD）、PFD+硬膜成形术（PFDwD）和PFD+硬膜成形术和枕骨探查术（PFDwDO）。25%的患者（69/276）进行了PFD，18%的患者（50/276）进行了PFDwD，57%的患者（157/276）进行了PFDwDO。平均随访35 ± 35个月。近一半的患者（132/276，48%）有空洞。在出现空洞的患者中，与仅PFD相比，PFDwDO与显著更高的空洞消退可能性相关（HR 2.65，p = 0.028），并且症状消退时间存在显著差异（HR 2.68，p = 0.033）。治疗组之间的脊柱侧凸结局无差异（p = 0.275）。在骨减压后进行任何硬脑膜成形术（PFDwD或PFDwDO）时，并发症并没有显著增加（p > 0.99）。在这一系列的儿童CM-I患者中，与仅接受骨减压的患者相比，接受可扩张硬脑膜成形术和奥贝克斯探查术的患者出现空洞的可能性显著更大，症状缓解的可能性也更大，而CSF相关并发症的风险没有增加。
While a select population of pediatric patients with Chiari malformation type I (CM-I) remain asymptomatic, some patients present with tussive headaches, neurological deficits, progressive scoliosis, and other debilitating symptoms that necessitate surgical intervention. Surgery entails a variety of strategies to restore normal CSF flow, including increasing the posterior fossa volume via bone decompression only, or bone decompression with duraplasty, with or without obex exploration. The indications for duraplasty and obex exploration following bone decompression remain controversial. The objective of this study was to describe an institutional series of pediatric patients undergoing surgery for CM-I, performed by a single neurosurgeon. For patients presenting with a syrinx, the authors compared outcomes following bone-only decompression with duraplasty only and with duraplasty including obex exploration. Clinical outcomes evaluated included resolution of syrinx, scoliosis, presenting symptoms, and surgical complications. A retrospective review was conducted of the medical records of 276 consecutive pediatric patients with CM-I operated on at a single institution between 2001 and 2015 by the senior author. Imaging findings of tonsillar descent, associated syrinx (syringomyelia or syringobulbia), basilar invagination, and clinical assessment of CM-I–attributable symptoms and scoliosis were recorded. In patients presenting with a syrinx, clinical outcomes, including syrinx resolution, symptom resolution, and impact on scoliosis progression, were compared for three surgical groups: bone-only/posterior fossa decompression (PFD), PFD with duraplasty (PFDwD), and PFD with duraplasty and obex exploration (PFDwDO). PFD was performed in 25% of patients (69/276), PFDwD in 18% of patients (50/276), and PFDwDO in 57% of patients (157/276). The mean follow-up was 35 ± 35 months. Nearly half of the patients (132/276, 48%) had a syrinx. In patients presenting with a syrinx, PFDwDO was associated with a significantly higher likelihood of syrinx resolution relative to PFD only (HR 2.65, p = 0.028) and a significant difference in time to symptom resolution (HR 2.68, p = 0.033). Scoliosis outcomes did not differ among treatment groups (p = 0.275). Complications were not significantly higher when any duraplasty (PFDwD or PFDwDO) was performed following bone decompression (p > 0.99). In this series of pediatric patients with CM-I, patients presenting with a syrinx who underwent expansile duraplasty with obex exploration had a significantly greater likelihood of syrinx and symptom resolution, without increased risk of CSF-related complications, compared to those who underwent bone-only decompression.