Neurological deterioration after foramen magnum decompression for Chiari malformation Type I: old or new pathology? Clinical article
Neurological deterioration after foramen magnum decompression for Chiari malformation Type I: old or new pathology? Clinical article
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DOI：
10.3171/2012.9.peds12110
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发表时间：
2012-12-01
影响因子：
1.9
通讯作者：
Klekamp, Joerg
中科院分区：
文献类型：
--
作者：
Klekamp, Joerg
Object.枕骨大孔减压术被广泛接受为基亚里畸形I型（CM-I）患者的首选手术。本研究旨在探讨枕大孔减压术后神经功能恶化的机制和二次干预的结果。1987年至2010年，559例CM-I患者，其中107例已经接受了枕骨大孔减压术，其中27例患者接受了空洞分流术。40名神经系统稳定的患者没有接受另一次手术。67名症状进展的患者接受了手术建议，16名患者拒绝了手术，而51名患者共接受了61次二次手术。分析住院和门诊记录、影像学研究和术中影像。通过电话和问卷调查获得额外的随访信息。3个月和12个月后确定短期结果，使用Kaplan-Meier分析法评估长期结果。61例在枕骨大孔减压后进行了二次手术。在这61例手术中，15例涉及与枕骨大孔无关的脊柱病变（脊柱组），而46例手术是因为枕骨大孔问题（枕骨大孔组）。除枕骨疼痛和吞咽障碍外，两组的临床病程相似。在脊髓组中，5个空洞分流导管由于神经根刺激或脊髓栓系而被移除。8名患者因神经根病或脊髓病共接受了10次颈椎手术。该组中未发生永久性手术并发症。在枕大孔组中，1名患者在减压7个月后因脑积水需要进行脑室腹腔分流术。其余45例二次干预为枕骨大孔翻修术，其中10例合并颅颈融合术。术中，蛛网膜瘢痕伴Magendie孔阻塞是最常见的发现。枕骨大孔翻修的并发症发生率与首次去骨瓣减压相似，而永久性手术发病率较高，为8.9%。两个手术组的术后临床改善均为轻微。除了1名患者接受了空洞导管移除术并有术后脑膜炎病史外，脊柱组的所有患者均能够在神经上稳定。枕骨大孔组的长期结果显示至少5年的临床稳定率为66%。因CM-I行枕骨大孔减压术后患者的神经功能恶化可能与新发脊柱病变、颅颈不稳定或枕骨大孔处复发性脑脊液流动阻塞有关。尽管脊柱病变手术后定期进行临床稳定，但由于这些患者中有很大一部分严重蛛网膜瘢痕，枕骨大孔翻修术的长期成功率仅为66%，持续5年。因此，枕骨大孔翻修术应仅限于症状进展的患者。(http：//thejns.org/doi/abs/10.3171/2012.9.PEDS12110）
Object. Decompression of the foramen magnum is widely accepted as the procedure of choice for patients with Chiari malformation Type I (CM-I). This study was undertaken to determine the mechanisms responsible for neurological deterioration after foramen magnum decompression and the results of secondary interventions.Methods. Between 1987 and 2010, 559 patients with CM-I presented, 107 of whom had already undergone a foramen magnum decompression, which included a syrinx shunt in 27 patients. Forty patients who were neurologically stable did not undergo another operation. Sixty-seven patients with progressive symptoms received a recommendation for surgery, which was refused by 16 patients, while 51 patients underwent a total of 61 secondary operations. Hospital and outpatient records, radiographic studies, and intraoperative images were analyzed. Additional follow-up information was obtained by telephone calls and questionnaires. Short-term results were determined after 3 and 12 months, and long-term outcomes were evaluated using Kaplan-Meier statistics.Results. Sixty-one secondary operations were performed after a foramen magnum decompression. Of these 61 operations, 15 involved spinal pathologies not related to the foramen magnum (spinal group), while 46 operations were required for a foramen magnum issue (foramen magnum group). Except for occipital pain and swallowing disturbances, the clinical course was comparable in both groups. In the spinal group, 5 syrinx shunt catheters were removed because of nerve root irritations or spinal cord tethering. Eight patients underwent a total of 10 operations on their cervical spine for radiculopathies or a myelopathy. No permanent surgical morbidity occurred in this group. In the foramen magnum group, 1 patient required a ventriculoperitoneal shunt for hydrocephalus 7 months after decompression. The remaining 45 secondary interventions were foramen magnum revisions, of which 10 were combined with craniocervical fusion. lntraoperatively, arachnoid scarring with obstruction of the foramen of Magendie was the most common finding. Complication rates for foramen magnum revisions were similar to first decompressions, whereas permanent surgical morbidity was higher at 8.9%. Postoperative clinical improvements were marginal in both surgical groups. With the exception of 1 patient who underwent syrinx catheter removal and had a history of postoperative meningitis, all patients in the spinal group were able to be stabilized neurologically. Long-term results in the foramen magnum group revealed clinical stabilizations in 66% for at least 5 years.Conclusions. Neurological deterioration in patients after a foramen magnum decompression for CM-I may be related to new spinal pathologies, craniocervical instability, or recurrent CSF flow obstruction at the foramen magnum. Whereas surgery for spinal pathologies is regularly followed by clinical stabilization, the rate of long-term success for foramen magnum revisions was limited to 66% for 5 years due to severe arachnoid scarring in a significant proportion of these patients. Therefore, foramen magnum revisions should be restricted to patients with progressive symptoms. (http://thejns.org/doi/abs/10.3171/2012.9.PEDS12110)