Sacco David, Scott R Michael
Department of Neurosurgery, The Children's Hospital, Harvard Medical School, Boston, Mass. 02115, USA.
Pediatr Neurosurg. 2003 Oct;39(4):171-8. doi: 10.1159/000072467.
We undertook this study to characterize those patients who required reoperations for Chiari malformation and to determine whether modifications in surgical technique at the initial procedure might have obviated the need for repeat surgery.
We reviewed the hospital records, imaging studies, operative reports, and follow-up data of those patients who were undergoing a second operation as part of a consecutive series of Chiari decompressions carried out by one neurosurgeon over a 14-year period. We wished to determine whether type of Chiari malformation, age at initial surgery, the presence of associated bony anomalies, or initial operative technique contributed to the need for reoperation.
Twenty-two (17%) of the surgical procedures represented reoperations (16 of 100 Chiari I and 6 of 33 Chiari II decompressions). Of the patients in the series who were operated on at age 5 years or younger, 7 (16%) were reoperations (5 of 33 Chiari I and 2 of 10 Chiari II decompressions); 15 patients (17%) of those older than 5 years at surgery were reoperations (11 of 67 Chiari I and 4 of 23 Chiari II decompressions). 8 of the 16 patients who underwent reoperations for Chiari I malformation and 4 of the 6 patients who underwent reoperations for Chiari II malformation had their initial decompression surgery at age 5 years or younger. Reoperation was required because of failure to treat adequately an associated syrinx (n=11), because of persisting neurological symptoms or headache (n=9), or because of a possible faulty fourth ventricular stent placement (n=2). 5 of 9 patients in the operative series with Chiari malformations associated with craniosynostosis represented reoperations (55%), and all 3 of the patients whose syrinx persisted after reoperation had craniosynostosis syndromes.
Approximately 17% of the patients with Chiari I and Chiari II malformations in this operative series were undergoing a second operation. Factors in this series which were associated with reoperation included a young age at initial surgery, the presence of complex bony anatomy at the foramen magnum, syndromic craniosynostosis, and failure of the surgeon at the initial operation either to assess patency of the foramen of Magendie or correctly place a fourth ventricular stent.
我们开展这项研究，旨在明确那些需要因Chiari畸形接受再次手术的患者特征，并确定初次手术时手术技术的改进是否可以避免再次手术的必要性。
我们回顾了一位神经外科医生在14年期间连续进行的一系列Chiari减压手术中接受二次手术患者的医院记录、影像学检查、手术报告及随访数据。我们希望确定Chiari畸形的类型、初次手术时的年龄、相关骨骼异常的存在情况或初次手术技术是否导致了再次手术的需要。
22例（17%）手术为再次手术（100例Chiari I型减压手术中的16例，33例Chiari II型减压手术中的6例）。在该系列中5岁及以下接受手术的患者中，7例（16%）为再次手术（33例Chiari I型减压手术中的5例，10例Chiari II型减压手术中的2例）；手术时年龄大于5岁的患者中有及以下接受手术的患者中，7例（16%）为再次手术（33例Chiari I型减压手术中的5例，10例Chiari II型减压手术中的2例）；手术时年龄大于5岁的患者中有15例（17%）为再次手术（67例Chiari I型减压手术中的11例，23例Chiari II型减压手术中的4例）。16例因Chiari I型畸形接受再次手术的患者中有8例，6例因Chiari II型畸形接受再次手术的患者中有4例初次减压手术时年龄为5岁及以下。再次手术的原因是未能充分治疗相关的空洞（n = 11）、持续存在神经症状或头痛（n = 9），或可能的第四脑室支架放置错误（n = 2）。手术系列中9例伴有颅缝早闭的Chiari畸形患者中有5例（55%）为再次手术，再次手术后空洞仍持续存在的所有3例患者均患有颅缝早闭综合征。
在这个手术系列中，约17%的Chiari I型和Chiari II型畸形患者接受了二次手术。该系列中与再次手术相关的因素包括初次手术时年龄较小、枕骨大孔处复杂的骨骼解剖结构、综合征性颅缝早闭，以及初次手术时外科医生未能评估马根迪孔的通畅情况或正确放置第四脑室支架。
