Alamar M, Teixidor P, Colet S, Muñoz J, Cladellas J M, Hostalot C, García-Armengol R, Bescós A, Cardiel I, Fiallos M, Florensa R
Servicio de Neurocirugía, Hospital Germans Trias i Pujol, Badalona (Barcelona).
Neurocirugia (Astur). 2008 Jun;19(3):233-41.
There are various surgical approaches to treat Chiari I malformation. In spite of the good clinical results that are reported with most of them, there is still controversy about the optimal treatment of this pathology.
To compare the clinical and radiological results of surgical treatment of the Chiari I malformation with suboccipital craniectomy, posterior arch of C1 resection with or without dural graft, analyzing clinical and radiological findings and describing the complications.
Retrospectively clinical cases series of patients who underwent Chiari I malformation surgery between 1998 and 2006 in the Hospital Germans Trias i Pujol in Badalona. The inclusion criteria consisted in: patients older than 18 years, who have had surgery in our hospital, detailed neurological examination before and after surgery (calculating the EDSS scale punctuation), craniospinal magnetic resonance imaging before and after surgery and minimal follow up period of 6 months. The election of the surgical approach was left to the discretion of the main surgeon. Patients were divided in two groups depending of the surgical technique: Group A (with dural graft) and Group B (without dural graft). To evaluate the morphological results in both groups, measurements of the position of the fastigium above a basal line in the midsagittal T1 weighted magnetic resonance images were obtained. In patients with syringomyelia, siringo-to-cord ratio was measured before and after surgery. To evaluate the clinical results, neurological examination was recorded in both groups before and after surgery.
The mean age of Group A patients was 47 (-/+12.89) years, and of Group B was 38.3 (-/+7.77) years. Mean follow up period was 2.48 (-/+2.44) years in Group A and 4.2 (-/+4.46) in Group B. Creation of an artificial cisterna magna was observed en 35.7% of Group A patients and only in 3.5% of Group B patients (p=0.022). In 8 patients front Group A, 8 patients (28.6%) an upward migration of the cerebellum was seen, whereas any of the Group B patients presented it (p=0.022) Siringo-to-cord ratios were decreased in both groups without significant differences. All of the Group A patients improved their clinical exploration. In Group B, 60% of the patients improved and the 40% left maintained clinical stability. Any patient worsened. All patients that maintained clinical stability belonged to Group B, the differences between the two groups were statistically significant (p=0.04). Five patients presented immediate surgical complications (2 pseudomeningoceles, 2 meningitis and 1 hydrocephalus). All this patients where operated with dural graft (p=0.049).
According to our study, suboccipital craniectomy with resection of the posterior arch of C1 and dural graft shows better clinical and radiological results than without dural graft. Nevertheless this technique can increase the incidence of surgical complications.
治疗Chiari I畸形有多种手术方法。尽管大多数方法都报告了良好的临床效果，但对于这种病变的最佳治疗仍存在争议。
比较枕下颅骨切除术、C1后弓切除加或不加硬脑膜移植治疗Chiari I畸形的临床和影像学结果，分析临床和影像学表现并描述并发症。
回顾性分析1998年至2006年在巴达洛纳的德国人特里亚斯-普约尔医院接受Chiari I畸形手术的患者临床病例系列。纳入标准包括：年龄大于18岁、在我院接受手术、手术前后详细的神经学检查（计算EDSS量表评分）、手术前后的颅颈磁共振成像以及至少6个月的随访期。手术方法的选择由主刀医生自行决定。根据手术技术将患者分为两组：A组（有硬脑膜移植）和B组（无硬脑膜移植）。为评估两组的形态学结果，在矢状面T1加权磁共振图像上测量小脑蚓部在基线以上的位置。对于有脊髓空洞症的患者，测量手术前后的脊髓空洞与脊髓比例。为评估临床结果，记录两组手术前后的神经学检查情况。
A组患者的平均年龄为47（±12.89）岁，B组为38.3（±7.77）岁。A组的平均随访期为2.48（±2.44）年，B组为4.2（±4.46）年。A组35.7%的患者观察到人工枕大池形成，而B组仅为3.5%（p = 0.022）。A组8例患者（28.6%）出现小脑向上移位，而B组患者均未出现（p = 0.022）。两组的脊髓空洞与脊髓比例均降低，但无显著差异。A组所有患者的临床检查均有改善。B组60%的患者病情改善，40%保持临床稳定。无患者病情恶化。所有保持临床稳定的患者均属于B组，两组之间的差异具有统计学意义（p = 0.04）。5例患者出现即刻手术并发症（2例假性硬脑膜膨出、2例脑膜炎和1例脑积水）。所有这些患者均接受了硬脑膜移植（p = 0.049）。
根据我们的研究，枕下颅骨切除术联合C1后弓切除及硬脑膜移植比不进行硬脑膜移植显示出更好的临床和影像学结果。然而，这种技术可能会增加手术并发症的发生率。
