Arnold-Chiari畸形合并脊髓空洞显微手术治疗的临床研究

目的 介绍Arnold-Chiari畸形合并脊髓空洞(ACM-SM)显微手术治疗的术式和注意点。方法 总结113例ACM-SM显微手术治疗的经验。结果 该组113例术后临床症状改善103例(91.15％)。并进行1年随访，获得随访102例，68例脊髓空洞消失，32例明显缩小。结论 在后颅窝减压基础上显微镜下松解小脑扁桃体与周围的粘连、恢复脊液循环是有效治疗ACM-SM的关键。     

Arnoid—Chiari畸形合并脊髓空洞症外科治疗（附27例）

目的：探讨Arnoid-Chiari畸形合并脊髓空洞症（ACM/SM）的外科治疗方法。方法：在27例患者中，对单纯性ACM者，行枕下颅骨切除及硬膜扩大修补术，ACM/SM者，行以上手术同时行空洞与蛛网膜下腔分流术，结果；大部分患者症状消除或缓解，手术有效率为92.6%。结论：外科治疗对ACM及ACM/SM不失为一种有效的治疗方法。     

Chiari畸形并脊髓空洞症的外科治疗

目的:对Chiari畸形并脊髓空洞症(SM)的手术治疗方法进行探讨,并初步评价其治疗效果.方法:对42 例Chiari畸形病例(合并SM 29例)根据其MRI影像,分为Ⅰ型36例和Ⅱ型6例,选择不同手术方式进行治疗:24例ACM-Ⅰ型无或合并轻度SM者行后颅窝减压术,12例ACM-Ⅰ型合并SM达C2以上者行后颅窝减压并脊髓空洞切开分流术,6例ACM-Ⅱ型合并远隔节段SM者行后颅窝减压并小脑扁桃体切除术.结果:患者术后临床症状均有不同程度改善.36例获随访1～4年,其中30例(83.3％)小脑扁桃体下疝得以回纳,25例(86.2％)空洞明显缩小或消失.结论:对Chiari畸形并SM病例依据其影像学分型采取不同的手术方式,疗效满意;手术能使延颈髓充分减压,有效缓解临床症状,并对SM有明显的治疗作用.     

CHIARI畸形伴脊髓空洞症的脑脊液动力学

目的探讨脑脊液动力学在Ｃｈｉａｒｉ畸形伴脊髓空洞症的发生、发展中的作用，提出本病脑脊液动力学异常的早期指标及相应的手术治疗方法。方法全组２２例病人经ＭＲＩ和ＣＴ检查，伴脑积水者进行颅内压监护，其他患者行颈部不同体位的术前和术后的脑脊液动力学研究，按其异常程度分别行脑室腹腔分流术、后颅＋颈１－２椎板减压术和硬膜减张。结果全部病人均有不同程度的脑脊液动力学的改善，术后１６例获得随访，其中１２例复查ＭＲＩ，空洞缩小９例，３例同术前。３例临床症状完全缓解，９例有不同程度改善，２例同术前，２例加重。结论脑脊液动力学的异常在Ｃｈｉａｒｉ畸形伴脊髓空洞症的发病和病程演变中有重要意义，而纠正其异常应是手术治疗的主要目的。合并颅内压增高者，脑室腹腔分流术同样可使空洞缩小。     

枕下减压及枕大池重建治疗Arnold-ChiariⅠ型畸形合并脊髓空洞症40例

目的:探讨枕下减压及枕大池重建治疗Arnold-ChiariⅠ型畸形(ACM-Ⅰ)合并脊髓空洞症(SM)的效果。方法:显微镜下对40例ACM-Ⅰ合并SM患者行后颅窝小骨窗枕下减压,改善脑脊液循环,并枕大池重建。结果:术后复查MRI示小脑扁桃体上抬至枕骨大孔水平,枕大池较前扩大。随访3~30个月,无死亡病例,临床症状改善35例,无变化5例,有效率87.50%;脊髓空洞缩小者33例,无变化7例,有效率82.50%。结论:枕下减压及枕大池重建是治疗ACM-Ⅰ合并SM的有效方法。     

改良小切口显微术式治疗Chiari''s畸形合并脊髓空洞症

目的 介绍一种新型改良小切口显微术式在治疗Chiari's畸形合并脊髓空洞症(ACM-SM)中的疗效及特点.方法 总结我院近1年共计76例Chiari's畸形合并脊髓空洞症患者的治疗及预后情况进行回顾性分析.结果 76例患者中症状明显改善71例(93%),随访发现43例脊髓空洞在术后3个月内消失,27例脊髓空洞明显缩小,6例改善不明显,未见加重患者.结论 新型改良小切口显微术式在治疗Chiari's畸形合并脊髓空洞症中疗效显著并能减小患者创伤,缩短患者平均住院时间.     

改良小切口显微术式治疗Chiari＇s畸形合并脊髓空洞症

目的 介绍一种新型改良小切口显微术式在治疗Chiari＇s畸形合并脊髓空洞症（ACM-SM）中的疗效及特点。方法 总结我院近1年共计76例Chiari＇s畸形合并脊髓空洞症患者的治疗及预后情况进行回顾性分析。结果76例患者中症状明显改善71例（93％），随访发现43例脊髓空洞在术后3个月内消失，27例脊髓空洞明显缩小，6例改善不明显，未见加重患者。结论新型改良小切口显微术式在治疗Chiari＇s畸形合并脊髓空洞症中疗效显著并能减小患者创伤，缩短患者平均住院时间。     

小骨窗枕下减压治疗 Arnold-Chiari畸形并脊髓空洞

目的探讨小切口入路小骨窗枕下减压治疗Arnold-Chiari畸形并脊髓空洞（ACM-SM）,并观察分析其治疗效果。方法对MRI检查明确诊断为ACM-SM的70例患者行小切口入路小骨窗枕下减压,同时行小脑扁桃体切除加枕大池重建术。结果术后1周患者症状消失或改善者共57例,有效率81.4%。随访时间3个月至1.5年不等,其中4例无效,2例失访,无效率为5.7%,失访率为2.9%,64例有效,远期总有效率为91.4%。结论ACM-SM诊断一旦成立,应该积极行手术治疗。小骨窗枕下减压加小脑扁桃体切除加枕大池重建手术,手术创伤小,可避免传统术式的并发症,术后恢复快,疗效佳,是治疗ACM-SM有效的手术方式,值得临床推广应用。     

小骨窗枕下减压治疗Arnold-Chiari畸形并脊髓空洞

目的探讨小切口入路小骨窗枕下减压治疗Arnold-Chiari畸形并脊髓空洞（ACM-SM）,并观察分析其治疗效果。方法对MRI检查明确诊断为ACM-SM的70例患者行小切口入路小骨窗枕下减压,同时行小脑扁桃体切除加枕大池重建术。结果术后1周患者症状消失或改善者共57例,有效率81.4%。随访时间3个月至1.5年不等,其中4例无效,2例失访,无效率为5.7%,失访率为2.9%,64例有效,远期总有效率为91.4%。结论ACM-SM诊断一旦成立,应该积极行手术治疗。小骨窗枕下减压加小脑扁桃体切除加枕大池重建手术,手术创伤小,可避免传统术式的并发症,术后恢复快,疗效佳,是治疗ACM-SM有效的手术方式,值得临床推广应用。     

小脑扁桃体下疝合并脑积水的手术治疗策略

目的 探讨小脑扁桃体下疝合并脑积水的术前评估方法和手术治疗策略.方法 回顾性分析24例小脑扁桃体下疝合并脑积水患者,年龄2～27岁,其中男17例,女7例.手术前后均行磁共振脑脊液电影成像(Cine MRI)检查来测量相关部位(中脑导水管、四脑室出口、枕大孔)脑脊液的流速流量,根据患者具体情况行内镜下三脑室底造瘘术(ETV)或行ETV术+内镜下后颅凹减压术.结果 术前Cine MRI发现所有患者枕骨大孔区脑脊液流体动力学均有不同程度异常,术后复查头Cine MRI显示所有患者三脑室底造瘘口处均有脑脊液通过.随访时间6～36个月,有21例患者的临床症状改善,2例患者临床症状无缓解,二期行内镜下后颅凹减压术.有14例患者小脑扁桃体下疝有不同程度改善.结论 Cine MRI能准确测量枕骨大孔区脑脊液的流速流量和流动方式,是判断手术时机和制定手术方案的重要参考.小脑扁桃体下疝合并脑积水多为梗阻性脑积水,ETV术治疗这类脑积水疗效确切,可代替传统的分流术.此外,它还有助于缓解小脑扁桃体下疝,对合并的脊髓空洞症也有治疗作用.     

Arnoid-Chiari畸形合并脊髓空洞症外科治疗(附27例)

目的:探讨Ａｒｎｏｉｄ－Ｃｈｉａｒｉ畸形合并脊髓空洞症(ＡＣＭ/ＳＭ)的外科治疗方法．方法:在２７例患者中,对单纯性ＡＣＭ者,行枕下颅骨切除及硬膜扩大修补术;ＡＣＭ/ＳＭ者,行以上手术同时行空洞与蛛网膜下腔分流术。结果:大部分患者症状消除或缓解,手术有效率为９２．６%。结论:外科治疗对ＡＣＭ及ＡＣＭ/ＳＭ不失为一种有效的治疗方法．     

脑脊液电影在神经内镜下三脑室底部造瘘脑脊液动力学改变中的应用

目的 探讨脑脊液电影在神经内镜下第三脑室底部造瘘术前后引起的脑脊液动力学方面改变.方法 本组病例共146例经CT和核磁共振证实为脑积水,给予内镜下三脑室底部造瘘术.其中随机选取36例进行脑脊液电影检查(磁共振相位对比电影法),判断造瘘术前后脑脊液动力学变化.同时在3个月至1年随访中应用脑脊液电影进行评价.结果 146例病人均成功进行了内镜下第三脑室底部造瘘术,其中121例(83%)术后症状明显好转.比较术前术后的脑脊液电影检测,显示脑室缩小、造瘘口流速、流量正常,脑脊液流动通畅.病人出院后随访表明症状明显改善的占110例(75.3%).结论 利用脑脊液电影评估神经内镜下第三脑室底部造瘘术的疗效,可以定量分析脑脊液动力学改变,为评价脑积水治疗提供客观依据.     

Syringomyelia after operation： diagnosis and its formational mechanism

Objective： To describe the MRI findings and discuss the pathogenesis formation mechanism of syringomyelia in the patients after spine surgical operation. Methods： Totally 13 patients were been enrolled in the study. Before operation, none of our patients presented with spinal cord syringomyelia. The mean follow-up duration was 6 years （range 2-10 months） by MRI. Four of the 13 patients after spinal cord tumor removed operation, 3 patients after spinal trauma operation, 2 cases had scoliosis before, 2 cases were cervical spondylotic myelopathy and 2 cases had tethered cord syndrome before operation. MR features of pre- and post-operation on all patients were been studied in contrast with surgical results and clinical symptoms. The radiology diagnostic was made by 3 different radiologists respectively. The characteristics of length, width, signals, shape of cavity and spinal cord position as well as subarachnoid shape were focused on. Results： All the patients had no syringomyelia on MRI before operation. The spinal cord of 7 patients showed persist compression and 2 patients had tethered cord before operation. MRI features of syringomyelia after operation in our cases showed longitudinal cavity with syrinx fluid had T1 and T2 relation characteristics of cerebrospinal fluid （CSF）. The mean length was 5.5 spinal segment, 4 cord of 13 patients presented cord compressed from anterior materials, 4 occurred postoperative adhesion to the back of lumbar spinal canal and spinal cord of 1 cases clung to the front wall of cervical spinal canal. Conclusion： The mechanism of syringomyelia in the patients after spinal surgical intervention may be the persisting compression or intention of the spinal cord in the period of pre- or post-operation. The edema, cyst, malacia of spinal cord are the most important lesions and risk factors resulted in the syringomyelia.     

Cerebrospinal fluid dynamics in Chiari malformation associated with syringomyelia

Background About 50%--70% of patients with Chiad malformation I （CMI） presented with syringomyelia （SM）, which is supposed to be related to abnormal cerebrospinal fluid （CSF） flow around the foramen magnum. The aim of this study was to investigate the cerebrospinal fluid dynamics at levels of the aqueduct and upper cervical spine in patients with CMI associated with SM, and to discuss the possible mechanism of formation of SM. Methods From January to Apdl 2004, we examined 10 adult patients with symptomatic CMI associated with SM and 10 healthy volunteers by phase-contrast MRI. CSF flow patterns were evaluated at seven regions of interest （ROI）： the aqueduct and ventral and dorsal subarachnoid spaces of the spine at levels of the cerebellar tonsil, C2-3, and C5-6. The CSF flow waveforms were analyzed by measuring CSF circulation time, durations and maximum velocities of cranial- and caudal-directed flows, and the ratio between the two maximum velocities. Data were analyzed by ttest using SPSS 11.5. Results We found no definite communication between the fourth ventricle and syringomyelia by MRI in the 10 patients. In both the groups, we observed cranial-directed flow of CSF in the early cardiac systolic phase, which changed the direction from cranial to caudal from the middle systolic phase to the early diastolic phase, and then turned back in cranial direction in the late diastolic phase. The CSF flow disappeared at the dorsal ROI at the level of C2-3 in 3 patients and 1 volunteer, and at the level of C5-6 in 6 patients and 3 volunteers. The durations of CSF circulation at all the ROIs were significantly shorter in the patients than those in the healthy volunteers （P=-0.014 at the midbrain aqueduct, P=-0.019 at the inferior margin of the cerebellar tonsil, P=-0.014 at the level of C2-3, and P=-0.022 at the level of C5-6）. No significant difference existed between the two groups in the initial point and duration of the caudal-directed CSF flow during a cardiac cycle at all the ROIs. The maximum velocities of both cranial- and caudal-directed CSF flows were significantly higher in the patients than those in the volunteers at the aqueduct （P=-0.018 and P=-0.007） and ventral ROI at the inferior margin of the cerebellar tonsil （P〈0.001 and P=-0.002）, as so did the maximum velocities of the caudal-directed flow in the ventral and dorsal ROIs at the level of C2-3 （P=-0.004; P=-0.007）. Conclusions The direction of CSF flow changes in accordance with cardiac cycle. The syringomyelia in patients with CMI may be due to the decreased circulation time and abnormal dynamics of the CSF in the upper cervical segment. The decompression of the foramen magnum with dural plasty is an alternative for patients with CMI associated with SM.     

先天性小脑扁桃体下疝畸形合并脊髓空洞症的手术治疗(附14例报告)

目的　了解先天性小脑扁桃体下疝畸形合并脊髓空洞症的手术治疗效果。方法　对 14例先天性小脑扁桃体下疝畸形合并脊髓空洞症患者 ,根据不同的病情采用相应的手术方式进行治疗。其中 9例单纯行后颅窝和上颈椎椎板切除减压、枕大池成形术 ;5例行后颅窝减压、枕大池成形加脊髓空洞分流术。结果　优 11例 ,良 3例 ,有效率为 10 0 %。 14例术后随访 ,复查MRI示脊髓空洞较术前明显缩小 12例 ,空洞无明显改变 2例。结论　先天性小脑扁桃体下疝合并脊髓空洞有临床症状者 ,根据不同的病例情况采用相应的手术方式。     

腰池置管脑脊液外引流术联合注入尿激酶治疗重症蛛网膜下腔出血

目的探讨腰池置管脑脊液持续外引流术联合注入尿激酶治疗重症蛛网膜下腔出血(SAH)的临床疗效。方法将2002年1月-2003年6月28例SAH患者为观察组应用腰池置管脑脊液外引流术并联合椎管注入尿激酶;2000年3月-2001年12月20例应用腰穿脑脊液置换术者为对照组。结果 蛛网膜下腔积血清除时间观察组较对照组短(P<0.01):头痛缓解时间观察组较对照组快(P<0.01);意识障碍时间观察组较对照组短(P<0.01);CSF压力下降时间较对照组短(P<0.01);明显降低再出血、脑血管痉挛、脑积水三大并发症的发生率。结论采用腰池置管脑脊液外引流术联合椎管注入尿激酶治疗重症蛛网膜下腔出血疗效优于腰穿脑脊液置换术。     

动脉导管未闭的外科治疗

目的探讨动脉导管未闻（ＰＤＡ）的手术治疗及其效果．方法ＰＤＡ患者８９例，单纯管型分别行双重结扎加贯穿缝孔（５４例），主动脉外膜下结扎（１８例）．单纯双重结扎（４例），心包内结扎（１例）和切断缝合（１例）．其余１１例在体外循环下切开肺动尽缝合导管内口。结果死亡１例（１．１２％）。术后杂音完全消失者８２例（９２．１３％）心尖区有轻度收缩期杂音２例（２．２５％），肺动脉井区有ＳＭⅡ～Ⅲ／６者４例（４．４９％）术后血压升高２２例．其中１例出现高血压脑病．６８例随访６ｍｏ～５ａ，未发现导管再通．结论双重结扎加贯穿缝扎治疗ＰＤＡ安全可靠，疗效满意．ＰＤＡ术后应重视高血压的防治．     

脑脊液切口漏的原因、治疗及预防

目的：探讨神经外科中较常见并发症脑脊液切口漏的原因与防治措施。方法：通过回颐性的方法对21例脑脊液切口漏患者的临床资料进行分析总结。结果：21例患者除1例因颅内感染未能控制死亡外，其余20例愈合满意。结论：脑脊液切口漏的发生与术后高分解代谢状态，并发外伤性脑积水、外伤性脑膨出，术中切口缝合张力过大，长期应用激素，并发颅内感染等均有一定关系。治疗包括控制感染、减少漏口继续漏液、漏口局部处理三个主要方面，给予足够的营养支持，术中尽量修补硬脑膜，放回骨瓣，保证皮缘血运良好，术后延迟拆线等可以预防脑脊液切口漏。     

应用磁共振相衬技术对ChiariⅠ型畸形合并脊髓空洞症的脑脊液动力学研究

目的应用磁共振相衬技术评估脑脊液动力学改变对ChiariⅠ型畸形脑脊液动力学的影响。方法选取ChiariⅠ型畸形合并脊髓空洞症病人17例（CMⅠ组）和同期健康志愿者16名（对照组）为研究对象，病人均行后颅窝减压术，并于术前及术后12个月分别针对颅颈交界区行磁共振相衬技术检查，志愿者仅检查一次，分析中脑导水管中央段、第四脑室出口段及第二颈椎水平脑脊液流速、流量等参数的改变。结果与对照组比较，CMⅠ组病人各被检处脑脊液峰流速均增快（P < 0.05~P < 0.01），且总体流量减少（P < 0.01）。病人术后各处流速较术前明显变缓（P < 0.01），流量增加（P < 0.01）。不同预后病人的中脑导水管中段脑脊液流量、流速和第二颈椎腹侧脑脊液流速差异均有统计学意义（P < 0.05~P < 0.01）。结论Chiari畸形Ⅰ型伴脊髓空洞症病人存在脑脊动力学变化，表现为脑脊液流动受阻，而脑脊液动力学的改善与病人预后具有相关性，应用磁共振相衬技术监测脑脊液动力学变化有助于评估病人预后。