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中华神经创伤外科电子杂志

中华神经创伤外科电子杂志 ›› 2024, Vol. 10 ›› Issue (04) : 206 -212. doi: 10.3877/cma.j.issn.2095-9141.2024.04.003

临床研究

后颅窝减压联合不同硬脑膜处理方式对Chiari畸形Ⅰ型患者预后的影响
李丽丽1, 陈鑫1, 赵世光1, 杨赫1,†()   
  1. 1.150001 哈尔滨，哈尔滨医科大学附属第一医院神经外科
  • 收稿日期:2024-01-10 出版日期:2024-08-15
  • 通信作者: 杨赫
  • 基金资助:
    黑龙江省自然科学基金优青项目（YQ2021H017）

Influence of posterior cranial fossa decompression combined with various dural management techniques on the prognosis of Chiari malformation type Ⅰ

Lili Li1, Xin Chen1, Shiguang Zhao1, He Yang1,†()   

  1. 1.Department of Neurosurgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001,China
  • Received:2024-01-10 Published:2024-08-15
  • Corresponding author: He Yang
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李丽丽, 陈鑫, 赵世光, 杨赫. 后颅窝减压联合不同硬脑膜处理方式对Chiari畸形Ⅰ型患者预后的影响[J]. 中华神经创伤外科电子杂志, 2024, 10(04): 206-212.

Lili Li, Xin Chen, Shiguang Zhao, He Yang. Influence of posterior cranial fossa decompression combined with various dural management techniques on the prognosis of Chiari malformation type Ⅰ[J]. Chinese Journal of Neurotraumatic Surgery(Electronic Edition), 2024, 10(04): 206-212.

目的

比较Chiari 畸形Ⅰ型（CM-Ⅰ）患者后颅窝减压后使用不同材质的人工硬膜行硬膜扩大成形术或硬膜外层切开术的短期疗效、术后并发症、手术时间及长期疗效。

方法

回顾性分析哈尔滨医科大学附属第一医院神经外科自2012 年9 月至2023 年12 月收治的169 例CM-Ⅰ患者的临床资料，其中30例行后颅窝减压术+硬膜外层切开术（A组），139例行后颅窝减压术+硬膜扩大成形术（B 组），包括61 例使用主要成分是胶原蛋白的生物成分硬膜（B1 组），59 例使用主要成分是聚酯尿烷纤维的人工合成材料硬膜（B2 组），19 例使用主要成分是Polyglactin910 缝线和聚二氧环己酮（PDO）无色缝线交织而成的人工硬膜（B3 组）。比较4 组患者的术后短期Tator 评分、并发症、手术时间及长期预后。

结果

A 组与B1 组、B2 组、B3 组患者的术后短期有效率、好转率和并发症发生率比较，差异均无统计学意义（P＞0.05）。A 组患者的中位手术时间较B1 组、B2组、B3组短，差异有统计学意义（P＜0.05）。Chicago-Chiari 预后量表评分和Tator 评分的评估结果显示，A组的改善率、好转率均高于B1 组、B2 组、B3 组，差异有统计学意义（P＜0.05）；而B1 组、B2 组、B3组比较，差异无统计学意义（P＞0.05）。

结论

CM-Ⅰ患者后颅窝减压后行硬膜外层切开术比使用不同材质硬膜行扩大成形术的手术时间相对更短，长期疗效更好。

关键词: Chiari畸形Ⅰ型, 后颅窝减压术, 硬膜外层切开术, 硬膜扩大成形术, 人工硬膜

Objective

To compare the short-term efficacy, postoperative complications, operative time, and long-term outcomes of using different materials of artificial dura for duraplasty or outer dural layer incision after posterior fossa decompression in patients with Chiari malformation type Ⅰ(CM-Ⅰ).

Methods

A retrospective analysis was performed on the clinical data of 169 patients with CM-I treated at Neurosurgery Department of the First Affiliated Hospital of Harbin Medical University from September 2012 to December 2023.Among them,30 patients underwent posterior fossa decompression+outer dural layer incision (group A), and 139 patients underwent posterior fossa decompression + duraplasty (group B), including 61 patients using collagen-based biological dura (group B1); 59 patients using polyester urethane fiber synthetic dura (group B2);and 19 patients using artificial dura composed of Polyglactin910 sutures and Polydioxanone (PDO) sutures (group B3). The postoperative short - term Tator scores,complications,surgical time,and long-term prognosis of four groups were compared.

Results

There was no statistically significant difference in the short-term efficacy, improvement rate, and complication rates between group A and groups B1, B2, and B3 (P＞0.05). The median surgical time of group A was shorter than that of groups B1, B2, and B3, and the differences were statistically significant (P＜0.05). The evaluation results of CCOS score and Tator score showed that the improvement rate and progression rate of group A were higher than those of groups B1, B2, and B3, and the differences were statistically significant (P＜0.05);there was no statistically significant differences among the B1,B2,and B3 groups(P＞0.05).

Conclusion

In CM-I patients,dural outer layer incision following posterior fossa decompression has a relatively shorter surgical time and better long-term outcomes compared to expanded duraplasty with different dural materials.

Key words: Chiari malformation type Ⅰ, Circumoccipital decompression, Epidural incision surgery, Epidural enlargement surgery, Artificial dura mater
表1 4组患者一般资料比较
Tab.1 Comparison of general information among 4 groups
组别 例数 年龄[岁，M（P25，P75）] 病程[个月，M（P25，P75）] 性别（男/女） 头痛、头晕 颈背部疼痛、麻木 肌肉萎缩 肢体麻木、疼痛 感觉、运动或步态异常 痛温觉障碍
A组 30 49.5（43.0，54.0） 12.0（4.0，48.0） 7/23 11 15 3 25 20 10
B1组 61 49.0（42.0，54.0） 12.0（3.0，36.0） 15/46 27 30 11 51 40 20
B2组 59 48.0（37.0，53.0） 12.0（3.0，45.0） 16/43 35 27 4 49 39 22
B3组 19 49.0（39.0，59.0） 36.0（6.0，96.0） 2/17 11 10 3 17 17 7
H/χ2值 1.423 3.206 2.235 5.455 0.345 3.851 0.481 3.300 0.332
P值 0.700 0.360 0.525 0.141 0.951 0.264 0.959 0.348 0.954
表2 4组患者术后短期疗效比较
Tab.2 Comparison of short-term postoperative efficacy among four groups
组别 例数 优 良 差 有效率[例（%）] 好转率[例（%）]
A组 30 22 8 0 30（100.0） 22（73.3）
B1组 61 36 23 2 59（96.7） 36（59.0）
B2组 59 41 16 2 57（96.6） 41（69.5）
B3组 19 13 5 1 18（94.7） 13（68.4）
H/χ2值 2.423 3.000 1.326
P值 0.489 0.392 0.723
表3 4组患者术后并发症比较
Tab.3 Comparison of postoperative complications among 4 groups
组别 例数 发热 头痛 颅内感染 切口裂开 静脉血栓形成 发生率[例（%）]
A组 30 1 0 0 1 1 3（10.0）
B1组 61 9 4 3 0 0 16（26.2）
B2组 59 8 11 2 1 0 22（37.2）
B3组 19 2 4 1 0 0 7（36.8）
χ 2值 27.687
P值 0.112
表4 4组患者随访CCOS评分比较
Tab.4 Comparison of CCOS score among 4 groups during follow-up
组别 例数 改善 不变 恶化 改善率[例（%）]
A组 30 28 2 0 28（93.3）
B1组 46 32 14 0 32（69.6）a
B2组 44 28 16 0 28（63.6）a
B3组 14 9 5 0 9（64.3）a
H/χ2值 9.197 8.847
P值 0.027 0.031
表5 4组患者随访Tator评分比较
Tab.5 Comparison of Tator score among 4 groups during follow-up
组别 例数 优 良 差 有效率[例（%）] 好转率[例（%）]
A组 30 28 2 0 30（100） 28（93.3）
B1组 46 32 14 0 46（100） 32（69.6）a
B2组 44 28 16 0 44（100） 28（63.6）a
B3组 14 9 5 0 14（100） 9（64.3）a
H/χ2值 9.197 0.000 8.847
P值 0.027 1.000 0.031
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