硬膜补片与自体筋膜成形修补术治疗Chiari畸形合并脊髓空洞症的对照研究.doc

硬膜补片与自体筋膜成形修补术治疗Chiari畸形合并脊髓空洞症的对照研究北京大学(医学版)JOURNAL0FPEKINGUNIVERSITY(HEAH,HSCIENCES)Vo1.37No.6Dec.2005?629?论着DuraplastywithNeuropatchversusautologousfascialataforChiariImalformationwithsyringomyelia:AcomparativestudyLIUBin.WANGZhenyu,LIZhendong,MAChangcheng,SUNJianjun,CHENXiaodongfDepartmentofNeurosurgery.PekingUnIYersityThirdHospital,Beijing100083,China)ABsTRAcTobjective:T0evaluatetheoutcomeandpostoperativereactionofduralsubstitute(Neuropatch)applyinginthetreatmentofChiariImalformation(CMI)associatedwithsyringomyelia(SM).Methods:FortvpatientsofCMIassociatedwithSMwereoperatedinourdepartmentfromJu1.2002toJu1.2004.A1lpatientsunderwentposteriorcranialfossadecompressionandduraplasty.Theyweredividedintotwogroups.20patientsbeingrepairedwithNeuropatch(Neuropatchgroup),andtheotherswithaHto1ogousfascialata(fasciagroup).Therewere6malesand14femalesinNeuropatchgroupand10malesandl0femalesinfasciagroup.Theoperationswereperformedundergeneralanesthesiaviasuboccipitalapproachandtheextentofposteriorcranialfossadecompressionrangedfrom20cnl(5cnl4cn1)to35cnl(5cnl7em),Therenloxralofposteriorarchofatlasdependedontheextentoftonsillarherniation.andthedurawasopenedi11shape.TheNeuropatchwascutintotriangularshape,andthesamesize(autologousfascialatawasuse(1infasciagroup.Thepatchesweresuturedtightlytotheduramatterineachgroup.lheincisionwas(_losedlayerbylayeranddrainagewasused.ifnecessary.Antibi-oticsandhormonewereroutinelyused.Fhedurationofoperation,postoperativefeverwereevaluated,theoutconleoftheoperationwasevaluatedbyTatorscale,andthedatawereanalyzedwithstatisticsoftwareSPSSl0.0.Results:Therewerel2patients(60%)whosufferedfrompostoperativefeverintheNeuropatchgroup,and9patients(45%)inthefasciagroup(x=0.902,P=0.342).Seventeenpatientsineachgroupwereimprovedpostoperatively.Thedurationofoperation,postoperativefeverandantibioticsusedwerecomparedbetweenthetwogroups.Nosignificantdifferencewasfound,butthedurationofpostoperativefeverandthetimeofhormoneusedweredifferent.TherewerenopostoperativeinfectionsthatoccuedafterthefollowuDf0rlto2years,exceptforonepatientinfasciagroupwhodevelopedin-fectivegranulomaandrecoveredlaterbytreatment.Conclusion:Neuropatchisausefulduralsubstitutef0rtherepairofduraldefectsinthetreatmentofCMIassociatedwithsyringomyelia.KEYWORDSArnoldChiarimalformation:Duramatter;Syringomyelia;Surgicalprocedures,operative硬膜补片与13体筋膜成形修补术治疗Chiari畸形合并脊髓空洞症的对照研究刘彬,王振宇,李振东,马长城,孙建军,陈晓东(北京大学第医院神经外科,北京100083)摘要目的:评价硬膜补片(Neuropatch,商品注册号:国药管字第2002346032)治疗Chiari畸形合并脊髓空洞的疗效及术后反应.方法:2002年6月至2004年6月收治Chiari畸形合并脊髓空洞患者40例,所有患者均行枕大孑L减及硬膜成形术,其中20例应用硬膜补片行硬膜修补(硬膜补片组),余20例患者应用自体阔筋膜修补(自体筋膜组).观察指标包括两组问手术的时日J,术后发热持续的时问,放置引流时间及引流量,术后应用激素及抗生素的时间,依据Tator评分评价术后效果采用t及x进行数据分析.结果:硬膜补片组术后有l2人(60%)出现发热,自体筋膜组有9人(45%)(x:0.902,P=0.342),脑脊液培养均阴性,硬膜补片组与自体筋膜组手术治疗改善均为l7例(85%),两组在手术时问,术后发热,引流放置时问及引流量,术后应用抗生素的时间,术后疗效评价差异均无统计学意义,而术后发热持续时间(t=一2.913,P:0.045)及激素应用时间差异有显着性(t:一3.116,P:0.006),随访12年自体筋膜组有1例出现迟发伤口炎性肉芽肿,余无迟发感染发生.结论:Chiari畸形合并脊髓空洞手术中,硬膜补片(Neuropateh)是一可靠的修补硬膜缺损的硬膜替代物.关键词ArnoldChiari畸形;硬膜;脊髓空洞症;外科手术中图分类号R744.4文献标识码A文章编号1671167X(2005)06-0629-04C0rremligauthorsPmail,wzy502mail.china.tom?630?北京大学(医学版)JOURNALOFPEKINGUNIVERSIIY(HEALTHSCIENCES)Vo1.37No.6Dec.2005IthasbeendecadesforthesurgicaltreatmentofChiariImalformation(CMI)associatedwithsyringomyelia(SM).Mostsurgeonsprefefredtododuralplastyafterdecompressionofforamenmagnum(DFM),butuptonowafinalconclusionhasnotbeendrawnaboutwhethertorepairtheduraldefectwithautologousfasciaorartificialduralsubstitutel.Malliti2foundthatthelatterhadmoreinfectiouscomplicationsaftertheoperationofposteriorfossaandproposedthattheautologousfasciashouldbeconsideredfirst.WealsofoundthatthepatientswhohadundergonetheDFMandrepairedtheduraldefectwithartificialdurafNeuropatch)showedmoreincidenceofpostoperativefever.andthemorbidityseemedtobehigherthanthatofrepairingwithautologousfascia.Toconfirmtheabovementioned,weanalyzedthesepatientswhosufferedfromCM1withSMandtreatedbyDFMretrospectively.Themorbidity,postoperativecomplicationandpostoperativeoutcomewerediscussedasfo11ows.1Patientsandnethods1.1PatientsmaterialsFromJanuary2002toJanuary2004,decompressionofforamenmagBumandduraplastywereperformedin40patientswhosufferedfromCMIassociatedwithSM.DiagnosisofCMIassociatedwithSMwasestablishedbymagneticresonanceimaging(MRI)scans.CaudaldisplacementofthetonsilswaslimitedtotheC.1eve1.In20patients(Neuropatchgroup)thesyntheticduralsubstitute(Neuropatch,B.BraunMelsungenAG)wasused,andintheother20patients(fasciagroup)theautologousfascialatawasusedtorepairtheduraldefect.Therewere6malesandl4femalesinNeuropatchgroup,meanagebeing41.4years,andthedurationofthesymptomsrangedfrom6monthstolOyears(mean5.4years),syringomyeliaextendedfromC1一T7;andl0malesandlOfemalesinthefasciagroup,meanagebeing39.5years,andthedurationofthesymptomsrangedfroml2monthsto9yearsfmean4.9years),syringomyeliaextendedfromC1一T.ClinicalmanifestationsarelistedinTable1.Table1ClinicalmanifestationbetweenJuropatchgroupandfasciagroup1.2OperativeprocedureTheprocedurefordecompressionofforamenmagBumhasbeendescribedindetailelsewhere【.Brief-ly.asuboccipitalmidlineincisionwasmadefromuncialligamentdowntospinousprocessofC2,andthedecompressionwindowontheoccipitalbonewas5cmx4cm5cmx7cm.atlaswasdependedRemovaloftheonthelengthofposteriorarchofcerebellartonsilherniation.TheduraopenedinYshapewhilethearachnoidadhesionwasrelievedaspossible,foramenofMagendiewasnotexploredroutinely,andrepairedwithNeuropatchorwithfacialatawhichwasshapedintotriangleandsuturedtightlytotheduraldefect.Drainagewasusedifnecessaryandremovedin2448hours.Antibioticsanddexamethasoneweregivenroutinely.Allthepatientsinthisstudywerevolunteersandsignedinformedconsent.Furthermore,wealsogottheagreementfromthehospitalethicscommitteeandregistered.A11therelevantdatawereanalyzedinYtestandttestbyusingdataanalysissoftwareSPSS10edition.TheoperativeresultswereassessedwithTatorSscale:Excellentresult:markedpostoperativeimprovementwithfurtherstabilization.Good:slightpostoperativeimprovementwithfurtherstabilization.Poor:temporaryornopostoperativeimprovementwithfurtherdeterioration.2ResultsTherewere12patients(60%)intheNeuropatchgroupand9patients(45%)inthefasciagroup(X2=0.902,P=0.342)whopresentedpostoperativefever.A1lthesepatientsunderwentcerebrospinalfluidfCSF)bacteriacultureandtheresultswerenegative,andallofthemrecovereduneventfully.Therewerenolongtermcomplicationthatoccurredafteroneyearfollowupexceptfor1patientinthefasciagroupwhosufferedfrominflammatorygranulomaofthewoundandcuredafterdebridement.Excellentresultswereachievedin17patients,goodresultsin3patientsineachgroup.ThedetaileddataofthetwogroupsareshowninTables25.Table2Comparisoninage,wogroups3Discussion3.IThechoicesofmaterialforduraplastyinCMIassociatedwithSMThemechanismabouttheformationofsyringomyeliainCMIisstillnotclarifiedL4.MostauthorsbelievedthattheformationofSMisrelatedtotheobstructionofCSFcirculationaroundtheforamenmagBuminCMI一.6-.ThesurgicaltreatmentofCM1withSMincludesdecompressionoftheposteriorfossa.1ettingtheduraopenorrepairingwithsomematerials(duraplasty),butuptonowitisstillarguedabouttheoptionofoperationl】.5.Milhoratsuggested刘彬,等硬膜补片与自体筋膜成形修补术治疗Chiari畸形合并脊髓空洞症的对照研究?63l?duraplastyshouldbedoneinmostpatients.Nowsomeduralsubstitutesincludingautologousperiosteumorfasciaandsyntheticduralsubstitutewereused.Inourhospital,thefollowingmaterialshavebeenusedforthispurpose:thefasciasuperficialisaroundtheinci-sioncanbeobtainedeasilybutisusuallythickerthanandneedsnonewincisiontheduramatterandoftenfoiTastoadefectaroundtheincision.causinginfectionoftheincisionduetobadhealing.Anotheralternativeoptionisthefascialatawhichistakenfronthethighofthepatient,andwhosetightnessandstrengtharesimilartothoseofthedurall.butanewincisionmustbemadeandinsomepatientsmaycausemuscleherniationthroughthefascialdefectafteroperation.Otherduralsubstitutessuchasxenogenicduraandbovinepericardiumhavebeenreposedforduraplasty.butadverseeffectswerefoundaboutthesemateri.als【14j.Inrecentyears.thesyntheticdurasubstitute(Neuropatch)hasbeenconsideredtobeagoodsubsti.tute.Cpek.I5_comparedtheNeuropatchwiththeautologousandhomologoustissuesandconsideredittobethemostsuitablematerialforduraplastyforbothpracticalandethicalreasons.RaulusedNeuro.patchinbrainandspinaloperationsforduraplasty,andfoundthatduringreoperationtherewasnoadhesiontothebraintissueandexcellenthistologicalintegrationwasobserved.TheporesoftheNeuropatchwerecolo.nizedbyfibroblastssynthesizingcollagen,andtherewasnoimmunohistologicalorinflammatoryreaction,after4to6yearsfollow.up.Table3Comparisonofpost一(【lfeverbetweentwogroupsTable4ComparisonofquantityandduralionofdrainageTable5RelationshipsbetweendaysofdrainageandpostoperativefeverX=4.668,P:O.0313.2CauseofpostoperativefeverRecently.Mallitiretrospectivelystudied61pa.tientswhounderwentduralplastywithNeuropatchand63patientswithpericraniumandfolloweduDf0r12monthsaftersurgery.Hefoundthatthewoundinfec.tionratesintheNeuropatchandpericraniumgroupswere15%and5%.respectively.andCSFleakagewassignificantlymoreequentintheNeuropatchgroup.HeconsideredtheNeuropatchwasaforeignmaterialtothehost,syntheticduralgraftsshouldbeusedwhenautologousgraftswerenotobtainable.Butaccordingtoourresult,therewerenosignificantpost.operativecomplicationscausedbyNeuropatchandfas.cialata(x:0.902,P:0.342),andCSFculturesofallpatientswerenegative.sotheinfectivecauseoffe.vercouldbeexcluded.ThepostoperativefevermainlyoccurredinpatientswithprolongeddrainagefTable5).ThedurationofpostoperativefeverwaslongerintheNeuropatchgroupcomparedwiththefasciagroup(P=0.045).ItindicatedthatthefluiditydrainedinNeuropatchgroupwasmorethanthatinfasciagroup,atwhichpointourresultwasconsonantwithMallitis.WefoundtheduraoftheseNeurapatch,whichindicatespatientswasthinnerthanthatnomatterhowexactlythesutureunderwent,theleakageofCSFdidhappen.Accordingtoourresult,themeanquantityofdrainageintheNeuropatchgroupishigherthanthatinthefasci.agroup.Sowethinkthatitwouldreducetheoppou.nityofpostoperativefeverifthebiogelcouldbeusedtosealthesuturemoretightly.Itisalsoimportanttoclosetheincisionlayerbylayerespeciallywiththedeepmusclesandcompressivebandageusedinordertodiminishthedeadspaceofincision.Inourresult.dexamethasonewasusefultocontrolthepostoperativefeverifitoccurred.Thatisthereasonwhythedurationofusingdexamethasonewassignificantlydeferredbe.tweentwogroups.ItalsoindicatesthatitwouldtakealongertimetoabsorbthefluidityoftheincisioninNeu.ropatchgroupthaninlasciagroup.3.3Long.termefficacyofduraplastySomesurgeonsfoundthatthecommoncauseofpostoperativesymptomthatrecurredinCM1withSMwaspseud0mening0cele13j.TheothersreposedthatpatientsofCM1withSMwhounderwentduraplastywithautologousfasciadeterioratedpostoperativelyandMRIshowedpseudomeningoceleformationwhichcouldbesolvedbyreoperationwithNeuropatch.Animalstudieshadconfirmedthatthestrengthofautologousfasciade.creasedalongwithtimeextendingbutNeuropatchhadnosignificantchangewhichmightleadtolessopponu.nitytocausepseud0mening0celesaHj.WealsofoundthatNeuropatchhadbetterappearanceofcisternamag.napost-operatively(Figures1,2).f,:-J,峨J【fc】fIjlI1hI,e,【iI,卜JlI,ll1I/1lI(1lt,t,l370I】|-21K)5Figure2MlJI一,blhf-ll_.I_lmIht,LomIllu.,llllIIIIcIItIr?nl(Iv.thl-llI,IF-ll1l(l1一II11tc,l_I?I,Hll【lt-Iulnhr-II-Ift?1IIlIt1wPf1.?,?.,10sllhal,?l_hIlliJt-IufdulI,【JJ)_l_Illh-iiiIlI_,iiJi(-JlIuIrlliIIIlffMILN,MI1iIIl(I1llJMcl1(【I-lI,l-.JI?rIIIJIllIllI114h1)d_lE-tit,arIl(?hnl,htIIllIIII-tf-,ilIIIII,1IIIIllI,IlfIIIPNtlll_III-IIRr-n:elili,lfIIII.l_1.II.I.H.IIi.I1l1i.I.lIv1iIIl.lillhJlLiIfliIj_Jl-IJ)【-HIrr.JNl叫.t)lt?lJl-llnhJf女nl3.s1-f)世J,J川版1i行埭洲手册J-引【!rH【lJ.j赴ill-I1)III,fL1IJnlifi,JrldIhailh1htmlJ!cIO5q7IJIi奴T1t川mmI|t.ditiI!l|fIJz-HmhmPtm-NlRHY,5】t:.SER:1Ill,1ttf耻啦监系缎fE兀1F斯版卜玎凛洲系境Il侉帆撕f1础n管系境.-耍_牧irf-盘.1运转gili糍3i,氧挠l【.由处川l也保健数lj啦川的轼仆,-II【.川集统汁广.前倪健,孕产高危索.廿姐.,.?.1Lf毳il证疵.家庭耻等谨【l段戈蚀i埘-FJ【_童仙l录c手册川均息.坫d地Jf相IJL哑触IW凡系统帕统行忻是情.fntilL陛数抖刊充廿刊2M.i】iIiM,I.|ctllIII:lJilllfillIilll,川-【】川IIIl?l_ll_i.iIIIii,IlhirIuJliIiiiIriJlI,-Imllh-f?ill1.iiiiir1)j.llIl1.hiiill?biiiJI:il?IIJiIiITil,1JYIlJI-LJnl_川,.2tX.599一州33lII.lii?h.JnIIbn山ll?i1JJl,tviIIiv,llliliehiiiiIhfI1Ifllr?,hiiIvlliaJJ,IJnlg.I982565l一51S4I_,llht1111tl,tlnnZ,lnti】il.I.IilJllw】1hl,l,.JIIIi-l:lllllHIrllirliillai?lit.IlrvjI.,JIMh,gIhl)FIIpl?,I.Il,