| Purpose:Arnold-Chiari Malformation(ACM)is a common clinical craninocervical junction malformation,in which syringomyelia(SM)is the most common concomitant lesion,and the mechanism is unknown.The disease greatly affects the quality of life of patients,and can develop to be severely life-threatening.Surgery is the best treatment,but there are still some huge controversies about the choice from different operative methods.In the present study,ACM-I patients with SM were further subdivided into different types according to clinical features and imaging features.A retrospective study was conducted to analyze the efficacy of the two most common surgical methods on clinical outcomes of various patients,which provides a theoretical basis for the individualized treatment plan of ACM-I with SM.It will meet the needs of modern medical diagnosis and treatment,reduce patient suffering,improve clinical prognosis,and further improve the patient's quality of life.Methods:Eighty-five ACM-I patients with SM who underwent neurosurgery in Shandong Provincial Hospital from January 2014 to June 2018 were selected strictly.All operations were performed by the same senior chief physicians.According to different clinical Characteristics,the patients were divided into:?those with occipitocervical compression syndrome;?those with central spinal cord injury syndrome;? those with cerebellar injury syndrome;?those with hydrocephalus(the same patient may have two or more clinical manifestations).According to different imaging manifestations,the patients with syringomyelia could be divided into 4 groups:the diameter of syringomyelia>50%effective diameter of the spinal canal,?50%,limited to the cervical spinal cord and beyond the cervical spinal cord.The patients with cerebellar tonsillar hernia were divided into?10 mm and>10 mm.According to different surgical methods,patients were divided into A and B groups.Group A underwent simple posterior cranial fossa decompression plus atlanto-occipital fasciolysis,and group B underwent duraplasty plus partial cerebellar tonsil resection on the basis of group A.After a one-year follow-up,the short-term and long-term outcomes,imaging changes and complications of the two groups were analyzed by Tator scoring and imaging examination to evaluate the prognostic impact of different surgical methods on different types of patients.Results:1.In terms of short-term efficacy,the improvement rate of cerebellar damage syndrome in group A was higher than that in group B(62.50%vs 46.15%).However,the difference was not statistically significant(p=0.379).And for the improvement of overall condition and other symptoms,the patients in two groups had little difference and were not statistically significant(the overall improvement rate of the two groups was 47.37%,53.57%,p=0.591).In regard to imaging findings,the improvement rate of syringomyelia in group B was higher than that in group A,but the difference was not statistically significant(p is greater than 0.05).For the improvement of cerebellar tonsillar sac,group B was significantly better than group A(p=0.020,P<0.001 respectively).In addition,the KPS scores of patients in group A were not significantly different from those before surgery(80.12±14.25),while the KPS scores in group B were significantly decreased(69.75±23.48).2.The one-year follow-up results showed that there was no significant difference between the overall improvement rate of group B and group A(75.44%vs 78.57%,p=0.749).In detail,the improvement of occipito-cervical compression syndrome was higher in group B than in group A(the improvement rate of the two groups was 90.48%,61.29%,p=0.020).For the improvement of central spinal cord syndrome and cerebellar damage syndrome,the difference between the two groups was not statistically significant(the improvement rate of group B was 47.06%and 61.54%,respectively,and the improvement rate of group A was 44%,75%,respectively.P=0.845 and 0.707 respectively).In addition,the KPS scores of patients of group A were higher than tha before surgery(85.61±12.75,p=0.029).The postoperative KPS scores in group B were slightly lower than those before surgery(71.59±19.86),which is significantly lower than those in group A.(p=0.037).With respect to imaging changes,although some indicators were not statistically significant between the two groups of patients,the improvement of syringomyelia and cerebellar retraction with iliac crest decompression+dura mater repair+cerebellar tonsil partial resection are significantly better than simple decompression.3.As for complication analysis,the incidence of complications such as intracranial infection,cerebrospinal fluid leakage,and hydrocephalus in group B was significantly higher than that in group A,and the difference was statistically significant(p=0.007?0.033?0.033).4.Except the surgical methods,the operation time>2h and cerebrospinal fluid leakage is the risk factor for intracranial infection(p=0.007,0.012 and<0.001).Conclusions:Surgery is an effective treatment for ACM-I with SM.The advantages of posterior fossa decompression plus occipital fascia lysis includes the less complications,less costs,and shorter hospital stay.In addition,this kind of surgery can achieve clinical effects similar to dural enlargement repair+cerebellar tonsil partial resection.We suggest it as the preferred procedure for most ACM-I type SM.Although the rate and level of remission the syringomyelia is slightly worse,it could be continued with a secondery operation if necessary.Although tonsil resection could rapidly improve the state of syringomyelia,the risk of complications such as intracranial infection is higher and may lead to malignant outcomes.In clinical work,individualized surgical plans should be developed based on the patient's clinical characteristics,imaging findings and condition. |
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