Research Progress on the Application of Goel Technique in Craniovertebral Junction Anomalies / 中国医学科学院学报

Craniovertebral junction anomalies are a group of diseases characterized by the pathological changes of occipital bone,atlantoaxial bone,cerebellar tonsil,surrounding soft tissue,and nervous system,which are caused by a variety of factors.Chiari malformation is a common type of craniovertebral junction anomalies,the conventional surgical therapy of which is posterior fossa decompression.Currently,scholars represented by Goel have proposed a new theory on the classification,pathogenesis,and treatment of Chiari malformation based on posterior atlantoaxial fixation (Goel technique).This article introduces the progress in Goel technique,aiming to provide reference for the clinical work.

The clinical effect of posterior fossa decompression combined with dural reconstruction in the treatment of Chiari malformation-Ⅰ complicated with syringomyelia / 中国医师进修杂志

Objective:To investigate the clinical effect of posterior fossa decompression combined with dural reconstruction in the treatment of Chiari malformation-Ⅰ(CM-Ⅰ) complicated with syringomyelia (SM).Methods:The clinical data of 50 patients with CM-Ⅰ complicated with SM who were treated in Yan′an University Xianyang Hospital from June 2019 to January 2021 were analyzed. They were divided into the study group (27 cases) and the control group (23 cases) according to the surgical methods. The former received posterior fossa decompression combined with dural reconstruction, while the latter received posterior fossa decompression alone. The clinical symptom improvement, neurological function, cerebrospinal fluid dynamics and syringomyelia changes were compared between the two groups before and after the surgery, and postoperative complications were compared.Results:The overall clinical symptom improvement rate between the two groups had no significant difference ( P> 0.05). After the surgery, the scores of pain, sensory disturbance, dyskinesia and ataxia in the study group were higher than those in the control group: (4.56 ± 0.35) points vs. (4.28 ± 0.43) points, (3.61 ± 0.82) points vs. (3.15 ± 0.73) points, (3.81 ± 0.44) points vs. (3.59 ± 0.50) points, (4.43 ± 0.41) points vs. (4.09 ± 0.53) points, there were statistical significant ( P<0.05). After the surgery, the cerebrospinal fluid stroke volume (SV) and mean flow (MF) in the study group were higher than those in the control group: (0.05 ± 0.02) ml vs. (0.04 ± 0.01) ml, (0.05 ± 0.01) ml/s vs. (0.04 ± 0.01) ml/s; the maximum peak flow velocity (V max) of the head and tail in the study group were lower than those in the control group: (3.14 ± 1.05) mm/s vs. (3.87 ± 1.13) mm/s, (5.56 ± 1.38) mm/s vs. (6.43 ± 1.22) mm/s, there were statistical significant ( P<0.05). There were no significant differences in the rate of reduction or disappearance of syringomyelia, the rate of no change and the rate of increase of syringomyelia after the surgery between the two groups ( P>0.05). There was no significant difference in the incidence of postoperative complications between the two groups ( P>0.05). Conclusions:Posterior fossa decompression combined with dural reconstruction in CM-Ⅰ complicated with SM can better improve cerebrospinal fluid dynamics, and promote the reduction of syringomyelia without increasing postoperative complications.

Efficacy of modified posterior fossa decompression in the treatment of Chiari type Ⅰ malformation with the neuroendoscope / 西安交通大学学报(医学版)

【Objective】 To investigate the clinical efficacy of modified posterior fossa decompression in treating Chiari type I malformation under the neuroendoscope. 【Methods】 We made a retrospective analysis of the clinical data of 63 patients with Chiari type I malformation treated at the Neurosurgery Department of The First Affiliated Hospital of Xi’an Jiaotong University from January 2015 to December 2019. Of the patients, 28 ones underwent modified posterior fossa decompression assisted with neuroendoscopy (observation group) while 35 received posterior fossa decompression with duraplasty (control group). Tator grading, syringomyelia improvement and complications were compared between the two groups to evaluate the postoperative efficacy. 【Results】 The operations were successful in all the 63 patients and no death or severe neurological dysfunction was observed. The efficacy rate was 78.6% in the observation group and 54.3% in the control group, with significant difference (P0.05). 【Conclusion】 Modified posterior fossa decompression assisted with neuroendoscope is a safe and effective treatment for Chiari type Ⅰ malformation. Intraoperative dural watertight suture and dural-muscle suspension can help reduce the occurrence of subcutaneous effusion.

Impacted cisterna magna without syringomyelia associated with lancinating headache, throbbed nuchal pain and paraparesis treated byposterior fossa decompression

A 29-year-old woman with acute lancinating headache, throbbed nuchal pain and subacute paraparesis underwent brain MRI in supine position that depicted: the absence of the cisterna magna, filled by non herniated cerebellar tonsils and compression of the brain stem and cisternae of the posterior fossa, which are aspects of the impacted cisterna magna without syringomyelia and without hydrocephalus. During eight days, pain was constant and resistant to drug treatment. Osteodural-neural decompression of the posterior fossa, performed with the patient in sitting position, revealed: compression of the brainstem, fourth ventricle and foramen of Magendie by herniated cerebellar tonsils, which were aspirated. Immediately after surgery, the headache and nuchal pain remmited. MRI depicted the large created cisterna magna and also that the cerebellar tonsils did not compress the fourth ventricle, the foramen of Magendie and the brainstem, besides the enlargement of posterior fossa cisternae. Four months after surgery, headache, nuchal pain and paraparesis had disappeared but hyperactive patellar and Achilles reflexes remained.

Uma paciente de 29 anos de idade com quadro agudo de cefaléia lancinante, dor terebrante na nuca e paraparesia subaguda foi submetida a RM do encéfalo, em posição supina, que revelou: ausência da cisterna magna, preenchida por tonsilas cerebelares não herniadas e compressão do tronco encefálico e das cisternas da fossa posterior, compatíveis com o diagnóstico de cisterna magna impactada sem siringomielia e sem hidrocefalia. Por oito dias a dor foi constante e resistente aos analgésicos. Com a paciente em posição sentada, foi realizada descompressão osteodural-neural da fossa posterior associada a aspiração das tonsilas cerebelares. Os achados perioperatórios foram caracterizados por herniação das tonsilas cerebelares que comprimiam o tronco cerebral, o quarto ventrículo e o forame de Magendie. No pós-operatório imediato houve remissão da cefaléia e da dor na nuca. A RM evidenciou a cisterna magna recém-criada, alargamento do quarto ventrículo e das cisternas do tronco encefálico. Quatro meses depois, a paciente continuava sem cefaléia, sem dor na nuca e sem paraparesia. Entretanto, permaneceu a hiperatividade dos reflexos patelares e aquileus.

Observation between Clinical Outcomes and the Size of the Syrinx with Magnetic Resonance Image

OBJECTIVE: This study was conducted to examine the correlation between clinical outcomes and the size of the syrinx in post-operative magnetic resonance imaging(MRI) and symptom duration. METHODS: The authors investigated twelve patients who underwent various operations for syringomyelia from January 1995 to December 2003. The authors retrospectively analyzed medical records, pre- and post-operative MRI findings, features and durations of symptoms, and the method of surgical treatments. The clinical outcomes were assessed on Prolo scale at 6 months of post-operative period. RESULTS: Neurologic symptoms did not promptly disappear after the shrinkage of syrinx, but post-operative MRI demonstrated most patients showed reductions in the size of the syrinx. There is no statistical relationship between clinical improvements and decrements of the syrinx size. However, patients who underwent surgical treatment within 2 years from the symptom onset had more favorable outcome than those who had operations after 2 years from the onset of symptoms. CONCLUSION: Change in the size of the syrinx in post-operative MRI is not directly proportional to favorable clinical outcomes. However, symptom duration before surgical treatment has considerable impact on the clinical outcomes.

Posterior Fossa Decompression in Syringomyelia with Chiari Malformation

Chiari malformation is a condition characterized by herniation of the posterior fossa contents below the level of the foramen magnum : The main pathologic change is downward displacement of the cerebellar tonsils to occlude the subarachnoid space at the level of the foramen magnum. For this reason, the practice of posterior fossa decompression in the treatment of syringomyelia with Chiari malformation has been widely accepted. In order to evaluate the usefulness of the procedure in the treatment of this condition, clinical data and surgical outcome in 20 patients who underwent posterior fossa decompression during the last five years were analyzed. The average age at presentation was 35.9(range 17 to 61) years. Chiari I malformation was found in 14 patients, and Chiari II malformation in six : weakness and pain were the most common symptoms. The most useful preoperative imaging study was magnetic resonance imaging. In order to expose the outlet of the fourth ventricle, all patients underwent suboccipital craniectomy and C1 or C1-2 laminectomy with the supportive procedure consisting of adhesiolysis and tonsillar elevation. Postoperatively, 75% of patients showed improvement, and the condition of 15% stabilized. Postoperative MRI was performed in 12 patients, and revealed that in 11 of these, the syrinx cavity had become smaller. Transient headache and vomiting was the most frequent postoperative complication. Patients with pain and numbness had a better prognosis than those with weakness and sensory loss, and it appears that in cases of syringomyelia with Chiari malformation, posterior fossa decompression is beneficial.

Surgical treatment of Chiari malformation accompanied by syringomyelia / 重庆医科大学学报

Objective:To study the different modus operandi of posterior fossa decompression on function recovery of spine cord in patients with Chiari malformation and syringomyelia.Methods:Of 87 patients with Chiari malformation and syringomyelia,51 patients were selected and big craniectomy was performed in all cases.The effects of big craniectomy in 51 patients and mini craniectomy in 36 patients were compared.Results:Among the 51 patients,22 patients(43.1%) improved significanly in their clinical symptoms,10 cases were stabilized,and 5 cases deteriorated.Among the 36 patients,28 patients(77.8%) improved significanly in their clinical symptoms,and 3 cases were stabilized.Conclusion:Surgical treatment may fully ameliorate the clinical syndromes.Mini craniectomy and expansile reconstruction of posterior fossa is a preferred surgery for the treatment of ChiariⅠmalformation.

The Early Diagnosis and Treatment in Cerebellar Infarction

Cerebellar infarction may be rapidly fatal when the patient is not diagnosed and treated promptly. Since 1980, we have encountered five patients of cerebellar infarction and here we analysed the cases and reviewed the literature. All patients were treated by means of the posterior fossa decompression with mortality rate of 20%. By the mode of onset and progression of symptoms and signs, the patient of cerebellar infarction could be divided into two groups;The patients who took the benign course showed the initial symptoms of headache, nausea, vomiting, dizziness and lack of balance, and were usually recovered spontaneously with the conservative treatment. On the contrary, the patients who took the progressive course showed rapidly progressive deterioration of the initial symptoms and signs and mental state. They could be recovered by the early posterior fossa decompression. The emphasis should be given to the early diagnosis and treatment for the purpose of recover in the patient of cerebellar infarction.