[Introduction to medical experts] Gu Jianwen, a famous neurosurgeon, is a high-level scientific and technological leader, doctoral tutor and brain surgeon in the whole army; Vice President of Air Force General Hospital; Director of the Chinese Medical Association, vice chairman of the PLA Neurosurgery Committee; Specializes in minimally invasive surgery for brain tumors. Treatment of cerebrovascular diseases, epilepsy, Parkinson’s disease and spinal diseases. Won the first prize of scientific and technological progress of the whole army in 2008 and many provincial and ministerial awards. More than 6,000 operations were completed.
[Author Brief Introduction] zhouyan, deputy chief physician of neurosurgery in Air Force General Hospital, is a doctor of medicine, and is good at treating spinal cord tumor, spinal diseases, meningioma, area spasm, trigeminal neuralgia and craniocervical junction malformation. The basic research of meningioma and microsurgical treatment of meningioma in the central area of skull base won the second prize of medical achievements of the whole army in 2007.
February 11, 2015 is a small year in the north. For Pony, a girl from Changchun, there is no joy today, only fear and anxiety. Her operation is scheduled for today. ……
25 years of "sensory separation"
From birth, she gave her parents the impression that she was particularly good. She didn’t cry when she was given an injection, and she didn’t make trouble when she bumped and wrestled. Although she was a girl, she always gave people the heroic spirit of a boy. I didn’t feel anything wrong myself. Until the 24-year-old that serious trauma, knee cruciate ligament rupture.
During the routine preoperative examination in the hospital, the doctor found that she was particularly insensitive to pain, but her sense of touch was normal. A serious problem was found in the next MRI. The pony has severe hydrops in the cervical spinal cord, which is what we call syringomyelia. And that’s not all. The cerebellar tonsil leaves its normal position and enters the cervical spinal canal, which further compresses the nerve tissue at the top of the cervical spinal canal. This is what we call "cerebellar tonsil hernia malformation", also known as Chiari malformation. To put it simply, this phenomenon of pony’s insensitivity to pain and normal touch is called "sensory separation", which is a typical symptom of syringomyelia.
For ponies that have grown for 25 years, this phenomenon does not affect their work and life. Should it be cured? My parents and newly married husband traveled to many big hospitals in Changchun and Beijing, and consulted many famous experts in detail. They learned that if they are not treated, they may continue to develop their illness, which may eventually lead to muscle atrophy and difficulty in walking, making it difficult to take care of themselves, let alone work.
Gu Jianwen, an expert in neurosurgery and vice president of the Air Force General Hospital, said: This is a congenital disease, which is caused by the abnormal development of the brain structure in the midline of the posterior cranial fossa during the embryonic period, the cerebellar tonsil extending downward, or protruding into the cervical spinal canal with the lower part of the medulla oblongata or even the IV ventricle through the foramen magnum. Syringomyelia is a chronic and progressive lesion of the spinal cord. The etiology is not very clear, and its pathological features are the formation of tubular cavities in the spinal cord (mainly gray matter) and the proliferation of glia (non-nerve cells). It often occurs in the cervical spinal cord. Obviously, it needs treatment, but,
Who will treat pony’s illness?
Who will treat the patient? For a family with an only daughter, the choice is difficult, and there is no choice to regret. Repeated comparisons, recommended by relatives and friends, after a year, I finally came to the Air Force General Hospital and found Professor Gu Jianwen, a neurosurgeon.
No matter how big the experts are, they have grown up through hardships. Faced with this case, Professor Gu Jianwen believes that the treatment is very difficult. Firstly, the stability of atlantoaxial joint needs to be evaluated in detail; Secondly, whether there is causal relationship between cerebellar tonsillar hernia and syringomyelia; Finally, how can we solve all the problems at once, so that patients can benefit greatly and suffer less. In fact, until now, these problems are still international problems. Professor Gu Jianwen decided that no matter how big the risk is, as long as there is a glimmer of hope, he will never give up. The operation must be done.
As the treating doctor of Pony, I made detailed preparations for the operation she will undergo. Arrange for her to take X-ray examination of cervical hyperextension and hyperflexion to understand the stability of atlantoaxial joint; Three-dimensional CT reconstruction of craniocervical junction was carried out to further understand the stability and observe whether there are other developmental malformations. Dr. Yu Panfeng from the Orthopedic Spinal Group was also invited to evaluate. Through evaluation, it is considered that the operation does not affect the stability of cervical spine.
Professor Gu Jianwen led us to determine the surgical plan: posterior cranial fossa enlargement+reconstruction of occipital cistern+partial cerebellar tonsillectomy+syringomyelia shunt. Four types of operations are completed at the same time, and the difficulty can be imagined.
go deep into the mountains, knowing well that there are tigers there—go on undeterred by the dangers ahead
On the day of the northern off-year, the operation began at 9: 30 am.
1. Release physical space
The first operation: the narrow posterior cranial fossa and vertebral bone were opened with rongeur, which opened the confined physical space.
2. Remove the "appendix" in the brain
The second operation: after opening the dura mater, we can see that the cerebellar tonsil herniates into the lower edge of the foramen magnum, tightly squeezing the very, very important nerve tissue. And this part of the tissue has become the "appendix" of the brain, completely useless tissue. The operation successfully removed some useless cerebellar tonsil tissue and retracted it to the normal position (foramen magnum). This is only the first step. Next, we should explore the outlet of the fourth ventricle and the opening of the central spinal canal, because this may also be the cause of syringomyelia. Exploration found that, as expected … These two openings were tightly locked by the thickened arachnoid membrane. The next step is to carefully separate and open up water channels.
3. Break through the stagnant spinal cord "dammed lake"
The third operation: exploration found that the most bulging position of the spinal cord started from the third cervical plane. The surface of the spinal cord, which used to have beautiful wrinkles, has been swollen and smooth by stagnant water. Sometimes, smoothness is not necessarily a good thing. Just as a dammed lake is a lake formed by blocking a valley or river bed and storing water by landslides caused by earthquake activities. There are four processes in the formation of the dammed lake: one is the original water system; Second, the original water system was blocked by plugs. Third, after the river valley and river bed are blocked, the flowing water gathers and overflows around. Fourth, the dammed lake will be formed when the water is stored to a certain extent. Once the dammed lake breaks, it will form a flood peak downstream, and improper disposal will lead to major disasters. Similarly, after the spinal cord is filled with water, the function of the spinal cord is gradually lost. The operation is to get through the "barrier lake" of this spinal cord.
Cutting the back of the spinal cord and placing the shunt tube is an extremely delicate and gentle job, because this position is too important, and the result of any slight difference may be disastrous. The length of the incision is only 2-3mm, and the shunt tube is as soft as hair. Moreover, there is a heavy procedure. Because this patient’s syringomyelia is not a whole, but divided into several compartments, this important operation is to use a shunt as thin as a hair to get through the compartments. This is more and more like the plot of a martial arts novel, but it is actually the case.
4. Put a big bed on the spinal cord.
The fourth operation: reconstruction of cisterna magna. The artificial dura mater is used to enlarge the cisterna magna to further reduce the pressure and provide a safer and more effective buffer zone. Let the spinal cord no longer sleep in a small bed. Instead, the external cavity of the spinal cord is enlarged, and a "Simmons" big bed is rebuilt, so that the spinal cord can sleep in the big bed this life.
The operation lasted 2 hours. After the pony recovered from anesthesia, she felt more sensitive pain in her hands. I believe that with the extension of time, the surgical effect will get better and better.
According to the custom, on the day of off-year, the Kitchen God will tell the Jade Emperor about a family’s good and evil, and return on New Year’s Eve with orders to reward the good and punish the evil, or to bless or reduce the disaster. In reality, I have never seen the characters in these customs, but as a doctor, at this moment, I suddenly feel that the wish for the well-being of patients is to repay the blessings. I sincerely hope Pony can recover smoothly and go home for the New Year.
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[Related knowledge link]
The malformation of cerebellar tonsil hernia, also known as Chiari malformation, is a congenital developmental abnormality that the cerebellar tonsil extends downward or protrudes into the cervical spinal canal with the inferior medulla oblongata or even the IV ventricle through the foramen magnum due to the abnormal development of the brain structure at the midline of the posterior cranial fossa during the embryonic period.
1, the medulla oblongata and upper compression can appear hemiparalysis or quadriplegia, tendon hyperreflexia and other pyramidal signs, sensory disorders, urinary and defecation disorders and dyspnea; Cerebral nerve involvement can include facial numbness, diplopia, tinnitus, hearing impairment, dysarthria and dysphagia, cervical nerve root symptoms such as pain in the lower occipital region, cerebellar symptoms such as nystagmus and gait irregularity;
2. There may be symptoms of increased intracranial pressure such as headache and papilla edema;
3. The brain stem and upper cervical segment are compressed and flattened, and the surrounding arachnoid adhesion and thickening can form cysts; The medulla oblongata and cervical spinal cord can be affected by compression ischemia and cerebrospinal fluid pressure, resulting in secondary syringomyelia and corresponding symptoms.