- In the process of the treatment
- Screening
- Baseline
- Follow-up（One week after surgery）
- Follow-up （One month after surgery）
- Follow-up （Three months after surgery）
- Follow-up （Six months after surgery）
- Follow-up （One year after surgery）
- Management and ethics documents
- ADR/ADE management system
- Research team
- Design, Methods
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Operation method | Posterior cranial fossa decompression(2×3cm area including posterior arch of atlas and foramen magnum)+Dural "Y" type incision+Dural expansion
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Time of operation | 2022-03-10 |
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ChiariⅠmalformation confirmed by MR imaging, have corresponding clinical symptoms and signs | Yes
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All genders, age from 18-70 years old | Yes
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Signed informed consent | Yes
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Doctor | 林江凯 |
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Date | 2022-03-08 |
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Congenital diseases, psychotic or neurotic diseases, serious diseases of heart,lung,liver or kidney. | No
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Other Chiari malformations, or Chiari Ⅰmalformations combined with basilar invagination, atlantoaxial dislocation or scoliosis | No
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Other cervical diseases(such as tumor,trauma and degeneration) resulted in cervical pain, limbs numbness or weekness, sphincter disturbance or sexual dysfunction. | No
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Recently(<3y) drug using or psychological problems that could affect outcome | No
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Attned other clinical trials in last 3 monthes | No
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Pregnant women | No
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Doctor | 林江凯 |
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Date | 2022-03-08 |
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The patient does not cooperate with this study | |
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The patient died | |
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The patient asked to quit | |
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Doctor |
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Date |
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- General information
- Physical examination
- Nervous system examination
- Blood Routine Tests
- Serum Liver Function Tests
- HBV Markers Test
- Renel Function Test
- ECG
- Blood type
- Image Examinations
- Preoperative JOA score
- Neck Disabilitve Index NDI
|
Name | HE HO |
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Sex | Man
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Age | 40 |
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ID | 8003297277 |
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Hospital number | G84815 |
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Birthplace | 重庆丰都县 |
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Nationality | 汉族 |
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Marital status | married
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Occupation | Unemployed
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Admission date | 2022-03-08 |
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Diagnosis on Admission | 1、小脑扁桃体下疝畸形； 2、脊髓空洞； 3、右侧颈内动脉微小动脉瘤？ |
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Smoking history | Daily Smoker
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Whether drinking | occasionally
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Family history | 父母均健在，具体不详 ，子女健康状况良好，家族中无传染病及遗传病史。 |
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Medical history | 平素体健，否认“高血压”“糖尿病”、“冠心病”等病史，否认肝炎、结核、疟疾等传染病史，否认手术史，否认外伤史，否认输血史，否认血制品史，否认药物、食物过敏史，预防接种史不详。 |
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General condition | 步入病区，神志清晰，智力正常，自主体位，查体合作。 |
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Skin and lymph nodes | 皮肤巩膜无黄染，全身浅表淋巴结无肿大。 |
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Head and neck region | 头颅未见明显畸形，未及明显头皮包块、颅骨凹陷等，颈部对称，耳、鼻未见漏液，未见颈静脉怒张，唇无发绀，甲状腺不大，气管居中。双侧面部对称。 |
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Chest | 胸廓无畸形，双肺呼吸音清晰，未闻及干湿罗音。心率96次／分，心律齐，各瓣膜听诊区未闻及病理性杂音。 |
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Abdomen | 全腹软，未见胃肠型及蠕动波，肝脾肋下未触及，移动性浊音阴性，肠鸣音正常。 |
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Spine and limbs | 脊柱、四肢无畸形，全身各关节活动未见明显受限，双下肢无水肿。 |
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Nervous system examination | 意识清楚，精神状态正常。双侧瞳孔等大、等圆，直径2mm，光反射灵敏。头颅无畸形，无压痛，无包块。四肢脊柱无畸形，生理曲度存在，四肢感觉及活动正常，精细活动基本正常。四肢肌力、肌张力正常。颈软，偶饮水呛咳，咽反射正常，病理征阴性。发作性头痛，咳嗽及用力时加重，VAS评分8分，偶出现四肢麻木。 |
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Hb | 162 g/L |
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RBC | 5.11 X10*12/L |
47.40 % |
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WBC | 5.90 X10*9/L |
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PLT | 185 X10*9/L |
0.20 % |
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Date of test | 2022-03-08 |
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ALT | 14.00 IU/L |
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AST | 15.10 IU/L |
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ADA | U/L |
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GGT | 32.50 U/L |
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Serum bilirubin | 8.30 μmol/L |
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Indirect bilirubin | 7.10 umol/L |
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Direct bilirubin | 1.20 umol/L |
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Serum albumin | 39.10 g/L |
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Serum globulin | 21.30 g/L |
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Serum total protein | 60.40 g/L |
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A/G | 1.84 |
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Date of test | 2022-03-08 yyyy-mm-dd |
Negative
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Date of test | 2022-03-08 yyyy-mm-dd |
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UN | 5.00 mmol/L |
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Cr | 70.10 μmol/L |
mg/L |
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mg/L |
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SOD | U/mL |
108.17 ml/min/l |
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UA | 335.00 μml/L |
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Date of test | 2022-03-08 yyyy-mm-dd |
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ECG | Normal
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Description for the abnormal findings |
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Date of examination | 2022-03-09 yyyy-mm-dd |
Positive
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Type of imaging (s) | / / / |
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Assessment of CT/MRI | 磁共振(头颈MR)检查提示：小脑扁桃体下疝；扫及颈髓异常信号，提示脊髓空洞可能。(2021-12-22 本院)行ＣＴ(头颈部)检查提示：1.头颅CTA：右颈内动脉 C6段动脉圆锥可能，微小动脉瘤不除外，建议随访；左侧大脑前动脉A1段纤细，左侧胚胎型大脑后动脉。2.小脑扁桃体位置似下移，请结合颈椎MRI评估。 |
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Upper extremity motor function | Normal
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Lower extremity motor function | Normal
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Upper limb sensory function | Mild sensory disorder or numbness
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Lower limb sensory function | Mild sensory disorder or numbness
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Torso sensory function | Mild sensory disorder or numbness
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Bladder | Normal
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Total | 14 |
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Total | 0 |
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Upper extremity motor function | Normal
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Lower extremity motor function | Normal
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Upper limb sensory functio | Normal
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Lower limb sensory function | Normal
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Torso sensory function | Mild sensory disorder or numbness
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Bladder | Normal
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Total | 16 分 |
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Pain | Improvement
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Not painful | Improvement
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Function | Can participate in less than 50% of life
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Complications | No complications
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Total | 12 |
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Whether to perform the chest CT | NO
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Whether to perform the head and neck CT | NO
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Whether to perform the spine CT | NO
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Whether to perform the spine MRI | Yes
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Occipital and neck pain | No
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Body or limbs feel abnormal | Yes
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Limb muscle strength decreased | NO
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Dizziness pain | Yes
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Bowel and bladder dysfunction | NO
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Sexual dysfunction | NO
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Autonomic nervous system dysfunction | NO
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With or without complications | NO
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specific description |
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- Image Examinations
- Symptom
- Complications
- JOA score
- Chicago Chiari Outcome Scale
- Neck Disabilitive Index NDI
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Whether to perform the chest CT | NO
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Whether to perform the head and neck CT | No
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Whether to perform the spine CT | No
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Whether to perform the spine MRI | Yes
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Occipital and neck pain | No
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Body or limbs feel abnormal | Yes
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Limb muscle strength decreased | No
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Dizziness pain | Yes
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Bowel and bladder dysfunction | No
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Sexual dysfunction | No
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Autonomic nervous system dysfunction | No
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With or without complications | No
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specific description |
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Upper limb motor function | Normal
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Lower limb motor function | Normal
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Upper limb sensory function | Normal
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Lower limb sensory function | Normal
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Trunk sensory function | Mild sensory disorder or numbness
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bladder | Normal
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Total | 16 分 |
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Pain | Improvement
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Not painful | Improvement
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Function | Can participate in less than 50% of life
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Complications | No complications
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Total | 12 分 |
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Total | 0 分 |
- Image Examinations
- Symptom
- Complications
- JOA score
- Chicago Chiari Outcome Scale
- Neck Disabilitve Index NDI
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Whether to perform the chest CT | NO
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Whether to perform the head and neck CT | No
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Whether to perform the spine CT | No
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Whether to perform the spine MRI | No
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Occipital and neck pain | No
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Body or limbs feel abnormal | Yes
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Limb muscle strength decreased | No
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Dizziness pain | No
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Bowel and bladder dysfunction | No
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Sexual dysfunction | No
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Autonomic nervous system dysfunction | No
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With or without complications | No
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specific description |
|
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Upper extremity motor function | Normal
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Lower extremity motor function | Normal
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Upper limb sensory function | Mild sensory disorder or numbness
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Lower limb sensory function | Normal
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Trunk sensory function | Normal
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Bladder | Normal
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Total | 16 分 |
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Pain | Complete remission
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Not painful | Improvement
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Function | Can participate in more than 50% of life
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Complications | No complications
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Total | 14 分 |
|
Total | 0 分 |
- Image Examinations
- Symptom
- Complications
- JOA score
- Chicago Chiari Outcome Scale
- Neck Disabilitve Index NDI
|
Whether to perform the chest CT | NO
|
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Whether to perform the head and neck CT | NO
|
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Whether to perform the spine CT | NO
|
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Whether to perform the spine MRI | NO
|
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Occipital and neck pain | No
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Body or limbs feel abnormal | No
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Limb muscle strength decreased | No
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Dizziness pain | No
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Bowel and bladder dysfunction | No
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Sexual dysfunction | No
|
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Autonomic nervous system dysfunction | No
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With or without complications | No
|
|
specific description |
|
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Upper extremity motor function | Normal
|
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Lower extremity motor function | Normal
|
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Upper limb sensory function | Normal
|
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Lower limb sensory function | Normal
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Torso sensory function | Normal
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Bladder | Normal
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Total | 17 分 |
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Pain | Complete remission
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Not painful | Improvement
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Function | Completely normal
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Complications | No complications
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Total | 15 分 |
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Total | 0 分 |
- Image Examinations
- Symptom
- Complications
- JOA score
- Chicago Chiari Outcome Scale
- Neck Disabilitve Index NDI
|
Whether to perform the chest CT | NO
|
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Whether to perform the head and neck CT | NO
|
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Whether to perform the spine CT | NO
|
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Whether to perform the spine MRI | Yes
|
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Occipital and neck pain | NO
|
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Body or limbs feel abnormal | NO
|
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Limb muscle strength decreased | NO
|
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Dizziness pain | NO
|
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Bowel and bladder dysfunction | NO
|
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Sexual dysfunction | NO
|
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Autonomic nervous system dysfunction | NO
|
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With or without complications | NO
|
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Specific description |
|
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Upper extremity motor function | Normal
|
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Lower extremity motor function | Normal
|
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Upper limb sensory function | Normal
|
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Lower limb sensory | Normal
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Torso sensory function | Normal
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Bladder | Normal
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Total | 17 分 |
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Pain | Complete remission
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Not painful | Complete remission
|
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Function | Completely normal
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Complications | No complications
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Total | 16 分 |
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Total | 0 分 |
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Whether got the informed consent? | Yes
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Date of sign the informed consent | 2022-03-10 xx年xx月xx日 |
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Types of violation | |
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Informed consent violant | |
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No. of the violance |
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Date of violance | yyyy-mm-dd-hh-min. |
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Inclusion and Exclusion criteria violation | |
yyyy-mm-dd-hh-min. |
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yyyy-mm-dd-hh-min. |
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Adverse events violantion | |
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yyyy-mm-dd-hh-min. |
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Follow-up violation | |
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yyyy-mm-dd-hh-min. |
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Loss of data violation | |
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yyyy-mm-dd-hh-min. |
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Data over the feild violation | |
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yyyy-mm-dd-hh-min. |
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Therapy or operation compliance violation | |
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yyyy-mm-dd-hh-min. |
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Any approach | |
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Date of action | yyyy-mm-dd-hh-min. |
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Violation information |
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Name of adverse event |
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Reason of adverse event |
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Start date | yyyymmdd |
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Interventions | |
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Interventions, please specify |
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Start date | yyyymmdd |
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Stop date | yyyymmdd |
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Attributed to the surgical plan | |
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Outcome of the event | |
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If recovered/resolved, the date is | yyyymmdd |
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Name of the recorder |
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Data | yyyymmdd |
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Site Investigator’s signature |
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Data | yyyymmdd |
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Southwest Hospital |
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Jiangkai Lin | |
|
Weihua Chu | |
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Guangjian He | |
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Xingsen Xue | |
|
Xin Chen | |
|
Na Wu |