- 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+Cerebellar tonsillectomy and adhesions+Dural expansion
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Time of operation | 2022-04-04 |
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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 | 2022-03-31 |
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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 | 2022-03-31 |
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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 | YA SF |
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Sex | Woman
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Age | 32 |
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ID | 8003566947 |
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Hospital number | G88032 |
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Birthplace | 重庆市 |
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Nationality | 汉族 |
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Marital status | married
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Occupation | Freelance
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Admission date | 2022-03-31 |
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Diagnosis on Admission | 1.小脑扁桃体下疝畸形；2.脊髓空洞；3.颈5/6、腰4/5椎间盘变性、突出（中央型） |
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Smoking history | non-smoking history
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Whether drinking | occasionally
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Family history | 父母健在，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 | 2010年、2017年分别行剖腹产，2009年曾有摔伤致鼻唇沟破裂，3周前有枕部摔伤 |
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General condition | 步入病区，神志清晰，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。 |
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Chest | 胸廓无畸形，双侧乳房呈中女性正常发育，双肺呼吸音粗，未闻及干湿罗音。心率74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 | 脊柱外观未见明显异常，四肢未见肌肉萎缩，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，精神状态一般。双侧瞳孔等大、等圆，直径2mm，光反射灵敏。间断头颈肩部疼痛，VAS评分6分。四肢可按吩咐活动，肌力、肌张力正常，右手握筷持物、书写等精细活动明显变差，右侧躯干、右上肢浅感觉减弱。病理征阴性，颈软。 |
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Hb | 98 g/L |
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RBC | 3.83 X10*12/L |
31.70 % |
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WBC | 4.49 X10*9/L |
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PLT | 194 X10*9/L |
0.23 % |
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Date of test | 2022-03-31 |
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ALT | 11.40 IU/L |
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AST | 18.00 IU/L |
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ADA | U/L |
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GGT | 10.20 U/L |
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Serum bilirubin | 5.70 μmol/L |
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Indirect bilirubin | 5.10 umol/L |
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Direct bilirubin | 0.60 umol/L |
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Serum albumin | 39.50 g/L |
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Serum globulin | 23.60 g/L |
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Serum total protein | 63.10 g/L |
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A/G | 1.67 |
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Date of test | 2022-03-31 yyyy-mm-dd |
Negative
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Date of test | 2022-03-31 yyyy-mm-dd |
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UN | 5.60 mmol/L |
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Cr | 53.80 μmol/L |
mg/L |
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mg/L |
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SOD | U/mL |
121.36 ml/min/l |
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UA | 265.00 μml/L |
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Date of test | 2022-03-31 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 | 2022-03-31 yyyy-mm-dd |
Positive
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Type of imaging (s) | / / / |
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Assessment of CT/MRI | 头部及脊柱MRI示：小脑扁桃体疝入枕骨大孔，颈2-胸8椎体可见脊髓空洞，颈2-胸1脊髓内囊变，增强后未见明显强化。颈5/6、腰4/5椎间盘信号减低、稍向后突出。 |
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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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Torso sensory function | Mild sensory disorder or numbness
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Bladder | Normal
|
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Total | 15 |
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Total | 15 |
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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 | Mild sensory disorder or numbness
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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 | 15 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 | Yes
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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 |
|
- 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 | 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 | 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 | 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 less than 50% of life
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Complications | No complications
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Total | 13 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 | 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 | 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 | 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
|
|
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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Torso 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 | Completely normal
|
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Complications | No complications
|
|
Total | 15 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
|
|
Whether to perform the head and neck CT | NO
|
|
Whether to perform the spine CT | NO
|
|
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 | 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 | Yes
|
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Specific description | 伤口处疼痛 |
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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 | Normal
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Torso sensory function | Normal
|
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Bladder | Normal
|
|
Total | 16 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 |
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Whether got the informed consent? | Yes
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Date of sign the informed consent | 2022-04-03 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 | |
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Weihua Chu | |
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Guangjian He | |
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Xingsen Xue | |
|
Xin Chen | |
|
Na Wu |