Comparison of dural grafts in Chiari decompression surgery: Review of the literature

Abstract

Background:Decompression of Chiari malformation is a common procedure in both pediatric and adult neurosurgery. Although the necessity for some bony removal is universally accepted, other aspects of Chiari surgery are the subject of debate. The most controversial points include the optimal amount of bony removal, the use of duraplasty (and the type of material), the need for subarachnoid dissection, and the need for tonsillar shrinkage.Material and Methods:We critically reviewed the literature to elucidate the risks and benefits of different graft types and to clarify optimal treatment options therein. Based on our search results, 108 relevant articles were identified. With specific inclusion and exclusion criteria, we noted three studies that directly compared two tlpes of dural substitutes in Chiari malformation surgery.Results:Our review did not support the superiority of either autologous or nonautologous grafts when duraplasty is employed. Our institutional experience, however, dictates that when the pericranium is available and of good quality, it should be utilized for duraplasty. It is non-immunogenic, inexpensive, and capable of creating a watertight closure with the dura.Conclusions:Discrepancies between the three comparative studies analyzed are likely attributable to increases in pericranial quality and thickness with maturity. Future randomized studies with large numbers and the power to resolve differences in the relatively low rates of complications in Chiari surgery are warranted.

Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note

“…Performing a craniotomy versus craniectomy reduces pseudomeningocele formation [ 11 - 12 ]. The use of autologous dural grafts as compared to non-autologous dural grafts can lower rates of wound complications [ 13 ]. Furthermore, a reduced rate of CSF-related complications can be seen with a variety of commercially available dural sealants [ 14 - 16 ].…”

The need in dural graft suturing in Chiari I malformation decompression: A prospective, single-blind, randomized trial comparing sutured and sutureless duraplasty materials

“…Similarly, no difference has been observed in prior studies comparing autologous and nonautologous grafts in duraplasty for Chiari decompression. [1] All patients showed a significant improvement in their response to the question “Compared to one year ago, how would you rate you health in general now?” – The average patient response to this question was “better” indicating treatment efficacy over the time course of the study. Neither DuraGen nor Dura-Guard had a significantly different response to this question.…”

Fibrin sealant augmentation with autologous pericranium for duraplasty after suboccipital decompression in Chiari 1 patients: A case series

“…[20] However, a recent literature review did not find any superiority when comparing autologous to nonautologous grafts, which we feel is most likely due to the heterogeneity amongst studies. [1] The authors of that study also state that their institutional experience dictates that autologous pericranium should be utilized when available and of good quality. [1]…”

“…[1] The authors of that study also state that their institutional experience dictates that autologous pericranium should be utilized when available and of good quality. [1]…”

“…Controversy persists around the optimal amount of bony removal, necessity for dissection of subarachnoid webs, need for duraplasty and choice of employed material, augmentation of dural closure with sealants, and need for tonsillar shrinkage. [18162739] A survey by the AANS of pediatric surgeons revealed that 9% performed prophylactic surgery in asymptomatic patients, with treatment for symptomatic patients varying widely with 20% performing bony decompression alone, 30% augmenting with a dural graft, another 25% including intradural dissection of adhesions along with dural grafting, and 30% performing tonsillar resection on top of everything else. [18] Recent meta-analysis comparing decompression with or without duraplasty found that added duraplasty was associated with a lower risk of reoperation than suboccipital decompression alone but had a greater risk of CSF-related complications.…”