Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium

Akbari, S. Hassan A.; Yahanda, Alexander T.; Ackerman, Laurie L.; Adelson, P. David; Ahmed, Raheel; Albert, Gregory W.; Aldana, Philipp R.; Alden, Tord D.; Anderson, Richard C. E.; Bauer, David F.; Bethel-Anderson, Tammy; Bierbrauer, Karin; Brockmeyer, Douglas L.; Chern, Joshua J.; Couture, Daniel E.; Daniels, David J.; Dlouhy, Brian J.; Durham, Susan; Ellenbogen, Richard G.; Eskandari, Ramin; Fuchs, Herbert E.; Grant, Gerald A.; Graupman, Patrick; Greene, Stephanie; Greenfield, Jeffrey P.; Gross, Naina L.; Guillaume, Daniel; Hankinson, Todd C.; Heuer, Gregory G.; Iantosca, Mark; Iskandar, Bermans J.; Jackson, Eric M.; Jallo, George I.; Johnston, James M.; Kaufman, Bruce A.; Keating, Robert F.; Khan, Nicklaus R; Krieger, Mark D.; Leonard, Jeffrey R.; Maher, Cormac O.; Mangano, Francesco T.; McComb, J. Gordon; McEvoy, Sean D.; Meehan, Thanda; Menezes, Arnold H.; Muhlbauer, Michael S.; O’Neill, Brent R; Olavarria, Greg; Ragheb, John; Selden, Nathan R.; Shah, Manish N.; Shannon, Chevis N.; Shimony, Joshua S.; Smyth, Matthew D.; Stone, Scellig; Strahle, Jennifer; Tamber, Mandeep S.; Torner, James C.; Tuite, Gerald F.; Tyler-Kabara, Elizabeth C.; Wait, Scott D.; Whitehead, William E.; Park, Tae Sung; Limbrick, David D.

doi:10.3171/2022.2.peds21446

Cited by 16 publications

(20 citation statements)

References 22 publications

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“…At a minimum, bone-only decompression (PFD) is performed to enlarge the extradural cisterna magna, usually the myodural bridges (atlantooccipital membrane) are removed, and sometimes partial-thickness dural splitting is used for additional expansion. 3,7,14,18,22 Dural opening is an option that may be chosen for all patients with either Chiari (as our institution does), syringomyelia, or intraoperative ultrasound appearance after bony decompression. Dural opening procedures usually involve expansile duraplasty to further enlarge the intradural cisterna magna, 31 arachnoid resection, 32,35 tonsillar reduction (pial coagulation or subpial resection), 11,35 and exploration of the obex, FoM, and basolateral cisterns.…”

Section: Chiari Surgery Techniquesmentioning

confidence: 99%

“…Decades of Chiari research have examined these techniques, and the findings suggest that dural opening in syringomyelia patients, as well as in some patients without syringomyelia, may be associated with fewer revision PFDD procedures and greater syrinx and symptom improvements. [3][4][5][6][7]9,12,[17][18][19][20][21][22]26,[32][33][34] The reported complication rates are low overall, but many report lower CSF-related complications in patients who undergo bone-only decompression or arachnoid-sparing dural opening techniques. 3,7,14,18,22 Some also report very low complication rates in dural opening and full intra-arachnoid microsurgical exploration procedures, as we do here.…”

Section: Chiari Surgery Techniquesmentioning

confidence: 99%

“…[3][4][5][6][7]9,12,[17][18][19][20][21][22]26,[32][33][34] The reported complication rates are low overall, but many report lower CSF-related complications in patients who undergo bone-only decompression or arachnoid-sparing dural opening techniques. 3,7,14,18,22 Some also report very low complication rates in dural opening and full intra-arachnoid microsurgical exploration procedures, as we do here. 34 Nevertheless, practice patterns remain mixed, with many surgeons performing mostly dural opening procedures.…”

Section: Chiari Surgery Techniquesmentioning

confidence: 99%

“…Definitive surgical management aims to functionally restore the cisterna magna and can be accomplished through either bone-only posterior fossa decompression (PFD) or PFD with duraplasty (PFDD). Although reported practices are mixed between bony decompression only versus bony decompression with dural opening and expansile duraplasty, 6,12,19,29 many case series and a recent trial 3,22,30,31 have demonstrated that PFD alone may not be enough for certain patients, particularly those with syringomyelia but also some without.…”

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confidence: 99%

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Reappraisal of intradural findings in Chiari malformation type I

Shao¹,

Wójcik²,

Kevin³

et al. 2023

Neurosurgical Focus

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OBJECTIVE Management of Chiari malformation type I (CM-I) requires the functional restoration of an obstructed cisterna magna. In posterior fossa decompression with duraplasty (PFDD), various intradural pathologies are suggested to alter CSF flow at the craniocervical junction and require surgical correction. However, reports of the spectrum of intraoperative intradural findings and their nuances are scarce, especially those characterizing rarer findings pertaining to the vascular structures and vascular compression. METHODS The authors conducted a retrospective cohort analysis of adults and children who underwent first-time PFDD for CM-I (2011–2021), with and without syringomyelia. The surgical reports and intraoperative videos were reviewed, and the frequency and nature of the intradural observations in regard to the tonsils, arachnoid, and vasculature were analyzed along with the clinical findings and surgical outcomes. RESULTS All 180 patients (age range 1–72 years; median [interquartile range] 24 (14–38) years; 37% of patients were children < 21 years of age) exhibited multiple intradural findings, with a median of 7 distinct concurrent observations in each patient. Novel findings not previously reported included posterior inferior communicating artery (PICA) branches compressing the neural elements at the cervicomedullary junction (26.7%). Other common findings included arachnoid adhesions (92.8%), thickening (90.6%), webs at the obex (52.2%), tonsillar gliosis (57.2%), tonsillar hypertrophy (18.3%), adhesions obstructing the foramen of Magendie (FoM) (62.2%), PICA obstruction of the FoM (17.2%), and dural scarring (87.8%). Tonsillar gliosis and intertonsillar adhesions obstructing the FoM were more common in children than adults. Tonsillar gliosis and arachnoid webs were more common among syringomyelia patients. After multivariable adjustment, none of the observed findings were independently associated with syringomyelia, preoperative symptoms, or postoperative improvement. The vast majority of patients improved postoperatively. The complication rate was low: 1.2% of patients required revision PFDD at > 3 years postoperatively, 3.6% experienced other operative complications, and 0% had CSF leaks. CONCLUSIONS The diversity of intradural findings and observations revealed in this study suggests that obstructive and compressive structural anomalies may be more common than previously reported among CM-I patients, both those patients with and those without syringomyelia and especially those with obstructive and compressive PICA branches. Although the authors cannot conclude that all these findings are necessarily pathological, further study may determine how they contribute to CM-I pathology and symptomatology in the setting of a compromised cisterna magna.

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Section: Chiari Surgery Techniquesmentioning

confidence: 99%

Section: Chiari Surgery Techniquesmentioning

confidence: 99%

Section: Chiari Surgery Techniquesmentioning

confidence: 99%

mentioning

confidence: 99%

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Reappraisal of intradural findings in Chiari malformation type I

Shao¹,

Wójcik²,

Kevin³

et al. 2023

Neurosurgical Focus

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“…

TO THE EDITOR: We read with interest the article by Akbari et al 1 (Akbari SHA, Yahanda AT, Ackerman LL, et al Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr.

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confidence: 99%

Letter to the Editor. Recovery of physical signs in Chiari malformation type I and syringomyelia after surgery

Cai

Liu

2022

Journal of Neurosurgery: Pediatrics

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TO THE EDITOR: We read with interest the article by Akbari et al. 1 (Akbari SHA, Yahanda AT, Ackerman LL, et al. Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr. 2022;30[1]:39-51), which reports better outcomes but more postoperative complications with posterior fossa decompression with duraplasty compared to posterior fossa decompression. As the first large-scale, multi-institutional study of pediatric patients undergoing these procedures, although the article did not have surprising results, it has important implications for the choice of surgical procedures to manage Chiari malformation type I (CM1) and syringomyelia (SM) in our clinical practice. In addition, we found some new insights worth sharing with the readers from the study's analysis of prognostic assessment.As we can see from the results of the outcome evaluation of this study, the rate resolution or improvement of symptoms (e.g., headache and back pain) after surgery was more than 80%, but the results for the associated signs were not satisfactory. Why is there a worse recovery of signs after CM1-SM surgery? A careful observation of the clinical outcomes shows that these signs are mainly associated with SM. These signs are usually due to prolonged and continuous compression of the spinal cord and brainstem by SM, and therefore they are difficult to resolve after surgery even after the compression has been removed. 2 We can also observe in previous studies that the prognosis of patients with CM1-SM is significantly worse than in patients with CM1 alone. Therefore, the latest edition of the international consensus document on diagnosis and treatment of CM1 in children includes progressive spinal cord cavities as an indication for surgery. 3 In addition, the analysis of prognostic risk factors in this study showed that postoperative complications were not associated with age in patients. However, another retrospective study, also from the Park-Reeves Syringomyelia Research database, found that younger patients were associated with postoperative syrinx improvement. 4 Therefore, we speculate whether the corresponding signs and symptoms are more likely to resolve postoperatively because of the shorter duration of spinal cord compression by the syrinx in younger patients with CM1-SM. If this is indeed the case, it will have a significant impact on the choice for the timing of surgery for patients with CM1-SM. Of course, it is necessary to validate this by further studying the natural history of CM1-SM and the relationship between the disease duration and prognosis.

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