Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence

Mutchnick, Ian; Janjua, Rashid M.; Moeller, Karen; Moriarty, Thomas

doi:10.3171/2010.1.peds09218

Cited by 81 publications

(62 citation statements)

References 20 publications

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“…[1][2][3][4][5][6][7][8][9][11][12][13][14][15][16][17][18][19][65][66][67]70,71,100,[102][103][104][105][106][107][108][109][110][111][113][114][115][116][117][118][119][120][121][122][123][124][125][126][127][128][129][130][132]…”

Section: General Informationunclassified

Pediatric and adult Chiari malformation Type I surgical series 1965–2013: a review of demographics, operative treatment, and outcomes

Arnautovic

Splavski

Boop

et al. 2015

PED

205

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OBJECT Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia. METHODS The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included. RESULTS The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (> 18 years of age; 27% of the cases), pediatric (≤ 18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series. CONCLUSIONS Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.

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Section: General Informationunclassified

Pediatric and adult Chiari malformation Type I surgical series 1965–2013: a review of demographics, operative treatment, and outcomes

Arnautovic

Splavski

Boop

et al. 2015

PED

205

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“…In our clinic's series one of the two patients who underwent a simple suboccipital craniectomy experienced reccurence of symptoms, and needed a second surgery for intraarachnoid dissection and tonsils coagulation with duraplasty. Given the low morbidity rates of these studies and the much better long term results in the literature for surgery techniques that involve at least duraplasty, the autor does not support decompression without duraplasty (2,14,22,24).…”

Section: Discussionmentioning

confidence: 99%

“…First of all, the craniectomy should not be larger than 3x3 cm in order to avoid cerebellar sag (11,16,24). The author recommends C1 laminectomy in most cases, but extension to C2 laminectomy is also possible this being directly related to caudal displacement of the cerebellar tonsils (figure 3).…”

Section: Osseus Decompression (Cranio-vertebral Decompression/ Lammentioning

confidence: 99%

Our experience in surgical treatment of Chiari Type 1 malformations

Bălaşa¹,

Gherasim²

2012

Romanian Neurosurgery

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Introduction: There are four types of Chiari malformations described in the literature. Due to the fact that it is a common finding in the general population (true Chiari being present in 0,75% of the population), Chiari 1 malformation was also called Chiari anomaly. Material and methods: In the last 5 years 17 patients with Chiari I malformation have been treated in our clinic. There were 12 women and 5 men. The mean age was 43 years (between 21 and 60 years). The symptoms were grouped in 6 syndromes: brain stem and bulbar palsy syndrome, cerebellar syndrome, central cord syndrome, paroxysmal intracranial hypertension, scoliosis, pyramidal syndrome. Surgical treatment: According to recent literature patients respond best when operated within 2 years from the onset of symptoms. We recommend early surgery for symptomatic patients. Surgical treatment of Chiari I malformation should accomplish several golds. First of all, there is the obvious need to decompress the lower part of the cerebellum. Chiari I malformation being related to a small posterior fossa, the surgical treatment should realise enlargement of the total volume of the posterior fossa(7, 12). In the author’s opinion the key point in surgical treatment of Chiari 1 malformation should be to reestablish the CSF flow at the level of the foramen of Magendie and foramen magnum. Various approaches were used in the last five years in our clinic for the treatment of symptomatic patients: only osseous decompression in 2 patients; osseus decompression with dural grafting and intradural dissection of adhesions in 4 patients; osseous decompression with dural grafting, intradural dissection, and tonsillar coagulation in 11 patients Results: The long-term (6 months postoperative) surgery-related result was considered excellent if symptoms resolved (7 patients). The result was considered good if the patient experienced significant improvement but also residual symptoms (8 patients). A poor result indicated no change in symptoms (2 patients). As for the surgical technique used, the vast majority of patients with good or excellent outcome at 6 months underwent osseous decompression with dural grafting, intradural dissection, and tonsillar coagulation Conclusions: Regarding Chiari I malformations, the author considers that a proper patient selection is critical to prevent unnecessary procedures and maximize the outcome. In light of this study results and recent literature, the author considers that the surgical gold standard consists in three key steps: posterior fossa craniectomy followed by durotomy and subarachnoid decompression of CSF flow and last duroplasty.

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“…5,9,24 As a result of these complications, many surgeons have moved toward less invasive surgical treatments such as "extradural decompression" alone, which involves bony decompression plus or minus thinning or splitting of the dura without actually entering the intradural space. 6,7,17,20,29 The theoretical advantages associated with this less invasive technique include reduced operative times, lower rates of CSF leakage and postoperative complications, and reduced postoperative hospital stay. 20 While there is growing evidence in the literature that many patients with CM-I can be effectively treated by posterior fossa decompression without duraplasty, there is no consensus regarding which surgical technique is the preferred treatment for CM-I.…”

Section: Discussionmentioning

confidence: 99%

Effect of symptomatic pseudomeningocele on improvement in pain, disability, and quality of life following suboccipital decompression for adult Chiari malformation Type I

Parker¹,

Godil²,

Zuckerman³

et al. 2013

JNS

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Object. Suboccipital decompression is a common procedure for patients with Chiari malformation Type I (CM-I). Published studies have reported complication rates ranging from 3% to 40%, with pseudomeningocele being one of the most common complications. To date, there are no studies assessing the effect of this complication on long-term outcome. Therefore, the authors set out to assess the effect of symptomatic pseudomeningocele on patient outcomes following suboccipital decompression for CM-I.Methods. The study comprised 50 adult patients with CM-I who underwent suboccipital craniectomy and C-1 laminectomy with or without duraplasty. Clinical presentation, radiological studies, operative variables, and complications were assessed for each case. Baseline and 1-year postoperative patient-reported outcomes were assessed to determine improvement in pain, disability, and quality of life. The extent of improvement was compared for patients with and without development of a postoperative symptomatic pseudomeningocele.Results. A symptomatic pseudomeningocele developed postoperatively in 9 patients (18%). There was no difference with regard to clinical, radiological, or operative variables for patients with or without a postoperative pseudomeningocele. Patients without a pseudomeningocele had significant improvement in all 9 patient-reported outcome measures assessed. On the other hand, patients with pseudomeningocele only had significant improvement in headache (as measured on the Numeric Rating Scale) and headache-related disability (as measured on the Headache Disability Index) but no improvement in quality of life. Twenty-nine (71%) of 41 patients without a pseudomeningocele reported improvement in health status postoperatively compared with only 3 (33%) of 9 patients with a postoperative pseudomeningocele (p = 0.05).Conclusions. Surgical management of CM-I in adults provides significant and sustained improvement in pain, disability, general health, and quality of life. Development of a postoperative symptomatic pseudomeningocele has lingering effects at 1 year, and it significantly diminishes the overall benefit of suboccipital decompression for CMrelated symptoms. Further research is needed to accurately predict which patients may benefit from decompression alone without duraplasty. (http://thejns.org/doi/abs/10.3171/2013.8.JNS122106) key worDS • symptomatic pseudomeningocele • Chiari malformation • suboccipital decompression • quality of life • pain

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Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence

Cited by 81 publications

References 20 publications

Pediatric and adult Chiari malformation Type I surgical series 1965–2013: a review of demographics, operative treatment, and outcomes

Pediatric and adult Chiari malformation Type I surgical series 1965–2013: a review of demographics, operative treatment, and outcomes

Our experience in surgical treatment of Chiari Type 1 malformations

Effect of symptomatic pseudomeningocele on improvement in pain, disability, and quality of life following suboccipital decompression for adult Chiari malformation Type I

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