Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome

Limonadi, Farhad M.; Selden, Nathan R.

doi:10.3171/ped.2004.101.2.0184

Cited by 75 publications

(71 citation statements)

References 16 publications

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“…In recent years, several neurosurgical series have compared extradural PFD to duraplasty with mixed evidence to suggest any significant difference in symptomatic outcome. 17,19,22,23 To address study limitations of unbalanced demographics between treatment groups, presenting symptoms, and radiological findings, Lee and colleagues provided a balanced treatment comparison focusing on long-term clinical outcome and radiological syrinx improvement and proposed that extradural decompression for CM-I leads to comparable clinical and radiological improvement compared with traditional PFDD, but offers decreased postoperative morbidity. The authors recommended the more invasive PFDD as first-line treatment for more severe patients with rapidly progressive symptoms or severe neurological deficits.…”

Section: Discussionmentioning

confidence: 99%

Natural and surgical history of Chiari malformation Type I in the pediatric population

Pomeraniec

Ksendzovsky

Awad

et al. 2016

PED

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OBJECT The natural and surgical history of Chiari malformation Type I (CM-I) in pediatric patients is currently not well described. In this study the authors discuss the clinical and radiological presentation and outcomes in a large cohort of pediatric CM-I patients treated with either conservative or surgical management. METHODS The authors retrospectively reviewed 95 cases involving pediatric patients with CM-I who presented between 2004 and 2013. The patients ranged in age from 9 months to 18 years (mean 8 years) at presentation. The cohort was evenly split between the sexes. Twenty-five patients underwent posterior fossa decompression (PFD) with either dural splitting or duraplasty. Seventy patients were managed without surgery. Patients were followed radiologically (mean 44.8 months, range 1.2–196.6 months) and clinically (mean 66.3 months, range 1.2–106.5 months). RESULTS Seventy patients were treated conservatively and followed with serial outpatient neurological and radiological examinations, whereas 25 patients were treated with PFD. Of these 25 surgical patients, 11 were treated with duraplasty (complete dural opening) and 14 were treated with a dura-splitting technique (incomplete dural opening). Surgical intervention was associated with better clinical resolution of symptoms and radiological resolution of tonsillar ectopia and syringomyelia (p = 0.0392). Over the course of follow-up, 20 (41.7%) of 48 nonsurgical patients who were symptomatic at presentation experienced improvement in symptoms and 18 (75%) of 24 symptomatic surgical patients showed clinical improvement (p = 0.0117). There was no statistically significant difference in resolution of symptoms between duraplasty and dura-splitting techniques (p = 0.3572) or between patients who underwent tonsillectomy and tonsillopexy (p = 0.1667). Neither of the 2 patients in the conservative group with syrinx at presentation showed radiological evidence of resolution of the syrinx, whereas 14 (87.5%) of 16 patients treated with surgery showed improvement or complete resolution of syringomyelia (p = 0.0392). In the nonsurgical cohort, 3 patients (4.3%) developed new or increased syrinx. CONCLUSIONS The overwhelming majority of CM-I patients (92.9%) managed conservatively do not experience clinical or radiological progression, and a sizeable minority (41.7%) of those who present with symptoms improve. However, appropriately selected symptomatic patients (sleep apnea and dysphagia) and those presenting with syringomyelia should be considered surgical candidates because of the high rates of clinical (75%) and radiological improvement (87.5%).

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Section: Discussionmentioning

confidence: 99%

Natural and surgical history of Chiari malformation Type I in the pediatric population

Pomeraniec

Ksendzovsky

Awad

et al. 2016

PED

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“…20 In a comparison of duraplasty with intradural manipulation and dural splitting, the latter led to faster operating times, shorter hospital stays, and therefore lower total hospital costs while yielding comparable clinical results. 15,16 More specifically, dural splitting in patients with CM-I without syringomyelia was deemed to be safer and more cost effective, not including the cost savings from the reduction in overall complications. 16 preoperative assessment and prediction of Surgical Success-a multimodal approach…”

Section: Extradural Chiari Decompression Is a Viable And Reproduciblymentioning

confidence: 99%

“…8 In extradural decompression, some suggest using intraoperative ultrasonography to determine adequate CSF flow, 8 whereas with intradural techniques it is difficult to assess CSF flow intraoperatively. 13 While there is no consensus on which surgical technique is more effective, 5,9,15,20 an external decompression via splitting of the dura avoids the complications of a dura-penetrating craniectomy and laminectomy, 7,13 where there is the potential for CSF leak and pseudomeningocele formation as well as meningitis. 13,15 The need for potential reoperation given inadequate symptom resolution is balanced by the lower complication rate.…”

Section: Extradural Chiari Decompression Is a Viable And Reproduciblymentioning

confidence: 99%

“…13 While there is no consensus on which surgical technique is more effective, 5,9,15,20 an external decompression via splitting of the dura avoids the complications of a dura-penetrating craniectomy and laminectomy, 7,13 where there is the potential for CSF leak and pseudomeningocele formation as well as meningitis. 13,15 The need for potential reoperation given inadequate symptom resolution is balanced by the lower complication rate. 9,14 However, others argue that the complication rate using an intradural opening with duraplasty is near negligible.…”

Section: Extradural Chiari Decompression Is a Viable And Reproduciblymentioning

confidence: 99%

“…7,13 In this dura-splitting technique, there must be 2 identifiable dural leaflets, with an extensive outer leaflet resection performed to allow relaxation of the inner dural layer. 15 In CM-I, symptoms can recur even with adequate surgical intervention of any kind, 15,17 and therefore the surgeon must ensure sufficient execution of surgical technique to minimize potential treatment failure. Given that a significant portion of the underlying pathology may be secondary to CSF flow obstruction, 21 cine flow MRI provides an important tool to assess CSF flow.…”

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confidence: 99%

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Multimodal evaluation of CSF dynamics following extradural decompression for Chiari malformation Type I

Quon¹,

Grant²,

DiLuna³

2015

SPI

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OBJECT Extradural decompression is a minimally invasive technique for treating Chiari malformation Type I (CM-I) that avoids the complications of dural opening. While there is no agreement on which surgical method is optimal, mounting evidence demonstrates that extradural decompression effectively treats clinical symptoms, with a minimal reoperation rate. Neurological symptoms such as headache may be related to obstructed flow of CSF, and one aspect of successful extradural decompression is improved CSF dynamics. In this series, the authors report on their use of phase-contrast cine flow MRI to assess CSF flow as well as satisfactory decompression. METHODS The authors describe their first surgical series of 18 patients with CM-I undergoing extradural decompression and correlate clinical improvement with radiological changes. Patients were categorized as having complete, partial, or no resolution of their symptoms. Posterior fossa area, cisterna magna area, and tonsillar herniation were assessed on T2-weighted MRI, whereas improvement of CSF flow was evaluated with phase-contrast cine flow MRI. All patients received standard pre- and postoperative MRI studies; 8 (44.4%) patients had pre- and postoperative phase-contrast cine, while the rest underwent cine studies only postoperatively. RESULTS All 18 patients presented with symptomatic CM-I, with imaging studies demonstrating tonsillar herniation ≥ 5 mm, and 2 patients had associated syringomelia. All patients underwent suboccipital decompression and C-1 laminectomy with splitting of the dura. Patients with complete resolution of their symptoms had a greater relative increase in cisterna magna area compared with those with only partial improvement (p = 0.022). In addition, in those with complete improvement the preoperative cisterna magna area was smaller than in those who had either partial (0.020) or no (0.025) improvement. Ten (91%) of the 11 patients with improved flow also had improvement in their symptoms. There was 1 postoperative complication of dysphagia and dysphonia. None of the patients have required a second operation. CONCLUSIONS Extradural decompression has the potential to be the first-line treatment for CM-I but has been lacking an objective measure by which to assess surgical success as well as the need for reoperation. An increase in the CSF spaces and improved CSF dynamics may be associated with resolution of clinical symptoms. Including cine imaging as part of routine pre- and postoperative evaluation can help identify which patients are most likely to benefit from surgery.

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Evaluating the cost‐effectiveness of prenatal surgery for myelomeningocele: a decision analysis

Werner

Han

Burd

et al. 2012

Ultrasound in Obstet & Gyne

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Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome

Cited by 75 publications

References 16 publications

Natural and surgical history of Chiari malformation Type I in the pediatric population

Natural and surgical history of Chiari malformation Type I in the pediatric population

Multimodal evaluation of CSF dynamics following extradural decompression for Chiari malformation Type I

Evaluating the cost‐effectiveness of prenatal surgery for myelomeningocele: a decision analysis

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