Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation Type I

Yeh, David D.; Koch, Bernadette L.; Crone, Kerry R.

doi:10.3171/ped.2006.105.1.26

Cited by 60 publications

(79 citation statements)

References 20 publications

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“…Recent studies have reported an incidence rate as high as 70% for syringomyelia [7,8,9,10] and hydromyelia [11,12,13], the two most common associated conditions. The mechanisms for the development of these conditions are still controversial and currently under investigation [1].…”

Section: Discussionmentioning

confidence: 99%

National Trends, Complications, and Hospital Charges in Pediatric Patients with Chiari Malformation Type I Treated with Posterior Fossa Decompression with and without Duraplasty

et al. 2015

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Background: The treatment of type 1 Chiari malformation (CM-1) with posterior fossa decompression without (PFD) or with duraplasty (PFDD) is controversial. The authors analyze both options in a national sample of pediatric patients. Methods: Utilizing the Kids' Inpatient Database, CM-1 patients undergoing PFD or PFDD from 2000 through 2009 were analyzed. Results: 1,593 patients with PFD and 1,056 with PFDD were evaluated. The average age was 10.3 years, slightly younger in PFD (9.8 vs. 10.9 years, p = 0.001). PFDD patients were more likely White (81.2 vs 75.6%, p = 0.04) and less likely admitted emergently (8.4 vs. 13.8%, p = 0.007). They also underwent more reoperations (2.1 vs. 0.7%, p = 0.01), had more procedure-related complications (2.3 vs. 0.8%, p = 0.003), a longer length of stay (4.4 vs. 3.8 days, p = 0.001) and higher charges (USD 35,321 vs. 31,483, p = 0.01). Conclusions: This large national study indicates that PFDD is performed more often in Caucasians, less so emergently, and associated with significantly more complications and immediate reoperations, while PFD is more frequent in those with syringomyelia and more economical, requiring fewer hospital resources. Overall, PFD is more favorable for CM-1, though it would be prudent to conduct a prospective trial, as this analysis is limited by data on preoperative presentations and long-term outcomes.

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Section: Discussionmentioning

confidence: 99%

National Trends, Complications, and Hospital Charges in Pediatric Patients with Chiari Malformation Type I Treated with Posterior Fossa Decompression with and without Duraplasty

et al. 2015

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“…These satisfactory neurological results in approximately three-quarters of all patients correspond with the similarly good improvement/resolution of syrinx. [154][155][156][157][158][159] However, only 16% of these series reported postoperative headache outcomes. As the other aspects of postoperative results showed, the improvement or resolution of headaches was also good, occurring in 73% of adult patients, 88% of pediatric patients, and 81% in all patients (Fig.…”

Section: Postoperative Outcomes: Neurological Statusmentioning

confidence: 99%

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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“…In a retrospective study, Yeh et al concluded that ultrasonography may be a useful tool to aid the surgeon in deciding which patients require duraplasty. 29 In that study, only 10% of patients in whom adequate CSF flow was seen on ultrasonography after bone decompression eventually required reoperation for persistence or recurrence of symptoms. On the other hand, a retrospective study by McGirt et al concluded that intraoperative ultrasonography may not effectively select patients in whom bone decompression alone is sufficient, as ultrasonography-guided decompression alone was associated with a 2-fold increased risk of symptom recurrence compared with patients who also underwent duraplasty (p = 0.01).…”

Section: Discussionmentioning

confidence: 99%

“…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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Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation Type I

Abstract: In patients who undergo decompressive surgery for CM-I, intraoperative ultrasonography may be a useful tool to aid the surgeon in deciding whether to opt for bone removal only or bone removal plus duraplasty and tonsillar shrinkage.

Cited by 60 publications

References 20 publications

National Trends, Complications, and Hospital Charges in Pediatric Patients with Chiari Malformation Type I Treated with Posterior Fossa Decompression with and without Duraplasty

National Trends, Complications, and Hospital Charges in Pediatric Patients with Chiari Malformation Type I Treated with Posterior Fossa Decompression with and without Duraplasty

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

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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