Outcomes after suboccipital decompression without dural opening in children with Chiari malformation Type I

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Symptomatic pediatric Chiari malformation Type I (CM-I) is most often treated with posterior fossa decompression (PFD), but controversy exists over whether the dura needs to be opened during PFD. While dural opening as a part of PFD has been suggested to result in a higher rate of resolution of CM symptoms, it has also been shown to lead to more frequent complications. In this paper, the authors present the largest reported series of outcomes after PFD without dural opening surgery, as well as identify risk factors for recurrence.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors performed a retrospective review of 156 consecutive pediatric patients in whom the senior authors performed PFD without dural opening from 2003 to 2013. Patient demographics, clinical symptoms and signs, radiographic findings, intraoperative ultrasound results, and neuromonitoring findings were reviewed. Univariate and multivariate regression analyses were performed to determine risk factors for recurrence of symptoms and the need for reoperation.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Over 90% of patients had a good clinical outcome, with improvement or resolution of their symptoms at last follow-up (mean 32 months). There were no major complications. The mean length of hospital stay was 2.0 days. In a multivariate regression model, partial C-2 laminectomy was an independent risk factor associated with reoperation (p = 0.037). Motor weakness on presentation was also associated with reoperation but only with trend-level significance (p = 0.075). No patient with &lt; 8 mm of tonsillar herniation required reoperation.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The vast majority (&gt; 90%) of children with symptomatic CM-I will have improvement or resolution of symptoms after a PFD without dural opening. A non–dural opening approach avoids major complications. While no patient with tonsillar herniation &lt; 8 mm required reoperation, children with tonsillar herniation at or below C-2 have a higher risk for failure when this approach is used.</jats:p></jats:sec>

Comparison of Three Different Cranio-Cervical Decompression Procedures in Children with Chiari Malformation Type I: Does the Surgical Technique Matter?

“…Kennedy et al [12] performed a retrospective review of 156 consecutive CM1 children, in whom they performed a posterior decompression without opening the dura (BD only). They reported very good clinical and radiological outcomes with a short hospital stay and no major complications.…”

“…Although several authors in the last 2 decades have reported very good outcomes, lower health care costs, and a reduced length of hospital stay when performing extradural bony decompression (BD) only (and reserving the intradural techniques for a minority of cases) [1,[11][12][13][14][15][16][17][18][19] , concerns regarding the possible higher risk of re-operation with BD and uncertainty about the selection of patients still persist [20] . It also remains controversial, amongst the authors who advocate dural opening, whether or not a watertight expansile duroplasty (DOPD) should be performed [21] .…”

Efficacy and Safety of Duraplasty in Chiari Malformation Type-I Patients Associated With Syringomyelia

“…Kennedy et al, 11 reported, in their series of outcomes after posterior fossa decompression (PFD) without dural opening, that 40 out of 57 patients (70%) demonstrated radiographic improvement, 13 patients (23%) remained stable, and (4) patients (7%) developed increased syrinx size or a new one. Furthermore, 8 patients (20%) with a syrinx underwent reoperation for persistent or recurrent symptoms or progression of associated scoliosis.…”

Delayed resolution of syrinx after posterior fossa decompression without dural opening in children with Chiari malformation Type I

“…24 Briefly, under general anesthesia, the patient was placed in 3-point Mayfield fixation, and neurophysiological monitoring of somatosensory evoked potentials (SSEPs) and brainstem auditory evoked responses (BAERs) was performed with the patient supine and after prone positioning and fixation with neck flexion. SSEP monitoring was performed to ensure safety of positioning with neck flexion, 2 while BAERs were monitored as a potential indicator of physiological decompression.…”