“Stealth cranioplasty:” A novel endeavor for symptomatic adult Chiari I patients with syringomyelia: Technical note, appraisal, and philosophical considerations

Abstract

Aim and Objective:In this article, we describe a novel technique of reconstruction of posterior fossa by cranioplasty with use of preshaped titanium mesh following posterior fossa decompression (PFD) for Chiari malformation type I (CMI) with syringomyelia (SM) in symptomatic adults.Materials and Methods:Eleven patients underwent limited PFD and expansive cranioplasty with preshaped titanium mesh, what we term as “Stealth Cranioplasty” (SCP), following arachnoid preserving duraplasty (APD) and hexagonal tenting of the duraplasty with the cranioplasty (HTDC) for the management of symptomatic adult CMI with SM. All these patients had syringes extending from 3 to >10 vertebral levels.Results:Seven male and four female symptomatic CMI adult patients, between age ranges of 22 and 44 years (mean 29.45 years), presented with different neurological symptoms related to CMI and SM for 6–84 months (mean 37.09 months). All the patients underwent PFD, APD followed by SCP and HTDC and were followed up for 7–54 months (mean 35.90 months). Of 11 patients, 8 patients improved according to the Chicago Chiari Outcome Scale (CCOS) with score of 13–15 while 3 patients remained unchanged with CCOS of 12, and there was no worsening. There was no complication related to Chiari surgery in any of the patients. All the patients had good reestablishment of cisterna magna. Two patients had marked reduction of syrinx while eight patients had moderate-to-mild reduction and one patient had no change of syrinx. None of the patients needed redo surgery.Conclusion:SCP is an effective, fruitful, and cost-effective technique for the management of symptomatic adult CMI with SM. This technique has the advantages of preventing complications and recurrences in addition to the improvement of symptoms by addressing the basic pathology.

A titanium implant for Chiari malformation Type 1 surgery

“…[ 4 ] Some authors have used autologous bone flaps[ 22 ] or titanium meshes to prevent compression of a large occipital cyst by edematous muscles[ 27 ] and by postoperative scars. [ 13 , 15 , 18 , 20 ]…”

“Stealth Cranioplasty” for Adult Chiari Malformation Type 1: A Philosophical Journey of Innovation, Adaptation, and Evolution

“…Cranioplasty as an attempt to treat and prevent further cerebellar subsidence during redo surgery has been described. Many techniques have been described in the literature like partial cranioplasty with methyl methacrylate (MMA) [115,116], with autologous bone [117][118][119][120][121][122], and cranioplasty with different varieties of titanium prosthesis [48,[123][124][125][126]. Tacking of duraplasty with or without cranioplasty has also been described by some authors with intention to keep the cistern patent and to prevent adhesion [48,120,122,123,127].…”

Role of Cranioplasty in Management of Chiari Malformation

“…For management of CM1, dura can be addressed in different ways like leaving the dura intact with removal of the constricting bands only [9], scoring of Role of Cranioplasty in Management of Chiari Malformation DOI: http://dx.doi.org /10.5772/intechopen.90055 the dura [10,11], resection of the outer layer of the dura [12][13][14], opening the dura and keeping it remain open [15][16][17], and performing duraplasty with different materials, both natural and artificial [13,[18][19][20][21][22][23][24]. The arachnoid manipulation equally differs from leaving it intact by doing an arachnoid preserving durotomy or arachnoid preserving duraplasty [9,[25][26][27], to opening and resecting it to remove adhesions [8,19,23,[28][29][30]. Dealing the cerebellar tonsils also vary like not touching them [27,31], separating them by dissection [28,32], shrinking by bipolar coagulation [13,19,23,33,34] or carrying out a subpial resection [8,19,35,36].…”

“…The arachnoid manipulation equally differs from leaving it intact by doing an arachnoid preserving durotomy or arachnoid preserving duraplasty [9,[25][26][27], to opening and resecting it to remove adhesions [8,19,23,[28][29][30]. Dealing the cerebellar tonsils also vary like not touching them [27,31], separating them by dissection [28,32], shrinking by bipolar coagulation [13,19,23,33,34] or carrying out a subpial resection [8,19,35,36]. Recently, minimal invasive endoscopy assisted decompression at the foramen magnum for CM have also been reported [37,38].…”

“…In 2017, we described a novel technique of reconstruction of posterior fossa by cranioplasty with the use of pre-shaped titanium mesh for CM1, which we call "Stealth cranioplasty" [27]. In the procedure, we set our goal to address all possible symptoms with maintenance of the surgical modifications continually as well as to prevent complications and recurrence.…”