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Zhou LN, Xiao X, Chen XY, Gu SX, Liu XD, Shou JJ, Gu WT, Che XM, Zhao JL, Xie R. The Surgical Strategy Cerebrospinal Fluid Decompression Facilitates Outcomes of Adults with Chiari Malformation Type I: An Observational, Real-World, Single-Center Study of 528 Patients. World Neurosurg 2024; 189:e841-e856. [PMID: 38986944 DOI: 10.1016/j.wneu.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVE We designed this study to introduce the surgical strategy cerebrospinal fluid (CSF) decompression in treatment of Chiari malformation type I and compared CSF decompression with other surgical strategies to provide a solid basis for patient counseling. METHODS The study enrolled 528 consecutive patients with CMI who underwent surgical interventions from 2012 to 2022. The surgical strategy for these patients was bony and dural decompression, anatomical reduction of herniated tonsils, or CSF decompression. Short-term results were determined after 3 months; long-term outcomes were evaluated at last follow-up (at least 18 months). RESULTS CSF decompression was independently associated with better long- or short-term primary outcomes than anatomical reduction of herniated tonsils or bony and dural decompression (P < 0.001). Compared with short-term, the long-term outcomes were better in patients who underwent CSF decompression (P = 0.035), but were worse in patients with bony and dural decompression (P = 0.03). Specific surgical techniques cannot affect the long- and short-term outcomes of patients with Chiari malformation type I. CSF decompression provided better long-term syringomyelia improvement than short-term (181/218, 83% vs. 169/218, 77.5%; P < 0.001). CONCLUSIONS CSF decompression, but not a specific surgical technique or operative method, was associated with favorable neurological outcomes in ADULT patients with Chiari malformation type I. The surgical technique and operative method should be selected according to the characteristics of each patient and the intraoperative condition to normalize CSF circulation at the craniovertebral junction area. The intraoperative target, smooth CSF flow out from the fourth ventricle and in to the bilateral Luschka foramina, could be observed.
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Affiliation(s)
- Long-Nian Zhou
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao Xiao
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Xing-Yu Chen
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Shi-Xin Gu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Dong Liu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Jun Shou
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Tao Gu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Ming Che
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian-Lan Zhao
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Rong Xie
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, Shanghai, China.
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Sun Y, Fang J, Wang S, Luan J, Wang N, Lv L, Xin C, Luo P, Yue Y, Cheng Z, Yang Z, Chen L. Clinical analysis of atlanto-occipital decompression in the management of chiari malformation with multi-segmental syringomyelia. Front Pediatr 2024; 12:1432706. [PMID: 39268357 PMCID: PMC11390536 DOI: 10.3389/fped.2024.1432706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 08/19/2024] [Indexed: 09/15/2024] Open
Abstract
Background Chiari malformation type I with syringomyelia (CM-I-S) is a very common disease in neurosurgery. There are also various surgical methods. But it is controversial. There are few reports about children, especially the treatment of multi-segmental beaded syringomyelia. The purpose of this study was to explore the clinical effects of atlanto-occipital decompression (AOD) in the management of Chiari malformation type I (CM-I) with multi-segmental beaded syringomyelia (MSBS) in pediatric patients. Methods This retrospective study were pediatric patients with CM-I combined with MSBS who were treated in our hospital from January 2015 to December 2023. The patients who received the AOD treatment were screened according to inclusion and exclusion criteria. Outcomes were assessed by comparison of pre- and postoperative clinical, Chicago Chiari Outcome Scale (CCOS), the diameter and volume of the syringomyelia, morphological parameters of posterior cranial fossa (cervical spinal cord angle of medulla oblongata, CSC-MO) and complications in the enrolled children. Results This study ultimately included 21 eligible pediatric patients with CM-I and MSBS. All the patients successfully completed the operation, which consists of atlanto-occipital decompression, partial resection of the posterior arch of the atlas, electrocoagulation of the cerebellar tonsil, pseudomembrane resection of the central canal orifice (latch) of the spinal cord, and artificial dura mater expansion repair. No death, no relapses, no serious neurological dysfunction and other complications. At the last follow-up, the clinical symptoms of all patients basically disappeared. The results of magnetic resonance imaging (MRI) showed that the average preoperative cerebellar tonsillar hernia was 12.4 ± 4.6 mm, and the postoperative were all above the foramen magnum. The average preoperative syringomyelia volume was 11.7 ± 3.7 cm2, and the syringomyelia disappeared or significantly shrunk after operation, with the volume unable to be accurately measured. The median preoperative CSC-MO was 132.5°, and the median postoperative CSC-MO was 150°, with a significant difference. The median preoperative pain and non-pain score of CCOS was 4 and 3 respectively. The symptoms disappeared after operation, and the score was 4. Only 5 children had cerebrospinal fluid leakage. Conclusion The AOD is safe and effective in CM-I with MSBS in pediatric patients. Pseudomembrane resection of the central canal orifice (latch) of the spinal cord is crucial for the treatment of syringomyelia.
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Affiliation(s)
- Yaning Sun
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Jiangshun Fang
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Shengjuan Wang
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Jimei Luan
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Na Wang
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Lige Lv
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Chaojun Xin
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Pengyuan Luo
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Yanke Yue
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Zhenghai Cheng
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Zhiguo Yang
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
| | - Liuyin Chen
- Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, Hebei, China
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Hoffman H, Bunch KM, Paul T, Krishnamurthy S. Comparison of Pericranial Autograft and AlloDerm for Duraplasty in Patients With Type I Chiari Malformation: Retrospective Cohort Analysis. Oper Neurosurg (Hagerstown) 2021; 21:386-392. [PMID: 34634804 DOI: 10.1093/ons/opab343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pericranial autograft is a popular option for duraplasty during Chiari decompression with several theoretical advantages, but comparisons to other materials have yielded mixed results. OBJECTIVE To compare outcomes between pericranial autograft and AlloDerm (BioHorizons). METHODS Consecutive suboccipital craniectomies for patients with type I Chiari malformation (CM-I) over an 8-yr period at a single institution were identified. Exclusion criteria included revision surgeries and suboccipital decompressions without duraplasty. Outcomes included incisional cerebrospinal fluid (CSF) leakage, length of stay (LOS), wound complication, aseptic meningitis, syrinx improvement, and symptomatic improvement. RESULTS A total of 101 patients (70 females and 31 males) with a median (interquartile range) age of 17 yr (11-32) met the inclusion criteria. There were 51 (50%) patients who underwent duraplasty with pericranial autograft, and the remainder underwent duraplasty with AlloDerm. There were 9 (9%) patients who experienced a postoperative CSF leak. After adjusting for confounding factors, obesity (odds ratio [OR]: 4.69, 95% CI: 1.03-25.6) and use of AlloDerm (OR: 10.54, 95% CI: 1.7-206.12) were associated with CSF leak. Wound complication occurred in 8 (8%) patients but was not associated with graft type (P = .8). Graft type was not associated with LOS, syrinx improvement, or symptom improvement. Reoperations occurred in 10 patients with 4 in the autograft group and 6 in the AlloDerm group (P = .71). CONCLUSION In patients with CM-I, expansile duraplasty with AlloDerm was associated with greater odds of CSF leakage than pericranial autograft. Obesity was also associated with increased odds of CSF leakage.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Katherine M Bunch
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Tyler Paul
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Satish Krishnamurthy
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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