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Hernández-Hernández A, Uribe-Pacheco R, Guinto-Nishimura GY, Álvarez-Castro A, Castro-Soto F, Villanueva-Castro E, Del Pino-Camposeco J, Rodríguez-Hernández LA, Gómez JAP, Arriada-Mendicoa N. Predictors of poor functional outcomes in adults with type I Chiari Malformation: Clinical and surgical factors assessed with the Chicago Chiari Outcome Scale over long-term follow-up. Clin Neurol Neurosurg 2024; 243:108392. [PMID: 38945118 DOI: 10.1016/j.clineuro.2024.108392] [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: 05/08/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE This study aimed to identify clinical and surgical features associated with poor long-term postoperative outcomes in patients diagnosed with Type I Chiari Malformation (CMI) treated with posterior fossa decompression with duroplasty (PFDD), with or without tonsillar coagulation. METHODS This retrospective, single-center study included 107 adult patients with CMI surgically treated between 2010 and 2021. The surgical technique involved a midline suboccipital craniectomy, C1 laminectomy, durotomy, arachnoid dissection, duroplasty, and tonsillar coagulation until 2014, after which tonsillar coagulation was discontinued. Postoperative outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) at a median follow-up of 35 months. Clinical, surgical, and neuroimaging data were analyzed using the Wilcoxon signed-rank test, Cox regression analysis, and Kaplan-Meier survival curves to identify predictors of poor functional outcomes. RESULTS Of the 107 patients (mean age 43.9 years, SD 13), 81 (75.5 %) showed functional improvement, 25 (23.4 %) remained unchanged, and 1 (0.9 %) experienced worsened outcomes. Cephalalgia, bilateral motor weakness, and bilateral paresthesia were the most frequent initial symptoms. Tonsillar coagulation was performed in 31 cases (28.9 %) but was clinically associated with higher rates of unfavorable outcomes. The Wilcoxon signed-rank test indicated that long-term follow-up CCOS was significantly higher than postoperative CCOS (Z = -7.678, p < 0.000). Multivariate Cox analysis identified preoperative bilateral motor weakness (HR 6.1, 95 % CI 1.9-18.9; p = 0.002), hydrocephalus (HR 3.01, 95 % CI 1.3-6.9; p = 0.008), and unilateral motor weakness (HR 2.99, 95 % CI 1.1-8.2; p = 0.033) as significant predictors of poor outcomes on a long-term follow-up. CONCLUSION This study highlights the high rate of functional improvement in CMI patients following PFDD. Preoperative motor weakness and hydrocephalus were significant predictors of poor long-term outcomes. Tonsillar coagulation did not demonstrate a clear clinical benefit and may be associated with worse outcomes. Our findings suggest that careful preoperative assessment and selection of surgical techniques are crucial for optimizing patient outcomes.
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Affiliation(s)
- Alan Hernández-Hernández
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Rodrigo Uribe-Pacheco
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | | | - Alfonso Álvarez-Castro
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Fernando Castro-Soto
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Eliezer Villanueva-Castro
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Jorge Del Pino-Camposeco
- Spine Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Juan Antonio Ponce Gómez
- Spine Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Nicasio Arriada-Mendicoa
- Spine Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
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Aydin L, Dereli D, Kartum TA, Sirinoglu D, Sahin B, Eksi MS, Musluman AM, Yilmaz A. Management of Persistent Syringomyelia in Patients Operated for Chiari Malformation Type 1. World Neurosurg 2024; 182:e360-e368. [PMID: 38013110 DOI: 10.1016/j.wneu.2023.11.109] [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: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The treatment of persistent syringomyelia associated with Chiari malformation type 1 (CM1) is unclear. This study aims to evaluate the clinical and radiologic outcomes of syringo-subarachnoid shunt (SSS) as a treatment for persistent syringomyelia following posterior fossa decompression (PFD) for CM1. METHODS Forty-nine cases treated for CM1 associated syringomyelia at a single center were analyzed, 17 of them undergoing reoperation due to persistent syrinx formation. The patients' demographic data, neurologic presentations, and radiologic results were analyzed, including cerebellar herniation, posterior fossa volume, the level at which the syrinx started and finished, the size and diameter of the syrinx. RESULTS Seventeen patients underwent SSS placement, with 1 minor surgical complication (a cerebrospinal fluid leak) occurring and requiring revision. No morbidity or mortality was observed. Among these 17 reoperated patients, partial or complete resorption of the syrinx was observed in all cases. The results suggest that if the syrinx diameter is >10 mm at its thickest point, extends for more than 10 vertebrae, and starts from the upper cervical region and extends to the upper thoracic region, the syrinx may not regress after the first surgery and potentially predicting the need for a second operation before PFD. CONCLUSIONS SSS placement for persistent syrinx following PFD for CM1 is a safe and effective surgical treatment method. These criteria may also help predict the need for a second surgery and the overall disease outcome for both the surgeon and patient.
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Affiliation(s)
- Levent Aydin
- Department of Neurosurgery, Medicana International Istanbul, Istanbul, Turkey.
| | - Duygu Dereli
- Department of Neurosurgery, Health Science University Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | | | - Deniz Sirinoglu
- Department of Neurosurgery, Health Science University, Okmeydani Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Balkan Sahin
- Department of Neurosurgery, Health Science University Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Murat Sakir Eksi
- Department of Neurosurgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Murat Musluman
- Department of Neurosurgery, Health Science University, Okmeydani Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Adem Yilmaz
- Department of Neurosurgery, Health Science University Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Perrini P, Lorenzini D, Vercelli A, Perrone A, Di Carlo DT. Post-Operative Complications after Foramen Magnum Decompression with Duraplasty Using Different Graft Materials in Adults Patients with Chiari I Malformation: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12103382. [PMID: 37240488 DOI: 10.3390/jcm12103382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Despite extensive investigations, the choice of graft material for reconstructive duraplasty after foramen magnum decompression for Chiari type I malformation (CMI) is still a topic of discussion. The authors performed a systematic review and meta-analysis of the literature examining the post-operative complications in adult patients with CMI after foramen magnum decompression and duraplasty (FMDD) using different graft materials. Our systematic review included 23 studies with a total of 1563 patients with CMI who underwent FMDD with different dural substitutes. The most common complications were pseudomeningocele (2.7%, 95% CI 1.5-3.9%, p < 0.01, I2 = 69%) and CSF leak (2%, 95% CI 1-2.9%, p < 0,01, I2 = 43%). The revision surgery rate was 3% (95% CI 1.8-4.2%, p < 0.01, I2 = 54%). A lower rate of pseudomeningocele was observed with autologous duraplasty when compared with synthetic duraplasty (0.7% [95% CI 0-1.3%] vs. 5.3% [95% CI 2.1-8.4%] p < 0.01). The rate of CSF leak and revision surgery was lower after autologous duraplasty than after non-autologous dural graft (1.8% [95% CI 0.5-3.1%] vs. 5.3% [95% CI 1.6-9%], p < 0.01 and 0.8% [95% CI 0.1-1.6%] vs. 4.9% [95% CI 2.6-7.2%] p < 0.01, respectively). Autologous duraplasty is associated with a lower rate of post-operative pseudomeningocele and reoperation. This information should be considered when planning duraplasty after foramen magnum decompression in patients with CMI.
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Affiliation(s)
- Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Daniele Lorenzini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | - Alberto Vercelli
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | - Alessandra Perrone
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | - Davide Tiziano Di Carlo
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
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Giannakaki V, Wildman J, Thejasvin K, Pexas G, Nissen J, Ross N, Mitchell P. Foramen Magnum Decompression for Chiari Malformation Type 1: Is There a Superior Surgical Technique? World Neurosurg 2023; 170:e784-e790. [PMID: 36455845 DOI: 10.1016/j.wneu.2022.11.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Foramen magnum decompression is a common operation used to treat Chiari malformation. There are different surgical techniques; however, some are anecdotally more effective than others. Our aim was to determine whether there is a superior technique in relation to revision rates, presence of persistent postoperative headache and nausea, and syrinx reduction. METHODS This was a retrospective analysis of foramen magnum decompressions performed between 2012 and 2017 for Chiari 1 in a single institution. Three types of operations were performed: 1) bony decompression alone; 2) bony decompression with durotomy and dura left open; 3) bony decompression with opening of dura and duraplasty. We compared postoperative symptoms and revision rates between these 3 operations. RESULTS In 168 patients, 185 foramen magnum decompressions were performed. Among the 168 primary operations, in 66 the dura was not opened, in 86 the dura was opened without a duraplasty, and in 16 a duraplasty was performed. Of 185 operations, 17 were revision surgery. For primary procedures, the revision rates were 12 (18%) where the dura was not opened, 4 (5%) where the dura was left open, and 1 (6%) when duraplasty was performed. Severe postoperative headache and nausea occurred in 2 (3%) patients where the dura was not opened, 4 (25%) patients after primary duraplasty, and 64 (74%) patients after primary durotomy. CONCLUSIONS In this study, rate of revision surgery was highest in patients who had bony decompression without dural opening. Rate of postoperative headache and nausea was highest in the durotomy group. Overall duraplasty had the best results.
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Affiliation(s)
- Venetia Giannakaki
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom.
| | - Jack Wildman
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - K Thejasvin
- Newcastle University Medical School, Newcastle upon Tyne, United Kingdom
| | - Georgios Pexas
- School of Biological Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - Justin Nissen
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Nicholas Ross
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Patrick Mitchell
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
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Role of Chiari Decompression in Managing Spinal Deformity Associated with Chiari I Malformation and Syringomyelia. Neurosurg Clin N Am 2023; 34:159-166. [DOI: 10.1016/j.nec.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Giannakaki V, Nissen J. Foramen magnum decompression for Chiari malformation type I - UK surgical practice. Br J Neurosurg 2022; 36:737-742. [PMID: 35946115 DOI: 10.1080/02688697.2022.2107177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Symptomatic Chiari 1 malformation (CM1) is a common condition in Neurosurgery. Surgery involves hindbrain decompression and restoration of CSF flow through different surgical approaches. No Class 1 evidence exists to suggest the superiority of any of the surgical techniques.Aims: To investigate current surgical practice for symptomatic CM1 patients in the United Kingdom (UK) and determine the willingness to participate in a randomised controlled trial (RCT) comparing different surgical techniques.Methods: An electronic survey was sent to consultant members of the Society of British Neurological Surgeons and the British Chiari-Syringomyelia Group. The questions covered pre-operative and intra-operative management, presence of equipoise/uncertainty in optimal technique and willingness to participate in an RCT.Results: 98 responses were received. 67% operate on adults. 30% on adult and paediatric patients. There is variation in routine pre-operative use of: ICP monitoring (18%), flexion/extension x-rays (16%), venography (20%) and ophthalmology assessment (26%). 18% of neurosurgeons would not offer foramen magnum decompression when the presenting symptom is only refractory cough/sneeze headache. 15% routinely perform bony decompression alone in adults vs 8% in children. In 68% of adult cases, durotomy is performed routinely (46% of them leave the dura open, 54% perform a type of duroplasty) and 16% routinely resect the cerebellar tonsils. Only 17% leave the dura open in children. The most common indicators for durotomy are syringomyelia and intra-operative ultrasound findings. 61% believe there is equipoise/uncertainty in the optimal strategy for decompression and would be willing to participate in an RCT. Comments also mention the heterogeneity of CM1 and that treatment should be tailored to each patient.Conclusion: There is wide variation in pre- and intra-operative management of CM1 patients in the UK and the majority of neurosurgeons would be willing to participate in an RCT comparing bony decompression alone vs dural opening with/without duroplasty.
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Affiliation(s)
- Venetia Giannakaki
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Justin Nissen
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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Florian IA, Pop MM, Timiș TL, Florian IS. Interlayer dural split technique for Chiari I malformation treatment in adult-Technical note. Int J Clin Pract 2021; 75:e14148. [PMID: 33709500 DOI: 10.1111/ijcp.14148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/07/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To present an alternative surgical technique in treating cases of Chiari I Malformation with mild-to-moderate syringomyelia after decompressive suboccipital craniectomy: incising only the outer layer of the dura mater, then dissecting it from the inner layer without opening the latter. PATIENTS AND METHODS We utilized this technique in a short series of three cases who were admitted to our department for mild symptoms such as intermittent headache and dissociated sensory loss in the upper limbs, caused by a Chiari Malformation Type I. The patients were placed in the sitting position. We performed a reduced median suboccipital craniectomy and resection of the posterior arch of C1 adapted to the level of tonsil descent, from a limited superior half to complete resection. Afterward, we incised the outer dural layer, while sparing the inner one. Using a fine dissector, we then split apart the outer and inner layers to the margin of the craniectomy. Through the transparency of the inner layer and the arachnoid, the cerebellum and the medulla were visible and pulsating. An autologous fascia duraplasty was then performed. RESULTS The postoperative course was favorable in all cases, the patients being discharged without any deficits and with complete symptom resolution. Follow-up at 3, 6, and 12 months after surgery revealed a significant reduction in brainstem compression and syringomyelia. CONCLUSIONS Interlayer dural split technique can be used effectively in treating symptomatic cases of type I Chiari malformation in adults, with mild-to-moderate syringomyelia. It is less invasive than opening the dura and possibly more effective than decompressive craniectomy and C1 laminectomy alone. This technique must be validated in a larger case-control series.
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Affiliation(s)
- Ioan Alexandru Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihaela Maria Pop
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
| | - Teodora Larisa Timiș
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioan Stefan Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Posterior Fossa Decompression and Duraplasty with and without Arachnoid Preservation for the Treatment of Adult Chiari Malformation Type 1: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 151:e579-e598. [PMID: 33940274 DOI: 10.1016/j.wneu.2021.04.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The best surgical treatment for adult Chiari malformation type 1 remains widely debated. OBJECTIVE This study aimed to assess the efficacy of posterior fossa decompression and duraplasty with arachnoid preservation compared with arachnoid dissection for the treatment of adult Chiari malformation type 1. METHODS Two reviewers (M.O.-G. and M.A.) performed a PubMed, MEDLINE, and Embase literature search using the following terms: ("Chiari" OR "Chiari 1") AND ("duraplasty" OR "arachnoid preservation" OR "arachnoid spar∗" OR "posterior fossa surgery" OR "posterior fossa decompression" OR "foramen magnum decompression"). Studies assessing the efficacy of posterior fossa decompression with duraplasty for the treatment of patients aged >18 years with Chiari malformation type 1 were included. Case reports with <10 patients, editorials, and non-English studies were excluded. RESULTS Of 195 studies identified, 24 were included for meta-analysis. In the 1006 participants, there was no difference in postoperative clinical or radiologic improvement between the 2 techniques. Patients who underwent posterior fossa decompression with duraplasty and arachnoid dissection had a greater prevalence of total complications (0.20, 95% confidence interval [CI], 0.13-0.29 vs. 0.09, 95% CI, 0.05-0.14; Q = 6.47; P = 0.01) and cerebrospinal fluid-related complications (0.15, 95% CI, 0.10-0.22 vs. 0.05, 95% CI, 0.02-0.12; Q = 4.88; P = 0.03) compared with arachnoid preservation. Furthermore, the prevalence of reoperation in the arachnoid dissection group was 25 times greater than in the arachnoid preservation group (0.08, 95% CI, 0.06-0.10 vs. 0.003, 95% CI, 0.00-0.02; Q = 10.73; P > 0.001). CONCLUSIONS Posterior fossa decompression and duraplasty with arachnoid preservation is a beneficial technique to treat Chiari malformation type 1 and reduces the risk of complications, particularly cerebrospinal fluid-related complications and the rate of reoperation.
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Gallo P, Copley PC, McAllister S, Kaliaperumal C. The impact of neurosurgical technique on the short- and long-term outcomes of adult patients with Chiari I malformation. Clin Neurol Neurosurg 2020; 200:106380. [PMID: 33387726 DOI: 10.1016/j.clineuro.2020.106380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study is aimed to compare and evaluate any differences in clinical and radiological outcomes of different operative techniques of cranio-cervical decompression (CCD) performed in adults with symptomatic Chiari malformation type I (CM-1) within a single tertiary neurosurgical center. METHODS A retrospective review using the Hospital theatre management system (ORSOS) and records of patients who underwent CCD for CM-1 between January 2011 and October 2019 was performed. Patients were divided in three cohorts according to the operative technique used: an extradural osteo-ligamentous decompression (BD), BD followed by dural opening either without duraplasty (DOWD) or plus duroplasty (DOPD). The primary clinical outcome was measured by utilizing the Chicago Chiari Outcome Scale (CCOS). Syrinx outcome was measured on post-op MRI. Statistical analysis was performed using IBM SPSS 24 with α = 0.05. RESULTS 67 adults underwent 69 CCD: 10 BD, 29 DOWD and 30 DOPD. Median follow-up was 47.3 months (Interquartile Range (IQR) 26.3-73.7). Patients who underwent DOPD had a shorter median hospital stay (p-value 0.001), fewer unplanned readmissions (p-value 0.015), a higher median CCOS (p-value 0.001) and a lower post-operative complications rate (p-value 0.001) compared to patients who underwent DOWD. BD revealed a 40 % failure rate and was ineffective in cases with syringomyelia. CONCLUSION Better clinical outcomes, lower complication risk, and short duration of hospital stay were associated with patients who underwent dural opening with augmentative watertight duraplasty. Bony decompression alone despite being a very safe technique, does not appear to be reliable and effective in controlling and relieving the clinical symptoms and the syringomyelia of adult patients with CM-1.
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Affiliation(s)
- Pasquale Gallo
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom.
| | - Phillip Correia Copley
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom
| | - Shannon McAllister
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom
| | - Chandrasekaran Kaliaperumal
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom
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Arnautovic KI, Qaladize BF, Pojskic M, Gienapp AJ, Splavski B, Boop FA. The 270° Circumferential Microsurgical Decompression of the Foramen Magnum in Adult Chiari Malformation Type I: Single Surgeon Series of 130 Patients with Syringomyelia, Neurologic, and Headache Outcomes. World Neurosurg 2020; 146:e1103-e1117. [PMID: 33249219 DOI: 10.1016/j.wneu.2020.11.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Chiari malformation type I (CM-I) is a craniocervical junction disorder associated with descent of the cerebellar tonsils >5 mm. The prevalence of CM-I is common, including 0.5%-3.5% in the general population, 0.56%-0.77% on magnetic resonance imaging, and 0.62% in anatomic dissection studies. We sought to measure our surgical outcomes related to resolution/improvement of headaches, neurologic outcomes, and syringomyelia compared with reported adult CM-I studies from 2000-2019. METHODS From December 2003 to June 2018, the first author (K.I.A.) performed 270° circumferential decompression on adult (>18 years) patients with CM-I. At admission and follow-up, all parameters were numerically evaluated; headaches were self-reported on the visual analog scale, neurologic condition was evaluated using Karnofsky Performance Status and European Myelopathy Score, and syrinx width (if present) was measured on magnetic resonance imaging by grades I-IV. All parameters were analyzed, compared, and statistically tested. We compared results with our previously reported and updated systematic review of operative adult CM-I studies (studies from 2000 to 2019). RESULTS In our series, 118/121 (98%) experienced headache improvements and 100% experienced neurologic improvements. Complete syrinx resolution was experienced by 35/43 (81%); 8 (19%) showed significant improvement. In data from reported studies (2000-2019), only 79% experienced headache resolution, 77% improvement of neurologic status, and 74% resolution/improvement of syrinx (mean). CONCLUSIONS Our modified 270° circumferential microsurgical foramen magnum decompression for adult CM-I appears to be beneficial in improvement of outcomes, namely in resolution of the syrinx, neurologic symptoms, and headaches. We also confirm the association of body mass index with CM-I. Further studies are needed to confirm our results.
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Affiliation(s)
- Kenan I Arnautovic
- Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA; Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA.
| | | | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Marburg, Germany; Medicinski Fakultet Osijek, Sveučilište Josip Juraj Strossmayer, Osijek, Croatia
| | - Andrew J Gienapp
- Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA; Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Bruno Splavski
- Department of Neurosurgery, Sisters of Mercy University Hospital Center, Zagreb, Croatia; Department of Neurosurgey, University School of Medicine, Osijek, Croatia
| | - Frederick A Boop
- Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA; Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
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Wang L, Zhao H, Zhu W, Yan P, Teng YD. A Combinatorial Approach with Cerebellar Tonsil Suspension to Treating Symptomatic Chiari Malformation Type I in Adults: A Retrospective Study. World Neurosurg 2020; 143:e19-e35. [DOI: 10.1016/j.wneu.2020.02.184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 02/06/2023]
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Mandel M, Ferreira da Silva IA, Paiva W, Li Y, Steinberg GK, Teixeira MJ. Minimally invasive foramen magnum durectomy and obexostomy for treatment of craniocervical junction-related syringomyelia in adults: case series and midterm follow-up. J Neurosurg Spine 2020; 33:148-157. [PMID: 32302978 DOI: 10.3171/2020.2.spine2032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniocervical junction-related syringomyelia (CCJS) is the most common form of syringomyelia. Approximately 30% of patients treated with foramen magnum decompression (FMD) will show persistence, recurrence, or progression of the syrinx. The authors present a pilot study with a new minimally invasive surgery technique targeting the pathophysiology of CCJS in adult patients. METHODS The authors retrospectively analyzed the clinical and radiological features of a consecutive series of patients treated for CCJS. An FMD and FM durectomy were performed through a 1.5- to 2-cm skin incision. Then arachnoid adhesions were cleared, creating a permanent communication from the fourth ventricle to the new paraspinal extradural cavity (obexostomy) and with the spinal subarachnoid space. The hypothesis was that the new CSF pouch acts like a pressure leak, interrupting the CCJS pathogenesis. RESULTS Twenty-four patients (13 female, 21-61 years old) were treated between 2014 and 2018. The etiology of CCJS was Chiari malformation type I (CM-I) in 20 patients (83.3%), Chiari malformation type 0 (CM-0) in 2 patients (8.3%), and CCJ arachnoiditis in 2 patients (8.3%). Two patients underwent reoperations after failed FMD for CM-I at other institutions. No major surgical complication occurred. One patient had postoperative meningitis with no CSF fistula. On postoperative MRI, shrinkage of the syrinx was seen in all patients. No patients experienced recurrence of the CCJS. No patient required a subsequent operation. The mean duration of surgery was 72 ± 11 minutes (mean ± SD), and blood loss was 35-80 ml (mean 51 ml). Follow-up ranged from 12 to 58 months. The average overall improvement in modified Japanese Orthopaedic Association scores was 10% (p < 0.001). The Odom scale showed that 19 patients (79.1%) were satisfied, 4 (16.7%) remained the same, and 1 (4.2%) reported a poor outcome. All patients experienced postoperative improvement in perception of quality of life (p < 0.001). CONCLUSIONS Minimally invasive FM durectomy and obexostomy is a safe and effective treatment for CCJS and for patients who have not responded to other treatment.
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Affiliation(s)
- Mauricio Mandel
- 1Department of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School, São Paulo
- 2Hospital Israelita Albert Einstein, São Paulo, Brazil; and
- 3Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Igor Araújo Ferreira da Silva
- 1Department of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School, São Paulo
- 2Hospital Israelita Albert Einstein, São Paulo, Brazil; and
| | - Wellingson Paiva
- 1Department of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School, São Paulo
| | - Yiping Li
- 3Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- 3Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Manoel Jacobsen Teixeira
- 1Department of Neurosurgery, Hospital das Clínicas of University of São Paulo Medical School, São Paulo
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Chotai S, Chan EW, Ladner TR, Hale AT, Gannon SR, Shannon CN, Bonfield CM, Naftel RP, Wellons JC. Timing of syrinx reduction and stabilization after posterior fossa decompression for pediatric Chiari malformation type I. J Neurosurg Pediatr 2020; 26:193-199. [PMID: 32330878 DOI: 10.3171/2020.2.peds19366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine the timeline of syrinx regression and to identify factors mitigating syrinx resolution in pediatric patients with Chiari malformation type I (CM-I) undergoing posterior fossa decompression (PFD). METHODS The authors conducted a retrospective review of records from pediatric patients (< 18 years old) undergoing PFD for the treatment of CM-I/syringomyelia (SM) between 1998 and 2015. Patient demographic, clinical, radiological, and surgical variables were collected and analyzed. Radiological information was reviewed at 4 time points: 1) pre-PFD, 2) within 6 months post-PFD, 3) within 12 months post-PFD, and 4) at maximum available follow-up. Syrinx regression was defined as ≥ 50% decrease in the maximal anteroposterior syrinx diameter (MSD). The time to syrinx regression was determined using Kaplan-Meier analysis. Multivariate analysis was conducted using a Cox proportional hazards model to determine the association between preoperative, clinical, and surgery-related factors and syrinx regression. RESULTS The authors identified 85 patients with CM-I/SM who underwent PFD. Within 3 months post-PFD, the mean MSD regressed from 8.1 ± 3.4 mm (preoperatively) to 5.6 ± 2.9 mm within 3 months post-PFD. Seventy patients (82.4%) achieved ≥ 50% regression in MSD. The median time to ≥ 50% regression in MSD was 8 months (95% CI 4.2-11.8 months). Using a risk-adjusted multivariable Cox proportional hazards model, the patients who underwent tonsil coagulation (n = 20) had a higher likelihood of achieving ≥ 50% syrinx regression in a shorter time (HR 2.86, 95% CI 1.2-6.9; p = 0.02). Thirty-six (75%) of 45 patients had improvement in headache at 2.9 months (IQR 1.5-4.4 months). CONCLUSIONS The maximum reduction in syrinx size can be expected within 3 months after PFD for patients with CM-I and a syrinx; however, the syringes continue to regress over time. Tonsil coagulation was associated with early syrinx regression in this cohort. However, the role of surgical maneuvers such as tonsil coagulation and arachnoid veil identification and sectioning in the overall role of CM-I surgery remains unclear.
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Affiliation(s)
- Silky Chotai
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily W Chan
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis R Ladner
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Andrew T Hale
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen R Gannon
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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Frič R, Eide PK. Chiari type 1-a malformation or a syndrome? A critical review. Acta Neurochir (Wien) 2020; 162:1513-1525. [PMID: 31656982 DOI: 10.1007/s00701-019-04100-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/08/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE As the understanding of pathophysiology behind Chiari malformation still is limited, the treatment of Chiari malformation type 1 remains rather empirical. This may result in suboptimal treatment strategy and outcome in many cases. In this review, we critically address whether the condition known today as Chiari malformation type I should rather be denoted Chiari syndrome. METHODS The current knowledge of Chiari malformation type 1 is summarized from the historical, etymological, genetic, clinical, and in particular pathophysiological perspectives. RESULTS There are several lines of evidence that Chiari malformation type 1 represents a condition significantly different from types 2 to 4. Unlike the other types, the type 1 should rather be considered a syndrome, thus supporting the reasons to reappraise the traditional classification of Chiari malformations. CONCLUSION We propose that Chiari malformation type 1 should rather be denoted Chiari syndrome, while the notation malformation is maintained for types 2-4.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Giammattei L, Messerer M, Daniel RT, Aghakhani N, Parker F. Long-term outcome of surgical treatment of Chiari malformation without syringomyelia. J Neurosurg Sci 2020; 64:364-368. [DOI: 10.23736/s0390-5616.17.04063-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Hale AT, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Leonard JR, Maher CO, Mangano FT, McComb JG, Meehan T, Menezes AH, O'Neill B, Olavarria G, Park TS, Ragheb J, Selden NR, Shah MN, Smyth MD, Stone SSD, Strahle JM, Wait SD, Wellons JC, Whitehead WE, Shannon CN, Limbrick DD. Factors associated with syrinx size in pediatric patients treated for Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2020; 25:629-639. [PMID: 32114543 DOI: 10.3171/2020.1.peds19493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors associated with syrinx size in pediatric patients undergoing posterior fossa decompression (PFD) or PFD with duraplasty (PFDD) for Chiari malformation type I (CM-I) with syringomyelia (SM; CM-I+SM) are not well established. METHODS Using the Park-Reeves Syringomyelia Research Consortium registry, the authors analyzed variables associated with syrinx radiological outcomes in patients (< 20 years old at the time of surgery) with CM-I+SM undergoing PFD or PFDD. Syrinx resolution was defined as an anteroposterior (AP) diameter of ≤ 2 mm or ≤ 3 mm or a reduction in AP diameter of ≥ 50%. Syrinx regression or progression was defined using 1) change in syrinx AP diameter (≥ 1 mm), or 2) change in syrinx length (craniocaudal, ≥ 1 vertebral level). Syrinx stability was defined as a < 1-mm change in syrinx AP diameter and no change in syrinx length. RESULTS The authors identified 380 patients with CM-I+SM who underwent PFD or PFDD. Cox proportional hazards modeling revealed younger age at surgery and PFDD as being independently associated with syrinx resolution, defined as a ≤ 2-mm or ≤ 3-mm AP diameter or ≥ 50% reduction in AP diameter. Radiological syrinx resolution was associated with improvement in headache (p < 0.005) and neck pain (p < 0.011) after PFD or PFDD. Next, PFDD (p = 0.005), scoliosis (p = 0.007), and syrinx location across multiple spinal segments (p = 0.001) were associated with syrinx diameter regression, whereas increased preoperative frontal-occipital horn ratio (FOHR; p = 0.007) and syrinx location spanning multiple spinal segments (p = 0.04) were associated with syrinx length regression. Scoliosis (HR 0.38 [95% CI 0.16-0.91], p = 0.03) and smaller syrinx diameter (5.82 ± 3.38 vs 7.86 ± 3.05 mm; HR 0.60 [95% CI 0.34-1.03], p = 0.002) were associated with syrinx diameter stability, whereas shorter preoperative syrinx length (5.75 ± 4.01 vs 9.65 ± 4.31 levels; HR 0.21 [95% CI 0.12-0.38], p = 0.0001) and smaller pB-C2 distance (6.86 ± 1.27 vs 7.18 ± 1.38 mm; HR 1.44 [95% CI 1.02-2.05], p = 0.04) were associated with syrinx length stability. Finally, younger age at surgery (8.19 ± 5.02 vs 10.29 ± 4.25 years; HR 1.89 [95% CI 1.31-3.04], p = 0.01) was associated with syrinx diameter progression, whereas increased postoperative syrinx diameter (6.73 ± 3.64 vs 3.97 ± 3.07 mm; HR 3.10 [95% CI 1.67-5.76], p = 0.003), was associated with syrinx length progression. PFD versus PFDD was not associated with syrinx progression or reoperation rate. CONCLUSIONS These data suggest that PFDD and age are independently associated with radiological syrinx improvement, although forthcoming results from the PFDD versus PFD randomized controlled trial (NCT02669836, clinicaltrials.gov) will best answer this question.
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Affiliation(s)
- Andrew T Hale
- 1Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, Tennessee
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - P David Adelson
- 3Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 10Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 11Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 12Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 13Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- 15Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, California
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gregory G Heuer
- 24Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- 25Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 26Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 27Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James M Johnston
- 28Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Jeffrey R Leonard
- 30Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 31Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Francesco T Mangano
- 32Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - J Gordon McComb
- 33Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, California
| | - Thanda Meehan
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Arnold H Menezes
- 35Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Brent O'Neill
- 36Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Tae Sung Park
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Matthew D Smyth
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- 41Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina; and
| | - John C Wellons
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - David D Limbrick
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Clinical and radiological outcomes of arachnoid-preseving suboccipital decompression for adult chiari I malformation with and without syringomyelia. Clin Neurol Neurosurg 2020; 188:105598. [DOI: 10.1016/j.clineuro.2019.105598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 11/21/2022]
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Caffo M, Cardali SM, Caruso G, Fazzari E, Abbritti RV, Barresi V, Germanò A. Minimally invasive posterior fossa decompression with duraplasty in Chiari malformation type I with and without syringomyelia. Surg Neurol Int 2019; 10:88. [PMID: 31528426 PMCID: PMC6744795 DOI: 10.25259/sni-70-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 04/02/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Posterior fossa decompression (PFD), with and without duraplasty, represents a valid treatment in Chiari malformation Type I (CM-I) with and without syringomyelia. Despite a large amount of series reported in literature, several controversies exist regarding the optimal surgical approach yet. In this study, we report our experience in the treatment of CM-I, with and without syringomyelia, highlighting how the application of some technical refinements could lead to a good outcome and a lesser rate of complications. Methods: Twenty-six patients with CM-I, with and without syringomyelia, underwent PFD through a 3 cm × 3 cm craniectomy with the removal of the most median third of the posterior arch of C1 and duraplasty. Signs and symptoms included sensory deficits, motor deficits, neck pain, paresthesias, headache, dizziness, lower cranial nerve deficits, and urinary incontinence. Postoperative magnetic resonance (MR) was performed in all patients. Results: Signs and symptoms improved in 76.9% of cases. Postoperative MR revealed a repositioning of cerebellar tonsils and the restoration of cerebrospinal fluid circulation. In our experience, the rate of complication was 23% (fistula, worsening of symptoms, and respiratory impairment). Conclusion: PFD through a 3 cm × 3 cm craniectomy and the removal of the most median third of posterior arch of C1 with duraplasty represents a feasible and valid surgical alternative to treat patients with CM-I, with and without syringomyelia, achieving a good outcome and a low rate of complications.
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Affiliation(s)
- Maria Caffo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Salvatore M Cardali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Gerardo Caruso
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Elena Fazzari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Rosaria V Abbritti
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Antonino Germanò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
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McDowell MM, Alhourani A, Pearce-Smith BA, Mazurkiewicz A, Friedlander RM. Cost-Effectiveness of Postoperative Ketamine in Chiari Decompression. World Neurosurg 2017; 110:e599-e604. [PMID: 29175573 DOI: 10.1016/j.wneu.2017.11.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/09/2017] [Accepted: 11/11/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In Chiari I patients, postoperative pain and discomfort frequently slow the transition back to the home setting. OBJECTIVE We sought to determine the effect of standardized ketamine infusion protocols on hospital length of stay (LOS). METHODS This retrospective cohort study reviewed 100 consecutive adult patients undergoing Chiari I decompression. Fifty-nine patients were placed on a 2-3 mg/hr ketamine drip until postoperative day 1. This group was compared with a group who received 2-3 mg/hr of ketamine until postoperative day 2 (19 patients) and patients who did not receive ketamine at all (22 patients). Clinical characteristics, opioid use, LOS, and relative hospitalization costs were assessed. All narcotic amounts were converted into milligram equivalents of morphine. RESULTS LOS of the short-ketamine group was 46.5 hours when compared with the long-ketamine group (66.8 hours) and no-ketamine group (56.9 hours). There was a statistically significant difference when comparing the short-ketamine group with the long-ketamine group and no-ketamine group together (P < 0.001), as well as when compared individually (P = 0.001 and 0.004). The mean cost of hospitalization was 20% less when a short-ketamine protocol was used (P < 0.001). Mean morphine milligram equivalents used postoperatively were 148 mg in the short-ketamine group, 196 mg in the long-ketamine group, and 187 mg in the no-ketamine group (P = 0.65). No adverse events from ketamine were noted. CONCLUSIONS Ketamine at subanesthetic levels may be an effective tool to facilitate early return home postoperatively and may significantly reduce medical costs.
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Affiliation(s)
- Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ahmad Alhourani
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Beverly A Pearce-Smith
- Acute Interventional Perioperative Pain & Regional Anesthesia, Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anna Mazurkiewicz
- University of Pittsburgh Medical Center, Department of Finance, Pittsburgh, Pennsylvania, USA
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Makler V, Goldstein CL, Hoernschemeyer D, Tanaka T. Chiari I malformation and syringomyelia in mucopolysaccharidosis type I (Hurler syndrome) treated with posterior fossa decompression: Case report and review of the literature. Surg Neurol Int 2017; 8:80. [PMID: 28607814 PMCID: PMC5461569 DOI: 10.4103/sni.sni_463_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/22/2017] [Indexed: 12/05/2022] Open
Abstract
Background: Hurler Syndrome is the most severe phenotype of mucopolysaccharidosis type I. With bone marrow transplant and enzyme replacement therapy, the life expectancy of a child with Hurler syndrome has been extended, predisposing them to multiple musculoskeletal issues most commonly involving the spine. Case Description: This is the case report of a 6-year-old male with Hurler syndrome who was diagnosed with Chiari I malformation and cervicothoracic syringomyelia on a preoperative magnetic resonance imaging (MRI) for his thoracolumbar kyphosis. This report details the successful management of a Chiari I malformation and syringomyelia with posterior fossa decompression in a child with Hurler syndrome. Conclusion: Children born with MPS I can have complex spine issues that require surgical management. The most common orthopedic spinal condition for these patients, thoracolumbar kyphosis, requires evaluation with an MRI before performing surgery. This resulted in the diagnosis of a Chiari I malformation and syringomyelia in our patient with Hurler syndrome. This was successfully treated with decompression of the posterior fossa.
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Affiliation(s)
- Vyacheslav Makler
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Christina L Goldstein
- Department of Orthopedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Daniel Hoernschemeyer
- Department of Orthopedic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Tomoko Tanaka
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
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The effect of posterior fossa decompression in adult Chiari malformation and basilar invagination: a systematic review and meta-analysis. Neurosurg Rev 2017; 41:311-321. [DOI: 10.1007/s10143-017-0857-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/15/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023]
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Krucoff MO, Cook S, Adogwa O, Moreno J, Yang S, Xie J, Firempong AO, Lad N, Bagley CA. Racial, Socioeconomic, and Gender Disparities in the Presentation, Treatment, and Outcomes of Adult Chiari I Malformations. World Neurosurg 2017; 97:431-437. [DOI: 10.1016/j.wneu.2016.10.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/30/2016] [Accepted: 10/04/2016] [Indexed: 01/12/2023]
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Zhou Y, Wang H, Li N, Lin Y, Zhu L, Cheng H. Chiari 0 malformation with syringomyelia syringobulbia and syrinx cavity in pons. INTERDISCIPLINARY NEUROSURGERY 2016. [DOI: 10.1016/j.inat.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lee W, Choo YS, Kim YB, Chung J. Neurological Deterioration after Decompressive Suboccipital Craniectomy in a Patient with a Brainstem-compressing Thrombosed Giant Aneurysm of the Vertebral Artery. J Cerebrovasc Endovasc Neurosurg 2016; 18:115-119. [PMID: 27790402 PMCID: PMC5081496 DOI: 10.7461/jcen.2016.18.2.115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/29/2016] [Accepted: 06/15/2016] [Indexed: 11/30/2022] Open
Abstract
We experienced a case of neurological deterioration after decompressive suboccipital craniectomy (DSC) in a patient with a brainstem-compressing thrombosed giant aneurysm of the vertebral artery (VA). A 60-year-old male harboring a thrombosed giant aneurysm (about 4 cm) of the right vertebral artery presented with quadriparesis. We treated the aneurysm by endovascular coil trapping of the right VA and expected the aneurysm to shrink slowly. After 7 days, however, he suffered aggravated symptoms as his aneurysm increased in size due to internal thrombosis. The medulla compression was aggravated, and so we performed DSC with C1 laminectomy. After the third post-operative day, unfortunately, his neurologic symptoms were more aggravated than in the pre-DSC state. Despite of conservative treatment, neurological symptoms did not improve, and microsurgical aneurysmectomy was performed for the medulla decompression. Unfortunately, the post-operative recovery was not as good as anticipated. DSC should not be used to release the brainstem when treating a brainstem-compressing thrombosed giant aneurysm of the VA.
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Affiliation(s)
- Woosung Lee
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeon Soo Choo
- Department of Neurosurgery, Dongsan Medical Center, College of Medicine, Keimyung University, Daegu, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.; Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
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Zhao JL, Li MH, Wang CL, Meng W. A Systematic Review of Chiari I Malformation: Techniques and Outcomes. World Neurosurg 2016; 88:7-14. [DOI: 10.1016/j.wneu.2015.11.087] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/24/2015] [Accepted: 11/26/2015] [Indexed: 11/25/2022]
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Spinal sealant system provides better intraoperative watertight closure than standard of care during spinal surgery: a prospective, multicenter, randomized controlled study. Spine (Phila Pa 1976) 2015; 40:505-13. [PMID: 25646746 DOI: 10.1097/brs.0000000000000810] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, 3:1 randomized, single-blind, multicenter investigational study. OBJECTIVE To assess the safety and efficacy of a low-swell spinal sealant when used as an adjunct to sutured dural repair compared with standard of care methods to obtain watertight dural closure in subjects undergoing spinal surgery. SUMMARY OF BACKGROUND DATA Watertight dural closure is paramount in spinal surgery to avoid complications of cerebrospinal fluid leak. Prior reports have proven the efficacy of a synthetic, absorbable polyethylene glycol (PEG) hydrogel sealant in spinal surgery compared with standard of care. Given the potential concerns of swelling in spinal applications, the hydrogel was modified to a low-swell formulation. METHODS The primary endpoint was success rate in obtaining intraoperative watertight dural closure in subjects receiving PEG hydrogel sealant versus a control group of subjects receiving any standard method designed to provide intraoperative watertight closure. Subjects were evaluated at discharge and at 30 and 90 days postprocedure for cerebrospinal fluid leaks, surgical site infections, and adverse events. RESULTS Between May 2007 and May 2009, 98 subjects (74 PEG hydrogel spinal sealant, 24 control) were randomized at 14 clinical sites in the United States. Patients treated with the PEG hydrogel spinal sealant had a significantly higher rate of watertight closure than the control (98.6% vs. 79.2%, P = 0.003). No statistical differences were seen in postoperative cerebrospinal fluid, infection, and wound healing. No neurological deficits were seen attributable to the sealant. CONCLUSION The low-swell PEG hydrogel spinal sealant evaluated in this study has been proven safe and effective for providing watertight closure when used as an adjunct to sutured closure of intentional durotomies during spinal surgery. PEG hydrogel sealants have again proved superior to other standard of care technologies for safe, efficacious dural closure. LEVEL OF EVIDENCE 2.
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Grossauer S, Koeck K, Vince GH. Intraoperative somatosensory evoked potential recovery following opening of the fourth ventricle during posterior fossa decompression in Chiari malformation: case report. J Neurosurg 2014; 122:692-6. [PMID: 25526275 DOI: 10.3171/2014.10.jns14401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The most appropriate surgical technique for posterior fossa decompression in Chiari malformation (CM) remains a matter of debate. Intraoperative electrophysiological studies during posterior fossa decompression of Type I CM (CM-I) aim to shed light on the entity's pathomechanism as well as on the ideal extent of decompression. The existing reports on this issue state that significant improvement in conduction occurs after craniotomy in all cases, but additional durotomy contributes a further improvement in only a minority of cases. This implies that craniotomy alone might suffice for clinical improvement without the need of duraplasty or even subarachnoid manipulation at the level of the craniocervical junction. In contrast to published data, the authors describe the case of a 32-year-old woman who underwent surgery for CM associated with extensive cervicothoracic syringomyelia and whose intraoperative somatosensory evoked potentials (SSEPs) did not notably improve after craniotomy or following durotomy; rather, they only improved after opening of the fourth ventricle and restoration of CSF flow through the foramen of Magendie. Postoperatively, the patient recovered completely from her preoperative neurological deficits. To the authors' knowledge, this is the first report of significant SSEP recovery after opening the fourth ventricle in the decompression of a CM-I. The electrophysiological and operative techniques are described in detail and the findings are discussed in the light of available literature. The authors conclude that there might be a subset of CM-I patients who require subarachnoid dissection at the level of the craniocervical junction to benefit clinically. Prospective studies with detailed electrophysiological analyses seem warranted to answer the question regarding the best surgical approach in CM-I decompression.
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Affiliation(s)
- Stefan Grossauer
- Department of Neurosurgery, General Hospital of Klagenfurt, Austria
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Chotai S, Medhkour A. Surgical outcomes after posterior fossa decompression with and without duraplasty in Chiari malformation-I. Clin Neurol Neurosurg 2014; 125:182-8. [PMID: 25171392 DOI: 10.1016/j.clineuro.2014.07.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/08/2014] [Accepted: 07/20/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Chiari malformation-I (CM) is one of the most controversial entities in the contemporary neurosurgical literature. Posterior fossa decompression (PFD) is the preferred treatment for CM with and without syringomyelia. A variety of surgical techniques for PFD have been advocated in the literature. The aim of this study was to evaluate our results of surgically treated patients for CM-I with and without syringomyelia; using extradural dura-splitting and intradural intraarachnoid techniques. METHODS A retrospective review of the medical records of all the patients undergoing PFD was conducted. Symptomatic patients with tonsillar herniation≥3-mm below the foramen magnum on neuroimaging, and CSF flow void study demonstrating restricted or no CSF flow at the craniocervical junction, were offered surgical treatment. In patients without syringomyelia, extradural decompression with thinning of the sclerotic tissue at the cervicomedullary junction and splitting of outer dural layer was performed. In patients with syringomyelia, the dura was opened and an expansile duraplasty was performed. RESULTS The mean age of 8 males and 34 females was 33.8 years (range, 16-58 years). Headache (39/41; 95%), and/or tingling and numbness (17/41; 42%) were the most common presenting symptoms. The syrinx was associated with CM-I in 5/41 (12%) patients. PFD without durotomy was performed in 29/41 (73%) patients. The mean duration of preoperative symptoms was significantly longer in duraplasty group (4.6 versus 1.7 years, P=0.005, OR=0.48, CI=0.29-0.8). The use of duraplasty was significantly associated with presence of complications (P=0.004, OR=0.5, CI=0.3-0.8) and longer duration of hospital stay (P=0.03, OR=2.7, CI=1.1-6.8). The overall complication rate was 6/41(15%) patients. The overall improvement rate was evident in 84% (36/41); 12% (5/41) were stable; and 5% (2/41) had worsening of symptoms. The history of prior CM decompression was associated with unfavorable outcomes (P=0.04, OR=14, CI=1.06-184). One patient experienced recurrence one year after the PFD with duraplasty. CONCLUSION The present study reports favorable surgical outcomes with extra-dural decompression of the posterior fossa in patients CM-I without syringomyelia. For patients with syringomyelia and history of prior PFD, intradural intra-arachnoid decompression is required. The prior history of decompression was associated with unfavorable outcomes. The use of duraplasty was associated with longer duration of hospital stay and higher complication rate. Further large cohort prospective study is needed to provide any recommendation on the indication of intra or extradural decompression for a given CM-I patient.
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Affiliation(s)
- Silky Chotai
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, USA
| | - Azedine Medhkour
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, USA.
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