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Joitescu I, Amelot A, Lot G, Aghakhani N, Parker F, Knafo S. A Staged Approach for Surgical Management of Basilar Invagination. Oper Neurosurg (Hagerstown) 2024; 27:424-430. [PMID: 38869484 DOI: 10.1227/ons.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/07/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with basilar invagination (BI) can be treated with several surgical options, ranging from simple posterior decompression to circumferential decompression and fusion. Here, we aimed at examining the indications and outcomes associated with these surgical strategies to devise a staged algorithm for managing BI. METHODS We conducted a retrospective cohort study in 2 neurosurgical centers and included patients with a BI, as defined by a position of the dens tip at least 5 mm above the Chamberlain line. Other craniovertebral junction anomalies, such as atlas assimilation, platybasia, and Chiari malformations, were documented. C1-C2 stability was assessed with a dynamic computed tomography scan. RESULTS We included 30 patients with BI with a mean follow-up of 56 months (min = 12, max = 166). Posterior decompression and fusion (n = 8) was only performed in cases of obvious atlanto-axial instability (eg, increased atlanto-dental interval or hypermobility on flexion/extension), while anterior decompression (transoral or transnasal) was reserved to patients with lower cranial nerves deficits (eg, swallowing dysfunction) and irreducible anterior compression (n = 9). Patients with posterior signs (eg, Valsalva headaches) or myelopathy but without C1-C2 instability nor anterior signs were managed with an isolated foramen magnum decompression, with or without duraplasty (n = 13). Complications were more frequent for combined procedures, including neurological deterioriation (n = 4) and tracheostomy (n = 2), but reinterventions were more likely in patients undergoing posterior decompression alone (n = 3). CONCLUSION Patient selection is key to determine the appropriate surgical strategy for BI: In our experience, combined approaches are only needed for patients with irreducible and symptomatic anterior compression, while fusion should be restricted to patient with obvious signs of atlanto-axial instability. Other BI patients can be managed by foramen magnum decompression alone to minimize surgical morbidity.
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Affiliation(s)
- Irina Joitescu
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre , France
| | - Aymeric Amelot
- Department of Neurosurgery, Bretonneau Hospital, CHRU de Tours , France
| | - Guillaume Lot
- Department of Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris , France
| | - Nozar Aghakhani
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre , France
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre , France
| | - Fabrice Parker
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre , France
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre , France
| | - Steven Knafo
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre , France
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre , France
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2
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Loftus JR, Wassef C, Ellika S. Chiari I Deformity: Beyond 5 mm below the Foramen Magnum. Radiographics 2024; 44:e230227. [PMID: 39115997 DOI: 10.1148/rg.230227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Although originally described as a consecutive series of pathologic changes, Chiari syndrome represents a spectrum of disease divided into two subsets: development deformities of the paraxial mesoderm manifesting after birth (types 0-1.5) and true congenital malformations due to failure of neural tube closure present in utero (types 2-5). Heterogeneity among patients with a Chiari deformity and incomplete understanding of its pathophysiologic characteristics have led to inconsistency in radiologic reporting and difficulty in defining appropriate management strategies tailored to an individual patient's condition. The radiologist is tasked with going beyond the criteria for cerebellar tonsillar herniation to define an individual patient's disease state, determine candidacy for surgery, and assist in selecting the proper surgical approach. In addition, the radiologist must be able to identify conditions that result in cerebellar tonsillar herniation that are not related to Chiari deformity to avoid inappropriate surgery. Last, the radiologist must be able to interpret postoperative imaging examinations to assess for adequacy of treatment and complications. The authors summarize recent literature regarding the pathophysiologic basis of Chiari 1 and related deformities and detail the ideal morphologic and physiologic imaging assessment, focusing on Chiari 1 and related deformities (Chiari 0, 0.5, and 1.5). Also discussed are surgical techniques and "pearls" of postsurgical imaging, including complications that must be recognized. This review provides clarity to a commonly encountered but less understood condition to optimize outcomes for patients with Chiari 1 and related deformities. ©RSNA, 2024 Supplemental material is available for this article. See the invited commentary by Huisman in this issue.
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Affiliation(s)
- James Ryan Loftus
- From the Department of Imaging Sciences, New York University Langone Health, 550 1st Ave, New York, NY 10016 (J.R.L.); and Departments of Neurosurgery (C.W.) and Imaging Sciences (S.E.), University of Rochester Medical Center, Rochester, NY
| | - Catherine Wassef
- From the Department of Imaging Sciences, New York University Langone Health, 550 1st Ave, New York, NY 10016 (J.R.L.); and Departments of Neurosurgery (C.W.) and Imaging Sciences (S.E.), University of Rochester Medical Center, Rochester, NY
| | - Shehanaz Ellika
- From the Department of Imaging Sciences, New York University Langone Health, 550 1st Ave, New York, NY 10016 (J.R.L.); and Departments of Neurosurgery (C.W.) and Imaging Sciences (S.E.), University of Rochester Medical Center, Rochester, NY
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3
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Cine HS, Avci I, Uysal E, Unsal UU, Gunaydin ME, Paksoy K, Senturk S, Yaman O. The New Alternative Technique Outcomes: Atlas Lateral Mass Screw and C2-3 Transfacet Screw Fixation for Complex Atlantoaxial Instability in Patients with Thin C2 Pedicle or High-Riding Vertebral Artery. World Neurosurg 2024:S1878-8750(24)01469-4. [PMID: 39197703 DOI: 10.1016/j.wneu.2024.08.100] [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: 06/11/2024] [Revised: 08/17/2024] [Accepted: 08/19/2024] [Indexed: 09/01/2024]
Abstract
OBJECTIVE The study aimed to evaluate the safety, feasibility, effect on fusion, and clinical efficacy of atlas lateral mass and C2-3 transfacet screw fixation technique, serves as an alternative method to traditional posterior atlantoaxial fixation. METHODS Patients with atlantoaxial instability who underwent atlas lateral mass and C2-3 transfacet fixation surgery were included. The duration of the surgery and the quantity of blood lost during the operation were recorded. Patients were monitored via X-ray and computed tomography scans to evaluate the degree of fusion at the 1-month and 12-month follow-up. The Neck Visual Analog Scale and Neck Disability Index were evaluated preoperatively, in the postoperative first week, and at the 12-month follow-up for clinical follow-up. RESULTS A total of 8 patients with atlantoaxial instability due to odontoid fracture or Arnold- Chiari malformation accompanied by bony or vascular abnormalities were included in the study between 2017 and 2024. All 8 patients underwent successful atlas lateral mass and C2-3 transfacet screw fixation, with no neurovascular injury noted during surgery. All patients with fracture exhibited fusion at the 12-month mark, and both the Neck Visual Analog Scale and Neck Disability Index scores demonstrated significant improvement at both the 1-week and 12-month postoperative periods (P < 0.05). CONCLUSIONS The atlas lateral mass and C2-3 transfacet screw fixation technique, an alternative to conventional posterior fixation, has been demonstrated to be an efficacious method for providing adequate stabilization and fusion in patients with atlantoaxial instability, even in the cases of thin C2 pedicle, high-riding vertebral artery, previous failed surgeries, or reoperation.
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Affiliation(s)
- Hidayet Safak Cine
- Department of Neurosurgery, Istanbul Medeniyet University, Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey.
| | - Idris Avci
- Department of Neurosurgery, Uskudar University, Istanbul, Turkey
| | - Ece Uysal
- Department of Neurosurgery, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Ulkun Unlu Unsal
- Department of Neurosurgery, Manisa City Hospital, Manisa, Turkey
| | - Mehmet Emre Gunaydin
- Department of Neurosurgery, University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Kemal Paksoy
- Department of Neurosurgery, Memorial Bahcelievler Hospital, Spine Center, Istanbul, Turkey
| | - Salim Senturk
- Department of Neurosurgery, Memorial Bahcelievler Hospital, Spine Center, Istanbul, Turkey
| | - Onur Yaman
- Department of Neurosurgery, Memorial Bahcelievler Hospital, Spine Center, Istanbul, Turkey
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4
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Sergeenko OM, Savin DM, Evsyukov AV, Burtsev AV. Reliability and validity of the pediatric adaptation of the mJOA scale for evaluating cervical spine disorders. Spine Deform 2024:10.1007/s43390-024-00931-x. [PMID: 39026126 DOI: 10.1007/s43390-024-00931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
PURPOSE The study aimed to evaluate the validity and reliability of the pediatric adaptation of the Japanese Orthopedic Association (mJOA) scale in pediatric patients with various cervical spine pathologies. METHODS Initial assessments were performed by a neurosurgeon, followed by an independent evaluation by a neurologist within 1-2 days to test inter-rater reliability. The same clinician assessed the same group of children using the adapted mJOA scale at different point in time (between 1 month and 1 year after the initial assessment) to test intra-rater reliability. For known-groups validity, the pediatric mJOA scale assessments were compared between two groups of pathologies with different prognosis. Concurrent validity was assessed against the McCormick scale, and convergent validity was tested by reassessing patients using the adult mJOA scale two or more years after the initial assessment by pediatric one. RESULTS A cohort of 169 pediatric patients aged 6 months to 18 years (mean age: 10 ± 4.6 years) with various cervical spine pathologies was recruited. Pathologies included atlanto-axial rotatory fixation (AARF), Chiari type I anomaly, congenital cervical spine scoliosis, atlanto-axial dislocation (AAD) and instability (AAI), cervical spine stenosis and trauma, and congenital cervicothoracic dislocations. The majority of patients underwent cervical spine surgery and were followed up for an average of 6.9 ± 2.97 years. The pediatric mJOA scale demonstrated high inter-rater reliability (r = 0.99, p < 0.0001) and strong intra-rater reliability (r = 0.82, p < 0.0001). Significant differences in pediatric mJOA scores were observed between patients with expected-intact neurological status and those with expected-pathological neurological status (p < 0.0001). The pediatric mJOA scale showed a strong correlation with the McCormick grading system (r = 0.97, p < 0.001) and good correlation with the adult mJOA scale during long-term follow-up (r = 0.82, p < 0.0001). CONCLUSIONS The pediatric version of the mJOA scale is a reliable and valid tool for assessing pediatric patients with cervical spine disorders. Its high reliability and validity support its use in both clinical practice and research.
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Affiliation(s)
| | - Dmitry M Savin
- Division of Spinal Surgery, Ilizarov Center, Kurgan, Russia
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5
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Vigneul E, Del Gaudio N, de Nijs L, Raftopoulos C. Neurological outcome following delayed traction and fixation in severe tetraparesis consecutive to posterior decompression for Chiari malformation: a case report. Childs Nerv Syst 2024; 40:1943-1947. [PMID: 38374472 DOI: 10.1007/s00381-024-06327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Chiari malformation type 1 (CM1) is a congenital hindbrain malformation characterized by herniation of the cerebellar tonsils below the foramen magnum. The term Chiari type 1.5 is used when herniation of the brainstem under the McRae line and anomalies of the craniovertebral junction are also present. These conditions are associated with several symptoms and signs, including headache, neck pain, and spinal cord syndrome. For symptomatic patients, surgical decompression is recommended. When radiographic indicators of craniovertebral junction (CVJ) instability or symptoms related to ventral brainstem compression are present, CVJ fixation should also be considered. CASE DESCRIPTION We report the case of a 13-year-old girl who presented with severe tetraparesis after posterior decompression for Chiari malformation type 1.5, followed 5 days later by partial C2 laminectomy. Several months after the initial surgery, she underwent two fixations, first without and then with intraoperative cervical traction, leading to significant neurological improvement. DISCUSSION AND CONCLUSION This case report underscores the importance of meticulous radiological analysis before CM surgery. For CM 1.5 patients with basilar invagination, CVJ fixation is recommended, and C2 laminectomy should be avoided. In the event of significant clinical deterioration due to nonadherence to these guidelines, our findings highlight the importance of traction with increased extension before fixation, even years after initial destabilizing surgery.
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Affiliation(s)
- Eric Vigneul
- Department of Neurosurgery, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Laboratory of Neural Differentiation (NEDI), Animal Molecular and Cellular Biology Group, Louvain Institute of Biomolecular Science and Technology, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Nicole Del Gaudio
- Department of Neurosurgery, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Loïc de Nijs
- Department of Neurosurgery, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Meng H, Xin Z, Zhang B, Qi M, Du Y, Duan W, Chen Z. A Global Bibliometric and Visualization Analysis of Craniovertebral Junction Bony Abnormalities Based on VOSviewer and Citespace. World Neurosurg 2024; 185:e1361-e1371. [PMID: 38522787 DOI: 10.1016/j.wneu.2024.03.090] [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: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE Recent years have witnessed a rapidly growing interest in CVJ bony abnormalities, and a qualitative and quantitative analysis of relevant literatures is necessary. This study aims to identify and summarize the published articles related to craniovertebral junction bony abnormalities, to analyze and visualize the current research trends and major contributors. METHODS We collected data from Web of Science, excluding certain article types. Two researchers screened articles for relevance. Data were organized with EndnoteX9, and analyzed using VOSviewer and CiteSpace for co-authorship, co-occurrence, keyword burst, and co-citation analyses to identify research trends and collaborations. RESULTS A total of 2,776 articles were included, revealing an increasing trend in annual publications of CVJ bony abnormalities. The USA was the leading country. King Edward Memorial Hospital was the most prolific institution, and Seth GS Medical College had the most citations. The Spine is the most popular journal with the highest number of publications and citations. Professor Goel Atul from India emerged as the most influential pioneer in this field. Keyword analysis highlighted surgical techniques, diagnosis, and anatomy as the primary research hotspots and Fixation, Placement, and Basilar invagination gradually become the new research trend. However, there is a relative weakness in basic research and epidemiology. CONCLUSIONS This study provides valuable insights into the current research trends and critical contributors in CVJ bony abnormalities, guiding evidence-based decisions and fostering international collaborations to advance knowledge in this field.
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Affiliation(s)
- Hongfeng Meng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zong Xin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Boyan Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Maoyang Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Yueqi Du
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China.
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7
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Goel A. Letter: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions. Neurosurgery 2024; 94:e33-e34. [PMID: 37962337 DOI: 10.1227/neu.0000000000002762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023] Open
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai , India
- Department of Neurosurgery, R.N Cooper Hospital and Medical College, Mumbai , India
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai , India
- Department of Neurosurgery, K.J. Somaiya Medical College and Hospital, Mumbai , India
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8
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Wan M, Zong R, Tong HY, Zhang ZZ, Zhao B, Yu XG. A morphometric study of the atlanto-occipital joint in adult patients with Chiari malformation type I. Br J Neurosurg 2024; 38:12-15. [PMID: 32969751 DOI: 10.1080/02688697.2020.1823940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are many morphometric studies on Chiari malformation type I (CMI) patients, most of which focus on the posterior cranial fossa (PCF). Less attention has been paid to the atlanto-occipital joint. In this study, we aim to evaluate the morphological characteristics of the atlanto-occipital joint in CMI patients. MATERIALS AND METHODS The cervical CT imaging data of adult patients diagnosed with CMI but without any bony malformation in craniovertebral junction (CVJ) who were treated by the authors between January 2014 and December 2019 were retrospectively analyzed. The equal number of sex and age-matched healthy individuals were included as the control group. The morphometric analysis was performed by measuring the length and depth of the atlanto-occipital joint, and the depth/length ratio was calculated to evaluate the curvature of the joint. RESULTS A total of 47 patients (15 males and 32 females) were included. The mean age of patients was 47.49 ± 9.01 years (range 19-62 years). The mean depth/length ratio of the atlanto-occipital joint in CMI patients was 0.141 ± 0.065 (range 0.027 - 0.274), which was smaller than that of control individuals (0.228 ± 0.057, range 0.069 - 0.379). And the difference was statistically significant (p < .01). CONCLUSIONS The atlanto-occipital joints in CMI patients are significantly flatter compared with those in healthy controls. This morphological variation could lead to differences of the atlanto-occipital stability between CMI patients and normal population, which may be related to the pathogenesis of CMI.
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Affiliation(s)
- Ming Wan
- Department of Neurosurgery, Medical School of Chinese PLA, Beijing, PR China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Rui Zong
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Huai-Yu Tong
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Zhi-Zhong Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Bo Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Xin-Guang Yu
- Department of Neurosurgery, Medical School of Chinese PLA, Beijing, PR China
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9
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Henderson FC, Schubart JR, Narayanan MV, Tuchman K, Mills SE, Poppe DJ, Koby MB, Rowe PC, Francomano CA. Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion. Neurosurg Rev 2024; 47:27. [PMID: 38163828 PMCID: PMC10758368 DOI: 10.1007/s10143-023-02249-0] [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: 06/16/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5-28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.
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Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Jane R Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Malini V Narayanan
- Division of Neurosurgery, University of Maryland Capital Region Medical Center, Largo, Maryland, USA
| | - Kelly Tuchman
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Susan E Mills
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Dorothy J Poppe
- Bobby Jones Chiari & Syringomyelia Foundation, Staten Island, New York, USA
| | - Myles B Koby
- Luminis Health, Doctors Community Medical Center, Lanham, Maryland, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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10
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Villeneuve LM, Evans AR, Bowen I, Gernsback J, Balsara K, Jea A, Desai VR. A systematic review of the power of standardization in pediatric neurosurgery. Neurosurg Rev 2023; 46:325. [PMID: 38049561 DOI: 10.1007/s10143-023-02218-7] [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: 09/04/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 12/06/2023]
Abstract
In the current neurosurgical field, there is a constant emphasis on providing the best care with the most value. Such work requires the constant optimization of not only surgical but also perioperative services. Recent work has demonstrated the power of standardized techniques in limiting complication while promoting optimal outcomes. In this review article, protocols addressing operative and perioperative care for common pediatric neurosurgical procedures are discussed. These articles address how various institutions have optimized procedures through standardization. Our objective is to improve patient outcomes through the optimization of protocols.
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Affiliation(s)
- Lance M Villeneuve
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA.
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA.
| | - Alexander R Evans
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Ira Bowen
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Joanna Gernsback
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Karl Balsara
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Andrew Jea
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Virendra R Desai
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
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11
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Mekbib KY, Muñoz W, Allington G, McGee S, Mehta NH, Shofi JP, Fortes C, Le HT, Nelson-Williams C, Nanda P, Dennis E, Kundishora AJ, Khanna A, Smith H, Ocken J, Greenberg ABW, Wu R, Moreno-De-Luca A, DeSpenza T, Zhao S, Marlier A, Jin SC, Alper SL, Butler WE, Kahle KT. Human genetics and molecular genomics of Chiari malformation type 1. Trends Mol Med 2023; 29:1059-1075. [PMID: 37802664 DOI: 10.1016/j.molmed.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 10/08/2023]
Abstract
Chiari malformation type 1 (CM1) is the most common structural brain disorder involving the craniocervical junction, characterized by caudal displacement of the cerebellar tonsils below the foramen magnum into the spinal canal. Despite the heterogeneity of CM1, its poorly understood patho-etiology has led to a 'one-size-fits-all' surgical approach, with predictably high rates of morbidity and treatment failure. In this review we present multiplex CM1 families, associated Mendelian syndromes, and candidate genes from recent whole exome sequencing (WES) and other genetic studies that suggest a significant genetic contribution from inherited and de novo germline variants impacting transcription regulation, craniovertebral osteogenesis, and embryonic developmental signaling. We suggest that more extensive WES may identify clinically relevant, genetically defined CM1 subtypes distinguished by unique neuroradiographic and neurophysiological endophenotypes.
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Affiliation(s)
- Kedous Y Mekbib
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA; Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Center for Hydrocephalus and Neurodevelopmental Disorders, Massachusetts General Hospital, Boston, MA, USA
| | - William Muñoz
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Center for Hydrocephalus and Neurodevelopmental Disorders, Massachusetts General Hospital, Boston, MA, USA
| | - Garrett Allington
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Neel H Mehta
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - John P Shofi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carla Fortes
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hao Thi Le
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Pranav Nanda
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Evan Dennis
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Arjun Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hannah Smith
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jack Ocken
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ana B W Greenberg
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Rui Wu
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Andres Moreno-De-Luca
- Department of Radiology, Autism and Developmental Medicine Institute, Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Shujuan Zhao
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Sheng Chih Jin
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Center for Hydrocephalus and Neurodevelopmental Disorders, Massachusetts General Hospital, Boston, MA, USA; Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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12
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He Y, Zhang M, Qin X, Huang C, Liu P, Tao Y, Wang Y, Guo L, Bao M, Li H, Mao Z, Li N, He Z, Wu B. Research process, recap, and prediction of Chiari malformation based on bicentennial history of nomenclature and terms misuse. Neurosurg Rev 2023; 46:316. [PMID: 38030943 DOI: 10.1007/s10143-023-02207-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/15/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
There is an absent systematic analysis or review that has been conducted to clarify the topic of nomenclature history and terms misuse about Chiari malformations (CMs). We reviewed all reports on terms coined for CMs for rational use and provided their etymology and future development. All literature on the nomenclature of CMs was retrieved and extracted into core terms. Subsequently, keyword analysis, preceding and predicting (2023-2025) compound annual growth rate (CAGR) of each core term, was calculated using a mathematical formula and autoregressive integrated moving average model in Python. Totally 64,527 CM term usage was identified. Of these, 57 original terms were collected and then extracted into 24 core-terms. Seventeen terms have their own featured author keywords, while seven terms are homologous. The preceding CAGR of 24 terms showed significant growth in use for 18 terms, while 13, three, three, and five terms may show sustained growth, remain stable, decline, and rare in usage, respectively, in the future. Previously, owing to intricate nomenclature, Chiari terms were frequently misused, and numerous seemingly novel but worthless even improper terms have emerged. For a very basic neuropathological phenomenon tonsillar herniation by multiple etiology, a mechanism-based nosology seems to be more conducive to future communication than an umbrella eponym. However, a good nomenclature also should encapsulate all characteristics of this condition, but this is lacking in current CM research, as the pathophysiological mechanisms are not elucidated for the majority of CMs.
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Affiliation(s)
- Yunsen He
- Department of Neurosurgery, Sichuan Lansheng Brain Hospital & Shanghai Lansheng Brain Hospital Investment Co., Ltd., 6 Anrong Road, Chadianzi Street, Jinniu District, Chengdu, 610036, Sichuan, China
| | - Mengjun Zhang
- Department of Neuropsychology, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Xiaohong Qin
- Department of Neuropsychology, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Caiquan Huang
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Ping Liu
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Ye Tao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Yishuang Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Lili Guo
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Mingbin Bao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Hongliang Li
- Department of Neurosurgery, Sichuan Lansheng Brain Hospital & Shanghai Lansheng Brain Hospital Investment Co., Ltd., 6 Anrong Road, Chadianzi Street, Jinniu District, Chengdu, 610036, Sichuan, China
| | - Zhenzhen Mao
- Emergency Department, Sichuan Taikang Hospital, Chengdu, 610000, Sichuan, China
| | - Nanxiang Li
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Zongze He
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China.
| | - Bo Wu
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China.
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13
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Harman F, Oglin V, Yilmaz MO, Orhun O, Baran O, Boyukyilmaz S, Gezercan Y, Dalbayrak S, Dagcinar A. Different C2 screw placement techniques with mobilization of the vertebral artery in high-riding vertebral artery cases: Cadaver dissection. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:341-345. [PMID: 38268685 PMCID: PMC10805154 DOI: 10.4103/jcvjs.jcvjs_73_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/20/2023] [Indexed: 01/26/2024] Open
Abstract
Objective In neurosurgery, posterior approaches intended at the craniovertebral junction are frequently used. The most popular procedures for treating upper cervical instability are C1 lateral mass, C2 pedicle, and C1-C2 transarticular screw stabilization. Due to their proximity to neural structures and the presence of the high-riding vertebral artery (VA), these techniques are complicated. The risk of VA damage can be decreased by mobilizing the VA. Using cadaveric specimens in this study was aimed to demonstrate C2 pedicle and C1-C2 transarticular screw placement with VA mobilization and a novel C2 inferior corpus screw placement technique. Methods In this study, twelve adult cadaveric specimens and two adult dry cadaveric C2 bones were used with the permission and decision of the University Research Ethics Committee. Colored silicone was injected into the arteries and veins of these twelve cadaveric specimens. Then, muscle dissection was performed stepwise, and the C2 vertebrae of the cadavers were revealed with a surgical microscope. Each specimen and entire stages of the dissections were recorded photographically. After cadaver dissections, screw placement was performed with three different techniques. Finally, radiological imaging was done with fluoroscopy. Results After dissection, the lateral mass of the C2 vertebra was observed, and lateral to it, the transverse process and foramen were detected with the help of a hook. Next, the posterior wall of the VA groove was removed using a 1 mm thin plate Kerrison rongeur until the VA loop could partially be observed the VA. This enables us to find the top of the loop of the VA and mobilize it inferiorly using a dissector. Following this step, the C1-2 transarticular, C2 pedicle, and the novel C2 inferior corpus screw placement can be performed safely by directly visualizing the artery. Conclusions Due to the nearby neurologic and vascular structures, placing the C2 pedicle and C1-2 transarticular screw is a challenging procedure, especially in high-riding VA cases. However, it is possible to place the C2 pedicle, C1-2 transarticular, and novel C2 inferior corpus screw after the mobilization of the VA. This study aimed to show all of them together on a cadaver for the first time, to understand the anatomy of the C2 vertebra, and to use screw placement techniques to minimize the risk of complications.
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Affiliation(s)
- Ferhat Harman
- Department of Neurosurgery, Marmara University Faculty of Medicine, Adana, Turkey
- Department of Neurosurgery, Marmara University Institute of Neurological Sciences, Adana, Turkey
- Department of Neurosurgery, Division of Microneurosurgery, Marmara University Institute of Health Sciences, Adana, Turkey
| | - Volkan Oglin
- Department of Neurosurgery, Marmara University Faculty of Medicine, Adana, Turkey
| | - Mehmet Ozgur Yilmaz
- Department of Neurosurgery, University of Health Science, Istanbul Training and Research Hospital, Adana, Turkey
| | - Omer Orhun
- Medical Student, Acıbadem University, School of Medicine, Adana, Turkey
| | - Oguz Baran
- Department of Neurosurgery, Koc University Faculty of Medicine, Adana, Turkey
| | - Seyma Boyukyilmaz
- Department of Emergency Medicine, Marmara University Faculty of Medicine, Adana, Turkey
| | - Yurdal Gezercan
- Department of Neurosurgery, Adana City Training and Research Hospital, Adana, Turkey
| | - Sedat Dalbayrak
- Department of Neurosurgery, Okan University Faculty of Medicine, Istanbul, Turkey
| | - Adnan Dagcinar
- Department of Neurosurgery, Marmara University Faculty of Medicine, Adana, Turkey
- Department of Neurosurgery, Marmara University Institute of Neurological Sciences, Adana, Turkey
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Han RK, Chae JK, Garton ALA, Cruz A, Navarro-Ramirez R, Hussain I, Härtl R, Greenfield JP. Intraoperative occipital to C2 angle and external acoustic meatus-to-axis angular measurements for optimizing alignment during posterior fossa decompression and occipitocervical fusion for complex Chiari malformation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:365-372. [PMID: 38268687 PMCID: PMC10805164 DOI: 10.4103/jcvjs.jcvjs_59_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/21/2023] [Indexed: 01/26/2024] Open
Abstract
Background Excess flexion or extension during occipitocervical fusion (OCF) can lead to postoperative complications, such as dysphagia, respiratory problems, line of sight issues, and neck pain, but posterior fossa decompression (PFD) and OCF require different positions that require intraoperative manipulation. Objective The objective of this study was to describe quantitative fluoroscopic morphometrics in Chiari malformation (CM) patients with symptoms of craniocervical instability (CCI) and demonstrate the intraoperative application of these measurements to achieve neutral craniocervical alignment while leveraging a single axis of motion with the Mayfield head clamp locking mechanism. Methods A retrospective cohort study of patients with CM 1 and 1.5 and features of CCI who underwent PFD and OCF at a single-center institution from March 2015 to October 2020 was performed. Patient demographics, preoperative presentation, radiographic morphometrics, operative details, complications, and clinical outcomes were analyzed. Results A total of 39 patients met the inclusion criteria, of which 37 patients (94.9%) did not require additional revision surgery after PFD and OCF. In this nonrevision cohort, preoperative to postoperative occipital to C2 angle (O-C2a) (13.5° ± 10.4° vs. 17.5° ± 10.1°, P = 0.047) and narrowest oropharyngeal airway space (nPAS) (10.9 ± 3.4 mm vs. 13.1 ± 4.8 mm, P = 0.007) increased significantly. These measurements were decreased in the two patients who required revision surgery due to postoperative dysphagia (mean difference - 16.6°° in O C2a and 12.8°° in occipital and external acoustic meatus to axis angle). Based on these results, these fluoroscopic morphometrics are intraoperatively assessed, utilizing a locking Mayfield head clamp repositioning maneuver to optimize craniocervical alignment prior to rod placement from the occipital plate to cervical screws. Conclusion Establishing a preoperative baseline of reliable fluoroscopic morphometrics can guide surgeons intraoperatively in appropriate patient realignment during combined PFD and OCF, and may prevent postoperative complications.
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Affiliation(s)
- Rachael K. Han
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - John K. Chae
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Andrew L. A. Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Amanda Cruz
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian-Och Spine, New York, NY, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian-Och Spine, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian-Och Spine, New York, NY, USA
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
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15
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Vazquez S, Dominguez JF, Das A, Soldozy S, Kinon MD, Ragheb J, Hanft SJ, Komotar RJ, Morcos JJ. Treatment of Chiari malformations with craniovertebral junction anomalies: Where do we stand today? World Neurosurg X 2023; 20:100221. [PMID: 37456684 PMCID: PMC10338356 DOI: 10.1016/j.wnsx.2023.100221] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/14/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Chiari malformation type 1 (CM-1) is characterized by cerebellar tonsil herniation through the foramen magnum and can be associated with additional craniovertebral junction anomalies (CVJA). The pathophysiology and treatment for CM-1 with CVJA (CM-CVJA) is debated. Objective To evaluate the trends and outcomes of surgical interventions for patients with CM-CVJA. Methods A systematic review of the literature was performed to obtain articles describing surgical interventions for patients with CM-CVJA. Articles included were case series describing surgical approach; reviews were excluded. Variables evaluated included patient characteristics, approach, and postoperative outcomes. Results The initial query yielded 403 articles. Twelve articles, published between 1998-2020, met inclusion criteria. From these included articles, 449 patients underwent surgical interventions for CM-CVJA. The most common CVJAs included basilar invagination (BI) (338, 75.3%), atlantoaxial dislocation (68, 15.1%) odontoid process retroflexion (43, 9.6%), and medullary kink (36, 8.0%). Operations described included posterior fossa decompression (PFD), transoral (TO) decompression, and posterior arthrodesis with either occipitocervical fusion (OCF) or atlantoaxial fusion. Early studies described good results using combined ventral and posterior decompression. More recent articles described positive outcomes with PFD or posterior arthrodesis in combination or alone. Treatment failure was described in patients with PFD alone that later required posterior arthrodesis. Additionally, reports of treatment success with posterior arthrodesis without PFD was seen. Conclusion Patients with CM-CVJA appear to benefit from posterior arthrodesis with or without decompressive procedures. Further definition of the pathophysiology of craniocervical anomalies is warranted to identify patient selection criteria and ideal level of fixation.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Merritt D. Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - John Ragheb
- Department of Neurosurgery, Brian Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Simon J. Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ricardo J. Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacques J. Morcos
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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16
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Bianchi F, Montedoro B, Frassanito P, Massimi L, Tamburrini G. Chiari I malformation: management evolution and technical innovation. Childs Nerv Syst 2023; 39:2757-2769. [PMID: 37368069 DOI: 10.1007/s00381-023-06051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND DEFINITION In recent years thanks to the growing use of radiological assessment, Chiari I malformation became one of the major diseases for a neurosurgeon to deal with. CIM can be classified according to the extent of cerebellar tonsil tip into the foramen magnum being a protrusion over five mm considered pathological. Such a disease is a heterogeneous condition with a multifactorial pathogenetic mechanism that can subdivided into a primary and secondary form. Regardless of the form, it seems that CIM is the result of an imbalance between the volume of the braincase and its content. Acquired CIMs are secondary to conditions causing intracranial hypertension or hypotension while the pathogenesis of primary forms is still controversial. PATHOGENESIS AND TREATMENT There are several theories in the literature but the most accepted one implies an overcrowding due to a small posterior cranial fossa. While asymptomatic CIM do not need treatment, symptomatic ones prompt for surgical management. Several techniques are proposed being the dilemma centered in the need for dural opening procedures and bony decompression ones. CONCLUSION Alongside the paper, the authors will address the novelty presented in the literature on management, diagnosis and pathogenesis in order to offer a better understanding of such a heterogeneous pathology.
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Affiliation(s)
- Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.
| | | | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Onafowokan OO, Das A, Mir JM, Alas H, Williamson TK, Mcfarland K, Varghese J, Naessig S, Imbo B, Passfall L, Krol O, Tretiakov P, Joujon-Roche R, Dave P, Moattari K, Owusu-Sarpong S, Lebovic J, Vira S, Diebo B, Lafage V, Passias PG. Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:336-340. [PMID: 38268684 PMCID: PMC10805163 DOI: 10.4103/jcvjs.jcvjs_140_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/10/2023] [Indexed: 01/26/2024] Open
Abstract
Background Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.
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Affiliation(s)
- Oluwatobi O. Onafowokan
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Ankita Das
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Jamshaid M. Mir
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Haddy Alas
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Tyler K. Williamson
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Kimberly Mcfarland
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | | | - Sara Naessig
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Bailey Imbo
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Lara Passfall
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Oscar Krol
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Peter Tretiakov
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Rachel Joujon-Roche
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Pooja Dave
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Kevin Moattari
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Stephane Owusu-Sarpong
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Jordan Lebovic
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Shaleen Vira
- Department of Orthopedic Surgery, Banner Health, Phoenix, AZ, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, RI, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, USA
| | - Peter Gust Passias
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
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18
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Atallah O, Wireko AA, Chaurasia B. Respiratory arrest after posterior fossa decompression in patients with Chiari malformations: An overview. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:217-220. [PMID: 37860018 PMCID: PMC10583799 DOI: 10.4103/jcvjs.jcvjs_70_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 10/21/2023] Open
Abstract
Background Chiari malformation type 1 (CM1) is a structural abnormality in the skull and cerebellum, causing cerebellar tonsils to shift downward. Decompression of the posterior fossa is a common surgical method to relieve symptoms and prevent neurological deterioration. After posterior fossa decompression (PFD), individuals with CM1 were more likely to have respiratory arrest. Here, we present, for the first time, a comprehensive overview of the potential risk factors and causes of respiratory arrest following PFD. Methods A review of the literature highlighting the risk factors for postoperative respiratory arrest in CM1 patients was conducted in the databases of PubMed, Medline, and Google Scholar. Results Patients with syringomyelia and CM1 are at increased risk for respiratory arrest due to a number of factors, including impaired respiratory mechanics, central respiratory center dysfunction from edema or ischemia, intraoperative brain stem ischemia, and delayed gastric emptying from autonomic dysfunction. Occipitalization of the first cervical vertebra, basilar impression, and fusion of C2-C3 are all risk factors for respiratory arrest. Conclusion Implications for CM1 patient care and prospects for further investigation of postoperative respiratory arrest's causes and risk factors were discussed.
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Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
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19
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Atallah O, Wolff Fernandes F, Krauss JK. The Chiari Malformations: A Bibliometric Analysis of the 100 Most Cited Articles. World Neurosurg 2023; 175:e754-e768. [PMID: 37037368 DOI: 10.1016/j.wneu.2023.04.015] [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: 01/20/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE The Chiari malformations present heterogeneous entities, raising many questions regarding their natural history, pathophysiology, treatment options, and prognosis. Bibliometric analyses have emerged as a method to assess the impact of articles in current clinical practice. METHODS The most cited articles were identified via Scopus Library by using the keywords "Chiari," "Arnold-Chiari," and "Chiari malformation." The 100 most cited articles were then assembled and analyzed in detail. RESULTS The top 100 articles yielded a mean of 155,28 citations per article, ranging from 87 to 896 citations, and from 1.63 to 38.96 per year. Years of publications ranged from 1950 to 2015. Oakes was the most cited author (n = 7), followed by Tubbs and Milhorat. The country with the highest cited articles was the United States (n = 63), followed by the United Kingdom (n = 6), Italy (n = 5), Spain (n = 5), Japan (n = 4), and Germany (n = 3). Neurosurgery is the journal with the most highly cited articles (n = 21), followed by Journal of Neurosurgery (n = 19). Most articles focused on Chiari malformation type I (n = 83). The topic discussed most often was imaging (n = 63), followed by the evaluation of treatment outcome (n = 58), clinical signs and symptoms (n = 57), and the role of surgery (n = 56). CONCLUSIONS The present bibliometric analysis provides a succinct appraisal of the most cited articles concerning Chiari malformation, allowing a deeper insight in this area and its main influential articles with their impact on current clinical practice and future research.
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Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | | | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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20
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Talamonti G, Picano M, Fragale M, Marcati E, Meccariello G, Boeris D, Cenzato M. Reoperation in Chiari-1 Malformations. J Clin Med 2023; 12:jcm12082853. [PMID: 37109192 PMCID: PMC10142814 DOI: 10.3390/jcm12082853] [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: 02/16/2023] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: The issue of unsuccessful surgery for Chiari-1 malformation (CM-1), as well as its potential causes and possible solutions, remains poorly documented and studied. (2) Methods: From a retrospective review of a personal series of 98 patients undergoing treatment for CM-1 during the past 10 years, we created two study groups. Group 1: 8 patients (8.1%) requiring additional surgeries owing to postoperative complications (7 cerebrospinal fluid leakage, 1 extradural hematoma); 7 patients (7.1%) undergoing reoperations for failed decompression during the follow-up. Group 2: During the same period, we also managed 19 patients who had previously been operated on elsewhere: 8 patients who required adequate CM-1 treatment following extradural section of the filum terminale; 11 patients requiring reoperations for failed decompression. Failed decompression was managed by adequate osteodural decompression, which was associated with tonsillectomy (6 cases), subarachnoid exploration (8 cases), graft substitution (6 cases), and occipito-cervical fixation/revision (1 case). (3) Results: There was no mortality or surgical morbidity in Group 1. However, one patient's condition worsened due to untreatable syrinx. In Group 2, there were two cases of mortality, and surgical morbidity was represented by functional limitation and pain in the patient who needed revision of the occipitocervical fixation. Twenty patients improved (58.8%), 6 remained unchanged (32.3%), 1 worsened (2.9%) and 2 died (5.9%). (4) Conclusions: The rate of complications remains high in CM-1 treatment. Unfortunately, a certain rate of treatment failure is unavoidable, but it appears that a significant number of re-operations could have been avoided using proper indications and careful technique.
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Affiliation(s)
| | - Marco Picano
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
| | - Maria Fragale
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
- La Sapienza, University of Rome, 00185 Rome, Italy
| | | | | | - Davide Boeris
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
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21
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Huang Q, Yang X, Zheng D, Zhou Q, Li H, Peng L, Ye J, Qi S, Lu Y. Exploring the Pathogenesis of Atlanto-Occipital Instability in Chiari Malformation With Type II Basilar Invagination: A Systematic Morphological Study. Neurosurgery 2023; 92:837-853. [PMID: 36700733 PMCID: PMC9988292 DOI: 10.1227/neu.0000000000002284] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/30/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Our previous study suggested that atlanto-occipital instability (AOI) is common in patients with type II basilar invagination (II-BI). OBJECTIVE To further understand the pathogenesis of AOI in Chiari malformations (CM) and CM + II-BI through systematic measurements of the bone structure surrounding the craniocervical junction. METHODS Computed tomography data from 185 adults (80 controls, 63 CM, and 42 CM + II-BI) were collected, and geometric models were established for parameter measurement. Canonical correlation analysis was used to evaluate the morphological and positional relationships of the atlanto-occipital joint (AOJ). RESULTS Among the 3 groups, the length and height of the condyle and superior portion of the lateral masses of the atlas (C1-LM) were smallest in CM + II-BI cases; the AOJ had the shallowest depth and the lowest curvature in the same group. AOJs were divided into 3 morphological types: type I, the typical ball-and-socket joint, mainly in the control group (100%); type II, the shallower joint, mainly in the CM group (92.9%); and type III, the abnormal flat-tilt joint, mainly in the CM + II-BI group (89.3%). Kinematic computed tomography revealed AOI in all III-AOJs (100%) and some II-AOJs (1.5%) but not in type I-AOJs (0%). Morphological parameters of the superior portion of C1-LM positively correlated with those of C0 and the clivus and significantly correlated with AOI. CONCLUSION Dysplasia of the condyle and superior portion of C1-LM exists in both CM and II-BI cases yet is more obvious in type II-BI. Unstable movement caused by AOJ deformation is another pathogenic factor in patients with CM + II-BI.
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Affiliation(s)
- Qinguo Huang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Neurosurgery, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Xiaoyu Yang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Dongying Zheng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiang Zhou
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lin Peng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junhua Ye
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nanfang Glioma Center, Guangzhou, China
| | - Yuntao Lu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nanfang Glioma Center, Guangzhou, China
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22
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Goel A. Commentary: Exploring the Pathogenesis of Atlanto-Occipital Instability in Chiari Malformation With Type II Basilar Invagination: A Systematic Morphological Study. Neurosurgery 2023; 92:e82-e83. [PMID: 36729751 DOI: 10.1227/neu.0000000000002312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai, India
- Department of Neurosurgery, R.N Cooper Hospital and Medical College, Mumbai, India
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
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23
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Türkmen C, Köse N, Bal E, Bilgin S, Çetin H, Zengin HY, Gümeler E, Mut M. Effects of Two Exercise Regimes on Patients with Chiari Malformation Type 1: a Randomized Controlled Trial. CEREBELLUM (LONDON, ENGLAND) 2023; 22:305-315. [PMID: 35325392 DOI: 10.1007/s12311-022-01397-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
This study aims to measure the effects of two different exercise programs on neck pain, proprioception, balance, coordination, posture, and quality of life in patients with Chiari malformation (CM) type 1. Sixteen patients were randomized to two different exercise programs: a tailored exercise protocol for CM (TEP-CM) and cervical spinal stabilization exercises (CSSE). Both exercise programs were implemented by a physiotherapist 3 days a week for 6 weeks. The primary outcome was Neck Disability Index. Secondary outcomes were visual analogue scale for pain, joint position sense error measurement, Berg Balance Scale, Time Up and Go Test, International Coordination Ataxia Rating Scale, PostureScreen Mobile, and Short Form-36. Assessments were done immediately before and after the intervention programs. Both groups showed significant improvement in Neck Disability Index, and some secondary outcome measures (P < 0.05). However, there were no statistical differences in post-intervention changes between the groups (P > 0.05). This is the first study to examine the effects of different exercise programs on symptoms in patients with CM type 1. Our preliminary findings indicate that exercise programs can improve pain, balance, proprioception, posture, coordination, and quality of life in CM type 1. Therefore, exercise should be considered safe, beneficial, and low-cost treatment option for CM type 1 patients without surgical indications.
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Affiliation(s)
- Ceyhun Türkmen
- Faculty of Health Sciences, Çankırı Karatekin University, 18200 Sıhhiye St., Çankırı, Turkey.
| | - Nezire Köse
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Ercan Bal
- Department of Neurosurgery, Ankara Yıldırım Beyazıt University, Ankara, 06100, Turkey
| | - Sevil Bilgin
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Hatice Çetin
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Hatice Yağmur Zengin
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Ekim Gümeler
- Department of Radiology, Faculty of Medicine, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Melike Mut
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
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24
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Minimally invasive foramen magnum decompression using tubular retractors (MIFT) for Chiari I malformations. Acta Neurochir (Wien) 2023; 165:767-770. [PMID: 36625908 DOI: 10.1007/s00701-023-05490-0] [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: 12/22/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Chiari malformation type 1 has been traditionally treated with foramen magnum decompression and C1 arch excision with or without duroplasty depending on the surgeon's preference. Each of the various surgical modifications has its advantages and disadvantages. METHODS We describe a minimally invasive tubular retractor-based approach to achieve bony decompression in these cases. We have had good results comparable to the open approach. CONCLUSIONS Strict orientation to the midline using soft tissue landmarks in between the muscles and bony landmarks in the deeper planes is important to achieve good surgical results. Operative time decreases with expertise and is comparable to the open technique. Minimal blood loss and decreased hospital stay and an excellent cosmetic scar make this procedure more appealing.
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25
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Wilson S, Menezes AH. MR documented craniocervical ligamentous injury at age 18 months: delayed formation of OS odontoideum. Complex management issues. Case-based review. Childs Nerv Syst 2023; 39:869-875. [PMID: 36828956 DOI: 10.1007/s00381-023-05892-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVE There are two separate theories regarding the genesis of os odontoideum: congenital and post-traumatic. Trauma documentation in the past has been the presence of a normal odontoid process at the time of initial childhood injury and subsequent development of the os odontoideum. True MR documentation of craniocervical injury in early childhood and subsequent os odontoideum formation has been very rare. METHODS An 18-month-old sustained craniocervical ligamentous injury documented on MRI with transient neurological deficit. Chiari I abnormality was also recorded. Subsequent serial imaging of craniocervical region showed the formation of os odontoideum and instability. He became symptomatic from the os odontoideum and the Chiari I abnormality. The patient underwent decompression and intradural procedure for Chiari I abnormality and occipitocervical fusion. Postoperative course was complicated by the failure of fusion and redo. He later required transoral ventral medullary decompression. He recovered. RESULTS This is an MR documented craniocervical ligamentous injury with sequential formation of os odontoideum with accompanying changes in the atlas. Despite a subsequent successful dorsal occipitocervical fusion, he became symptomatic requiring transoral decompression. CONCLUSIONS Os odontoideum here is recognized as a traumatic origin with the presence of congenital Chiari I abnormality as a separate entity. The changes of the anterior arch of C1 as well as the os formation were serially documented and give credence to blood supply changes in the os and atlas as a result of the trauma. The recognized treatment of dorsal occipitocervical fusion failed in this case requiring also a ventral decompression of the medulla.
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Affiliation(s)
- Saul Wilson
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Stead Family Children's Hospital, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, 1824 JPP, Iowa City, IA, 52242, USA.
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26
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Goel A, Vutha R, Shah A. Evolving Concepts of Craniovertebral and Spinal Instability. Adv Tech Stand Neurosurg 2023; 46:125-147. [PMID: 37318573 DOI: 10.1007/978-3-031-28202-7_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Weakness of the muscles of the nape of the neck and back of the spine and its related instability is the nodal point of pathogenesis of a number of clinical and pathological events at the craniovertebral junction and the spine. Whilst acute instability results in sudden and relatively severe symptoms, chronic or long-standing instability is associated with a range of musculoskeletal and structural spinal alterations. Telescoping of the spinal segments results in "vertical" spinal instability in the subaxial spine and central or axial atlantoaxial instability (CAAD) at the craniovertebral junction. Instability in such cases might not be observed on dynamic radiological imaging. Chiari formation, basilar invagination, syringomyelia, and Klippel-Feil alteration are some of the secondary alterations as a result of chronic atlantoaxial instability. Radiculopathy/myelopathy related to spinal degeneration or ossification of posterior longitudinal ligament appears to have their origin from vertical spinal instability. All the secondary alterations in the craniovertebral junction and subaxial spine that are traditionally considered pathological and to have compressive and deforming role are essentially protective in nature, are indicative of instability, and are potentially reversible following atlantoaxial stabilization. Stabilization of unstable spinal segments is the basis of surgical treatment.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, India
- Department of Neurosurgery, R.N Cooper Hospital and Medical College, Mumbai, India
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Abhidha Shah
- Seth G.S. Medical College and K.E.M Hospital, Mumbai, India
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27
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Goel A, Vutha R, Shah A, Prasad A, Gupta A, Kumar A. Central Atlantoaxial Dislocation: Presenting Symptoms, Diagnostic Parameters, and Surgical Treatment from Reports on 15 Surgically Treated Patients. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:265-272. [PMID: 38153480 DOI: 10.1007/978-3-031-36084-8_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
AIM This chapter reviews the clinical entity of central or axial atlantoaxial instability (CAAD). MATERIAL AND METHODS From January 2018 to November 2020, 15 patients were identified as having CAAD, wherein there was no atlantoaxial instability when analyzed by conventional radiological parameters and wherein there was no evidence of neural or dural compression due to the odontoid process. The patients were identified as having atlantoaxial instability on the basis of the alignment of facets on lateral profile imaging and a range of telltale clinical and radiological indicators. The clinical statuses of the patients were recorded both before and after surgical treatment by using the specially designed Goel symptom severity index and visual analog scale (VAS) scores. All patients were treated via atlantoaxial fixation. RESULTS There were six men and nine women ranging in age from 18 to 45 years (average: 37 years). The presenting clinical symptoms were relatively subtle and long-standing. Apart from symptoms that are generally related to neural compromise at the craniovertebral junction, a range of nonspecific cranial and spinal symptoms were prominent. The follow-up time after surgery ranged from 6 to 34 months. All patients showed early postoperative and sustained clinical recovery. CONCLUSIONS The correct diagnosis and appropriate surgical treatment of CAAD can provide an opportunity for quick and lasting clinical recovery.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, India
- Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India
| | - Ravikiran Vutha
- Department of Neurosurgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India
| | - Abhidha Shah
- Department of Neurosurgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India
| | - Apurva Prasad
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, India
| | - Achal Gupta
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, India
| | - Abhinav Kumar
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, India
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28
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Goel A. Joint "release" and joint "realignment:" Are they necessary for the treatment of basilar invagination? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:1-3. [PMID: 37213582 PMCID: PMC10198205 DOI: 10.4103/jcvjs.jcvjs_14_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
- Department of Neurosurgery, R. N. Cooper Hospital and Medical College, Mumbai, Maharashtra, India
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
- Department of Neurosurgery, K. J. Somaiya Medical College, Hospital and Research Center, Mumbai, Maharashtra, India
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29
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Soleman J, Roth J, Constantini S. Chiari Type 1 Malformation and Syringomyelia in Children: Classification and Treatment Options. Adv Tech Stand Neurosurg 2023; 48:73-107. [PMID: 37770682 DOI: 10.1007/978-3-031-36785-4_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Chiari type 1 malformation (CIM) is defined as tonsillar ectopia of >5 mm, while syringomyelia (SM) is defined as a cerebrospinal fluid (CSF)-filled cavity larger than 3 mm dissecting the spinal cord. Over the last decades, our understanding of these pathologies has grown; however, many controversies still exist almost in every aspect of CIM and SM, including etiology, indication for treatment, timing of treatment, surgical technique, follow-up regime, and outcome. This chapter provides a comprehensive overview on different aspects of CIM and SM and on the still existing controversies, based on the evidence presently available. Future directions for clinical research concerning CIM and SM treatment and outcome are elaborated and discussed as well.
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Affiliation(s)
- Jehuda Soleman
- Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Children's University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel.
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30
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Shao B, Poggi JA, Amaral-Nieves N, Wojcik D, Ma KL, Leary OP, Klinge PM. Compromised Cranio-Spinal Suspension in Chiari Malformation Type 1: A Potential Role as Secondary Pathophysiology. J Clin Med 2022; 11:jcm11247437. [PMID: 36556053 PMCID: PMC9788407 DOI: 10.3390/jcm11247437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
In Chiari Malformation Type I (CM1), low-lying tonsils obstruct the cisterna magna at the foramen magnum, thereby compromising the essential juncture between the cranial and spinal compartments. The anatomical obstruction of the cisterna magna inhibits bi-directional CSF flow as well as CSF pulse pressure equilibration between the intracranial compartment and the intraspinal compartment in response to instances of increased intracranial pressure. Less understood, however, are the roles of the spinal cord suspension structures at the craniocervical junction which lend viscoelastic support to the spinal cord and tonsils, as well as maintain the anatomical integrity of the cisterna magna and the dura. These include extradural ligaments including the myodural bridges (MDBs), as well as intradural dentate ligaments and the arachnoid framework. We propose that when these elements are disrupted by the cisterna magna obstruction, tonsillar pathology, and altered CSF dynamics, there may arise a secondary pathophysiology of compromised and dysfunctional cranio-spinal suspension in CM1. We present intraoperative images and videos captured during surgical exposure of the craniocervical junction in CM1 to illustrate this proposal.
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31
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Mazerand E, Benichi S, Taverne M, Paternoster G, Rolland A, Antherieu P, Todeschi J, Kamdem Noumoye L, Gilard V, Bretonnier M, Fournier LL, Jecko V, Gimbert E, Proust F, Boetto S, Roujeau T, James S, Khonsari RH, Riffaud L, Delion M, Zerah M, Scavarda D. Chiari malformation type I surgery in children: French multicenter 10-year cohort. J Neurosurg Pediatr 2022; 30:210-216. [PMID: 35916100 DOI: 10.3171/2022.4.peds21410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type I (CM-I) is frequent in children and remains a surgical challenge. Several techniques have been described for posterior fossa decompression. No decision algorithm has been validated, and strategies are highly variable between institutions. The goal of this study was to define therapeutic guidelines that take into consideration patient specificities. METHODS The authors retrospectively collected data from patients who were < 18 years of age, were diagnosed with CM-I, and were treated surgically between 2008 and 2018 in 8 French pediatric neurosurgical centers. Data on clinical features, morphological parameters, and surgical techniques were collected. Clinical outcomes at 3 and 12 months after surgery were assessed by the Chicago Chiari Outcome Scale. The authors used a hierarchical clustering method to define clusters of patients by considering their anatomical similarities, and then compared outcomes between surgical strategies in each of these clusters. RESULTS Data from 255 patients were collected. The mean age at surgery was 9.6 ± 5.0 years, syringomyelia was reported in 60.2% of patients, the dura mater was opened in 65.0% of patients, and 17.3% of patients underwent a redo surgery for additional treatment. The mean Chicago Chiari Outcome Scale score was 14.4 ± 1.5 at 3 months (n = 211) and 14.6 ± 1.9 at 12 months (n = 157). The hierarchical clustering method identified three subgroups with potentially distinct mechanisms underlying tonsillar herniation: bony compression, basilar invagination, and foramen magnum obstruction. Each cluster matched with specific outcomes. CONCLUSIONS This French multicenter retrospective cohort study enabled the identification of three subgroups among pediatric patients who underwent surgery for CM-I, each of which was associated with specific outcomes. This morphological classification of patients might help in understanding the underlying mechanisms and providing personalized treatment.
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Affiliation(s)
| | - Sandro Benichi
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris
| | - Maxime Taverne
- 3Craniofacial Growth and Form, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris
| | - Giovanna Paternoster
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,12Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France
| | - Alice Rolland
- 4Department of Pediatric Neurosurgery, Montpellier University Hospital, Montpellier
| | - Pierre Antherieu
- 5Department of Neurosurgery, Toulouse University Hospital, Toulouse
| | - Julien Todeschi
- 6Department of Neurosurgery, Strasbourg University Hospital, Strasbourg
| | | | - Vianney Gilard
- 8Department of Neurosurgery, Rouen University Hospital, Rouen
| | | | - Luc Le Fournier
- 1Department of Neurosurgery, Angers University Hospital, Angers
| | - Vincent Jecko
- 7Department of Pediatric Neurosurgery, Bordeaux University Hospital, Bordeaux
| | - Edouard Gimbert
- 7Department of Pediatric Neurosurgery, Bordeaux University Hospital, Bordeaux
| | - François Proust
- 6Department of Neurosurgery, Strasbourg University Hospital, Strasbourg
| | - Sergio Boetto
- 5Department of Neurosurgery, Toulouse University Hospital, Toulouse
| | - Thomas Roujeau
- 4Department of Pediatric Neurosurgery, Montpellier University Hospital, Montpellier
| | - Syril James
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,10Department of Neurosurgery, French Reference Center for Chiari and Rare Vertebral and Medullary Malformations (C-MAVEM), Montpellier University Hospital, Montpellier
| | - Roman H Khonsari
- 3Craniofacial Growth and Form, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,11Department of Pediatric Maxillofacial and Plastic Surgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris; and
| | - Laurent Riffaud
- 9Department of Neurosurgery, Rennes University Hospital, Rennes
| | - Matthieu Delion
- 1Department of Neurosurgery, Angers University Hospital, Angers
| | - Michel Zerah
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,10Department of Neurosurgery, French Reference Center for Chiari and Rare Vertebral and Medullary Malformations (C-MAVEM), Montpellier University Hospital, Montpellier
| | - Didier Scavarda
- 12Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France
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Zhou Q, Song C, Huang Q, Li H, Yang X, Peng L, Li J, Chen L, Shi L, Qi S, Lu Y. Evaluating craniovertebral stability in Chiari malformation coexisting with Type II basilar invagination: an observational study based on kinematic computed tomography and its clinical application. World Neurosurg 2022; 164:e724-e740. [PMID: 35595047 DOI: 10.1016/j.wneu.2022.05.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Treatment of Chiari malformation (CM) is controversial, especially when it coexists with "stable" or Type II basilar invagination (CM+II-BI). Precise evaluation of craniovertebral junction (CVJ) stability is crucial in such patients; however, this has never been validated. This study aimed to dynamically evaluate atlanto-condyle and atlantoaxial stability by kinematic computed tomography (CT) and report its surgical treatment. METHODS The study recruited 101 patients (control, CM, and CM+II-BI groups: 48, 34, and 19 patients, respectively). During kinematic CT, the CVJ stability-related parameters were measured and compared between the three groups. The surgical strategy for treating CM+II-BI was based on these results. Pre- and postoperative images were acquired, and functional scores were used to assess the outcome. RESULTS Among the three groups, the length of the clivus and the height of the condyle were the shortest in the CM+II-BI group, which was accompanied by the greatest rotation of the atlas and atlanto-condyle facet movement on cervical flexion and extension. Moreover, in such patients, increased Chamberlain's baseline violation indicated the aggregate invagination of the odontoid in the flexed position, and asymmetric displacement of atlantoaxial facets was observed. Seventeen CM+II-BI patients underwent surgical treatment with atlantoaxial distraction and occipitocervical fusion. The syringomyelia width and tonsillar herniation decreased significantly, and functional scores indicated symptom relief and good outcomes. CONCLUSIONS CVJ instability, especially the ultra-movement of atlanto-condyle facets, commonly exists in II-BI as evaluated using kinematic CT. The surgical strategy of atlantoaxial distraction and occipitocervical fusion should be considered to treat such patients.
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Affiliation(s)
- Qiang Zhou
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chong Song
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qinguo Huang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoyu Yang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lin Peng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junjie Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lei Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linyong Shi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Glioma Center, Guangzhou, China
| | - Yuntao Lu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Glioma Center, Guangzhou, China.
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Sangwanloy P, Vaniyapong T, Norasetthada T, Jetjumnong C. Influence of clivo-axial angle on outcome after foramen magnum decompression in adult symptomatic Chiari type 1 malformation. Clin Neurol Neurosurg 2022; 216:107214. [PMID: 35339104 DOI: 10.1016/j.clineuro.2022.107214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/05/2022] [Accepted: 03/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A significant number of patients with Chiari type 1 malformation (CM1) have abnormal clivo-axial angle (CXA) without other radiographic indicators of basilar invagination or craniovertebral junction (CVJ) instability. This study aimed to investigate whether abnormal CXA alone influences postoperative outcomes among patients who underwent foramen magnum decompression (FMD). METHODS A total of 44 adult patients with symptomatic CM1 undergoing FMD without CVJ fixation were enrolled. Preoperative clinical characteristics and radiographic measurement include the CXA as well as the radiographic indicators of basilar invagination and instability were recorded. The univariate and multivariate binary logistic regression tests were used to identify the potential prognostic factors for favorable outcomes. RESULTS Eighteen patients (41%) and 26 patients (59%) were divided into unfavorable and favorable outcome groups, respectively. Baseline demographic and imaging characteristics were similar between the two patient groups. The mean CXA was 132.3 ± 15.8 and 145 ± 13.6 degrees in the unfavorable and favorable groups, respectively (P = 0.091). In the favorable outcome group, the proportion of patients with CXA > 135 degrees was significantly higher than that of the unfavorable outcome group (77% vs. 44%; P = 0.05). The CXA > 135 degrees was found to be the only independent predictor associated with favorable outcomes (adjusted risk ratio 2.16; 95% CI 1.01-4.76; P = 0.047). CONCLUSION The preoperative CXA of greater than 135 degrees was identified as a prognostic factor associated with a favorable outcome at one-year follow-up after FMD among adult patients with symptomatic CM1 without basilar invagination or CVJ instability. This factor should be incorporated into preoperative considerations.
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Affiliation(s)
- Prawit Sangwanloy
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Tanat Vaniyapong
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thunya Norasetthada
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chumpon Jetjumnong
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand.
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Klekamp J. Relevance of C1/2 facet configurations and clivus-canal-angles for adult patients with Chiari I malformation with and without basilar invagination. World Neurosurg 2022; 162:e156-e167. [PMID: 35247617 DOI: 10.1016/j.wneu.2022.02.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE C1/2 facet configurations and clivus-canal angles (CXA) have been proposed as criteria for posterior fusion in Chiari I malformation (CMI). METHODS 340 adults with CMI without basilar invagination (BI), 111 with CMI with BI and 100 age and sex matched controls were studied using sagittal T2-weighted MRI scans analyzing pre- and postoperative values with their impact on progression-free survival rates. RESULTS For CMI without BI, C1/2 facet configurations and CXA were similar to controls (142+11° and 144+10°, respectively) with low rates for posterior C1 displacements (7.1% and 10%, respectively). In CMI with BI, C1 facet displacements were common (54.9%) with lower CXA (120+15°). After foramen magnum decompression (FMD) in CMI without BI (n = 169), 1.8% developed posterior C1 facet displacements without CXA changes and a 97% progression-free survival rate for 10 years. In CMI with BI, patients without ventral compression or instability underwent FMD without fusion (n = 19). 5.3% developed a posterior C1 facet displacement without CXA changes and a 94% progression-free survival rate for 10 years. The remainder of CMI with BI underwent FMD with C1/2 fusion (n = 48). Among these, CXA values increased with 10 year progression-free survival rates of 74% and 93% with and without ventral compression, respectively. CONCLUSION For adult CMI without BI, C1/2 facet configurations and CXA are irrelevant. FMD alone provides excellent long-term outcomes. In CMI with BI, anterior C1 facet displacements indicate C1/2 instability. Posterior fusions can be reserved for patients with ventral compression or C1/2 instability.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Quakenbrück Christian Hospital, Quakenbrück, Germany.
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Arslan A, Olguner SK, Acik V, İstemen İ, Arslan B, Ökten Aİ, Gezercan Y. Surgical Outcomes of C1-2 Posterior Stabilization in Patients With Chiari Malformation Type 1. Global Spine J 2022; 12:37-44. [PMID: 32787628 PMCID: PMC8965300 DOI: 10.1177/2192568220945293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVES Chiari malformation (CM) is characterized by a downward displacement of the cerebellar tonsils through the foramen magnum. This tonsillar herniation may sometimes be accompanied by syringomyelia and/or basilar invagination (BI). In this study, we examined the surgical outcomes of patients by underwent C1-2 reduction + fixation (C1-2RF), which is a new method defined by Goel, in the literature. METHODS Between 2015 and 2018, 21 patients (mean age and duration of follow-up: 39 years and 20 months, respectively) with CM were treated with atlantoaxial fixation. We found syringomyelia in all patients and BI in 9 of them. In all cases, radiography, computed tomography, and magnetic resonance imaging were performed radiologically. C1-2RF was performed in all patients. Preoperative and postoperative clinical Japanese Orthopaedic Association scores were obtained. Syrinx size and cerebrospinal fluid flow rate were compared radiologically. RESULTS All patients were treated with C1-2RF. None of the patients underwent foramen magnum decompression or intervention for the syrinx. Occipital bone and subaxial spinal structures were not included in the fixation. In addition to significant clinical improvement, significant improvement in syringomyelia and cerebrospinal fluid flow rate was seen on the radiographs of all patients. CONCLUSIONS Although posterior fossa decompression and/or duraplasty is a common treatment modality in CM, we propose that the C1-2RF method described by Goel is a radiologically and clinically effective treatment method, whether or not BI and/or syringomyelia in CM are present. This article is the first article of central and axial atlantoaxial dislocation, except for Goel's writings in the literature.
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Affiliation(s)
- Ali Arslan
- Adana City Training and Research Hospital, Adana, Turkey,Ali Arslan, Department of Neurosurgery, Adana City Training and Research Hospital, Dr. Mithat Özsan Bulvarı Kışla Mah. 4522 Sok. No:1 Yüreğir, Adana, Turkey.
| | | | - Vedat Acik
- Adana City Training and Research Hospital, Adana, Turkey
| | - İsmail İstemen
- Adana City Training and Research Hospital, Adana, Turkey
| | - Barış Arslan
- Adana City Training and Research Hospital, Adana, Turkey
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Goel A. External syringomyelia − is it an evidence of focal spinal instability? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:221-223. [PMID: 36263338 PMCID: PMC9574111 DOI: 10.4103/jcvjs.jcvjs_109_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/07/2022] [Indexed: 11/04/2022] Open
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Tam SKP, Chia J, Brodbelt A, Foroughi M. Assessment of patients with a Chiari malformation type I. BRAIN & SPINE 2021; 2:100850. [PMID: 36248113 PMCID: PMC9560699 DOI: 10.1016/j.bas.2021.100850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022]
Abstract
Introduction The prevalence of Chiari malformation type I (CM-I) has been estimated as up to 1% of the general population. The majority of patients are asymptomatic and usually do not need treatment. Symptomatic patients, and some asymptomatic patients with associated conditions, may benefit from further assessment and treatment. Research question The aim of this review was to describe the clinical and radiological assessment of patients presenting with a CM-I. Material and methods A literature search was performed using the PubMed and Embase databases focused on clinical assessment and imaging techniques used to diagnose CM-I. Results Following a complete clinical evaluation in patients with symptomatic CM-I and/or radiologically significant CM-I (tonsillar impaction, resulting tonsillar asymmetry and loss of CSF spaces), MRI of the brain and whole spine enables an assessment of the CM-I and potential associated or causative conditions. These include hydrocephalus, syringomyelia, spinal dysraphism, and tethered cord. Flow and Cine MRI can provide information on CSF dynamics at the craniocervical junction, and help in surgical decision-making. Hypermobility or instability at the upper cervical and craniocervical junction is less common and can be measured with CT imaging and flexion/extension or upright MRI. Discussion and conclusion The majority of CM-I detected are incidental findings on MRI imaging of brain or spine, and do not require intervention. Once a radiological diagnosis and concern has been raised, clinical assessment by an appropriate specialist is required. A MRI brain and cervical spine is indicated in all radiologically labelled CM-I. In symptomatic patients or cases of radiologically significant CM-I, MRI of the brain and entire spine is indicated. Further investigations should be tailored to individuals' needs.
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Affiliation(s)
- Sharon Ka Po Tam
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
| | - Jonathan Chia
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
| | | | - Mansoor Foroughi
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
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38
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Goel A. Letter to the Editor Regarding "Chiari Malformation: An Unhelpful Eponym". World Neurosurg 2021; 156:164. [PMID: 34802680 DOI: 10.1016/j.wneu.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra, Mumbai, India.
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39
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Goel A. Basilar invagination, spinal "degeneration," and "lumbosacral" spondylolisthesis: Instability is the cause and stabilization is the treatment. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:327-328. [PMID: 35068814 PMCID: PMC8740803 DOI: 10.4103/jcvjs.jcvjs_140_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/06/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India.,Department of Neurosurgery, R N Cooper Hospital and Medical College, Mumbai, Maharashtra, India.,Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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40
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Goel A. Degenerative arthritis of the craniovertebral junction. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:323-326. [PMID: 35068813 PMCID: PMC8740806 DOI: 10.4103/jcvjs.jcvjs_142_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
- Department of Neurosurgery, R. N Cooper Hospital and Medical College, Mumbai, Maharashtra, India
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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Saletti V, Farinotti M, Peretta P, Massimi L, Ciaramitaro P, Motta S, Solari A, Valentini LG. The management of Chiari malformation type 1 and syringomyelia in children: a review of the literature. Neurol Sci 2021; 42:4965-4995. [PMID: 34591209 DOI: 10.1007/s10072-021-05565-9] [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: 05/02/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
In anticipation of the "Chiari and Syringomyelia Consensus Conference" held in Milan in 2019, we performed a systematic literature review on the management of Chiari malformation type 1 (CM1) and syringomyelia (Syr) in children.We aimed to summarize the available evidence and identify areas where consensus has not been reached and further research is needed.In accordance with PRISMA guidelines, we formulated seven questions in Patients-Interventions-Comparators-Outcomes (PICO) format. Six PICOs concerned CM1 children with/without additional structural anomalies (Syr, craniosynostosis, hydrocephalus, tethered cord, and cranio-vertebral junction anomalies), and one PICO Syr without CM1. We searched Medline, Embase, Cochrane, and NICE databases from January 1, 1999, to May 29, 2019. Cohort studies, controlled and randomized clinical trials (CCTs, RCTs), and systematic reviews were included, all pertinent only to patients ≤ 18 years of age.For CM1, 3787 records were found, 460 full texts were assessed and 49 studies (46 cohort studies, one RCT, and two systematic reviews) were finally included. For Syr, 376 records were found, 59 full texts were assessed, and five studies (one RCT and four cohort studies) were included. Data on each PICO were synthetized narratively due to heterogeneity in the inclusion criteria, outcome measures, and length of follow-up of the included studies.Despite decades of experience on CM1 and Syr management in children, the available evidence remains limited. Specifically, there is an urgent need for collaborative initiatives focusing on the adoption of shared inclusion criteria and outcome measures, as well as rigorous prospective designs, particularly RCTs.
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Affiliation(s)
- Veronica Saletti
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria, 11, 20133, Milan, Italy.
| | - Mariangela Farinotti
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paola Peretta
- Pediatric Neurosurgery Unit, Ospedale Infantile Regina Margherita, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Massimi
- Pediatric Neurosurgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Ciaramitaro
- Clinical Neurophysiology, Department of Neuroscience, Presidio CTO, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Grazia Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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42
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Rodriguez VV, Tello CA, Piantoni L, Wilson IAF, Galareto E, Remondino RG, Bersusky SE, Davies R, Noel MA. Chiari 1: Is decompression always necessary previous to scoliosis surgery? Spine Deform 2021; 9:1253-1258. [PMID: 33792837 DOI: 10.1007/s43390-021-00336-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
The association between Chiari 1 malformation and scoliosis is well known in the literature. Prevalence has increased after the advent of magnetic resonance imaging. In children with this association, prophylactic suboccipital decompression prior to scoliosis correction is a common surgical procedure although the rationale for this surgical management and whether not performing it may lead to spinal cord injury has not been clearly elucidated. We conducted a systematic review of the literature with the aim to obtain strong data to support the hypothesis that it is safe to proceed with scoliosis correction without prior prophylactic suboccipital decompression for Chiari 1 in an asymptomatic population. Using the Prisma methodology, we analyzed 3250 studies published between 1972 and 2018. Only four studies met the inclusion criteria. None of the studies had a level of evidence high enough to recommend prophylactic decompression previous to correction of the spinal deformity.
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Affiliation(s)
- V Vazquez Rodriguez
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - C A Tello
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - L Piantoni
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina.
| | - I A Francheri Wilson
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - E Galareto
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - R G Remondino
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - S E Bersusky
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - R Davies
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - M A Noel
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
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Asghar Ali Turabi MA, Pruthi N, Bhat D, Bhagavatula ID. Complex Chiari Malformation: Proposal of a New Set of Diagnostic Criteria and Outcomes After fusion Surgery. World Neurosurg 2021; 154:e677-e682. [PMID: 34343684 DOI: 10.1016/j.wneu.2021.07.115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The proposal of C1-C2 fusion as a better treatment option compared with foramen magnum decompression (FMD) for the treatment of Chiari 1 malformations has led to controversy. Although FMD is a time-tested treatment option, a group of patients exists who will benefit from C1-C2 fusion. We have proposed an objective system for defining complex Chiari malformations and studied the outcomes of fusion with decompression versus decompression alone for these patients. METHODS A total of 26 patients with complex Chiari malformations were identified using our criteria (any 4 of 7 clinicoradiological parameters). Of the 26 patients, 13 had undergone C1-C2 fusion with FMD and 13 had undergone FMD alone. They had also undergone pre- and postoperative clinicoradiological evaluations, and the outcomes were assessed using the Chicago Chiari outcome score. RESULTS Of the 13 patients in the fusion group, 12 (92.3%) showed improvement compared with only 6 of 13 patients (46.2%) in the nonfusion group using the Chicago Chiari outcome score, a statistically significant difference (P = 0.036, χ2 test). The mean hospital length of stay was longer for the fusion group (6.15 ± 1.46 days) than for the nonfusion group (4.38 ± 2.22 days; P = 0.02). CONCLUSIONS We have proposed a novel set of criteria for defining complex Chiari malformations. Fusion with decompression provided better outcomes than decompression alone.
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Affiliation(s)
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India.
| | - Dhananjaya Bhat
- Department of Neurosurgery, RV Aster Hospital, Bengaluru, India
| | - Indira Devi Bhagavatula
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
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Shuman WH, DiRisio A, Carrasquilla A, Lamb CD, Quinones A, Pionteck A, Yang Y, Kurt M, Shrivastava RK. Is there a morphometric cause of Chiari malformation type I? Analysis of existing literature. Neurosurg Rev 2021; 45:263-273. [PMID: 34254195 DOI: 10.1007/s10143-021-01592-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Although many etiologies have been proposed for Chiari malformation type I (CM-I), there currently is no singular known cause of CM-I pathogenesis. Advances in imaging have greatly progressed the study of CM-I. This study reviews the literature to determine if an anatomical cause for CM-I could be proposed from morphometric studies in adult CM-I patients. After conducting a literature search using relevant search terms, two authors screened abstracts for relevance. Full-length articles of primary morphometric studies published in peer-reviewed journals were included. Detailed information regarding methodology and symptomatology, craniocervical instability, syringomyelia, operative effects, and genetics were extracted. Forty-six studies met inclusion criteria, averaging 93.2 CM-I patients and 41.4 healthy controls in size. To obtain measurements, 40 studies utilized MRI and 10 utilized CT imaging, whereas 41 analyzed parameters within the posterior fossa and 20 analyzed parameters of the craniovertebral junction. The most commonly measured parameters included clivus length (n = 30), tonsillar position or descent (n = 28), McRae line length (n = 26), and supraocciput length (n = 26). While certain structural anomalies including reduced clivus length have been implicated in CM-I, there is a lack of consensus on how several other morphometric parameters may or may not contribute to its development. Heterogeneity in presentation with respect to the extent of tonsillar descent suggests alternate methods utilizing morphometric measurements that may help to identify CM-I patients and may benefit future research to better understand underlying pathophysiology and sequelae such as syringomyelia.
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Affiliation(s)
- William H Shuman
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA.
| | - Aislyn DiRisio
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Alejandro Carrasquilla
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Colin D Lamb
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Aymeric Pionteck
- Department of Mechanical Engineering, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Yang Yang
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Mehmet Kurt
- Department of Mechanical Engineering, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine At Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
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Goel A. Indicators of atlantoaxial instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:103-106. [PMID: 34194154 PMCID: PMC8214233 DOI: 10.4103/jcvjs.jcvjs_55_21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, Maharashtra, India
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Letter to the Editor Regarding "Chiari 1 Formation Redefined-Clinical and Radiographic Observations in 388 Surgically Treated Patients". World Neurosurg 2021; 145:548-549. [PMID: 33348517 DOI: 10.1016/j.wneu.2020.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 11/24/2022]
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47
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Goel A. In Reply to the Letter to the Editor Regarding "Chiari 1 Formation Redefined - Clinical and Radiographic Observations in 388 Surgically Treated Patients". World Neurosurg 2021; 145:550-551. [PMID: 33348518 DOI: 10.1016/j.wneu.2020.10.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, King Edward VII Memorial Hospital and Seth G.S. Medical College, Parel, Mumbai, India.
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Joaquim AF, Evangelista Santos Barcelos AC, Daniel JW. Role of Atlas Assimilation in the Context of Craniocervical Junction Anomalies. World Neurosurg 2021; 151:201-208. [PMID: 34023466 DOI: 10.1016/j.wneu.2021.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/18/2022]
Abstract
Atlas assimilation (AA) may be associated with atlantoaxial dislocation, Chiari malformation (CM), and basilar invagination. The importance of AA in the context of craniocervical junction (CVJ) anomalies is unclear. Considering this context, this study's objective is to discuss the role of AA in the management of CVJ anomalies, especially in CM. A comprehensive literature review was performed. In addition, some illustrative cases were discussed on the basis of our review. Finally, we propose a theoretic algorithm to evaluate patients with AA and CM. AA is a proatlas segmentation anomaly that may be complete or incomplete. It may be totally asymptomatic or symptomatic as the result of transferred shifted forces onto the C1-2 joints, leading to clear instability (atlantoaxial dislocation) or mild C1-2 instability. Cautious surgical planning may be required due to associated vertebral artery anomalies. AA with concomitant C2-C3 segmentation failure is highly associated with late C1-C2 instability. CVJ decompression failure was reported in patients with CM and a low clivus canal angle (<130-135 degrees). Patients with assimilated anterior C1 arches usually have evident AAD. CM patients with AA generally have type 1 BI or type 2 BI and are reported with higher rates of CVJ instabilities when compared with those "pure" CM. Dynamic examinations may provide additional evidence of atlantoaxial instability. Although AA per se is not considered an unstable configuration, further and detailed evaluations of patients with CM associated with AA are necessary. Some associated unstable configurations required concomitant CVJ fixation.
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Affiliation(s)
| | | | - Jefferson Walter Daniel
- Division of Neurosurgery, Faculty of Medicine of the Holy House of Mercy of São Paulo, São Paulo, Brazil
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Yerramneni VK, Sharma N. Os Odontoideum: A Single-Center Experience with Controversies in Management and Evolution of Treatment Strategies. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0039-1686960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractOs odontoideum is an independent ossicle of variable size and shape separated from the body of C2. There are various theories on the etiology. Different hypothesis on etiology include traumatic and congenital. Because of the laxity of the ligaments associated with the anomalous odontoid, there can be associated instability at the craniovertebral junction. The authors presented their experience of treating these anomalies, their clinical presentations, evolution of the treatment strategies over years, and a brief review of literature on etiopathogenesis.
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Affiliation(s)
- Vamsi Krishna Yerramneni
- Department of Neurosurgery, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Neeraj Sharma
- Department of Neurosurgery, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
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50
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Goel A, Darji H, Shah A, Prasad A, Hawaldar A. Retro-Odontoid and Retro-C2 Body Pseudotumor, Pannus, and/or Cyst. A Study Based on Analysis of 63 Cases. World Neurosurg 2021; 151:e170-e177. [PMID: 33845178 DOI: 10.1016/j.wneu.2021.03.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The potential significance of relationship of atlantoaxial instability with retro-odontoid pseudotumor, pannus, and/or cyst (RPC) is analyzed. METHODS We searched the database of patients with craniovertebral junction-related instability treated by atlantoaxial fixation from January 2000 to March 2020. We identified 63 patients in whom there was an RPC in the region posterior to the odontoid process or posterior to the posterior aspect of the C2 body. RESULTS The RPC was solid in 10 patients, predominantly cystic in 39 patients, and had both solid and cystic components in 14 patients. The vertical dimension of the RPC varied from 4.5 to 10.5 mm (average, 7.9 mm) and the transverse dimension ranged from 2 to 5.2 mm (average, 3.4 mm). In 51 patients, the RPC was in the midline and in 9 patients, it was eccentric in location. In 38 patients, there was erosion of the C2 body adjoining the RPC. Analysis of investigations showed that in 100% of patients, the dome of the RPC was in line with the most susceptible point of potential bone compression of neural structures. The RPC was eccentric in location in 9 patients presenting with torticollis. RPC indicated the presence of atlantoaxial instability even when there were no other positive and validated radiologic indicators. After atlantoaxial stabilization, the RPC spontaneously regressed or disappeared. Direct resection of the RPC was neither performed nor was necessary in any case. CONCLUSIONS RPCs are secondary consequences of atlantoaxial instability and need not be primarily addressed by surgical resection. Their location suggests that they might have a neural protective function.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India.
| | - Hardik Darji
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Apurva Prasad
- Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra, Mumbai, India
| | - Akshay Hawaldar
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
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