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Jha R, Chalif JI, Lu Y. Evaluating the Need for Durotomy and Duraplasty in Adults Undergoing Suboccipital Craniectomy for Chiari Decompression: A Case Series Analysis of Radiographic and Clinical Outcomes. Cureus 2024; 16:e60694. [PMID: 38899249 PMCID: PMC11186607 DOI: 10.7759/cureus.60694] [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] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Background Suboccipital craniectomy (SOC) in conjunction with dura opening and duraplasty for posterior fossa decompression is an effective treatment for symptomatic Chiari 1 malformations (CM1), primarily carried out in the pediatric population. However, dural opening and reconstruction are associated with an increased risk of complications, and their necessity in the adult population has not yet been robustly demonstrated. Given differences in clinical presentation and disease severity between the pediatric and adult patients, we aimed to identify if SOC alone with intraoperative ultrasound confirmation of adequate restoration of pulsatile motion of cerebellar tonsil is sufficient to treat symptomatic CM1 while mitigating surgical risks. Methods We identified a retrospective, institutional cohort of adult patients who underwent SOC for Chiari decompression between 2014 and 2023. Demographic, clinical, and radiographic features were extracted for each patient. Clinical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) and Motor-Sensory-Sphincter signs score (Clinical Sign Score (CSS)). Radiographic outcomes assessed cerebellar ectopia and associated syrinx characteristics. Results A total of 15 patients were identified, with an average follow-up period of three years. Eight patients underwent SOC with duraplasty, whereas seven patients underwent SOC only without duraplasty. Both groups of patients were of similar age at surgery and had similar nature and duration of symptoms prior to surgery. On pre-operative radiographic evaluation, both groups of patients had similar lengths of cerebellar ectopia (9.9±11.0 mm to 11.1±5.7 mm, p=0.591), and associated syrinxes (75% vs. 42.9%, p=0.205). Intraoperatively, both groups had similar estimated blood losses, though the length of surgery was significantly shorter when durotomy was spared (202±58.3 minutes to 116.3±47.8 minutes, p=0.011). The length of ICU stay was also significantly longer in the durotomy group (1.1±0.6 days to 0.0 days, p<0.001). Neither group reported any post-operative complications. On follow-up, both groups demonstrated similar reductions in cerebellar ectopia and syrinx characteristics. Clinically, the CCOS and CSS scores were similar between the two cohorts at follow-up, with no repeat surgery required in either group. Conclusion Our cohort suggests that for adult CM1 patients, SOC decompression alone without dural reconstruction might lead to comparable clinical and radiographic outcomes to SOC decompression with durotomy/duraplasty, especially if intraoperative ultrasound confirms good cerebrospinal fluid (CSF) flow after SOC. Notably, sparing durotomy and duraplasty is also associated with decreased operative time and decreased ICU stay.
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Affiliation(s)
- Rohan Jha
- Neurosurgery, Harvard Medical School, Boston, USA
| | | | - Yi Lu
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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Yamahata H, Ijiri K, Tanabe F, Murasumi K, Nagano Y, Makino R, Higa N, Hanaya R. Radiological Analysis of Cerebrospinal Fluid Dynamics at the Craniovertebral Junction Using Time-Spatial Labeling Inversion Pulse Magnetic Resonance Imaging in Patients with Cervical Spinal Canal Stenosis. World Neurosurg 2024; 184:e731-e736. [PMID: 38340799 DOI: 10.1016/j.wneu.2024.02.020] [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: 01/22/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Spondylotic changes in the cervical spine cause degeneration, leading to cervical spinal canal stenosis. This stenotic change can affect cerebrospinal fluid (CSF) dynamics by compressing the dural sac and reducing space in the subarachnoid space. We examined CSF dynamics at the craniovertebral junction (CVJ) using time-spatial labeling inversion pulse magnetic resonance imaging (Time-SLIP MRI) in patients with cervical spinal canal stenosis. METHODS The maximum longitudinal movement of the CSF at the CVJ was measured as length of motion (LOM) in the Time-SLIP MRI of 56 patients. The sum of ventral and dorsal LOM was defined as the total LOM. Patients were classified into 3 groups depending on their spinal sagittal magnetic resonance imaging findings: control (n = 27, Kang classification grades 0 and 1), stenosis (n = 14, Kang classification grade 2), and severe stenosis (n = 15, Kang classification grade 3). RESULTS Time-SLIP MRI revealed pulsatile movement of the CSF at the CVJ. The mean total, ventral, and dorsal LOM was 14.2 ± 9, 8.1 ± 5.7, and 3.8 ± 2.9 mm, respectively. The ventral LOM was significantly larger than the dorsal LOM. The total LOM was significantly smaller in the severe stenosis group (6.1 ± 3.4 mm) than in the control (16.0 ± 8.4 mm) or stenosis (11 ± 5.4 mm) groups (P < 0.001, Kruskal-Wallis H-test). In 5 patients, postoperative total LOM was improved after adequate decompression surgery. CONCLUSIONS This study demonstrates that CSF dynamics at the CVJ are influenced by cervical spinal canal stenosis. Time-SLIP MRI is useful for evaluating CSF dynamics at the CVJ in patients with spinal canal stenosis.
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Affiliation(s)
- Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | | | | | | | - Yushi Nagano
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ryutaro Makino
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Nayuta Higa
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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Hu Y, Zhang M, Duan C, Song D, Wei M, Guo F. A long-term follow-up study of adults with Chiari malformation type I combined with syringomyelia. Front Neurol 2023; 14:1274971. [PMID: 38107634 PMCID: PMC10722987 DOI: 10.3389/fneur.2023.1274971] [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: 08/10/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Background There is a considerable amount of controversy regarding the treatment and prognosis of adult patients with Chiari malformation type I (CM-I) at home and abroad; furthermore, no large-sample, long-term, follow-up studies have examined CM-I patients with syringomyelia (SM) comparing posterior fossa decompression with resection of tonsils (PFDRT) vs. posterior fossa decompression with duraplasty (PFDD). Objective This study retrospectively analyzed the factors affecting the treatment and long-term prognosis of adults with CM-I combined with SM. Methods We retrospectively analyzed data from 158 adult CM-I patients combined with SM who underwent PFDRT or PFDD, including 68 patients in group PFDRT and 90 patients in group PFDD. We examined the clinical manifestations, imaging features, and follow-up data of patients. Clinical outcomes were assessed using the Chicago Chiari Outcomes Scale (CCOS), and radiographic outcomes were indicated by the syrinx remission rate. Multivariate logistic regression analysis and multiple linear regression analysis were used to explore the relevant factors affecting the long-term prognosis of patients. Results This study showed that compared with preoperative patients in the PFDRT group and PFDD group, the sensory impairment, cough-related headache, and movement disorder were significantly improved (p < 0.01); meanwhile, the diameter of the syrinx and the volume of the syrinx decreased significantly (p < 0.001). Additionally, the study found that there were significant differences in the syrinx remission rate (p = 0.032) and the clinical cure rates (p = 0.003) between the two groups. Multivariate logistic regression analysis showed that age (p = 0.021), cerebellar-related symptoms (p = 0.044), preoperative cisterna magna volume (p = 0.043), and peak systolic velocity (p = 0.036) were independent factors for clinical outcomes. Multiple linear regression analysis showed that different surgical procedures were positively correlated with the syrinx remission rate (p = 0.014), while preoperative syrinx diameter (p = 0.018) and age (p = 0.002) were negatively correlated with the syrinx remission rate. Conclusion In conclusion, this study suggested that, in a long-term follow-up, although both surgical procedures are effective in treating patients with CM-I and SM, PFDRT is better than PFDD; age and cerebellar-related signs independently affect the patient's prognosis. Additionally, an effective prognosis evaluation index can be developed for patients, which is based on imaging characteristics, such as preoperative cisterna magna volume, preoperative syrinx diameter, and preoperative cerebrospinal fluid (CSF) hydrodynamic parameters to guide clinical work.
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Affiliation(s)
- Yan Hu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Mingchu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Chengcheng Duan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Mingkun Wei
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
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Gezer B, Sahinoglu M, Cebeci H, Topaloglu OF, Koktekir E, Karabagli H. A different perspective on the dilemma of durotomy or duraplasty in Chiari type 1 malformation surgery. Br J Neurosurg 2023; 37:1112-1116. [PMID: 35924846 DOI: 10.1080/02688697.2022.2106353] [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: 01/25/2022] [Accepted: 07/22/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Symptomatic Chiari type 1 malformation (CIM) patients may elect to be treated; however, choosing the optimum surgical method remains problematic: posterior fossa decompression with duraplasty (PFDD) or without duraplasty (PFD). Many studies have compared these surgical methods from several perspectives. We looked at soft tissue density (STD) at the foramen magnum to add another perspective to the comparison of PFD with PFDD. MATERIALS AND METHODS Eighty-six patients who underwent surgery in our clinic were included in the study. We examined preoperative and postoperative MR images taken in the 1st year. We obtained the foramen magnum area (FMA) and soft tissue at the level of the foramen magnum. The STD within the foramen magnum was calculated as the percentage ratio of soft tissue area (STA) to FMA. Anteroposterior diameters of the syrinx cavities in sagittal T2 sections were measured preoperatively and at 1-year postoperatively. Measurements were double-blind and were performed by the neurosurgeon and by the neuroradiologist. RESULTS There was no statistically significant difference between the postoperative FMA increases, STA changes, STD changes in patients who underwent PFD and PFDD. In this study, there was no statistically significant difference between PFD and PFDD in terms of syrinx changes. CONCLUSIONS The medium-term anatomical outcome following craniovertebral decompression for CIM, is no different whether performed PFD or PFDD.
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Affiliation(s)
- Burak Gezer
- Department of Neurosurgery, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Mert Sahinoglu
- Department of Neurosurgery, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Hakan Cebeci
- Department of Radiology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Omer F Topaloglu
- Department of Radiology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Ender Koktekir
- Department of Neurosurgery, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Hakan Karabagli
- Department of Neurosurgery, Faculty of Medicine, Selcuk University, Konya, Turkey
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de Oliveira Ribeiro EC, de Barros DPM, do Nascimento JJC, da Silva Neto EJ, de Araújo Neto SA, Valença MM. Anatomical Implications of Chiari I and Basilar Invagination (Type B) in the IV Ventricle and Cisterna Magna. World Neurosurg 2023; 178:e750-e757. [PMID: 37562686 DOI: 10.1016/j.wneu.2023.07.154] [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: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE To analyze the anatomical changes of the IV ventricle and cisterna magna in the Chiari malformation I (CMI) and basilar invagination (type B). METHODS This is a controlled study with 161 exams of magnetic resonance imaging (MRI) of adults grouped into control (n = 37), basilar invagination (BI; n = 31), Chiari malformation I (CMI; n = 37), and CMI+BI (n = 56). The MRIs were analyzed using the visualization software Osirix (Pixmeo, Bernex, Geneva, version 3.8.2). The morphometric variables were: distance from the obex to the McRae line; length of the IV ventricle floor; and the area and volume of the cisterna magna. The univariate ANOVA followed by Tukey's post-hoc test was applied to evaluate the difference between the groups. The difference between sexes was evaluated by the t test for each group. RESULTS Alterations in the cisterna magna and IV ventricle were more evident only in the CMI and CMI+BI groups. For both sexes, the CMI and CMI+BI groups showed: a reduction in the CSF space (P < 0.001), cisterna magna with volume reduction (P < 0.001), low position of the obex (P < 0.001), and IV ventricle more elongated (male P = 0.007 and female P < 0.001). The BI group had no significant change in the analysis by sex. CONCLUSIONS The CMI (isolated and associated with BI) showed a low obex position and elongation of the IV ventricle due to traction towards the spinal canal. The reduction of cisterna magna volume added to the occupation of the cerebellar tonsils can impact in the cerebrospinal fluid dynamics. The BI when isolated was not related to alterations in the parameters of cerebrospinal fluid spaces studied.
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Affiliation(s)
- Elayne Cristina de Oliveira Ribeiro
- Postgraduate Program in Biological Sciences of the Federal University of Pernambuco, Recife, Brazil; Center of Medical Sciences of the Federal University of Paraíba, João Pessoa, Brazil
| | | | - José Jailson Costa do Nascimento
- Departament of Anatomy of the Federal University of Pernambuco, Recife, Brazil; Center of Medical Sciences of the Federal University of Paraíba, João Pessoa, Brazil.
| | | | | | - Marcelo Moraes Valença
- Postgraduate Program in Biological Sciences of the Federal University of Pernambuco, Recife, Brazil; Center of Medical Sciences of the Federal University of Paraíba, João Pessoa, Brazil
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Ibrahimy A, Wu T, Mack J, Scott GC, Cortes MX, Cantor FK, Loth F, Heiss JD. Prospective, Longitudinal Study of Clinical Outcome and Morphometric Posterior Fossa Changes after Craniocervical Decompression for Symptomatic Chiari I Malformation. AJNR Am J Neuroradiol 2023; 44:1150-1156. [PMID: 37709353 PMCID: PMC10549945 DOI: 10.3174/ajnr.a7993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/16/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND AND PURPOSE The time course of changes in posterior fossa morphology, quality of life, and neurologic function of patients with Chiari I malformation after craniocervical decompression requires further elaboration. To better understand the pace of these changes, we longitudinally studied patients with Chiari I malformation, with or without syringomyelia, before and after the operation for up to 5 years. MATERIALS AND METHODS Thirty-eight symptomatic adult patients (35 women, 3 men) diagnosed with Chiari I malformation only (n = 15) or Chiari I malformation and syringomyelia (n = 23) and without previous Chiari I malformation surgery were enrolled in a clinical study. Patients underwent outpatient study visits and MR imaging at 7 time points (ie, initial [before the operation], 3 months, 1 year, 2 years, 3 years, 4 years, and 5 years) during 5 years. The surgical procedure for all patients was suboccipital craniectomy, C1 laminectomy, and autologous duraplasty. RESULTS Morphometric measurements demonstrated an enlargement of the CSF areas posterior to the cerebellar tonsils after the operation, which remained largely stable through the following years. There was a decrease in pain and improved quality of life after the operation, which remained steady during the following years. Reduction in pain and improved quality of life correlated with CSF area morphometrics. CONCLUSIONS Most changes in MR imaging morphometrics and quality of life measures occurred within the first year after the operation. A 1-year follow-up period after Chiari I malformation surgery is usually sufficient for evaluating surgical efficacy and postoperative MR imaging changes.
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Affiliation(s)
- Alaaddin Ibrahimy
- From the Surgical Neurology Branch (A.I., J.M., G.C.S., M.X.C., F.K.C., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
- Department of Biomedical Engineering (A.I.), Yale University, New Haven, Connecticut
| | - Tianxia Wu
- Clinical Trials Unit (T.W.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Jessica Mack
- From the Surgical Neurology Branch (A.I., J.M., G.C.S., M.X.C., F.K.C., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Gretchen C Scott
- From the Surgical Neurology Branch (A.I., J.M., G.C.S., M.X.C., F.K.C., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Michaela X Cortes
- From the Surgical Neurology Branch (A.I., J.M., G.C.S., M.X.C., F.K.C., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Fredric K Cantor
- From the Surgical Neurology Branch (A.I., J.M., G.C.S., M.X.C., F.K.C., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Francis Loth
- Departments of Mechanical and Industrial Engineering, and Bioengineering (F.L.), Northeastern University College of Engineering, Boston, Massachusetts
| | - John D Heiss
- From the Surgical Neurology Branch (A.I., J.M., G.C.S., M.X.C., F.K.C., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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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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Posterior Fossa Decompression with or Without Duraplasty for Chiari I Malformation. Neurosurg Clin N Am 2022; 34:105-111. [DOI: 10.1016/j.nec.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mugge L, Caras A, Henkel N, Dassi C, Schroeder J, Prevedello DM. Headache and Other Symptoms in Chiari Malformation Type I Are Associated with Cerebrospinal Fluid Flow Improvement After Decompression: A Two-Institutional Study. World Neurosurg 2022; 163:e253-e262. [PMID: 35364297 DOI: 10.1016/j.wneu.2022.03.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Chiari malformation type I (CMI) is a common neurologic condition and surgery is the standard treatment. We aim to establish the cerebrospinal fluid (CSF) flow change as a potential objective indicator of surgical efficacy to improve symptoms. METHODS We performed a retrospective 2-center analysis of surgically treated patients with CMI. Qualitative CSF flow studies obtained preoperatively and postoperatively were analyzed by the neuroradiologist, seeking improvement in CSF flow. Symptom status, including headache and neck pain, were recorded. RESULTS Forty-nine patients were identified between 2010 and 2017. The average age was 36 years, with 47 females. After decompression, CSF flow was improved in 41 patients (group A) and unchanged in 8 (group B). Group A and B had a mean age of 34 and 42 years (P < 0.05) and an average tonsillar herniation of 8.3 and 8.5 mm (P = 0.40), respectively. Group A had improved clinical outcomes, compared with group B (P = 0.024), more specifically, in headache (50% vs. 37%), neck pain (66% vs. 33%), dizziness (78% vs. 50%), vision symptoms (84% vs. 80%), and weakness (100% vs. 66%), respectively. Group B had the only patient who did worse on clinical follow-up. CONCLUSIONS Patients with CMI often present with a constellation of symptoms. We showed a significant association between improved CSF flow after decompression and symptom alleviation. Further, our study suggests that the presence of improved CSF flow postoperatively could represent an objective indicator for improved patient outcomes.
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Affiliation(s)
- Luke Mugge
- Department of Neurosciences, Inova Neuroscience and Spine Institute, Falls Church, Virginia, USA
| | - Andrew Caras
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Nicholas Henkel
- Department of Neurosurgery, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Camila Dassi
- Department of Neurosurgery, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Jason Schroeder
- Department of Neurosurgery, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Medical Center, Columbus, Ohio, USA.
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Antkowiak L, Rogalska M, Stogowski P, Anuszkiewicz K, Mandera M. Clinical Application of Diffusion Tensor Imaging in Chiari Malformation Type I- Advances and Perspectives. A Systematic Review. World Neurosurg 2021; 152:124-136. [PMID: 34147690 DOI: 10.1016/j.wneu.2021.06.052] [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: 05/04/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diffusion tensor imaging (DTI) application in Chiari malformation type I (CMI) is still poorly defined. This study aimed to systematically review the literature and propose perspectives toward the clinical application of DTI in CMI. METHODS PubMed and Embase were searched for English-language articles published until October 20, 2020. Clinical studies and case series, evaluating fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), or radial diffusivity values in patients with CMI, were included. RESULTS Eight articles were included. Lower FA values were found at the syrinx level, which decreased with syrinx extent and intensity of symptoms, reflecting myelopathy severity. Decreased AD and MD in the middle cerebellar peduncles in symptomatic patients with CMI might explain the presence of cerebellar signs. Increased FA in various supratentorial structures positively correlated with pain severity. Worse performance in neuropsychological tests correlated with decreased FA, increased MD, and radial diffusivity, reflecting axonal degeneration. Postoperative FA decrease in the brainstem compression area reflects successful decompression. A positive correlation was found between the extent of tonsillar ectopia and increased FA, MD, and AD values, which could act as an early indicator of acute brainstem compression. CONCLUSIONS DTI might provide a valuable insight into the neurobiological foundation of symptomatic CMI presentation. The severity of white matter injury evident on DTI could serve as a reliable predictor of postoperative outcomes, therefore facilitating selection of appropriate surgical candidates. Postinterventional DTI reassessment might enable differentiation between unsuccessful surgical technique and irreversible myelopathy. The extent of tonsillar ectopia reflects the severity of microstructural brainstem injury.
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Affiliation(s)
- Lukasz Antkowiak
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland.
| | - Marta Rogalska
- Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Stogowski
- Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | | | - Marek Mandera
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland
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Outcomes of dura-splitting technique compared to conventional duraplasty technique in the treatment of adult Chiari I malformation: a systematic review and meta-analysis. Neurosurg Rev 2020; 44:1313-1329. [PMID: 32567026 DOI: 10.1007/s10143-020-01334-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
Chiari malformation type I is a developmental abnormality with an array of surgical techniques introduced for the management of it. The most common technique is foramen magnum decompression with duraplasty. Dura-splitting technique as one of the non-dura-opening techniques is a less known procedure that spares the internal layer of the dura and can theoretically result in fewer complications compared to duraplasty. So, we performed a review of literature and meta-analysis on different clinical and radiological aspects of this technique and compared its outcomes to duraplasty. MOOSE guidelines were followed. A systematic search of three databases based on predefined search strategy and inclusion/exclusion criteria was performed. After quality assessment and data extraction by two authors, summarized data were presented in form of tables, and meta-analysis results were illustrated in forest plots. A review of 10 included studies consisting of 370 patients revealed significantly shorter operation duration and less intraoperative blood loss in the dura-splitting technique compared to duraplasty. Interestingly, there was no significant difference between these two techniques in terms of clinical and radiological outcomes. Overall complication rate and incidence of CSF-related complications or infections were significantly in favor of the dura-splitting technique. Dura-splitting technique can be considered as a safe and effective surgical procedure for Chiari I malformation with comparable outcomes and fewer complications compared to duraplasty, although this interpretation is derived from retrospective observational studies and lack of a prospective clinical trial is evident.
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Outcomes and complications for individual neurosurgeons for the treatment of Chiari I malformation at a children's hospital. Childs Nerv Syst 2019; 35:1895-1904. [PMID: 31127343 DOI: 10.1007/s00381-019-04201-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the outcomes and complications for individual surgeons at British Columbia Children's Hospital for the treatment of Chiari I Malformation (CMI) in children. METHODS This was a retrospective review of patients with CMI who had surgery from 1986 to 2015. We assessed the Chicago Chiari Outcome Scores (CCOS) and complication rates by surgeon. RESULTS Seventy patients, 38 males and 32 females, underwent posterior fossa decompression including 14 extradural and 56 intradural approaches. Syringomyelia was present in 74.3%. Most syringomyelia improved with no difference between intradural and extradural surgeries. After initial surgery, 13 patients (18.6%) had complications including 2/14 (14.3%) of extradural and 11/56 (19.6%) of intradural surgeries. Two patients required surgical intervention for complications whereas 11 had transient complications. The complication rate by surgeon ranged from 11 to 20% for extradural (2 surgeons only) and 10.5 to 40% for intradural surgeries (4 surgeons). The CCOS ranged from 12 to 15 for extradural and 6 to 16 for intradural. The CCOS ranges for surgeons 1 and 2 were 12-15 and 13-15 respectively for extradural. The CCOS ranges for surgeons 1, 2, 3, and 4 were 12-16, 6-15, 12-16, and 12-16 respectively for intradural. Thirteen patients had a second surgery for CMI. The final CCOS was good in 86% and moderate in 14%. CONCLUSION There was variability in surgeries performed at BCCH by different surgeons, with variations in CCOS and complication rates. This information is important during decision making, consent process, and for quality improvement.
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Massimi L, Frassanito P, Bianchi F, Tamburrini G, Caldarelli M. Bony decompression vs duraplasty for Chiari I malformation: does the eternal dilemma matter? Childs Nerv Syst 2019; 35:1827-1838. [PMID: 31209642 DOI: 10.1007/s00381-019-04218-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE The management of Chiari I malformation (CIM) still raises the problem of the optimal surgical treatment, with special regard to the "eternal dilemma" of the posterior fossa bony decompression alone (PFBD) or with duraplasty (PFBDD). The goal of the present review is to update the results (outcome and complications) of both techniques to better understand the correct indication for each of them. METHODS A review of the literature has been performed, focusing on the articles and the meta-analyses specifically addressing the problem of PFBD vs PFBDD. Also, the personal authors' experience is briefly discussed. RESULTS PFBD (usually with C1 laminectomy, often with delamination of the external dural layer) is the most commonly used technique in children, especially if syringomyelia is absent. It ensures a high success rate, with > 80% clinical improvement and about 75% reduction of the syringomyelia, and a very low risk of complications, hospital stay, and costs. A certain risk of recurrence is present (2-12%). PFBDD (with autologous tissues or dural substitutes), on the other hand, is mostly used not only in adults but also in children with large syringomyelia. It is burdened by a higher risk of complications (namely, the CSF-related ones), longer hospital stay, and higher costs; however, it warrants a better clinical improvement (> 85%) and a lower risk of reoperation (2-3.5%). Eight meta-analyses of the literature (three on pediatric series and five in adult series) and one prospective study in children, published in the last decade, largely confirm these findings. CONCLUSION PFBD and PFBDD are different techniques that are indicated for different types of patients. In children, PFBD has been demonstrated to represent the best choice, although some patients may require a more aggressive treatment. Therefore, the success in the management of CIM, with or without syringomyelia, depends on the correct indication to surgery and on a patient-tailored choice rather than on the surgical technique.
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Affiliation(s)
- Luca Massimi
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy. .,Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy.
| | - P Frassanito
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - F Bianchi
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - G Tamburrini
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy
| | - M Caldarelli
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy
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Eppelheimer MS, Biswas D, Braun AM, Houston JR, Allen PA, Bapuraj JR, Labuda R, Loth DM, Frim D, Loth F. Quantification of changes in brain morphology following posterior fossa decompression surgery in women treated for Chiari malformation type 1. Neuroradiology 2019; 61:1011-1022. [PMID: 31119343 DOI: 10.1007/s00234-019-02206-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/01/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE While 84% of patients surgically treated for Chiari malformation type 1 (CM1) demonstrate improved quality of life after posterior fossa decompression surgery, there are many risks associated with this surgery. Surgical planning to identify candidates likely to improve postoperatively may benefit from an improved understanding of morphological changes after decompression surgery. To evaluate these changes, we quantified 59 morphological parameters on 42 CM1 adult female patients before and after CM1 decompression surgery. METHODS Fifty-nine morphological parameters in the posterior cranial fossa, cranio-cervical, and intracranial regions in the midsagittal plane were evaluated using 42 T1-weighted magnetic resonance images of female CM1 patients before and after surgery, and 42 healthy female controls. Morphological differences before and after surgery were compared through the development of a technique to establish the opisthion location, a key reference point not present after surgery. RESULTS In addition to the expected reduction of the cranio-caudal dimension of the cerebellum, objective analyses showed a significant increase in the area of the cerebrospinal fluid spaces, posterior (6×) and inferior (2.6×) to the cerebellum (+ 112 ± 102 and + 140 ± 127 mm2, respectively). This increased area was primarily impacted by an average reduction in the occipital bone length of 24.5 ± 7.3 mm following surgery. Based on multiple angles, results demonstrated a 2°-4° anterior rotation of the cerebellum after surgery. CONCLUSION Our results show that decompression surgery results in significant changes in the cerebellum and cerebrospinal fluid spaces. Further investigation should determine how these morphological changes impact clinical outcomes.
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Affiliation(s)
- Maggie S Eppelheimer
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, OH, USA.
| | - Dipankar Biswas
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
| | - Audrey M Braun
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
| | - James R Houston
- Department of Psychology, Middle Tennessee State University, Murfreesboro, TN, USA
| | - Philip A Allen
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, OH, USA
| | | | | | - Dorothy M Loth
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, OH, USA
| | - David Frim
- Department of Neurosurgery, University of Chicago, Chicago, IL, USA
| | - Francis Loth
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, OH, USA
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
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Treatment failure of syringomyelia associated with Chiari I malformation following foramen magnum decompression: how should we proceed? Neurosurg Rev 2018; 42:705-714. [DOI: 10.1007/s10143-018-01066-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/21/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022]
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Abnormalities of the craniovertebral junction in the paediatric population: a novel biomechanical approach. Clin Radiol 2018; 73:839-854. [DOI: 10.1016/j.crad.2018.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 05/15/2018] [Indexed: 12/20/2022]
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Lawrence BJ, Luciano M, Tew J, Ellenbogen RG, Oshinski JN, Loth F, Culley AP, Martin BA. Cardiac-Related Spinal Cord Tissue Motion at the Foramen Magnum is Increased in Patients with Type I Chiari Malformation and Decreases Postdecompression Surgery. World Neurosurg 2018; 116:e298-e307. [PMID: 29733988 DOI: 10.1016/j.wneu.2018.04.191] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Type 1 Chiari malformation (CM-I) is a craniospinal disorder historically defined by cerebellar tonsillar position greater than 3-5 mm below the foramen magnum (FM). This definition has come under question because quantitative measurements of cerebellar herniation do not always correspond with symptom severity. Researchers have proposed several additional radiographic diagnostic criteria based on dynamic motion of fluids and/or tissues. The present study objective was to determine if cardiac-related craniocaudal spinal cord tissue displacement is an accurate indicator of the presence of CM-I and if tissue displacement is altered with decompression. METHODS A cohort of 20 symptomatic patients underwent decompression surgery. Fifteen healthy volunteers were recruited for comparison with the CM-I group. Axial phase-contrast magnetic resonance imaging (PC-MRI) measurements were collected before and after surgery at the FM with cranial-caudal velocity encoding and 20 frames per cardiac cycle with retrospective reconstruction. Spinal cord motion (SCM) at the FM was quantified based on the peak-to-peak integral of average spinal cord velocity. RESULTS Tissue motion for the presurgical group was significantly greater than controls (P = 0.0009). Motion decreased after surgery (P = 0.058) with an effect size of -0.151 mm and a standard error of 0.066 mm. Postoperatively, no statistical difference from controls in bulk displacement at the FM was found (P = 0.200) after post hoc testing using the Tukey adjustment for multiple comparisons. CONCLUSIONS These results support SCM measurement by PC-MRI as a possible noninvasive radiographic diagnostic for CM-I. Dynamic measurement of SCM provides unique diagnostic information about CM-I alongside static quantification of tonsillar position and other intracranial morphometrics.
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Affiliation(s)
- Braden J Lawrence
- School of Medicine, University of Washington, Seattle, Washington, USA; Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Department of Biological Engineering, University of Idaho, Moscow, Idaho, USA
| | - Mark Luciano
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - John Tew
- Department of Neurosurgery, University of Cincinnati Neuroscience Institute and University of Cincinnati College of Medicine, and Mayfield Clinic, Cincinnati, Ohio, USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - John N Oshinski
- Department of Radiology & Imaging Science and Biomedical Engineering, Emory University, Atlanta, Georgia
| | - Francis Loth
- Conquer Chiari Research Center, Department of Mechanical Engineering, University of Akron, Ohio, USA
| | - Amanda P Culley
- Department of Statistical Science, University of Idaho, Moscow, Idaho, USA
| | - Bryn A Martin
- Department of Biological Engineering, University of Idaho, Moscow, Idaho, USA.
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The effect of posterior fossa decompression in adult Chiari malformation and basilar invagination: a systematic review and meta-analysis. Neurosurg Rev 2017; 41:311-321. [DOI: 10.1007/s10143-017-0857-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/15/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023]
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Zuev AA, Kostenko GV. [Treatment of syringomyelia associated with Chiari 1 malformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:102-106. [PMID: 28399105 DOI: 10.17116/jnevro201711731102-106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Syringomyelia (SM) develops due to the disturbance of cerebrospinal fluid dynamics, spinal fixation or a spinal tumor. The disturbance of cerebrospinal fluid dynamics in the area of the foramen magnum leads to the progression of SM in Chiari 1 malformation (CM1). CM1 is the most prevalent pathology of craniovertebral junction associated with SM. The prevalence of CM1 varies from 3 to 8 per 100 000 population but SM is diagnosed in 65% of patients with CM1. Clinical symptoms of CM1 and SM include pain in the occipital area, gait disturbances due to sensitive ataxia, dissociated sensory disorders, dysphagia, paresis of the extremities. In most patients, symptoms of SM progressed over the years. The diagnosis is based on MRI results of the brain and spinal cord. Phase-contrast MRI is used to study the disturbance of cerebrospinal fluid dynamics in details. Progression of SM or CM1 symptoms needs surgical treatment - decompression of the posterior cranial fossa for the recovery of normal cerebrospinal fluid dynamics.
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Affiliation(s)
- A A Zuev
- FGBU 'Natsional'nyj mediko-hirurgicheskij tsentr im. N.I. Pirogova', Moskva, Rossija
| | - G V Kostenko
- FGBU 'Natsional'nyj mediko-hirurgicheskij tsentr im. N.I. Pirogova', Moskva, Rossija
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Pakzaban P. Technique for Mini-open Decompression of Chiari Type I Malformation in Adults. Oper Neurosurg (Hagerstown) 2017; 13:465-470. [DOI: 10.1093/ons/opx027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/31/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: The technique for decompression of Chiari type I malformation relies on open exposure of craniocervical junction for suboccipital craniectomy and upper cervical laminectomy with or without duraplasty. There is no detailed technical report of a minimally invasive approach for Chiari decompression in adults.
OBJECTIVE: To describe a mini-open technique for decompression of Chiari type I malformation (including duraplasty) in adults.
METHODS: Six consecutive adult patients with symptomatic Chiari type I malformation underwent decompression through a 3 to 4 cm midline incision via a speculum retractor. All patients underwent a limited suboccipital craniectomy and C1 laminectomy with an ultrasonic bone scalpel. All patients underwent duraplasty with a synthetic dural substitute. In the 2 patients with syringomyelia, the arachnoid was opened and intradural dissection was carried out. In the remaining 4 patients, the arachnoid was left intact.
RESULTS: All operations were completed successfully through the mini-open exposure. Mean surgery time, blood loss, and length of stay were 114 min, 55 mL, and 1.3 days, respectively. Mean follow-up was 13.2 months (range 9-18). All patients had excellent clinical outcomes as defined by scores of 15 (3 patients) or 16 (3 patients) on Chicago Chiari Outcome Scale. There were no neurological complications or cerebrospinal fluid leaks. Postop computed tomography revealed good boney decompression. In the 2 patients with syringomyelia, MRI at 6 months revealed resolution of the syrinx.
CONCLUSION: Decompression of Chiari type I malformation in adults can be performed safely and effectively through the mini-open exposure described in this report.
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Rahman A, Rana MS, Bhandari PB, Asif DS, Uddin ANW, Obaida ASMA, Rahman MA, Alam MS. "Stealth cranioplasty:" A novel endeavor for symptomatic adult Chiari I patients with syringomyelia: Technical note, appraisal, and philosophical considerations. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:243-252. [PMID: 29021676 PMCID: PMC5634111 DOI: 10.4103/jcvjs.jcvjs_76_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim and Objective: In this article, we describe a novel technique of reconstruction of posterior fossa by cranioplasty with use of preshaped titanium mesh following posterior fossa decompression (PFD) for Chiari malformation type I (CMI) with syringomyelia (SM) in symptomatic adults. Materials and Methods: Eleven patients underwent limited PFD and expansive cranioplasty with preshaped titanium mesh, what we term as “Stealth Cranioplasty” (SCP), following arachnoid preserving duraplasty (APD) and hexagonal tenting of the duraplasty with the cranioplasty (HTDC) for the management of symptomatic adult CMI with SM. All these patients had syringes extending from 3 to >10 vertebral levels. Results: Seven male and four female symptomatic CMI adult patients, between age ranges of 22 and 44 years (mean 29.45 years), presented with different neurological symptoms related to CMI and SM for 6–84 months (mean 37.09 months). All the patients underwent PFD, APD followed by SCP and HTDC and were followed up for 7–54 months (mean 35.90 months). Of 11 patients, 8 patients improved according to the Chicago Chiari Outcome Scale (CCOS) with score of 13–15 while 3 patients remained unchanged with CCOS of 12, and there was no worsening. There was no complication related to Chiari surgery in any of the patients. All the patients had good reestablishment of cisterna magna. Two patients had marked reduction of syrinx while eight patients had moderate-to-mild reduction and one patient had no change of syrinx. None of the patients needed redo surgery. Conclusion: SCP is an effective, fruitful, and cost-effective technique for the management of symptomatic adult CMI with SM. This technique has the advantages of preventing complications and recurrences in addition to the improvement of symptoms by addressing the basic pathology.
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Affiliation(s)
- Asifur Rahman
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md Sumon Rana
- Department of Neurosurgery, Dhaka Medical College and Hospital, Dhaka, Bangladesh
| | | | - Dewan Shamsul Asif
- Department of Neurosurgery, Anwer Khan Modern Medical College, Dhaka, Bangladesh
| | - Abu Naim Wakil Uddin
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Md Atikur Rahman
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md Shamsul Alam
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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