1
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Pattisapu JV, Ackerman LL, Infinger LK, Maher CO, Quinsey C, Rocque BG, Silberstein H, Jackson EM, Jernigan S, Niazi T, Qaiser R, Raskin JS, Vachhrajani S, Bauer DF. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions. Neurosurgery 2023; 93:731-735. [PMID: 37646504 DOI: 10.1227/neu.0000000000002635] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Chiari malformation type I (CIM) diagnoses have increased in recent years. Controversy regarding the best operative management prompted a review of the literature to offer guidance on surgical interventions. OBJECTIVE To assess the literature to determine (1) whether posterior fossa decompression or posterior fossa decompression with duraplasty is more effective in preoperative symptom resolution; (2) whether there is benefit from cerebellar tonsillar resection/reduction; (3) the role of intraoperative neuromonitoring; (4) in patients with a syrinx, how long should a syrinx be observed for improvement before additional surgery is performed; and 5) what is the optimal duration of follow-up care after preoperative symptom resolution. METHODS A systematic review was performed using the National Library of Medicine/PubMed and Embase databases for studies on CIM in children and adults. The most appropriate surgical interventions, the use of neuromonitoring, and clinical improvement during follow-up were reviewed for studies published between 1946 and January 23, 2021. RESULTS A total of 80 studies met inclusion criteria. Posterior fossa decompression with or without duraplasty or cerebellar tonsil reduction all appeared to show some benefit for symptom relief and syrinx reduction. There was insufficient evidence to determine whether duraplasty or cerebellar tonsil reduction was needed for specific patient groups. There was no strong correlation between symptom relief and syringomyelia resolution. Many surgeons follow patients for 6-12 months before considering reoperation for persistent syringomyelia. No benefit or harm was seen with the use of neuromonitoring. CONCLUSION This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. In patients with CIM with or without syringomyelia, treatment options include bone decompression with or without duraplasty or cerebellar tonsil reduction. Improved syrinx resolution may potentially be seen with dural patch grafting. Symptom resolution and syrinx resolution did not correlate directly. Reoperation for a persistent syrinx was potentially beneficial if the syrinx had not improved 6 to 12 months after the initial operation. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions .
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Affiliation(s)
- Jogi V Pattisapu
- Pediatric Neurosurgery, University of Central Florida College of Medicine, Orlando , Florida , USA
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University Health, Indianapolis , Indiana , USA
| | - Libby Kosnik Infinger
- Department of Neurosurgery, Medical University of South Carolina (MUSC), Charleston , South Carolina , USA
| | - Cormac O Maher
- Department of Neurosurgery, Stanford Medicine, Palo Alto , California , USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina Chapel Hill, Chapel Hill , North Carolina , USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , Alabama , USA
| | - Howard Silberstein
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester , New York , USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Sarah Jernigan
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
| | - Toba Niazi
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami , Florida , USA
| | - Rabia Qaiser
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Shobhan Vachhrajani
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton , Ohio , USA
| | - David F Bauer
- Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston , Texas , USA
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2
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Li J, Ouyang T, Xu P, Huang X, Song X, Wang P, Meng W, Xu J, Zhang N. Outcome evaluation of decompression surgery combined with cerebellar tonsillectomy compared without cerebellar tonsillectomy for Chiari type I malformation patients. Neurosurg Rev 2022; 45:3315-3326. [PMID: 35821537 DOI: 10.1007/s10143-022-01829-w] [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: 04/10/2022] [Revised: 05/31/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Surgical intervention is an important treatment option to improve the prognosis for Chiari type I malformation (CM-I) patients. However, there is no consensus about surgical strategies. The article intends to evaluate the effect of decompression combined with or without cerebellar tonsillectomy in the treatment of CM-I. METHOD Following PRISMA's principles, Embase, PubMed, Web of Science, and Cochrane databases and references to relevant articles were searched to include only original articles on decompression combined with or without cerebellar tonsillectomy in CM-I patients. Through meta-analysis, the data on clinical improvement, radiological improvement, and complications were pooled. RESULTS Nine articles, including 399 CM-I patients undergoing decompression alone and 343 undergoing decompression with cerebellar tonsillectomy, meet the inclusion standard. In comparison, the improvement rate of clinical symptoms or signs in patients with cerebellar tonsillectomy is higher and statistically significant (RR: 0.85, 95% CI: 0.75-0.95; P = 0.006). However, decompression with cerebellar tonsillectomy is also significantly higher in the incidence of postoperative complications (RR: 0.54, 95% CI: 0.36-0.80; P = 0.002). No statistical difference is discovered between the two groups in the improvement rate of syringomyelia (RR: 0.77, 95% CI: 0.57-1.03; P = 0.08). CONCLUSIONS Although decompression with cerebellar tonsillectomy is superior than decompression alone in clinical improvement for CM-I patients, it also faces a higher risk of postoperative complications. The reduction of syringomyelia in the two groups can be considered equally effective without significant differences. In the future, the results of the research require multicenter and large-scale randomized controlled trials to verify in clinical practice. TRIAL REGISTRATION CRD42022321750 (PROSPERO).
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Affiliation(s)
- Jun Li
- Department of Neurology, the First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi Province, China.,Department of the Second Clinical Medical College of Nanchang University, Nanchang, Jiangxi Province, China
| | - Taohui Ouyang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Ping Xu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xiaofei Huang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xie Song
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Ping Wang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Wei Meng
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jiang Xu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China.
| | - Na Zhang
- Department of Neurology, the First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi Province, China.
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3
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Guo F, Turgut M. Precise Management of Chiari Malformation with Type I. Front Surg 2022; 9:850879. [PMID: 35558380 PMCID: PMC9088844 DOI: 10.3389/fsurg.2022.850879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/10/2022] [Indexed: 11/21/2022] Open
Abstract
Diagnosis of Chirai malformation type I (CM-I) is based on magnetic resonance imaging of the brain or cervical spinal cord. The main goal of surgery is to relieve the blockage to the free pulsatile flow of cerebrospinal fluid beyond the foramen magnum and to stop the progression of a syringomyelia. Despite recent advances in imaging and surgery, even today, there is no consensus on optimal management of CM-I. Ongoing focus is devoted to a better consideration of the pathophysiology of CM-I and the development of more effective medical and surgical treatments. It is hoped that proposed algorithm helps the neurosurgeon to provide a precise management for patients with CM-I in advance.
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Affiliation(s)
- Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan International Joint Laboratory of Nervous System Malformation, Zhengzhou, China
- Correspondence: Fuyou Guo
| | - Mehmet Turgut
- Henan International Joint Laboratory of Nervous System Malformation, Zhengzhou, China
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Efeler, Aydın, Turkey
- Department of Histology and Embryology, Aydın Adnan Menderes University Health Sciences Institute, Efeler, Aydın, Turkey
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4
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Sellyn GE, Tang AR, Zhao S, Sherburn M, Pellegrino R, Gannon SR, Guidry BS, Ladner TR, Wellons JC, Shannon CN. Effectiveness of the Chiari Health Index for Pediatrics instrument in measuring postoperative health-related quality of life in pediatric patients with Chiari malformation type I. J Neurosurg Pediatr 2021; 27:139-144. [PMID: 33276337 DOI: 10.3171/2020.7.peds20250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' previously published work validated the Chiari Health Index for Pediatrics (CHIP), a new instrument for measuring health-related quality of life (HRQOL) for pediatric Chiari malformation type I (CM-I) patients. In this study, the authors further evaluated the CHIP to assess HRQOL changes over time and correlate changes in HRQOL to changes in symptomatology and radiological factors in CM-I patients who undergo surgical intervention. Strong HRQOL evaluation instruments are currently lacking for pediatric CM-I patients, creating the need for a standardized HRQOL instrument for this patient population. This study serves as the first analysis of the CHIP instrument's effectiveness in measuring short-term HRQOL changes in pediatric CM-I patients and can be a useful tool in future CM-I HRQOL studies. METHODS The authors evaluated prospectively collected CHIP scores and clinical factors of surgical intervention in patients younger than 18 years. To be included, patients completed a baseline CHIP captured during the preoperative visit, and at least 1 follow-up CHIP administered postoperatively. CHIP has 2 domains (physical and psychosocial) comprising 4 components, the 3 physical components of pain frequency, pain severity, and nonpain symptoms, and a single psychosocial component. Each CHIP category is scored on a scale, with 0 indicating absent and 1 indicating present, with higher scores indicating better HRQOL. Wilcoxon paired tests, Spearman correlations, and linear regression models were used to evaluate and correlate HRQOL, symptomatology, and radiographic factors. RESULTS Sixty-three patients made up the analysis cohort (92% Caucasian, 52% female, mean age 11.8 years, average follow-up time 15.4 months). Dural augmentation was performed in 92% of patients. Of the 63 patients, 48 reported preoperative symptoms and 42 had a preoperative syrinx. From baseline, overall CHIP scores significantly improved over time (from 0.71 to 0.78, p < 0.001). Significant improvement in CHIP scores was seen in patients presenting at baseline with neck/back pain (p = 0.015) and headaches (p < 0.001) and in patients with extremity numbness trending at p = 0.064. Patients with syringomyelia were found to have improvement in CHIP scores over time (0.75 to 0.82, p < 0.001), as well as significant improvement in all 4 components. Additionally, improved CHIP scores were found to be significantly associated with age in patients with cervical (p = 0.009) or thoracic (p = 0.011) syrinxes. CONCLUSIONS The study data show that the CHIP is an effective instrument for measuring HRQOL over time. Additionally, the CHIP was found to be significantly correlated to changes in symptomatology, a finding indicating that this instrument is a clinically valuable tool for the management of CM-I.
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Affiliation(s)
- Georgina E Sellyn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 2Vanderbilt University School of Medicine; and
- 5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan R Tang
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 2Vanderbilt University School of Medicine; and
| | - Shilin Zhao
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 3Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madeleine Sherburn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel Pellegrino
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Stephen R Gannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley S Guidry
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 2Vanderbilt University School of Medicine; and
| | - Travis R Ladner
- 4Department of Neurological Surgery, Mt. Sinai Hospital, New York, New York; and
| | - John C Wellons
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt
- 5Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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5
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Lara-Reyna J, Chae J, Tosi U, Souweidane MM, Uribe-Cardenas R, Greenfield JP. Syringomyelia Resolution Following Chiari Surgery: A Novel Scale for Communication and Research. Neurosurgery 2020; 88:E60-E66. [PMID: 32779709 DOI: 10.1093/neuros/nyaa326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 05/26/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The pathophysiological connection between Chiari malformation and syringomyelia is accepted. Debate remains, however, how can we best define changes in syringomyelia following surgery. OBJECTIVE To introduce a grading system focusing on syrinx reduction based on routinely and reproducible radiological information, and provide a suggestion of the application of this scale for prediction of patient's prognoses. METHODS Data from 48 patients with Chiari malformation and syringomyelia were compiled. We calculated syrinx cross-sectional area by approximating an ellipse in the largest axial plane. We compared the percentage of reduction or enlargement following surgery. The percentage change was grouped into four grades: Grade 0 = Increasing size, grade I ≤ 50% reduction, grade II = 50% to 90% reduction, grade III ≥ 90% reduction. RESULTS A total of 89.6% of patients had syrinx improvement after surgery. A total of 5 patients were grade 0, 14 were grade I, 20 patients were grade II, and 9 patients met criteria for grade III. The mean postoperative syrinx area was 24.1 mm2 (0-169 mm2) with a mean syrinx reduction of 62.7%. CONCLUSION Radiological improvement of syringomyelia can be mathematically defined and standardized to assist in communication in outcome-based trials. Radiological resolution is expected most patients.
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Affiliation(s)
- Jacques Lara-Reyna
- Department of Neurological Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, New York.,Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John Chae
- Department of Neurological Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, New York
| | - Umberto Tosi
- Department of Neurological Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, New York
| | - Mark M Souweidane
- Department of Neurological Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, New York.,Department of Neurosurgery, Memorial Sloan - Kettering Cancer Center, New York, New York
| | - Rafael Uribe-Cardenas
- Department of Neurological Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, New York.,Department of Neurosurgery, Memorial Sloan - Kettering Cancer Center, New York, New York
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, New York.,Department of Neurosurgery, Memorial Sloan - Kettering Cancer Center, New York, New York
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6
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Yates C, Campbell R, Wood M, Chaseling R, Tollesson G, Ma N. Chiari 1 malformation: age-based outcomes in a paediatric surgical cohort. Childs Nerv Syst 2020; 36:2807-2814. [PMID: 32130483 DOI: 10.1007/s00381-020-04556-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/27/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Substantial evidence exists describing differences between paediatric and adult Chiari 1 malformation (CM1) patients. Differences in clinical presentation between very young (0-6 years old) and older (7-18 years old) paediatric patients is similarly well-established. However, progression on these findings with regard to surgical outcomes is limited. We aimed to establish whether inter-paediatric age group modifies surgical outcome for CM1 decompression. METHODS Retrospective chart review was conducted for 65 patients receiving posterior fossa decompression between 2006 and 2018. Presenting features, surgical management, and outcome were evaluated and stratified into very young patients (0-6 years) or older patients (7-18 years). Outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS), a validated 16-point framework for comparison. RESULTS Very young patients (21 patients) scored significantly lower in surgical outcome overall compared with older patients (44 patients) (12.1 ± 3.2/16 vs 14.2 ± 1.6/16, p = 0.011), and across 3/4 CCOS subscores: non-pain symptoms, functionality, and complications. Very young patients also returned to theatre more commonly (47.6% vs 13.6%, p = 0.003), primarily for re-do decompression (7/10 patients, 70%). Finally, the presentation of very young patients differed to older patients with significantly more oropharyngeal (38.1% vs 9.0%, p = 0.014) and motor symptoms (47.6% vs 22.7%, p = 0.042). DISCUSSION Very young patients (0-6 years) do not appear to respond as well to standard posterior fossa decompression, as their older (7-18 years) paediatric counterparts, in the absence of several baseline cohort characteristic differences. We hypothesise underlying anatomical differences may contribute to this finding.
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Affiliation(s)
- Charles Yates
- Department of Neurosurgery, Queensland Children's Hospital, Brisbane, Queensland, Australia.
| | - Robert Campbell
- Department of Neurosurgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Martin Wood
- Department of Neurosurgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Raymond Chaseling
- Department of Neurosurgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Gert Tollesson
- Department of Neurosurgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Norman Ma
- Department of Neurosurgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
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7
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Chotai S, Chan EW, Ladner TR, Hale AT, Gannon SR, Shannon CN, Bonfield CM, Naftel RP, Wellons JC. Timing of syrinx reduction and stabilization after posterior fossa decompression for pediatric Chiari malformation type I. J Neurosurg Pediatr 2020; 26:193-199. [PMID: 32330878 DOI: 10.3171/2020.2.peds19366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine the timeline of syrinx regression and to identify factors mitigating syrinx resolution in pediatric patients with Chiari malformation type I (CM-I) undergoing posterior fossa decompression (PFD). METHODS The authors conducted a retrospective review of records from pediatric patients (< 18 years old) undergoing PFD for the treatment of CM-I/syringomyelia (SM) between 1998 and 2015. Patient demographic, clinical, radiological, and surgical variables were collected and analyzed. Radiological information was reviewed at 4 time points: 1) pre-PFD, 2) within 6 months post-PFD, 3) within 12 months post-PFD, and 4) at maximum available follow-up. Syrinx regression was defined as ≥ 50% decrease in the maximal anteroposterior syrinx diameter (MSD). The time to syrinx regression was determined using Kaplan-Meier analysis. Multivariate analysis was conducted using a Cox proportional hazards model to determine the association between preoperative, clinical, and surgery-related factors and syrinx regression. RESULTS The authors identified 85 patients with CM-I/SM who underwent PFD. Within 3 months post-PFD, the mean MSD regressed from 8.1 ± 3.4 mm (preoperatively) to 5.6 ± 2.9 mm within 3 months post-PFD. Seventy patients (82.4%) achieved ≥ 50% regression in MSD. The median time to ≥ 50% regression in MSD was 8 months (95% CI 4.2-11.8 months). Using a risk-adjusted multivariable Cox proportional hazards model, the patients who underwent tonsil coagulation (n = 20) had a higher likelihood of achieving ≥ 50% syrinx regression in a shorter time (HR 2.86, 95% CI 1.2-6.9; p = 0.02). Thirty-six (75%) of 45 patients had improvement in headache at 2.9 months (IQR 1.5-4.4 months). CONCLUSIONS The maximum reduction in syrinx size can be expected within 3 months after PFD for patients with CM-I and a syrinx; however, the syringes continue to regress over time. Tonsil coagulation was associated with early syrinx regression in this cohort. However, the role of surgical maneuvers such as tonsil coagulation and arachnoid veil identification and sectioning in the overall role of CM-I surgery remains unclear.
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Affiliation(s)
- Silky Chotai
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily W Chan
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis R Ladner
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Andrew T Hale
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen R Gannon
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
- 4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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8
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Tosi U, Lara-Reyna J, Chae J, Sepanj R, Souweidane MM, Greenfield JP. Persistent Syringomyelia After Posterior Fossa Decompression for Chiari Malformation. World Neurosurg 2020; 136:454-461.e1. [PMID: 32204297 DOI: 10.1016/j.wneu.2020.01.148] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Chiari malformation (CM) is often comorbid with syringomyelia. The treatment of CM via posterior fossa decompression (PFD) may not improve syringomyelia in up to 40% of patients, based on historical cohorts. Management of these patients is problematic, as both reoperation and syrinx shunting have high failure rates in the long term. METHODS We retrospectively reviewed our cases in which patients with CM type 1 or 1.5 and syringomyelia underwent PFD without postoperative improvement in syringomyelia. Symptomatology and radiographic measurements were collected at presentation and on the first and latest available postoperative scans and analyzed. We present 2 cases to illustrate the challenges in the management of these patients. RESULTS Our cohort consisted of 48 consecutive patients with CM and syringomyelia who underwent PFD. Of these, 41 patients had postoperative improvement in or resolution of syringomyelia. We subsequently studied the cohort of 7 patients who underwent PFD with (n = 5) or without (n = 2) durotomy and demonstrated worsening of syringomyelia following surgery. This cohort had mean (±SEM) preoperative syrinx area of 23.9 ± 10.0 mm2. Postoperatively, the mean syrinx area increased to 40.5 ± 9.6 mm2 and 57.3 ± 12.5 mm2 on the first and latest postoperative scans available (P = 0.02), for an increase of 106.9% ± 94.4% and 186.0% ± 107.4% (P = 0.04). Presenting symptoms included occipital headache, paresthesias, visual deterioration, and paraspinal pain. On last follow-up (mean 13.9 ± 4.9 months), the majority of symptoms were resolved in this cohort, despite persistence of syringomyelia. CONCLUSIONS In this small cohort of unique patients, syrinx resolution was not achieved via decompression surgery. Despite "radiographic failure," good symptom control was achieved, with most patients remaining or becoming asymptomatic postoperatively, thus supporting our rationale for what has largely been a conservative approach in this population.
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Affiliation(s)
- Umberto Tosi
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - John Chae
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - Roshann Sepanj
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - Mark M Souweidane
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
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9
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Koueik J, Sandoval-Garcia C, Kestle JRW, Rocque BG, Frim DM, Grant GA, Keating RF, Muh CR, Oakes WJ, Pollack IF, Selden NR, Tubbs RS, Tuite GF, Warf B, Rajamanickam V, Broman AT, Haughton V, Rebsamen S, George TM, Iskandar BJ. Outcomes in children undergoing posterior fossa decompression and duraplasty with and without tonsillar reduction for Chiari malformation type I and syringomyelia: a pilot prospective multicenter cohort study. J Neurosurg Pediatr 2020; 25:21-29. [PMID: 31628281 DOI: 10.3171/2019.8.peds19154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite significant advances in diagnostic and surgical techniques, the surgical management of Chiari malformation type I (CM-I) with associated syringomyelia remains controversial, and the type of surgery performed is surgeon dependent. This study's goal was to determine the feasibility of a prospective, multicenter, cohort study for CM-I/syringomyelia patients and to provide pilot data that compare posterior fossa decompression and duraplasty (PFDD) with and without tonsillar reduction. METHODS Participating centers prospectively enrolled children suffering from both CM-I and syringomyelia who were scheduled to undergo surgical decompression. Clinical data were entered into a database preoperatively and at 1-2 weeks, 3-6 months, and 1 year postoperatively. MR images were evaluated by 3 independent, blinded teams of neurosurgeons and neuroradiologists. The primary endpoint was improvement or resolution of the syrinx. RESULTS Eight clinical sites were chosen based on the results of a published questionnaire intended to remove geographic and surgeon bias. Data from 68 patients were analyzed after exclusions, and complete clinical and imaging records were obtained for 55 and 58 individuals, respectively. There was strong agreement among the 3 radiology teams, and there was no difference in patient demographics among sites, surgeons, or surgery types. Tonsillar reduction was not associated with > 50% syrinx improvement (RR = 1.22, p = 0.39) or any syrinx improvement (RR = 1.00, p = 0.99). There were no surgical complications. CONCLUSIONS This study demonstrated the feasibility of a prospective, multicenter surgical trial in CM-I/syringomyelia and provides pilot data indicating no discernible difference in 1-year outcomes between PFDD with and without tonsillar reduction, with power calculations for larger future studies. In addition, the study revealed important technical factors to consider when setting up future trials. The long-term sequelae of tonsillar reduction have not been addressed and would be an important consideration in future investigations.
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Affiliation(s)
- Joyce Koueik
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - John R W Kestle
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon G Rocque
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - David M Frim
- 4Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Gerald A Grant
- 5Department of Pediatric Neurosurgery, Stanford Health Care, Palo Alto, California
| | - Robert F Keating
- 6Department of Neurosurgery, Children's National Health System, Washington, DC
| | - Carrie R Muh
- 7Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - W Jerry Oakes
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Ian F Pollack
- 8Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, Pennsylvania
| | - Nathan R Selden
- 9Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - R Shane Tubbs
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Gerald F Tuite
- 10Department of Neurosurgery, Johns Hopkins All Children's Hospital, Tampa, Florida
| | - Benjamin Warf
- 11Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Victor Haughton
- 13Radiology, University of Wisconsin-Madison, Wisconsin; and
| | - Susan Rebsamen
- 13Radiology, University of Wisconsin-Madison, Wisconsin; and
| | - Timothy M George
- 14Department of Neurosurgery, Dell Medical School, Austin, Texas
| | - Bermans J Iskandar
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
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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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Bartoli A, Soleman J, Berger A, Wisoff JH, Hidalgo ET, Mangano FT, Keating RF, Thomale UW, Boop F, Roth J, Constantini S. Treatment Options for Hydrocephalus Following Foramen Magnum Decompression for Chiari I Malformation: A Multicenter Study. Neurosurgery 2019; 86:500-508. [DOI: 10.1093/neuros/nyz211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 02/24/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Andrea Bartoli
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
| | - Jehuda Soleman
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery and Division of Pediatric Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Assaf Berger
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, NYU Langone Health, New York, New York
| | | | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Ulrich W Thomale
- Pediatric Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
| | - Frederick Boop
- Department of Pediatrics, Neuroscience Institute, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Jonathan Roth
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
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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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13
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Dlouhy BJ, Menezes AH. Autologous cervical fascia duraplasty in 123 children and adults with Chiari malformation type I: surgical technique and complications. J Neurosurg Pediatr 2018; 22:297-305. [PMID: 29932369 DOI: 10.3171/2018.3.peds17550] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Techniques for combined extradural and intradural decompression with expansile duraplasty for Chiari malformation type I (CM-I) have been well described, with various allogenic and autologous materials used for duraplasty. However, the approach and surgical technique used for duraplasty in our treatment of CM-I and developed by the senior author in the 1990s has not been described. METHODS A prospective database was initiated in March 2003 to denote the use of cervical fascia for duraplasty and incorporate an ongoing detailed record of complications during the surgical treatment of children and adults with CM-I with and without syringomyelia. A total of 389 surgeries for CM-I were performed on 379 patients from March 2003 to June 2016. A total of 123 posterior procedures were performed on 123 patients in which both a posterior fossa extradural and intradural decompression with duraplasty (extra-intradural) was performed. In this paper the authors describe the surgical technique for harvesting and using cervical fascia for duraplasty in the surgical treatment of CM-I and analyze and discuss complications from a prospective database spanning 2003-2016. RESULTS The authors found that cervical fascia can be harvested in patients of all ages (2-61 years old) without difficulty, and it provides a good substitute for dura in creating an expansile duraplasty in patients with CM-I. Cervical fascia is an elastic-like material with a consistency that allows for a strong watertight closure. Harvesting the cervical fascia graft does not require any further extension of the incision superiorly or inferiorly to obtain the graft. Complications were uncommon in this study of 123 children and adults. The risk of any type of complication (aseptic meningitis, CSF leak, pseudomeningocele, infection, development of hydrocephalus, and need for ventriculoperitoneal shunt) for the 78 patients in the pediatric age group was 0%. The risk of complication in the adult group was 6.7% (1 patient with aseptic meningitis and 2 patients with CSF leak). CONCLUSIONS Autologous cervical fascia is easy to obtain in patients of all ages and provides an effective material for duraplasty in the treatment of CM-I. Complications from the combination of both an extradural and intradural decompression with autologous cervical fascia duraplasty are uncommon.
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Affiliation(s)
- Brian J Dlouhy
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, University of Iowa Stead Family Children's Hospital; and.,3Pappajohn Biomedical Institute, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Arnold H Menezes
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, University of Iowa Stead Family Children's Hospital; and
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Hidalgo ET, Dastagirzada Y, Orillac C, Kvint S, North E, Bledea R, McQuinn MW, Redel-Traub G, Rodriguez C, Wisoff JH. Time to Resolution of Symptoms After Suboccipital Decompression with Duraplasty in Children with Chiari Malformation Type I. World Neurosurg 2018; 117:e544-e551. [PMID: 29933088 DOI: 10.1016/j.wneu.2018.06.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Duraplasty is a technique successfully used to treat Chiari malformation type I (CM-I). This study describes the timely manner of clinical outcomes and the postoperative course after craniectomy and duraplasty for the treatment of symptomatic CM-I in children. METHODS A retrospective chart review was performed in 105 consecutive children who underwent surgical decompression of symptomatic CM-I with dural opening by a single surgeon between 1999 and 2015. RESULTS In 16 of 28 children (57%) with typical Valsalva-related/tussive and mixed headaches, the symptoms resolved before discharge; by 6 months, all children were headache-free. Two of 28 children (7%) had recurrent headaches 9 months after surgery. Among the 78 children with syrinx, syrinx resolved or decreased in 68 (87%), recurred in 8 (10%), and was stable in 2 children (3%). Syrinx was resolved or decreased by 3 months in 51 children (65%) and by 6 months in 62 children (79%). Complications included aseptic meningitis requiring reoperation in 3 children (3%) and infection in one child (1%). Twelve children underwent reoperation, none within the first 30 days. No child had a major morbidity or mortality. CONCLUSIONS In carefully selected children with CM-I, a high success rate can be achieved with suboccipital decompression and duraplasty. Valsalva-related/tussive headaches resolved by the time of discharge from the hospital in the majority of children, and syrinx resolved or decreased in two-thirds of the children by 3 months. By 6 months, headaches were resolved in all cases, and syrinx was resolved or decreased in 79% of cases.
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Affiliation(s)
- Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA.
| | - Yosef Dastagirzada
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Cordelia Orillac
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Svetlana Kvint
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Emily North
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Ramona Bledea
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Michelle W McQuinn
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Gabriel Redel-Traub
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Crystalann Rodriguez
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
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Sanakoeva AV, Korshunov AE, Kadyrov SU, Khukhlaeva EA, Kushel' YV. [Posterior decompression of the craniovertebral junction in syringomyelia combined with Chiari-1 malformation in children]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 81:48-57. [PMID: 28665388 DOI: 10.17116/neiro201781348-56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE to develop the algorithm for defining the amount of posterior decompression of the craniovertebral junction in children with syringomyelia combined with Chiari-1 malformation. MATERIAL AND METHODS Sixty eight children with syringomyelia and Chiari-1 malformation, under age of 18 years, underwent posterior decompression of the craniovertebral junction (PDCVJ) in the period from January 2001 to June 2016. Seven (10%) patients underwent extradural decompression (EDD), 16 (24%) patients underwent extra-arachnoid duraplasty (EAD), 25 (37%) patients underwent intra-arachnoid dissection (IAD) and duraplasty, and 20 (29%) patients underwent PDCVJ and placement of a fourth ventricle-subarachnoid shunt. RESULTS Clinical improvement occurred in 85% of patients, and stabilization was observed in 11% of patients. Syringomyelia regressed in 78% of cases. There were no complications associated with EDD; however, re-operation was required in 3 (43%) cases. In the case of EAD, treatment results were satisfactory in 11 (79%) patients; re-operation was required in 2 (12.5%) cases; there were no complications in the early postoperative period. The highest complication rate of 6 (30%) cases was associated with shunt placement and duraplasty. However, long-term results in this group of patients were satisfactory in 16 (94%) cases, and MRI-based positive changes were observed in 100% of cases. CONCLUSION According to our analysis, EAD is the method of choice for PDCVJ in children with syringomyelia and Chiari-1 malformation without myelopathy symptoms. In the presence of myelopathy symptoms, intra-arachnoid dissection (with or without shunting) is an acceptable alternative. To our opinion, the use of EDD in syringomyelia is unadvisable.
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Affiliation(s)
| | | | - Sh U Kadyrov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - Yu V Kushel'
- Burdenko Neurosurgical Institute, Moscow, Russia
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Abstract
The craniovertebral junction (CVJ) has attracted more attention in pediatric medicine in recent years due to the progress in surgical technologies allowing a direct approach to the CVJ in children. The CVJ is the site of numerous pathologies, most originating in bone anomalies resulting from abnormal CVJ development. Before discussing the surgical approaches to CVJ, three points should be borne in mind: first, that developmental anatomy demonstrates age-dependent mechanisms and the pathophysiology of pediatric CVJ anomalies; second, that CT-based dynamic simulations have improved our knowledge of functional anatomy, enabling us to locate CVJ lesions with greater certainty; and third, understanding the complex structure of the pediatric CVJ also clarifies the surgical anatomy. This review begins with a description of the embryonic developmental process of the CVJ, comprising ossification and resegmentation of the somite. From the clinical perspective, pediatric CVJ lesions can be divided into three categories: developmental bony anomalies with or without instability, stenotic CVJ lesions, and others. After discussing surgery and management based on this classification, the author describes surgical outcomes on his hands, and finally proceeds to address controversial issues specific for pediatric CVJ surgery. The lessons, which the author has gleaned from his experience in pediatric CVJ surgery, are also presented briefly in this review. Recent technological progress has facilitated pediatric surgery of the CVJ. However, it is important to recognize that we are still far from reliably and consistently obtaining satisfactory results. Further progress in this area awaits contributions of the coming generations of pediatric surgeons.
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Affiliation(s)
- Nobuhito MOROTA
- Division of Neurosurgery, Tokyo Metropolitan Children’s Medical Center, Fuchu, Tokyo, Japan
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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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Oldfield EH. Letter to the Editor: Tonsil cautery in children with Chiari Type I malformation. J Neurosurg Pediatr 2016; 18:251. [PMID: 27104631 DOI: 10.3171/2016.1.peds15721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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