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Costa M, Avila MJ, Vivanco-Suarez J, Karas P, Monteith S, Patel A. Minimally Invasive Technique for Chiari I Decompression Without Durotomy: Surgical Technique and Preliminary Case Series. World Neurosurg 2024; 188:e145-e154. [PMID: 38759783 DOI: 10.1016/j.wneu.2024.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Chiari I malformation, marked by severe headaches and potential brainstem/spinal cord issues, often requires surgical intervention when conservative methods fail. This study introduces a minimally invasive surgery (MIS) Chiari decompression technique utilizing a 3-blade retractor, aiming to reduce postoperative discomfort and optimize outcomes. METHODS Chiari type I malformation patients who underwent a MIS technique were included. Technique consisted of a minimal-soft tissue opening using a 3-blade retractor, suboccipital craniectomy, C1 laminectomy, and resection of the atlantooccipital band without a durotomy. RESULTS Ten patients were treated. Mean age was 43.3 years, with 7 female patients. All patients presented with occipital headaches; 50% retroorbital pain; 40% neck, upper back, or shoulder pain; and 30% limb paresthesias. Median pre-surgical modified Rankin Scale (mRS) was 3 (2-4) and pain visual analog score (VAS) was 7 (5-9). Mean operative time was 59 (59-71) minutes, with mean blood loss of 88.5 (50-140) mL. In our sample, 90% of patients were discharged the same surgical day (mean 7.2 [5.3-7.7] hours postoperative). No immediate or delayed postoperative complications were evidenced. At 6 months, 90% of patients had mRS 0-1. At last follow-up the mean VAS was 1.5 (range: 0-4, P < 0.001). CONCLUSIONS The MIS 3-blade flexible retractor technique for Chiari decompression is feasible, provides wide visualization angles of the suboccipital region and C1 arch, allows 2-surgeon work, and minimizes skin and soft tissue disruption. This combination may diminish postoperative discomfort, reduce the risk of surgical site infections, and optimize outcomes.
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Affiliation(s)
- Matias Costa
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA.
| | - Mauricio J Avila
- Division of Neurosurgery, Saint Louis University, St. Louis, Missouri, USA
| | - Juan Vivanco-Suarez
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Patrick Karas
- Department of Neurological Surgery, University of Texas Medical Branch, Texas, USA
| | - Stephen Monteith
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Akshal Patel
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
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2
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Sachdev B, Najmi VS, Rodrigues D, Solanki GA, Afshari FT. Retroflexed dens in paediatric Chiari 1 patients and implications: Single centre retrospective study. Childs Nerv Syst 2024; 40:1449-1454. [PMID: 38217729 DOI: 10.1007/s00381-023-06264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/19/2023] [Indexed: 01/15/2024]
Abstract
INTRODUCTION Chiari 1 malformation and hind brain hernia can be associated with skull base and craniocervical anomalies. One of the more recently associated anomalies is a retroverted or retroflexed odontoid process or dens. We conducted a retrospective study of our operated symptomatic and conservatively managed asymptomatic Chiari cohort to assess the impact of dens retroflexion on rate of revision or cerebrospinal fluid diversion following primary foramen magnum decompression (FMD). METHODS We undertook a retrospective study of all foramen magnum decompression (FMD) cases for Chiari type 1 malformation performed over a 15-year period in a single tertiary paediatric neurosurgical unit. For comparison, non-operated asymptomatic Chiari cases were considered as reference cohort. Information gathered included: demographics, age, sex, length of cerebellar tonsils below McRae's line, pB-C2 distance (a line drawn perpendicular to one drawn between the basion and the posterior aspect of the C2 body), angle of retroflexion (angle formed between a line drawn through the odontoid synchondrosis and its intersection with a line drawn from the tip of the odontoid process) and angle of retroversion (angle formed between the line drawn from the base of C2 and its intersection with a line drawn from the tip of the odontoid process). Grade of retroflexion was measured using pre-operative mid-sagittal MR images and classified as grade 0 (> 90°), grade 1 (85°-89°); grade 2 (80°-84°) and grade 3 (< 80°). The rates for redo surgery or need for cerebrospinal fluid (CSF) diversion were obtained from clinical records and compared in the operated and non-operated groups. RESULTS One hundred twenty-six Chiari 1 patients were included in this study with adequate imaging. Sixty-five patients were in the non-operated asymptomatic cohort with 61 patients in the operated symptomatic cohort. Mean age of non-operated cohort was 10.2 years with M:F ratio (30:35). Mean cerebellar tonsillar length below McRae's line was 10.3 mm. 7.7% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 76 and 78°, respectively. Retroflexion grades included (9.2% grade 1, 35% grade 2 and 52.3% grade 3). pB-C2 distance was 6.8 mm. Mean age of operated cohort was 11.3 years, with M:F ratio (21:40). Mean cerebellar tonsillar length below McRae's line was 15 mm. 45.9% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 73 and 74.5°, respectively. Retroflexion grades included (4.9% grade 1, 16.5% grade 2 and 78.6% grade 3). pB-C2 distance was 6.9 mm. No association was identified between retroflexion grade and rate of revision or CSF diversion following primary foramen magnum decompression. CONCLUSION The operated Chiari 1 cohort had more retroflexed dens, longer tonsils and associated syrinx compared to the non-operated asymptomatic cohort.
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Affiliation(s)
- Bobby Sachdev
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Vesta S Najmi
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Desiderio Rodrigues
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Guirish A Solanki
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Fardad T Afshari
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
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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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4
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Bianchi F, Montedoro B, Frassanito P, Massimi L, Tamburrini G. Chiari I malformation: management evolution and technical innovation. Childs Nerv Syst 2023; 39:2757-2769. [PMID: 37368069 DOI: 10.1007/s00381-023-06051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND DEFINITION In recent years thanks to the growing use of radiological assessment, Chiari I malformation became one of the major diseases for a neurosurgeon to deal with. CIM can be classified according to the extent of cerebellar tonsil tip into the foramen magnum being a protrusion over five mm considered pathological. Such a disease is a heterogeneous condition with a multifactorial pathogenetic mechanism that can subdivided into a primary and secondary form. Regardless of the form, it seems that CIM is the result of an imbalance between the volume of the braincase and its content. Acquired CIMs are secondary to conditions causing intracranial hypertension or hypotension while the pathogenesis of primary forms is still controversial. PATHOGENESIS AND TREATMENT There are several theories in the literature but the most accepted one implies an overcrowding due to a small posterior cranial fossa. While asymptomatic CIM do not need treatment, symptomatic ones prompt for surgical management. Several techniques are proposed being the dilemma centered in the need for dural opening procedures and bony decompression ones. CONCLUSION Alongside the paper, the authors will address the novelty presented in the literature on management, diagnosis and pathogenesis in order to offer a better understanding of such a heterogeneous pathology.
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Affiliation(s)
- Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.
| | | | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Onafowokan OO, Das A, Mir JM, Alas H, Williamson TK, Mcfarland K, Varghese J, Naessig S, Imbo B, Passfall L, Krol O, Tretiakov P, Joujon-Roche R, Dave P, Moattari K, Owusu-Sarpong S, Lebovic J, Vira S, Diebo B, Lafage V, Passias PG. Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:336-340. [PMID: 38268684 PMCID: PMC10805163 DOI: 10.4103/jcvjs.jcvjs_140_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/10/2023] [Indexed: 01/26/2024] Open
Abstract
Background Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.
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Affiliation(s)
- Oluwatobi O. Onafowokan
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Ankita Das
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Jamshaid M. Mir
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Haddy Alas
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Tyler K. Williamson
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Kimberly Mcfarland
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | | | - Sara Naessig
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Bailey Imbo
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Lara Passfall
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Oscar Krol
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Peter Tretiakov
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Rachel Joujon-Roche
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Pooja Dave
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Kevin Moattari
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Stephane Owusu-Sarpong
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Jordan Lebovic
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Shaleen Vira
- Department of Orthopedic Surgery, Banner Health, Phoenix, AZ, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, RI, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, USA
| | - Peter Gust Passias
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
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Samantray S, Silva AHD, Valetopoulou A, Tahir Z. Foramen magnum decompression with cervical syringotomy for Chiari malformation type I with syringomyelia - A useful adjunct in selected cases. Surg Neurol Int 2023; 14:341. [PMID: 37810310 PMCID: PMC10559380 DOI: 10.25259/sni_419_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
Background Persistent or worsening syringomyelia after foramen magnum decompression (FMD) for Chiari I malformation (CIM) can be challenging to manage. We present a previously unpublished surgical technique of FMD with concomitant cervical syringotomy in selected patients. Methods A retrospective analysis of prospectively collected data was carried out. Patients who underwent FMD and expansion duraplasty (FMDD) with concomitant syringotomy were collected. Results Three patients with CIM with high cervical syringomyelia who underwent FMDD with concurrent syringotomy were identified. All cases had an idiopathic CIM. Improvement in clinical symptoms was noticed in all patients. Early postoperative imaging (within 6 weeks-4 months) showed syrinx transverse diameter reduction in the range of 85-100%. There were no postoperative complications. Conclusion FMDD with concurrent high cervical syringotomy through a standard approach in selected cases of CIM with high cervical syringes achieves clinical improvement without additional complications.
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Affiliation(s)
| | | | | | - Zubair Tahir
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom
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Kim JH, Choo YH, Jeong H, Kim M, Ha EJ, Oh J, Lee S. Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management. Korean J Neurotrauma 2023; 19:128-148. [PMID: 37431371 PMCID: PMC10329888 DOI: 10.13004/kjnt.2023.19.e24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/12/2023] Open
Abstract
Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Talamonti G, Picano M, Fragale M, Marcati E, Meccariello G, Boeris D, Cenzato M. Reoperation in Chiari-1 Malformations. J Clin Med 2023; 12:jcm12082853. [PMID: 37109192 PMCID: PMC10142814 DOI: 10.3390/jcm12082853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: The issue of unsuccessful surgery for Chiari-1 malformation (CM-1), as well as its potential causes and possible solutions, remains poorly documented and studied. (2) Methods: From a retrospective review of a personal series of 98 patients undergoing treatment for CM-1 during the past 10 years, we created two study groups. Group 1: 8 patients (8.1%) requiring additional surgeries owing to postoperative complications (7 cerebrospinal fluid leakage, 1 extradural hematoma); 7 patients (7.1%) undergoing reoperations for failed decompression during the follow-up. Group 2: During the same period, we also managed 19 patients who had previously been operated on elsewhere: 8 patients who required adequate CM-1 treatment following extradural section of the filum terminale; 11 patients requiring reoperations for failed decompression. Failed decompression was managed by adequate osteodural decompression, which was associated with tonsillectomy (6 cases), subarachnoid exploration (8 cases), graft substitution (6 cases), and occipito-cervical fixation/revision (1 case). (3) Results: There was no mortality or surgical morbidity in Group 1. However, one patient's condition worsened due to untreatable syrinx. In Group 2, there were two cases of mortality, and surgical morbidity was represented by functional limitation and pain in the patient who needed revision of the occipitocervical fixation. Twenty patients improved (58.8%), 6 remained unchanged (32.3%), 1 worsened (2.9%) and 2 died (5.9%). (4) Conclusions: The rate of complications remains high in CM-1 treatment. Unfortunately, a certain rate of treatment failure is unavoidable, but it appears that a significant number of re-operations could have been avoided using proper indications and careful technique.
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Affiliation(s)
| | - Marco Picano
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
| | - Maria Fragale
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
- La Sapienza, University of Rome, 00185 Rome, Italy
| | | | | | - Davide Boeris
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, ASST Niguarda, 20162 Milan, Italy
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Hwang JK, Park EK, Shim KW, Kim DS. Effectiveness of C1 Laminectomy for Chiari Malformation Type 1: Posterior Fossa Volume Expansion and Syrinx-Volume Decrease Rate. Yonsei Med J 2023; 64:191-196. [PMID: 36825345 PMCID: PMC9971440 DOI: 10.3349/ymj.2022.0506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to analyze the effect of foramen magnum decompression with C1 laminectomy (C1L) for Chiari malformation type 1 (CM-1) in terms of improving clinical symptoms, expanding posterior fossa volume, and decreasing syrinx volume. MATERIALS AND METHODS Between January 2007 and June 2019, 107 patients with CM-1 were included. The median patient age was 13±13 years (range: 9 months-60 years), female-to-male ratio was 1:1, and average length of tonsil herniation was 13±5 mm (range: 5-24 mm). Surgical techniques were divided into four groups based on duraplasty or C1L usage. Among the study subjects, 38 patients underwent duraplasty and had their syrinx volumes measured separately on serial magnetic resonance imaging. A three-dimensional visualization software was used to evaluate the syrinx-volume decrease rate. RESULTS Bony decompression exhibited a mere 20% volume expansion of the lower-half posterior fossa. C1L offered a 3% additional volume expansion, which rose to 5% when duraplasty was added (p=0.029). There were no significant differences in complication rate when C1L was combined with duraplasty (p=0.526). Syrinx volumes were analyzed in 38 patients who had undergone duraplasty. Among them, 28 patients who had undergone duraplasty without C1L demonstrated a 5.9% monthly decrease in syrinx volume, which was 7.5% in the remaining 10 patients with C1L (p=0.040). CONCLUSION C1L was effective in increasing posterior fossa volume expansion, both with and without duraplasty. A more rapid decrease in syrinx volume occurred when C1L was combined with duraplasty.
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Affiliation(s)
- Jun Kyu Hwang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Eun Kyung Park
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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10
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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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11
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Silva A, Thanabalasundaram G, Wilkinson B, Tsermoulas G, Flint G. Experience with revision craniovertebral decompression in adult patients with Chiari malformation type 1, with or without syringomyelia. Br J Neurosurg 2022; 36:750-755. [PMID: 32965133 DOI: 10.1080/02688697.2020.1823935] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Craniovertebral decompression is performed for symptomatic Chiari malformation type 1, with or without syringomyelia. In a few patients the symptoms and/or syrinx persist or recur, in which case revision surgery may be offered. The aim of this study was to examine the cause of failure of primary surgery and to assess the outcomes for revision cranio-vertebral decompression. METHODS We retrospectively reviewed all revision cranio-vertebral decompressions performed in our centre over an eighteen-year period. A total of 35 patients were identified (23 females; 12 males). Twenty patients had isolated Chiari malformation type 1 and a further fifteen had associated syringomyelia. The mean follow up period was 4-years (range:1-12 years). RESULTS The mean time to revision was 7 years after the primary surgery. The commonest operative finding was that of dense arachnoid scar tissue, obstructing movement of CSF across the craniovertebral junction. Overall, 32 of the 35 patients reported improvement after surgery, including all 15 patients with syringomyelia. Improvement was maintained in the longer term in more than two thirds of those patients who underwent revision craniovertebral decompression. CONCLUSIONS Failure of primary craniovertebral decompression for Chiari malformation most often results from the formation dense scar tissue at the operation site, obstructing CSF movement. Revision cranio-vertebral decompression can provide early symptomatic relief in most patients and this benefit is sustained in at least two thirds of cases, in the medium term at least. Patients with concomitant syringomyelia appear to derive most benefit from revision surgery.
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Affiliation(s)
- Adikarige Silva
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Edgbaston, UK
| | | | - Ben Wilkinson
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Edgbaston, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Edgbaston, UK
| | - Graham Flint
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Edgbaston, UK
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A Clinical Study on the Treatment of Recurrent Chiari (Type I) Malformation with Syringomyelia Based on the Dynamics of Cerebrospinal Fluid. BIOMED RESEARCH INTERNATIONAL 2022; 2022:9770323. [DOI: 10.1155/2022/9770323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022]
Abstract
Objective. Combining the dynamics of cerebrospinal fluid, our study investigates the clinical effects of syringomyelia after the combination of fourth ventricle-subarachnoid shunt (FVSS) for recurrent Chiari (type I) malformations after cranial fossa decompression (foramen magnum decompression (FMD)). Methods. From December 2018 to December 2020, 15 patients with recurrent syringomyelia following posterior fossa decompression had FVSS surgery. Before and after the procedure, the clinical and imaging data of these individuals were retrospectively examined. Results. Following FVSS, none of the 15 patients experienced infection, nerve injury, shunt loss, or obstruction. 13 patients improved dramatically after surgery, while 2 patients improved significantly in the early postoperative period, but the primary symptoms returned 2 months later. The Japanese Orthopedic Association (JOA) score was
, which was considerably better than preoperatively (
,
0.001). The MRI results revealed that the cavities in 13 patients were reduced by at least 50% compared to the cavities measured preoperatively. The shrinkage rate of syringomyelia was 86.67% (13/15). One patient’s cavities nearly vanished following syringomyelia. The size of the cavity in the patient remain unchanged, and the cavity’s maximal diameter was significantly smaller than the size measured preoperatively (
) PC-MRI results indicated that the peak flow rate of cerebrospinal fluid at the central segment of the midbrain aqueduct and the foramen magnum in patients during systole and diastole were significantly reduced after surgery (
). Conclusion. After posterior fossa decompression, FVSS can effectively restore the smooth circulation of cerebrospinal fluid and alleviate clinical symptoms in patients with recurrent Chiari (type I) malformation and syringomyelia. It is a highly effective way of treatment.
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Surgical Management after Chiari Decompression Failure: Craniovertebral Junction Revision versus Shunting Strategies. J Clin Med 2022; 11:jcm11123334. [PMID: 35743405 PMCID: PMC9224814 DOI: 10.3390/jcm11123334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/20/2022] [Accepted: 06/02/2022] [Indexed: 11/16/2022] Open
Abstract
Revision surgery after posterior fossa decompression for Chiari malformation is not uncommon and poses both strategic and technical challenges. We conducted a single-center retrospective cohort study including all adult patients who underwent revision surgery after posterior fossa decompression for Chiari type I malformation between 2010 and 2019. Among 311 consecutive patients operated on for Chiari malformation at our institution, 35 patients had a least one revision surgery with a mean follow-up of 70.2 months. Mean delay for revision was 28.8 months. First revision surgery was performed at the level of the foramen magnum in 25/35 cases and consisted in duraplasty revision in all cases, arachnolysis (51.4%), additional bone decompression (37.1%), tonsillar coagulation or resection (25.7%), 4th ventricle to cervical subarachnoid spaces shunt (5.7%). Most repeat revisions consisted in CSF diversion procedures, with either ventriculo-peritoneal or syringo-peritoneal shunts. Mean number of interventions per patient was 3.2, with 22.9% of patients undergoing 4 or more surgeries. Based on our experience, we propose that revision at the level of the foramen magnum should be considered as a first-line strategy for Chiari decompression failure. Shunting procedures can be performed in case of extensive arachnoiditis or repeated failures.
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Balasa A, Kunert P, Bielecki M, Kujawski S, Marchel A. Significance of Pseudomeningocele After Decompressive Surgery for Chiari I Malformation. Front Surg 2022; 9:895444. [PMID: 36034387 PMCID: PMC9406808 DOI: 10.3389/fsurg.2022.895444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPseudomeningoceles (PMCs) as abnormal collections of cerebrospinal fluid are quite common findings on follow-up MRI after Chiari decompression surgery (CDS). However, the importance of their identification has not been truly determined, especially when PMCs are described occasionally in the process of radiological follow-up. We retrospectively analyzed surgical outcomes and imaging findings after CDS depending upon the occurrence and thickness of PMCs.MethodsA total of 76 adult patients who underwent CDS were analyzed. The clinical and radiological outcomes of patients with a pseudomeningocele (wPMC) were evaluated and compared to those of patients without a pseudomeningocele (w/oPMC). Radiological morphometric measurements were performed and compared between groups. Comparisons of the maximal PMC thickness were made within the wPMC group.ResultsPMCs were recognized in 27 (35.5%) patients, of whom 3 (11.1%) required reoperation. Differences in satisfactory result rates regarding gestalt assessment and Chicago Chiari Outcome Scale were statistically insignificant between the w/oPMC and wPMC groups (p = 1 and p = 0.56, respectively). The postoperative syringomyelia decrease and cerebellar tonsil elevation were similar between the groups (p = 1 and p = 0.74, respectively) in the long-term follow-up. Additionally, the clinical or radiological outcomes with radiological details were not related to PMC thickness in the long-term follow-up. However, radiological details showed the cooccurrence of PMCs with a postsurgical of cerebello-tentorial distance increase (p < 0.05), basion-pontomedullary sulcus distance decrease (p < 0.05) and tonsillo-graft distance decrease (p < 0.05).ConclusionsWe found no significant relationships between PMC presence or thickness and clinical or radiological outcomes. However, postoperative changes within the posterior fossa associated with PMCs resemble brain sagging, which occurs in intracranial hypotension. Therefore, extradural cerebrospinal fluid escape may also be responsible for symptoms in some patients with PMCs after CDS.
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Affiliation(s)
- Artur Balasa
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
- Correspondence: Przemysław Kunert
| | - Mateusz Bielecki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun´, Bydgoszcz, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Massimi L, Peretta P, Erbetta A, Solari A, Farinotti M, Ciaramitaro P, Saletti V, Caldarelli M, Canheu AC, Celada C, Chiapparini L, Chieffo D, Cinalli G, Di Rocco F, Furlanetto M, Giordano F, Jallo G, James S, Lanteri P, Lemarchand C, Messing-Jünger M, Parazzini C, Paternoster G, Piatelli G, Poca MA, Prabahkar P, Ricci F, Righini A, Sala F, Sahuquillo J, Stoodley M, Talamonti G, Thompson D, Triulzi F, Zucchelli M, Valentini L. Diagnosis and treatment of Chiari malformation type 1 in children: the International Consensus Document. Neurol Sci 2022; 43:1311-1326. [PMID: 34097175 PMCID: PMC8789635 DOI: 10.1007/s10072-021-05317-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/08/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chiari malformation type 1 (CM1) is a rare condition where agreed classification and treatment are still missing. The goal of this study is to achieve a consensus on the diagnosis and treatment of CM1 in children. METHODS A multidisciplinary panel formulated 57 provisional statements based on a review of the literature. Thirty-four international experts (IE) participated in a Delphi study by independently rating each statement on a 4-point Likert scale ("strongly disagree," "disagree," "agree," "strongly agree"). Statements that were endorsed ("agree" or "strongly agree") by < 75% of raters were re-formulated, or new statements were added, and another Delphi round followed (up to a maximum of three). RESULTS Thirty-five IE were contacted and 34 agreed to participate. A consensus was reached on 30/57 statements (52.6%) after round 1. Three statements were added, and one removed. After round 2, agreement was reached on 56/59 statements (94.9%). Finally, after round 3, which took place during the 2019 Chiari Consensus Conference (Milan, Italy), agreement was reached on 58/59 statements (98.3%) about four main sections (Definition and Classification, Planning, Surgery, Isolated Syringomyelia). Only one statement did not gain a consensus, which is the "definition of radiological failure 24 month post-surgery." CONCLUSIONS The consensus document consists of 58 statements (24 on diagnosis, 34 on treatment), serving clinicians and researchers following children with CM1. There is a clear need for establishing an international network and registry and to promote collaborative studies to increase the evidence base and optimize the long-term care of this patient population.
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Affiliation(s)
- Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Paola Peretta
- Pediatric Neurosurgery, AOU Citta' della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Erbetta
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Solari
- Neuroepidemiology Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mariangela Farinotti
- Neuroepidemiology Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Palma Ciaramitaro
- Department of Neuroscience, AOU Citta' della Salute e della Scienza di Torino, Torino, Italy
| | - Veronica Saletti
- Department of Pediatric Neurology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Massimo Caldarelli
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | | | - Carlo Celada
- "Associazione Italiana Siringomielia e Arnold Chiari", Garino, Italy
| | - Luisa Chiapparini
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Daniela Chieffo
- Clinical Psychology Unit, Fondazione Policlinico Universitario A Gemelli IRCCS and UCSC, Rome, Italy
| | - Giuseppe Cinalli
- Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Federico Di Rocco
- Pediatric Neurosurgery Department, Université de Lyon, INSERM U1033, Hopital Femme Mère Enfant, Lyon, France
| | - Marika Furlanetto
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Flavio Giordano
- Department of Neurosurgery, Meyer Pediatric Hospital, Florence, Italy
| | - George Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Syril James
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, Paris, France
| | - Paola Lanteri
- Department of Diagnostic and Technology, Neurophysiopathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | | | - Cecilia Parazzini
- Department of Pediatric Radiology and Neuroradiology, Children Hospital V. Buzzi, Milan, Italy
| | - Giovanna Paternoster
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, Paris, France
| | - Gianluca Piatelli
- Department of Neurosurgery, Gaslini Children's Hospital, Genoa, Italy
| | - Maria A Poca
- Neurosurgery and Pediatric Neurosurgery, Vall d'Hebron Hospital Universitari, Neurotrauma and Neurosurgery Research Unit, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Prab Prabahkar
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Federica Ricci
- Pediatric Neuropsychiatric Unit, AOU Citta' della Salute e della Scienza di Torino, Torino, Italy
| | - Andrea Righini
- Department of Pediatric Radiology and Neuroradiology, Children Hospital V. Buzzi, Milan, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Juan Sahuquillo
- Neurosurgery and Pediatric Neurosurgery, Vall d'Hebron Hospital Universitari, Neurotrauma and Neurosurgery Research Unit, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcus Stoodley
- Department of Clinical Medicine, Macquarie University Clinical Associates, Sidney, Australia
| | | | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
| | - Fabio Triulzi
- Department of Pathophysiology and Transplantation, Neuroradiology Unit, University of Milan, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mino Zucchelli
- Neurochirurgia Pediatrica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Laura Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Arachnoiditis – A challenge in diagnosis and success in outcome – Case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Özlen F, Kucukyuruk B, Alizada O, Guler H, Akgun MY, Kafadar AM, Tuzgen S, Sanus GZ, Hanci M. Comparison of two surgical techniques in Chiari Malformation Type 1 Patients: Duraplasty alone vs duraplasty with arachnoid dissection. Clin Neurol Neurosurg 2021; 206:106686. [PMID: 34053804 DOI: 10.1016/j.clineuro.2021.106686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECT Optimal surgical technique to restore the cerebrospinal fluid flow through the foramen magnum remains to be debated in Chiari malformation type 1 (CM-1) patients. METHOD This study included 46 patients with CM-1 who underwent surgical treatment by one of two methods: posterior fossa bone decompression (BD) with arachnoid preserving duraplasty (Group 1) and BD with duraplasty and arachnoid dissection (Group 2). Complaints of the patient population and neurological findings were assessed with Neck Disability Index (NDI) and Europe Quality of Life 5 Dimensions (EQ-5D) in pre- and postoperative periods. RESULTS NDI and EQ-5D scores improved in overall patient population and in each individual surgical group. Both groups showed a significant decrease in size of syringomyelia cavity. Complications resulting in recurrent treatments and re-operations occurred in 15% of patients (n = 7); six of them were from Group 2. CONCLUSION CM-1 patients benefit significantly from surgical treatment. Duraplasty should be included to surgical technique. Avoiding arachnoid dissection may lead to better results regarding complication rates.
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Affiliation(s)
- Fatma Özlen
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Baris Kucukyuruk
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey.
| | - Orkhan Alizada
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Huseyin Guler
- Department of Anesthesiology and Intensive Care Medicine, Evangelisches Waldkrankenhaus Spandau, Berlin, Germany
| | | | - Ali Metin Kafadar
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Saffet Tuzgen
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Murat Hanci
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
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Mishinov S, Samokhin A, Panchenko A, Stupak V. A titanium implant for Chiari malformation Type 1 surgery. Surg Neurol Int 2021; 12:72. [PMID: 33767876 PMCID: PMC7982118 DOI: 10.25259/sni_960_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/21/2021] [Indexed: 11/04/2022] Open
Abstract
Background Concepts of Chiari malformation Type 1 (CM1) surgery in the present time significantly different. The most common complications are pseudomeningocele (12%) and postoperative CSF leak (5%). The development of pseudomeningocele may be associated with inappropriate restoration of bone and muscles relations. Methods The pilot study involved 11 patients aged 24-64 years with a diagnosis of CM1 who had indications for surgical treatment. Special titanium implant enabling fixation of the occipital and cervical muscles at the projections of their normal attachments was developed, it was placed to occipital bone on the final stages of surgical intervention. Surgical technique promoted tightened wound closure neutralizing formation of "dead space" at the place of occipital craniectomy and between muscle layers. The implant was produced by direct metal laser sintering method for each patient individually. Results There were no complications during the hospitalization and follow-up period. Postoperative MRI demonstrated adequate formation of the cisterna magna and the absence of pseudomeningocele. During follow-up period there were no signs of pseudomeningocele, CSF leak, surgical scar complications, implant-associated infections, and other complications. Conclusion In the study group, no pseudomeningocele cases as long as any other complications associated with surgery had been revealed. The efficacy of the proposed surgical technique using the developed implant should be evaluated in clinical trials with larger patient samples. To simplify preoperative planning and manufacturing of the implant for each patient individually, a set of implants with different specified sizes was developed.
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Affiliation(s)
- Sergey Mishinov
- Department of Neurosurgery, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
| | - Alexander Samokhin
- Department of Experimental, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
| | - Andrey Panchenko
- Department of 3D Printing, LLC Logeeks MS, Novosibirsk, Russian Federation
| | - Vyacheslav Stupak
- Department of Neurosurgery, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
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Histological and intraoperative evaluations of the arachnoid in patients with Chiari I malformation. Acta Neurochir (Wien) 2021; 163:219-225. [PMID: 33025091 DOI: 10.1007/s00701-020-04582-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Arachnoid dissection for decompression of Chiari I malformation is controversial. Whether arachnoid changes have an impact on the clinical course is not established. This paper documents the histological spectrum of arachnoid changes and evaluates correlations with preoperative, intraoperative, and postoperative data. METHOD Arachnoid samples of 162 consecutive foramen magnum decompressions from 2006 to 2016 were studied. Arachnoid thickness and degrees of fibrosis and cellularity were determined with the examiner blinded for clinical data. Based on 145 first time decompressions, a histological classification for arachnoid features was developed. RESULTS The arachnoid was thicker in secondary compared with primary decompressions (176.1 ± 158.2 μm vs. 35.9 ± 43.5 μm; p = 0.0026) and in adults compared to children (37.3 ± 45.3 μm vs. 21.8 ± 7.7 μm; p = 0.0007). In primary decompressions, arachnoid thickness, degrees of fibrosis, and cellularity followed a normal distribution with all features shifted significantly to higher grades in secondary decompressions. The histological classification correlated with the preoperative severity of gait ataxia, motor weakness, and sensory deficits, whereas it had no predictive power for postoperative short- or long-term results. By comparison, the intraoperative evaluation of arachnoid changes accounting for relationships between arachnoid and surrounding tissues showed higher correlations with preoperative symptoms and had significant predictive power for postoperative short- and long-term results. CONCLUSIONS Histological changes of the arachnoid correlate with preoperative symptoms. Relationships between arachnoid and surrounding tissues show even higher correlations with predictive power for short- and long-term outcomes. These findings suggest a pathophysiological role for the arachnoid in Chiari I malformation.
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Yuan C, Guan J, Du Y, Zhang C, Ma L, Yao Q, Cheng L, Liu Z, Wang K, Duan W, Wang X, Wu H, Chen Z, Jian F. Repeat Craniocervical Decompression in Patients with a Persistent or Worsening Syrinx: A Preliminary Report and Early Results. World Neurosurg 2020; 138:e95-e105. [DOI: 10.1016/j.wneu.2020.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 11/25/2022]
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21
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Mathkour M, Keen JR, Huang B, Werner C, Scullen T, Garces J, Skovgard M, Iwanaga J, Tubbs RS, Dumont A, Biro E, Bui CJ. “Two-Birds-One-Stone” Approach for Treating an Infant with Chiari I Malformation and Hydrocephalus: Is Cerebrospinal Fluid Diversion as Sole Treatment Enough? World Neurosurg 2020; 137:174-177. [DOI: 10.1016/j.wneu.2020.01.188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
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22
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Neuroanatomic Correlates for the Neuropsychological Manifestations of Chiari Malformation Type I. World Neurosurg 2020; 136:462-469. [PMID: 32204298 DOI: 10.1016/j.wneu.2020.01.149] [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: 09/30/2019] [Accepted: 01/15/2020] [Indexed: 01/13/2023]
Abstract
Chiari malformation comprises a spectrum of congenital malformations characterized by a herniation of the cerebellar tonsils below the foramen magnum. Chiari malformation type I (CM-I) is the most prevalent subtype seen in clinical practice. This condition variably compresses the cerebellum and medulla-spinal cord junction secondary to malformation of the posterior fossa. Most neurologists and neurosurgeons recognize the sensorimotor and lower brainstem manifestations that result in the clinical picture of CM-I. The effects of CM-I on cognitive functioning, however, and their impact on neuropsychological performance are poorly understood, despite having long been recognized. This article reviews neuropsychological deficits demonstrated by individuals with CM-I, and explores cerebellocortical neuroanatomic pathways to provide possible rationale for the neurocognitive impairments present in affected individuals.
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Zhao Y, Chen L, Zhang J, You N, Liu Y, Yao A, Zhao K, Zhang J, Xu B. Duraplasty with Cervical Fascia Autograft to Reduce Postoperative Complications of Posterior Fossa Tumor Surgery with Suboccipital Midline Approach. World Neurosurg 2019; 134:e1115-e1120. [PMID: 31785439 DOI: 10.1016/j.wneu.2019.11.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The suboccipital midline approach is common dealing with posterior fossa tumors but has a high risk of postoperative complications, such as pseudomeningocele, cerebrospinal fluid (CSF) leak, and meningitis. Neurosurgeons used various kinds of method to lower its rate. METHODS A retrospective, single-center review of patients diagnosed with posterior fossa tumor underwent a suboccipital midline approach. Compare the rates of pseudomeningocele, CSF leak, and meningitis between 2 groups (artificial dura mater or cervical fascia autograft). We get the cervical fascia autograft from the superficial layer of deep cervical fascia just above the trapezius. RESULTS Our retrospective review involved 123 patients matching the inclusion criteria between January 2009 and April 2019. The complication rate of pseudomeningocele, CSF leak and meningitis were 8.9%, 4.9%, and 17.9%, respectively. The presence of pseudomeningocele or CSF leak for group "artificial" was 11 of 75 (14.67%) and for group "autograft" it was 3 of 48 (6.25%). The rate of meningitis for group "artificial" (24.0%, 18 of 75) was significantly higher (P = 0.027) than the one for group "autograft" (8.33%, 4 of 48). Multivariate regression analysis suggested that the age was negatively correlated with postoperative pseudomeningocele or CSF leak (P = 0.006), with meningitis (P < 0.001). Using cervical fascia autograft decreased the rate of meningitis (P = 0.021) while showing no statistically significant clinical impact on pseudomeningocele or CSF leak. CONCLUSIONS Applying the cervical fascia autograft to reconstruct the dura during posterior fossa surgery is a simple and effective method to reduce the rate of meningitis as compared with artificial dura mater.
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Affiliation(s)
- Yue Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Li Chen
- Department of Radiology, People's Hospital of Qinghai Province, Xining, Qinghai, China
| | - Jiashu Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Na You
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Yuyang Liu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Anhui Yao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Kai Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Bainan Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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Garcia MA, Allen PA, Li X, Houston JR, Loth F, Labuda R, Delahanty DL. An examination of pain, disability, and the psychological correlates of Chiari Malformation pre- and post-surgical correction. Disabil Health J 2019; 12:649-656. [PMID: 31147250 DOI: 10.1016/j.dhjo.2019.05.004] [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: 07/03/2018] [Revised: 04/25/2019] [Accepted: 05/17/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND 50% of patients with Chiari Malformation (CM) report a history of depression; however, rates of other psychological symptoms are unknown. Further, it is unclear whether surgical correction impacts pain, disability, and psychological symptoms. OBJECTIVE /Hypothesis: We examined rates of symptoms in a nationwide sample of CM patients who had (n = 639) and had not (n = 551) undergone surgical correction. We hypothesized lower symptom severity in the latter group. METHODS Participants completed assessments and submitted pre-surgical MRI scans online (n = 286). Informed by the Fear-Avoidance Model of pain, we controlled for psychological symptoms when assessing pain/disability, and pain/disability when assessing psychological symptoms. RESULTS Overall, high rates of depression (44% moderate-severe) and anxiety (60% moderate-severe) were reported. Groups (surgery vs. no-surgery) did not differ in the proportion of patients meeting cutoff scores for current disability; however, the no-surgery group was more likely to meet cutoffs for anxiety (χ2 = 11.26, p < .05), stress (χ2 = 14.63, p < .01) and health anxiety (χ2 = 4.63, p < .05). The surgery group reported lower levels of continuous affective pain F(1, 1065) = 10.28, p < .001), anxiety F(1,1026) = 4.96, p < .05) and stress F(1, 978) = 5.67, p < .05) although effect sizes were small (η2s ranging from 0.010 to 0.006, Cohen's D ranging from 0.17 to 0.25). CONCLUSION CM patients experience high rates of psychological symptomatology regardless of surgical status, suggesting that all CM patients may benefit from evidence-based interventions to address anxiety and depression.
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Affiliation(s)
- Monica A Garcia
- Kent State University, Department of Psychological Sciences, USA
| | - Philip A Allen
- University of Akron, Department of Psychology, USA; Conquer Chiari Research Center, USA
| | - Xuan Li
- University of Akron, Department of Psychology, USA; Conquer Chiari Research Center, USA
| | - James R Houston
- University of Akron, Department of Psychology, USA; Conquer Chiari Research Center, USA
| | - Francis Loth
- University of Akron, Department of Psychology, USA; Conquer Chiari Research Center, USA
| | | | - Douglas L Delahanty
- Kent State University, Department of Psychological Sciences, USA; Northeastern Ohio Medical University (NEOMED), Department of Psychiatry, USA.
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Direct syrinx drainage in patients with Chiari I malformation. Childs Nerv Syst 2019; 35:1863-1868. [PMID: 31152219 DOI: 10.1007/s00381-019-04228-7] [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: 04/29/2019] [Accepted: 05/24/2019] [Indexed: 12/29/2022]
Abstract
While FMD is, to date, the primary treatment of symptomatic CM I, the treatment of Chiari malformation type I (CM I) associated syrinx remains controversial. In cases of persistent, progressive, or recurrent syrinx following FMD, direct syrinx drainage (DSD) is described as a safe and efficient option, leading to a good clinical and radiological outcome. However, studies at hand mostly include very heterogeneous patient populations, small cohorts, and are of retrospective nature. We provide an overview of the possible indications and outcome for DSD in CM I-associated syrinx. We discuss the different surgical techniques of DSD and review the available literature comparing different DSD techniques. Finally, we discuss the possible complications that might occur after DSD and how they can be prevented.
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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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Zagzoog N, Reddy K(K. Use of Minimally Invasive Tubular Retractors for Foramen Magnum Decompression of Chiari Malformation: A Technical Note and Case Series. World Neurosurg 2019; 128:248-253. [DOI: 10.1016/j.wneu.2019.04.094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 01/21/2023]
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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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Syringo-Subarachnoid Shunt for the Treatment of Persistent Syringomyelia Following Decompression for Chiari Type I Malformation: Surgical Results. World Neurosurg 2017; 108:836-843. [DOI: 10.1016/j.wneu.2017.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 07/29/2017] [Accepted: 08/01/2017] [Indexed: 01/08/2023]
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Lu VM, Phan K, Crowley SP, Daniels DJ. The addition of duraplasty to posterior fossa decompression in the surgical treatment of pediatric Chiari malformation Type I: a systematic review and meta-analysis of surgical and performance outcomes. J Neurosurg Pediatr 2017; 20:439-449. [PMID: 28885133 DOI: 10.3171/2017.6.peds16367] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Surgery is the definitive treatment of Chiari malformation Type I (CM-I). It involves posterior fossa decompression, which can be performed along with C-1 laminectomy, reconstructive duraplasty, or tonsil shrinkage. The aim of this study was to provide an updated systematic review and meta-analysis of the latest available evidence regarding posterior fossa decompression only (PFDO) versus posterior fossa decompression with duraplasty (PFDD) in the treatment of CM-I in children. METHODS A literature search was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for article identification, screening, eligibility, and inclusion. Relevant articles were identified from 6 electronic databases from their inception to April 2016. These articles were screened against established criteria for inclusion into this study. RESULTS From 12 relevant studies identified, 1492 pediatric patients treated via PFDD were compared with 1963 pediatric patients treated by PFDO for CM-I. PFDD was associated with greater overall clinical improvement (p = 0.009), along with longer length of stay (p < 0.0001) and more postoperative complications (p = 0.0001) compared with PFDO. No difference was observed between PFDD and PFDO in terms of revision surgery incidence (p = 0.13), estimated blood loss (p = 0.14), syrinx improvement (p = 0.09), or scoliosis improvement (p = 0.95). CONCLUSIONS It appears that the addition of duraplasty to posterior decompression in the definitive treatment of CM-I in children may alter surgical and performance outcomes. In particular, parameters of overall clinical improvement, length of stay, and postoperative complication may differ between children undergoing PFDD and those undergoing PFDO. Current evidence in the literature is of low to very low quality that, as of yet, has not been able to completely control for inherent selection bias both in study design and surgeon preference. Future, large prospective registries and randomized controlled trials are warranted to validate the findings of this study.
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Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and.,Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Kevin Phan
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Sean P Crowley
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - David J Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and
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Davidson KA, Rogers JM, Stoodley MA. Syrinx to Subarachnoid Shunting for Syringomyelia. World Neurosurg 2017; 110:e53-e59. [PMID: 29017977 DOI: 10.1016/j.wneu.2017.09.205] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/28/2017] [Accepted: 09/30/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Surgery for syringomyelia generally aims to treat the underlying cause, if it is known. Optimal management is unclear for idiopathic syringomyelia, or when treatment of the putative cause has failed or is high risk. Syrinx to subarachnoid shunting is an option for these cases; a series is reported to assess the outcomes of this approach. METHODS We retrospectively analyzed the clinical and radiologic features of a consecutive series of patients with syringomyelia treated with syrinx to subarachnoid shunting. RESULTS Forty-one patients (19 male, 4-79 years old) were treated from 2000 to 2016, including 15 patients with idiopathic syringomyelia, 13 with spinal trauma, 5 with Chiari malformation, 4 with arachnoiditis, 3 with tethered cord, and 1 with arachnoid bands. The patients were treated with a syrinx to subarachnoid shunt, and a subset also underwent expansile duraplasty. At follow-up (3-108 months, mean 36 months) syrinx size was reduced in 37 patients, and there was improvement or stabilization of symptoms in all but 1 patient. Three patients had temporary lower limb sensory symptoms after surgery. Other complications were 2 transient cerebrospinal fluid leaks, a pseudomeningocoele, and 1 postoperative myocardial infarction. Two cases of shunt dislodgement required reoperation, and a third case required early reoperation for an enlarging syrinx. There were no cases of shunt blockage or infection. CONCLUSIONS Syrinx to subarachnoid shunting is a safe and effective treatment for idiopathic syringomyelia and for patients who are not suitable for, or have not responded to, other treatment.
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Affiliation(s)
- Keryn A Davidson
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Sydney, Australia
| | - Jeffrey M Rogers
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Sydney, Australia
| | - Marcus A Stoodley
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Sydney, Australia.
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Guan J, Riva-Cambrin J, Brockmeyer DL. Chiari-related hydrocephalus: assessment of clinical risk factors in a cohort of 297 consecutive patients. Neurosurg Focus 2017; 41:E2. [PMID: 27798986 DOI: 10.3171/2016.8.focus16203] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients treated for Chiari I malformation (CM-I) with posterior fossa decompression (PFD) may occasionally and unpredictably develop postoperative hydrocephalus. The clinical risk factors predictive of this type of Chiari-related hydrocephalus (CRH) are unknown. The authors' objective was to evaluate their experience to identify risk factors that may predict which of these patients undergoing PFD will develop CRH after surgery. METHODS The authors performed a retrospective clinical chart review of all patients who underwent PFD surgery and duraplasty for CM-I at the Primary Children's Hospital in Utah from June 1, 2005, through May 31, 2015. Patients were dichotomized based on the need for long-term CSF diversion after PFD. Analysis included both univariate and multivariable logistic regression analyses. RESULTS The authors identified 297 decompressive surgeries over the period of the study, 22 of which required long-term postoperative CSF diversion. On multivariable analysis, age < 6 years old (OR 3.342, 95% CI 1.282-8.713), higher intraoperative blood loss (OR 1.003, 95% CI 1.001-1.006), and the presence of a fourth ventricular web (OR 3.752, 95% CI 1.306-10.783) were significantly associated with the need for long-term CSF diversion after decompressive surgery. CONCLUSIONS Younger patients, those with extensive intraoperative blood loss, and those found during surgery to have a fourth ventricular web were at higher risk for the development of CRH. Clinicians should be alert to evidence of CRH in this patient population after PFD surgery.
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Affiliation(s)
- Jian Guan
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Alberta, Canada
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
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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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Felbaum DR, Mueller K, Anaizi A, Mason RB, Jean WC, Voyadzis JM. Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note. Cureus 2016; 8:e946. [PMID: 28133584 PMCID: PMC5268379 DOI: 10.7759/cureus.946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Suboccipital craniotomy is a workhorse neurosurgical operation for approaching the posterior fossa but carries a high risk of pseudomeningocele and cerebrospinal fluid (CSF) leak. We describe our experience with a simple T-shaped fascial opening that preserves the occipital myofascial cuff as compared to traditional methods to reduce this risk. Methods: A single institution, retrospective review of prospectively collected database was performed of patients that underwent a suboccipital craniectomy or craniotomy. Patient data was reviewed for craniotomy or craniectomy, dural graft, and/or sealant use as well as CSF complications. A pseudomeningocele was defined as a subcutaneous collection of cerebrospinal fluid palpable clinically and confirmed on imaging. A CSF leak was defined as a CSF-cutaneous fistula manifested by CSF leaking through the wound. All patients underwent regular postoperative visits of two weeks, one month, and three months. Results: Our retrospective review identified 33 patients matching the inclusion criteria. Overall, our cohort had a 21% (7/33) rate of clinical and radiographic pseudomeningocele formation with 9% (3/33) requiring surgical revision or a separate procedure. The rate of clinical and radiographic pseudomeningocele formation in the myofascial cuff preservation technique was less than standard techniques (12% and 31%, respectively). Revision or further surgical procedures were also reduced in the myofascial cuff preservation technique vs. the standard technique (6% vs 13%). Conclusions: Preservation of the myofascial cuff during posterior fossa surgery is a simple and adoptable technique that reduces the rate of pseudomeningocele formation and CSF leak as compared with standard techniques.
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Affiliation(s)
| | - Kyle Mueller
- Neurosurgery, Medstar Georgetown University Hospital
| | - Amjad Anaizi
- Neurosurgery, Medstar Georgetown University Hospital
| | | | - Walter C Jean
- Neurosurgery, Medstar Georgetown University Hospital
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Complicated Pseudomeningocele Repair After Chiari Decompression: Case Report and Review of the Literature. World Neurosurg 2015; 88:688.e1-688.e7. [PMID: 26704196 DOI: 10.1016/j.wneu.2015.11.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/11/2015] [Accepted: 11/14/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pseudomeningocele is a recognised complication after posterior fossa decompression for Chiari malformation. Its management can be challenging and treatment options vary in literature. CASE DESCRIPTION A difficult-to-treat case of a pseudomeningocele after posterior fossa decompression for a Chiari I malformation is presented. A 34-year-old woman underwent an initial decompression followed by multiple revision surgeries after the development of a symptomatic pseudomeningocele and a low-grade infection. Complications associated with standard treatment modalities, including lumbar drainage and dural repair, are discussed. A review of the existing literature is presented. CONCLUSIONS The reported case ultimately required complete removal of all dural repair materials to eliminate the patient's low-grade infection, a muscular flap, and placement of a ventricular-peritoneal shunt for definitive treatment after a trial of a lumbar drain led to herniation and development of a syrinx.
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Li A, Wilkinson M, McGrillen K, Stoodley M, Magnussen J. Clinical Applications of Cine Balanced Steady-State Free Precession MRI for the Evaluation of the Subarachnoid Spaces. Clin Neuroradiol 2015; 25:349-60. [DOI: 10.1007/s00062-015-0383-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/26/2015] [Indexed: 11/28/2022]
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Assina R, Meleis AM, Cohen MA, Iqbal MO, Liu JK. Titanium mesh-assisted dural tenting for an expansile suboccipital cranioplasty in the treatment of Chiari 1 malformation. J Clin Neurosci 2014; 21:1641-6. [DOI: 10.1016/j.jocn.2014.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/09/2014] [Indexed: 11/30/2022]
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Chotai S, Medhkour A. Surgical outcomes after posterior fossa decompression with and without duraplasty in Chiari malformation-I. Clin Neurol Neurosurg 2014; 125:182-8. [PMID: 25171392 DOI: 10.1016/j.clineuro.2014.07.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/08/2014] [Accepted: 07/20/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Chiari malformation-I (CM) is one of the most controversial entities in the contemporary neurosurgical literature. Posterior fossa decompression (PFD) is the preferred treatment for CM with and without syringomyelia. A variety of surgical techniques for PFD have been advocated in the literature. The aim of this study was to evaluate our results of surgically treated patients for CM-I with and without syringomyelia; using extradural dura-splitting and intradural intraarachnoid techniques. METHODS A retrospective review of the medical records of all the patients undergoing PFD was conducted. Symptomatic patients with tonsillar herniation≥3-mm below the foramen magnum on neuroimaging, and CSF flow void study demonstrating restricted or no CSF flow at the craniocervical junction, were offered surgical treatment. In patients without syringomyelia, extradural decompression with thinning of the sclerotic tissue at the cervicomedullary junction and splitting of outer dural layer was performed. In patients with syringomyelia, the dura was opened and an expansile duraplasty was performed. RESULTS The mean age of 8 males and 34 females was 33.8 years (range, 16-58 years). Headache (39/41; 95%), and/or tingling and numbness (17/41; 42%) were the most common presenting symptoms. The syrinx was associated with CM-I in 5/41 (12%) patients. PFD without durotomy was performed in 29/41 (73%) patients. The mean duration of preoperative symptoms was significantly longer in duraplasty group (4.6 versus 1.7 years, P=0.005, OR=0.48, CI=0.29-0.8). The use of duraplasty was significantly associated with presence of complications (P=0.004, OR=0.5, CI=0.3-0.8) and longer duration of hospital stay (P=0.03, OR=2.7, CI=1.1-6.8). The overall complication rate was 6/41(15%) patients. The overall improvement rate was evident in 84% (36/41); 12% (5/41) were stable; and 5% (2/41) had worsening of symptoms. The history of prior CM decompression was associated with unfavorable outcomes (P=0.04, OR=14, CI=1.06-184). One patient experienced recurrence one year after the PFD with duraplasty. CONCLUSION The present study reports favorable surgical outcomes with extra-dural decompression of the posterior fossa in patients CM-I without syringomyelia. For patients with syringomyelia and history of prior PFD, intradural intra-arachnoid decompression is required. The prior history of decompression was associated with unfavorable outcomes. The use of duraplasty was associated with longer duration of hospital stay and higher complication rate. Further large cohort prospective study is needed to provide any recommendation on the indication of intra or extradural decompression for a given CM-I patient.
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Affiliation(s)
- Silky Chotai
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, USA
| | - Azedine Medhkour
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, USA.
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Chotai S, Kshettry VR, Lamki T, Ammirati M. Surgical outcomes using wide suboccipital decompression for adult Chiari I malformation with and without syringomyelia. Clin Neurol Neurosurg 2014; 120:129-35. [DOI: 10.1016/j.clineuro.2014.02.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/16/2014] [Indexed: 02/02/2023]
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40
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McVige JW, Leonardo J. Imaging of Chiari Type I Malformation and Syringohydromyelia. Neurol Clin 2014; 32:95-126. [DOI: 10.1016/j.ncl.2013.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Litvack ZN, Lindsay RA, Selden NR. Dura Splitting Decompression for Chiari I Malformation in Pediatric Patients: Clinical Outcomes, Healthcare Costs, and Resource Utilization. Neurosurgery 2013; 72:922-8; discussion 928-9. [DOI: 10.1227/neu.0b013e31828ca1ed] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Dural splitting decompression may be an effective and safe treatment for Chiari I malformation.
OBJECTIVE:
To compare clinical outcomes, complications, and resource utilization for patients undergoing Chiari I decompression with or without duraplasty.
METHODS:
Between 2000 and 2009, the senior author performed 113 Chiari I decompression operations with dural splitting or duraplasty in children less than 18 years of age; 110 were included in a retrospective cohort analysis of safety, efficacy, and treatment cost. Patients without significant syringomyelia underwent dural splitting decompression, and patients with syringomyelia underwent duraplasty.
RESULTS:
Sixty-three patients without significant syringomyelia (57%) underwent dural splitting decompression. They were significantly younger than patients undergoing duraplasty (8.3 ± 4.9 years vs 10.4 ± 4.4 years; P < .05). Headaches improved or resolved in most patients in both groups (90.5% vs 93.6%; P = .59). Dysphagia, long tract signs, cranial nerve, and bulbar symptoms also improved similarly in both groups. Three duraplasty patients were treated medically for aseptic meningitis; one underwent reoperation for a symptomatic pseudomeningocele. No patient undergoing dural splitting decompression experienced a cerebrospinal fluid-related complication. Extradural decompression required less operative time than duraplasty (105.5 vs 168.9 minutes, P < .001), a shorter length of stay (2.4 vs 2.8 days, P = .011), and lower total cost for the primary hospitalization ($26 837 vs $29 862, P = .015).
CONCLUSION:
In this retrospective cohort study, dural splitting decompression was equally effective, safer, and lower cost for treatment of Chiari I malformation without syringomyelia. A multicenter trial with groups balanced for the presence of syringomyelia is necessary to determine whether these results are generalizable.
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Affiliation(s)
- Zachary N. Litvack
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Rebecca A. Lindsay
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Nathan R. Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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42
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Klekamp J. Neurological deterioration after foramen magnum decompression for Chiari malformation type I: old or new pathology? J Neurosurg Pediatr 2012; 10:538-47. [PMID: 23039841 DOI: 10.3171/2012.9.peds12110] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Decompression of the foramen magnum is widely accepted as the procedure of choice for patients with Chiari malformation Type I (CM-I). This study was undertaken to determine the mechanisms responsible for neurological deterioration after foramen magnum decompression and the results of secondary interventions. METHODS Between 1987 and 2010, 559 patients with CM-I presented, 107 of whom had already undergone a foramen magnum decompression, which included a syrinx shunt in 27 patients. Forty patients who were neurologically stable did not undergo another operation. Sixty-seven patients with progressive symptoms received a recommendation for surgery, which was refused by 16 patients, while 51 patients underwent a total of 61 secondary operations. Hospital and outpatient records, radiographic studies, and intraoperative images were analyzed. Additional follow-up information was obtained by telephone calls and questionnaires. Short-term results were determined after 3 and 12 months, and long-term outcomes were evaluated using Kaplan-Meier statistics. RESULTS Sixty-one secondary operations were performed after a foramen magnum decompression. Of these 61 operations, 15 involved spinal pathologies not related to the foramen magnum (spinal group), while 46 operations were required for a foramen magnum issue (foramen magnum group). Except for occipital pain and swallowing disturbances, the clinical course was comparable in both groups. In the spinal group, 5 syrinx shunt catheters were removed because of nerve root irritations or spinal cord tethering. Eight patients underwent a total of 10 operations on their cervical spine for radiculopathies or a myelopathy. No permanent surgical morbidity occurred in this group. In the foramen magnum group, 1 patient required a ventriculoperitoneal shunt for hydrocephalus 7 months after decompression. The remaining 45 secondary interventions were foramen magnum revisions, of which 10 were combined with craniocervical fusion. Intraoperatively, arachnoid scarring with obstruction of the foramen of Magendie was the most common finding. Complication rates for foramen magnum revisions were similar to first decompressions, whereas permanent surgical morbidity was higher at 8.9%. Postoperative clinical improvements were marginal in both surgical groups. With the exception of 1 patient who underwent syrinx catheter removal and had a history of postoperative meningitis, all patients in the spinal group were able to be stabilized neurologically. Long-term results in the foramen magnum group revealed clinical stabilizations in 66% for at least 5 years. CONCLUSIONS Neurological deterioration in patients after a foramen magnum decompression for CM-I may be related to new spinal pathologies, craniocervical instability, or recurrent CSF flow obstruction at the foramen magnum. Whereas surgery for spinal pathologies is regularly followed by clinical stabilization, the rate of long-term success for foramen magnum revisions was limited to 66% for 5 years due to severe arachnoid scarring in a significant proportion of these patients. Therefore, foramen magnum revisions should be restricted to patients with progressive symptoms.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus, Danziger Strausse 2, Quakenbrück, Germany.
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43
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Klekamp J. Surgical Treatment of Chiari I Malformation—Analysis of Intraoperative Findings, Complications, and Outcome for 371 Foramen Magnum Decompressions. Neurosurgery 2012; 71:365-80; discussion 380. [DOI: 10.1227/neu.0b013e31825c3426] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Abstract
BACKGROUND:
Foramen magnum decompression is widely accepted as the treatment of choice for Chiari I malformation. However, important surgical details of the procedure are controversial.
OBJECTIVE:
This study analyzes 371 decompressions focusing on intraoperative findings, analysis of complications, and long-term outcomes.
METHODS:
Among 644 patients between 1985 and 2010, 359 patients underwent 371 decompressions. Surgery for symptomatic patients consisted of suboccipital craniectomy, C1 laminectomy, arachnoid dissection, and duraplasty. Short-term results were determined after 3 months; long-term outcomes were evaluated with Kaplan-Meier statistics.
RESULTS:
The mean age was 40 ± 16 years; mean follow-up was 49 ± 56 months; 75.8% demonstrated syringomyelia. The complication rate was 21.8% with permanent surgical morbidity of 3.2% and surgical mortality of 1.3%. Of the patients, 73.6% reported improvement after 3 months; 21% were unchanged. Overall, 14.3% demonstrated a neurological deterioration within 5 years and 15.4% within 10 years. The severity of neurological symptoms correlated with the grade of arachnoid pathology. Outcome data correlated with the number of previous decompressions, severity of arachnoid pathology, handling of the arachnoid, type of duraplasty, and surgical experience. First-time decompressions with arachnoid dissection and an alloplastic duraplasty resulted in surgical morbidity for 2.0%, a 0.9% mortality rate, postoperative improvement after 3 months for 82%, and neurological recurrence rates of 7% after 5 years and 8.7% after 10 years.
CONCLUSION:
Arachnoid pathology in Chiari I malformation has an impact on clinical symptoms and postoperative results. Decompressions with arachnoid dissection and an alloplastic duraplasty performed by surgeons experienced with this pathology offer a favorable long-term prognosis.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus, Quakenbrück, Germany
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44
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El-Ghandour NMF. Long-term outcome of surgical management of adult Chiari I malformation. Neurosurg Rev 2012; 35:537-46; discussion 546-7. [PMID: 22527628 DOI: 10.1007/s10143-012-0387-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 12/02/2011] [Accepted: 03/01/2012] [Indexed: 02/01/2023]
Affiliation(s)
- Nasser M F El-Ghandour
- Department of Neurosurgery, Faculty of Medicine, Cairo University, 81 Nasr Road, Nasr City, Cairo, Egypt.
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45
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Bahl A, Murphy M, Thomas N, Gullan R. Management of infratentorial subdural hygroma complicating foramen magnum decompression: a report of three cases. Acta Neurochir (Wien) 2011; 153:1123-8. [PMID: 21258949 DOI: 10.1007/s00701-010-0920-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 12/12/2010] [Indexed: 11/30/2022]
Abstract
Decompression of the foramen magnum for symptomatic Chiari malformation attends a small but significant risk of infratentorial subdural extra-arachnoid hygroma when an arachnoid-sparing procedure is attempted. We present three cases whereby an arachnoid-sparing procedure was carried out and resulted in infratentorial subdural hygroma and hydrocephalus. The complication was managed by re-exploration of the posterior fossa and wide arachnoidotomy. In cases whereby the decision has been made to open the dura, we recommend routine arachnoidotomy in foramen magnum decompression, avoiding the risks of infratentorial subdural hygroma. In cases where arachnoid-sparing procedures have been attempted and subdural hygroma subsequently develops, we advocate re-exploration of the posterior fossa rather than cerebrospinal fluid diversion.
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Affiliation(s)
- Anuj Bahl
- Department of Neurosurgery, King's College Hospital, London, UK.
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46
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Noudel R, Gomis P, Sotoares G, Bazin A, Pierot L, Pruvo JP, Bordet R, Roche PH. Posterior fossa volume increase after surgery for Chiari malformation Type I: a quantitative assessment using magnetic resonance imaging and correlations with the treatment response. J Neurosurg 2011; 115:647-58. [PMID: 21294619 DOI: 10.3171/2010.11.jns102148] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECT The aim of this paper was to measure the posterior fossa (PF) volume increase resulting from a given-sized occipital craniectomy in Chiari malformation Type I surgery and to analyze its correlations with the PF size and the treatment response, with the perspective of tailoring the amount of bone removal to the patient-specific PF dimensions. METHODS Between January 2005 and June 2006, 11 adult patients with symptomatic Chiari malformation Type I underwent a standardized PF decompression. A prospective evaluation with clinical examination, functional grading, and MR imaging measurement protocols was performed pre- and postoperatively. A method is reported for the measurement of PF volume (PFV) after surgery. The degree of PFV increase was compared with the preoperative size of the PF and with the clinical outcome. RESULTS All 11 patients improved postoperatively, with complete and partial recovery in 4 and 7 patients, respectively. No postoperative complication occurred after a mean follow-up period of 45 months. The mean relative increase in PFV accounted for 10% (range 1.5%-19.7%) of the initial PFV; the increase was greater in cases in which the PF was small (r = -0.52, p = 0.09) and the basiocciput was short (r = -0.37, p = 0.2). A statistically significant positive correlation was found between the degree of PFV increase and the treatment response (p = 0.014); complete recovery was observed with a PFV increase of 15% and partial recovery with an increase of 7%. CONCLUSIONS The treatment response is significantly influenced by the degree of PFV increase, which is dependent on the size of the PF and the extent of the craniectomy, suggesting that the optimal patient-specific PFV increase could be predicted on the basis of preoperative MR imaging and enhancing the perspective that the craniectomy size could be tailored to the individual PFV.
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Affiliation(s)
- Rémy Noudel
- Department of Neurosurgery, Maison Blanche Hospital, University of Reims, France.
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47
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Complicaciones postquirúrgicas de la malformación de Chiari tipo I: duroplastia y fístula de líquido cefalorraquídeo. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70003-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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48
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Heiss JD, Suffredini G, Smith R, DeVroom HL, Patronas NJ, Butman JA, Thomas F, Oldfield EH. Pathophysiology of persistent syringomyelia after decompressive craniocervical surgery. Clinical article. J Neurosurg Spine 2010; 13:729-42. [PMID: 21121751 PMCID: PMC3822767 DOI: 10.3171/2010.6.spine10200] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECT Craniocervical decompression for Chiari malformation Type I (CM-I) and syringomyelia has been reported to fail in 10%-40% of patients. The present prospective clinical study was designed to test the hypothesis that in cases in which syringomyelia persists after surgery, craniocervical decompression relieves neither the physiological block at the foramen magnum nor the mechanism of syringomyelia progression. METHODS The authors prospectively evaluated and treated 16 patients with CM-I who had persistent syringomyelia despite previous craniocervical decompression. Testing before surgery included the following: 1) clinical examination; 2) evaluation of the anatomy using T1-weighted MR imaging; 3) assessment of the syrinx and CSF velocity and flow using cine phase-contrast MR imaging; and 4) appraisal of the lumbar and cervical subarachnoid pressures at rest, during a Valsalva maneuver, during jugular compression, and following the removal of CSF (CSF compliance measurement). During surgery, ultrasonography was performed to observe the motion of the cerebellar tonsils and syrinx walls; pressure measurements were obtained from the intracranial and lumbar intrathecal spaces. The surgical procedure involved enlarging the previous craniectomy and performing an expansile duraplasty with autologous pericranium. Three to 6 months after surgery, clinical examination, MR imaging, and CSF pressure recordings were repeated. Clinical examination and MR imaging studies were then repeated annually. RESULTS Before reexploration, patients had a decreased size of the CSF pathways and a partial blockage in CSF transmission at the foramen magnum. Cervical subarachnoid pressure and pulse pressure were abnormally elevated. During surgery, ultrasonographic imaging demonstrated active pulsation of the cerebellar tonsils, with the tonsils descending during cardiac systole and concomitant narrowing of the upper pole of the syrinx. Three months after reoperation, patency of the CSF pathways was restored and pressure transmission was improved. The flow of syrinx fluid and the diameter of the syrinx decreased after surgery in 15 of 16 patients. CONCLUSIONS Persistent blockage of the CSF pathways at the foramen magnum resulted in increased pulsation of the cerebellar tonsils, which acted on a partially enclosed cervical subarachnoid space to create elevated cervical CSF pressure waves, which in turn affected the external surface of the spinal cord to force CSF into the spinal cord through the Virchow-Robin spaces and to propel the syrinx fluid caudally, leading to syrinx progression. A surgical procedure that reestablished the CSF pathways at the foramen magnum reversed this pathophysiological mechanism and resolved syringomyelia. Elucidating the pathophysiology of persistent syringomyelia has implications for its primary and secondary treatment.
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Affiliation(s)
- John D Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
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49
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Yanni DS, Mammis A, Ebersole K, Roonprapunt C, Sen C, Perin NI. Revision of Chiari decompression for patients with recurrent syrinx. J Clin Neurosci 2010; 17:1076-9. [DOI: 10.1016/j.jocn.2009.11.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 10/09/2009] [Accepted: 11/29/2009] [Indexed: 11/30/2022]
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50
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Cacciola F, Capozza M, Perrini P, Benedetto N, Di Lorenzo N. Syringopleural shunt as a rescue procedure in patients with syringomyelia refractory to restoration of cerebrospinal fluid flow. Neurosurgery 2009; 65:471-6; discussion 476. [PMID: 19687691 DOI: 10.1227/01.neu.0000350871.47574.de] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Syringomyelia should be treated by reconstruction of the subarachnoid space and restoration of cerebrospinal fluid homeostasis. Direct intervention on the syrinx is a difficult choice and should be considered a rescue procedure. Data in the literature examining the various options are scanty, with generally unsatisfying results. We report our experience with shunting of the syrinx into the pleural space. METHODS Twenty patients with syringomyelia refractory to cerebrospinal fluid flow restoration underwent a procedure for placement of a syringopleural shunt between 1998 and 2008. Modified Japanese Orthopaedic Association Scale scores and magnetic resonance imaging were available for each patient preoperatively and at the latest follow-up evaluation. A 2-tailed Wilcoxon signed-rank test was used for statistical analysis. Complications related to the operative procedure and to hardware failure were noted. RESULTS Nineteen patients were available for follow-up with a mean duration of 37.5 (standard deviation, 31.1) months. The condition of 1 patient deteriorated, 2 remained stable, and the remainder improved. The overall mean improvement on the Modified Japanese Orthopaedic Association Scale was 19.5% (95% confidence interval, 8.5-30.5). The median improvement was 4 points on the 17-point scale. Results were statistically significant (P < 0.001). Follow-up magnetic resonance imaging showed syrinx collapse in 17 cases and marked shrinkage in 2 cases. Except for 1 case of meningitis followed by fatal pulmonary embolism, no significant complications were noted. CONCLUSION A syringopleural shunt should, in our view, be the syrinx diversion procedure of choice. More series of institutional experiences with a homogeneous approach would be helpful to verify this recommendation.
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Affiliation(s)
- Francesco Cacciola
- Clinica Neurochirurgica, c/o Centro Tramautologico Ortopedico, Firenze, Italy
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