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Poca MA, Lopez-Bermeo D, Moncho D, Ferre A, Sanchez-Montañez A, Mestres O, Galve S, Sahuquillo J. Surgical Outcomes in Chiari 1 and Chiari 1.5 Malformation Treated by Posterior Fossa Reconstruction: A Comprehensive Analysis of 110 Pediatric Cases and Literature Review. J Clin Med 2024; 13:3852. [PMID: 38999418 PMCID: PMC11242314 DOI: 10.3390/jcm13133852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: The management of Chiari malformations (CMs) remains a clinical challenge and a topic of great controversy. Results may vary between children and adults. The purpose of the current single-center study is to critically assess the one-year surgical outcomes of a cohort of 110 children with CM-1 or CM-1.5 who were treated using "posterior fossa reconstruction" (PFR), a surgical technique described in 1994 that has since been used in both adults and children. We also review the literature and discuss the possible causes of the drawbacks and pitfalls in children in whom PFR was ineffective in controlling the disease. Methods: The present cohort was selected from a prospective registry of adults and children with CMs collected since 2006. Patients included in this study were selected from a group of children with CMs who were operated on in our Pediatric Neurosurgical Unit between 1 January 2007 and 31 November 2023. Surgical outcome was defined based on clinical and neuroradiological results as very good, good, or bad. Results: The mean age of our child cohort was 9.9 ± 4.7 years, with 54 girls (49%) and 56 boys (51%). Sixty-six children had CM-1 (60%) while forty-four had CM-1.5 (40%). Following surgery, there was no neurological worsening or death among the children. Most children (70%) had an uneventful recovery and were discharged home on average one week after surgery. However, in 33 children (30%), we recorded at least one postoperative adverse event. Aseptic meningitis syndrome was the most frequent adverse event (n = 25, 22.7%). The final surgical outcome was evaluated one year after PFR by using both clinical and neuroradiological results. The one-year surgical outcome was excellent in 101 children (91.9%), good in 5 (4.5%), and bad in 4 (3.6%). Conclusions: PFR significantly enlarges the volume of the posterior fossa and recreates a CSF environment that generates buoyancy of the cerebellum, with a high percentage of excellent and good clinical results evaluated one year post-surgery.
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Affiliation(s)
- Maria A. Poca
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.L.-B.); (J.S.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (A.F.); (O.M.)
- Department of Surgery (Neurosurgery), Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Diego Lopez-Bermeo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.L.-B.); (J.S.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (A.F.); (O.M.)
| | - Dulce Moncho
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (A.F.); (O.M.)
- Clinical Neurophysiology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Alex Ferre
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (A.F.); (O.M.)
- Clinical Neurophysiology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Sleep Unit, Pneumology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Angel Sanchez-Montañez
- Department of Pediatric Neuroradiology, Institut de Diagnostic per la Imatge (IDI), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Olga Mestres
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (A.F.); (O.M.)
- Department of Surgery (Neurosurgery), Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Sandra Galve
- Pediatric Anesthesiology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.L.-B.); (J.S.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.M.); (A.F.); (O.M.)
- Department of Surgery (Neurosurgery), Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
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He Y, Zhang M, Qin X, Huang C, Liu P, Tao Y, Wang Y, Guo L, Bao M, Li H, Mao Z, Li N, He Z, Wu B. Research process, recap, and prediction of Chiari malformation based on bicentennial history of nomenclature and terms misuse. Neurosurg Rev 2023; 46:316. [PMID: 38030943 DOI: 10.1007/s10143-023-02207-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/15/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
There is an absent systematic analysis or review that has been conducted to clarify the topic of nomenclature history and terms misuse about Chiari malformations (CMs). We reviewed all reports on terms coined for CMs for rational use and provided their etymology and future development. All literature on the nomenclature of CMs was retrieved and extracted into core terms. Subsequently, keyword analysis, preceding and predicting (2023-2025) compound annual growth rate (CAGR) of each core term, was calculated using a mathematical formula and autoregressive integrated moving average model in Python. Totally 64,527 CM term usage was identified. Of these, 57 original terms were collected and then extracted into 24 core-terms. Seventeen terms have their own featured author keywords, while seven terms are homologous. The preceding CAGR of 24 terms showed significant growth in use for 18 terms, while 13, three, three, and five terms may show sustained growth, remain stable, decline, and rare in usage, respectively, in the future. Previously, owing to intricate nomenclature, Chiari terms were frequently misused, and numerous seemingly novel but worthless even improper terms have emerged. For a very basic neuropathological phenomenon tonsillar herniation by multiple etiology, a mechanism-based nosology seems to be more conducive to future communication than an umbrella eponym. However, a good nomenclature also should encapsulate all characteristics of this condition, but this is lacking in current CM research, as the pathophysiological mechanisms are not elucidated for the majority of CMs.
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Affiliation(s)
- Yunsen He
- Department of Neurosurgery, Sichuan Lansheng Brain Hospital & Shanghai Lansheng Brain Hospital Investment Co., Ltd., 6 Anrong Road, Chadianzi Street, Jinniu District, Chengdu, 610036, Sichuan, China
| | - Mengjun Zhang
- Department of Neuropsychology, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Xiaohong Qin
- Department of Neuropsychology, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Caiquan Huang
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Ping Liu
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Ye Tao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Yishuang Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Lili Guo
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Mingbin Bao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Hongliang Li
- Department of Neurosurgery, Sichuan Lansheng Brain Hospital & Shanghai Lansheng Brain Hospital Investment Co., Ltd., 6 Anrong Road, Chadianzi Street, Jinniu District, Chengdu, 610036, Sichuan, China
| | - Zhenzhen Mao
- Emergency Department, Sichuan Taikang Hospital, Chengdu, 610000, Sichuan, China
| | - Nanxiang Li
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China
| | - Zongze He
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China.
| | - Bo Wu
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, West Section 2, First Ring Road, Chengdu, 610072, Sichuan, China.
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Kohut EA, Graff SA, Wakelin SH, Arhin M, Nair G, Heiss JD. Developing Semiautomated Methods to Measure Pre- and Postoperative Syrinx Volumes. J Clin Med 2023; 12:6725. [PMID: 37959191 PMCID: PMC10650856 DOI: 10.3390/jcm12216725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 11/15/2023] Open
Abstract
Neurosurgeons evaluate MRI scans to document whether surgical treatment has reduced syrinx size. Manual measurement of syrinx volume is time-consuming and potentially introduces operator error and bias. Developing convenient semiautomated volumetric analysis methods may encourage their clinical implementation and improve syringomyelia monitoring. We analyzed 30 SPGR axial MRI scans from 15 pre- and postoperative Chiari I and syringomyelia patients using two semiautomated (SCAT and 3DQI) methods and a manual Cavalieri (CAV) method. Patients' spinal cord and syrinx volumes pre- and postoperatively were compared by paired t-test. A decrease in syrinx volume (mm3) after surgery was detected across all methods. Mean syrinx volume (± SD) measured by CAV (n = 30) was, preoperatively, 4515 mm3 ± 3720, postoperatively 1109 ± 1469; (p = 0.0004). SCAT was, pre, 4584 ± 3826, post, 1064 ± 1465; (p = 0.0007) and 3DQI was, pre, 4027 ± 3805, post, 819 ± 1242; (p = 0.001). 3DQI and CAV detected similar mean spinal cord volumes before (p = 0.53) and after surgery (p = 0.23), but SCAT volumes differed significantly (p = 0.005, p = 0.0001). The SCAT and 3DQI semiautomated methods recorded surgically related syrinx volume changes efficiently and with enough accuracy for clinical decision-making and research studies.
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Affiliation(s)
- Eric A. Kohut
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, The National Institutes of Health, Bethesda, MD 20892, USA; (E.A.K.); (S.H.W.); (M.A.); (J.D.H.)
| | - Shantelle A. Graff
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, The National Institutes of Health, Bethesda, MD 20892, USA; (E.A.K.); (S.H.W.); (M.A.); (J.D.H.)
| | - Samuel H. Wakelin
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, The National Institutes of Health, Bethesda, MD 20892, USA; (E.A.K.); (S.H.W.); (M.A.); (J.D.H.)
| | - Martin Arhin
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, The National Institutes of Health, Bethesda, MD 20892, USA; (E.A.K.); (S.H.W.); (M.A.); (J.D.H.)
| | - Govind Nair
- qMRI Core Facility, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892, USA;
| | - John D. Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, The National Institutes of Health, Bethesda, MD 20892, USA; (E.A.K.); (S.H.W.); (M.A.); (J.D.H.)
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Ciaramitaro P, Migliaretti G, Ferraris M, Garnero A, Morana G, Carucci P, Stura I, Massaro F, Garbossa D. Syringomyelia Associated with Chiari 1 Malformation in Adults: Positive Outcome Predictors after Posterior Fossa Decompression with Duraplasty. J Clin Med 2023; 12:jcm12083019. [PMID: 37109355 PMCID: PMC10143011 DOI: 10.3390/jcm12083019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Syringomyelia (Syr) in patients with Chiari 1 malformation (CM1) may be attributable to abnormal dynamics of cerebrospinal fluid (CSF) in the upper cervical segment; fourth ventricle enlargement has been reported in association with a worse clinical and radiological presentation, independently of the posterior fossa volume. In this study, we analyzed presurgery hydrodynamic markers to evaluate if their changes could be associated with clinical and radiological improvement after posterior fossa decompression and duraplasty (PFDD). As a primary endpoint, we aimed to correlate improvement in the fourth ventricle area with positive clinical outcomes. METHODS In total, in this study, we enrolled 36 consecutive adults with Syr and CM1 who were followed by a multidisciplinary team. All the patients were prospectively evaluated with clinical scales and neuroimaging, including CSF flow, the fourth ventricle area, and the Vaquero Index by using a phase-contrast MRI before (T0) and after surgical treatment (T1-Tlast, with a range of 12-108 months). The CSF flow at the craniocervical junction (CCJ), the fourth ventricle area, and the Vaquero Index changes were statistically analyzed and compared to the clinical and quality of life improvement after surgery. The good outcome prediction ability of presurgical radiological variables was tested. RESULTS Surgery was associated with positive clinical and radiological outcomes in more than 90% of cases. The fourth ventricle area significantly reduced after surgery (T0-Tlast, p = 0.0093), but no significant associations with clinical improvement were found. The presurgical presence of CSF flow at the CCJ was able to predict a good outcome (AUC = 0.68, 95% CI 0.50-0.87 and LH+ = 2.1, IC 95% 1.16-3.07) and was also significantly associated with post-surgical pain relief (rho = 0.61 and p = 0.0144). CONCLUSIONS Presurgery CSF flow at the CCJ is proposed as a radiological marker with the ability to predict a positive outcome after PFDD in adults with syringomyelia and CM1. Measurements of the fourth ventricle area could be useful additional information for evaluating surgical long-term follow-up; further experience on larger cohorts is required to better define the prognostic yield of this radiological parameter.
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Affiliation(s)
- Palma Ciaramitaro
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- CRESSC, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Giuseppe Migliaretti
- Department of Public Health and Paediatric Sciences, University of Torino, 10126 Torino, Italy
| | - Marilena Ferraris
- Diagnostic Imaging Department, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Andrea Garnero
- Diagnostic Imaging Department, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Giovanni Morana
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- Diagnostic Imaging Department, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Paolo Carucci
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- CRESSC, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Ilaria Stura
- Neuroscience Department, University of Torino, 10126 Torino, Italy
| | - Fulvio Massaro
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- Neurosurgery Unit, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Diego Garbossa
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- Neurosurgery Unit, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
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Wang S, Zhang D, Wu K, Fan W, Fan T. Potential association among posterior fossa bony volume and crowdedness, tonsillar hernia, syringomyelia, and CSF dynamics at the craniocervical junction in Chiari malformation type I. Front Neurol 2023; 14:1069861. [PMID: 36891476 PMCID: PMC9986261 DOI: 10.3389/fneur.2023.1069861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/26/2023] [Indexed: 02/22/2023] Open
Abstract
Objective The characteristic morphological parameters (bony posterior fossa volume (bony-PFV), posterior fossa crowdness, cerebellar tonsillar hernia, and syringomyelia) and CSF dynamics parameters at the craniocervical junction (CVJ) in Chiari malformation type I (CMI) were measured. The potential association between these characteristic morphologies and CSF dynamics at CVJ was analyzed. Methods A total of 46 cases of control subjects and 48 patients with CMI underwent computed tomography and phase-contrast magnetic resonance imaging. Seven morphovolumetric measures and four CSF dynamics at CVJ measures were performed. The CMI cohort was further divided into "syringomyelia" and "non-syringomyelia" subgroups. All the measured parameters were analyzed by the Pearson correlation. Results Compared with the control, the posterior cranial fossa (PCF) area, bony-PFV, and CSF net flow were significantly smaller (P < 0.001) in the CMI group. Otherwise, the PCF crowdedness index (PCF CI, P < 0.001) and the peak velocity of CSF (P < 0.05) were significantly larger in the CMI cohort. The mean velocity (MV) was faster in patients with CMI with syringomyelia (P < 0.05). In the correlation analysis, the degree of cerebellar tonsillar hernia was correlated with PCF CI (R = 0.319, P < 0.05), MV (R = -0.303, P < 0.05), and the net flow of CSF (R = -0.300, P < 0.05). The Vaquero index was well correlated with the bony-PFV (R= -0.384, P < 0.05), MV (R = 0.326, P < 0.05), and the net flow of CSF (R = 0.505, P < 0.05). Conclusion The bony-PFV in patients with CMI was smaller, and the MV was faster in CMI with syringomyelia. Cerebellar subtonsillar hernia and syringomyelia are independent indicators for evaluating CMI. Subcerebellar tonsillar hernia was associated with PCF crowdedness, MV, and the net flow of CSF at CVJ, while syringomyelia was associated with bony-PFV, MV, and the net flow of CSF at the CVJ. Thus, the bony-PFV, PCF crowdedness, and the degree of CSF patency should also be one of the indicators of CMI evaluation.
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Affiliation(s)
- Shengxi Wang
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Dongao Zhang
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Kun Wu
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Wayne Fan
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada
| | - Tao Fan
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
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Valentini LG, Galbiati TF, Saletti V, Farinotti M, Erbetta A, Croci C, Vetrano IG. Evaluation of Adult and Pediatric Chiari Type 1 Malformation Patients: Do Consensus Documents Fit Everyday Practice? ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:147-155. [PMID: 38153463 DOI: 10.1007/978-3-031-36084-8_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
The management of Chiari 1 malformation (CM1) and Syringomyelia (Syr) has shown many changes in surgical indications and techniques over time. The dedicated neurosurgical and neurological community recently planned to analyze the state of the art and find conduct uniformity. This led to international consensus documents on diagnostic criteria and therapeutic strategies. We aimed to evaluate, in a large, monocentric surgical series of adult and children CM1 patients, if the daily clinical practice reflects the consensus documents. Our series comprises 190 pediatric and 220 adult Chiari patients submitted to surgery from 2000 to 2021. The main indications for the treatment were the presence of Syr and symptoms related to CM1. While there is great correspondence with the statements derived from the consensus documents about what to do for Syr and symptomatic CM1, the accordance is less evident in CM1 associated with craniosynostosis or hydrocephalus, especially when considering the early part of the series. However, we think that performing such studies could increase the homogeneity of surgical series, find a common way to evaluate long-term outcomes, and reinforce the comparability of different strategies adopted in different referral centers.
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Affiliation(s)
- Laura Grazia Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Veronica Saletti
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mariangela Farinotti
- Neuroepidemiology Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Erbetta
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carolina Croci
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
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Diagnosis and treatment of Chiari malformation and syringomyelia in adults: international consensus document. Neurol Sci 2022; 43:1327-1342. [PMID: 34129128 DOI: 10.1007/s10072-021-05347-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Syringomyelia and Chiari malformation are classified as rare diseases on Orphanet, but international guidelines on diagnostic criteria and case definition are missing. AIM OF THE STUDY to reach a consensus among international experts on controversial issues in diagnosis and treatment of Chiari 1 malformation and syringomyelia in adults. METHODS A multidisciplinary panel of the Chiari and Syringomyelia Consortium (4 neurosurgeons, 2 neurologists, 1 neuroradiologist, 1 pediatric neurologist) appointed an international Jury of experts to elaborate a consensus document. After an evidence-based review and further discussions, 63 draft statements grouped in 4 domains (definition and classification/planning/surgery/isolated syringomyelia) were formulated. A Jury of 32 experts in the field of diagnosis and treatment of Chiari and syringomyelia and patient representatives were invited to take part in a three-round Delphi process. The Jury received a structured questionnaire containing the 63 statements, each to be voted on a 4-point Likert-type scale and commented. Statements with agreement <75% were revised and entered round 2. Round 3 was face-to-face, during the Chiari Consensus Conference (Milan, November 2019). RESULTS Thirty-one out of 32 Jury members (6 neurologists, 4 neuroradiologists, 19 neurosurgeons, and 2 patient association representatives) participated in the consensus. After round 2, a consensus was reached on 57/63 statements (90.5%). The six difficult statements were revised and voted in round 3, and the whole set of statements was further discussed and approved. CONCLUSIONS The consensus document consists of 63 statements which benefited from expert discussion and fine-tuning, serving clinicians and researchers following adults with Chiari and syringomyelia.
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Zuev AA. [Features of syringomyelia natural course]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:76-81. [PMID: 32649816 DOI: 10.17116/neiro20208403176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rarity of syringomyelia (SM), a small amount of information about this disease leads to the lack of a unified concept of treatment and continuity between neurologists and neurosurgeons. Currently, there is no objective information on the timing, goals and objectives of surgery for SM, as well as the risks associated with this treatment. AIM Of this article was to study the natural course of syringomyelia and to determine in which part of the patients the disease progresses with time, how do the cysts' size change, and does this affect the condition of the patients, what symptoms appear first when the disease progresses? We retrospectively analyzed the medical records of 40 patients with SM who did not undergo surgery for various reasons (lack of indications, patient refusal from surgery, surgery was not offered to the patient, etc.) Clinical manifestations of the disease at the time of diagnosis were registered in 28 (70%) patients. Despite the conservative treatment, in 17 (60.7%) of them, symptoms began to progress over time. In 8 (28.6%) patients, the symptoms did not change during the observation; in 5 patients in this group, the disease clinically manifested in childhood, and did not progress in time after that. Three patients (10.7%) noted an improvement in their general condition, in two of them the syringomyelic cysts did not change according to MRI, and in one patient it regressed 2.5 years after it was found. Of the 12 patients without symptoms of the disease, within 62±13 months, only one patient (8.3%) developed sensory disorders in the hands, which eventually began to progress. Based on the data obtained, indications for surgery for SM are determined.
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Affiliation(s)
- A A Zuev
- N.I. Pirogov National Medical and Surgical Center, Moscow, Russia
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Chiari malformations in adults: A single center surgical experience with special emphasis on the kinetics of clinical improvement. Neurochirurgie 2019; 65:69-74. [DOI: 10.1016/j.neuchi.2018.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 08/26/2018] [Accepted: 10/06/2018] [Indexed: 11/20/2022]
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Zuev AA, Epifanov DS. [Treatment of patients with ossifying arachnoiditis and progressive syringomyelia (analysis of three cases and a literature review)]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:71-80. [PMID: 29795089 DOI: 10.17116/oftalma201882271-80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To date, only 12 cases of ossifying arachnoiditis with concomitant syringomyelia have been reported in the world literature. In this article, we presented our experience of treating three patients with syringomyelia associated with ossifying arachnoiditis. OBJECTIVE based on the literature data and our own experience, we tried to define the most optimal treatment approach for this disease. MATERIAL AND METHODS We analyzed the data of 15 patients (12 cases reported in the literature and 3 our own cases). The diagnosis was established on the basis of complaints, medical history, patient examination, MRI and CT of the spinal cord, and intraoperative data. Progression of syringomyelia was evaluated by comparison of the neurological status and calculation of the Vaquero index before and after surgery; the Domenicucci classification was used to evaluate the severity of ossifying arachnoiditis. Surgical treatment included several stages: decompressive laminectomy, elimination of spinal cord fixation, excision of ossifying arachnoiditis, shunting of the syrinx, and repair of the dura mater. RESULTS An analysis of the patient data reported in the literature (12 cases) and those in our series (3) revealed that in the early postoperative period, 7 (46.7%) of these 15 patients had improvements, 5 (33.3%) patients had no changes, and 3 (20%) patients experienced a worsening. At present, there is no clear algorithm for diagnosing and treating this disease. CONCLUSION Further investigation of the problem may facilitate an earlier diagnosis of the disease and provide more effective medical care.
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Affiliation(s)
- A A Zuev
- Pirogov National Medical Surgical Center, Nizhnyaya Pervomayskaya Str., 70, Moscow, Russia, 105203
| | - D S Epifanov
- Pirogov National Medical Surgical Center, Nizhnyaya Pervomayskaya Str., 70, Moscow, Russia, 105203
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Vaquero J, Zurita M, Rico MA, Aguayo C, Fernandez C, Rodriguez-Boto G, Marin E, Tapiador N, Sevilla M, Carballido J, Vazquez D, Garcia-Olmo D, Guadalajara H, Leon M, Valverde I. Cell therapy with autologous mesenchymal stromal cells in post-traumatic syringomyelia. Cytotherapy 2018; 20:796-805. [PMID: 29784434 DOI: 10.1016/j.jcyt.2018.04.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/10/2018] [Accepted: 04/21/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AIMS Recently, clinical studies show that cell therapy with mesenchymal stromal cells (MSCs) improves the sequelae chronically established in paraplegic patients, being necessary to know which of them can obtain better benefit. METHODS We present here a phase 2 clinical trial that includes six paraplegic patients with post-traumatic syringomyelia who received 300 million MSCs inside the syrinx and who were followed up for 6 months. Clinical scales, urodynamic, neurophysiological, magnetic resonance (MR) and studies of ano-rectal manometry were performed to assess possible improvements. RESULTS In all the cases, MR at the end of the study showed a clear reduction of the syrinx, and, at this time, signs of improvement in the urodynamic studies were found. Moreover, four patients improved in ano-rectal manometry. Four patients improved in neurophysiological studies, with signs of improvement in evoked potentials in three patients. In the American Spinal Injury Association (ASIA) assessment, only two patients improved in sensitivity, but clinical improvement in neurogenic bowel dysfunction was observed in four patients and three patients described improvement in bladder dysfunction. Spasms reduced in two of the five patients who had them previous to cell therapy, and spasticity was improved in the other two patients. Three patients had neuropathic pain before treatment, and it was reduced or disappeared completely during the study. Only two adverse events ocurred, without relation to the cell therapy. CONCLUSIONS Cell therapy can be considered as a new alternative to the treatment of post-traumatic syringomyelia, achieving reduction of syrinx and clinical improvements in individual patients.
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Affiliation(s)
- Jesús Vaquero
- Neurosurgery Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain.
| | - Mercedes Zurita
- Neurosurgery Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Miguel A Rico
- Neurosurgery Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Concepcion Aguayo
- Neurosurgery Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Cecilia Fernandez
- Neurosurgery Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Gregorio Rodriguez-Boto
- Neurosurgery Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Esperanza Marin
- Clinical Neurophysiology Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Noemi Tapiador
- Rehabilitation Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Marta Sevilla
- Rehabilitation Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - Joaquin Carballido
- Urology Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | - David Vazquez
- Urology Service, University Hospital Puerta de Hierro-Majadahonda, Autonomous University, Madrid, Spain
| | | | | | - Miguel Leon
- Service of Coloproctology, Hospital General de Villalba, Madrid, Spain
| | - Ignacio Valverde
- Service of Coloproctology, Hospital General de Villalba, Madrid, Spain
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Leschke JM, Mumert ML, Kurpad SN. Syringosubarachnoid shunting using a myringotomy tube. Surg Neurol Int 2016; 7:S8-S11. [PMID: 26862456 PMCID: PMC4722522 DOI: 10.4103/2152-7806.173559] [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] [Received: 09/01/2015] [Accepted: 11/02/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Syringomyelia results from obstruction of cerebrospinal fluid (CSF) flow due to a multitude of causes. Often symptoms of pain, weakness, and sensory disturbance are progressive and require surgical treatment. We present here a rare technique for syringosubarachnoid shunting. CASE DESCRIPTION We present the case of a 38-year-old male who suffered a traumatic cervical spinal cord injury due to a motor vehicle accident. With progressive pain and motor decline, a magnetic resonance imaging was obtained and showed a new syrinx extending cervical multiple segments. A unique surgical procedure using a myringotomy tube to shunt CSF into the subarachnoid space was employed in this case. The patient's examination stabilized postoperatively, and at 2 months and 6 months follow-up visits, his strength and sensation continued to improve. CONCLUSION We used a myringotomy tube for syringosubarachnoid shunting for the surgical management of a posttraumatic syrinx with good results. This technique minimizes suturing and may minimize shunt-related complications.
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Affiliation(s)
- Jack M Leschke
- Department of Neurology, Medical College of Wisconsin, West Allis, WI 53227, USA
| | - Michael L Mumert
- Department of Neurosurgery, Springfield Neurological and Spine Institute, Springfield, MO 65804, USA
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Froedtert Hospital, Milwaukee, WI 53226, USA
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Arnautovic A, Splavski B, Boop FA, Arnautovic KI. Pediatric and adult Chiari malformation Type I surgical series 1965-2013: a review of demographics, operative treatment, and outcomes. J Neurosurg Pediatr 2015; 15:161-77. [PMID: 25479580 DOI: 10.3171/2014.10.peds14295] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECT Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia. METHODS The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included. RESULTS The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series. CONCLUSIONS Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.
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Affiliation(s)
- Aska Arnautovic
- George Washington University School of Medicine, Washington, DC
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Schuster JM, Zhang F, Norvell DC, Hermsmeyer JT. Persistent/Recurrent syringomyelia after Chiari decompression-natural history and management strategies: a systematic review. EVIDENCE-BASED SPINE-CARE JOURNAL 2014; 4:116-25. [PMID: 24436709 PMCID: PMC3836893 DOI: 10.1055/s-0033-1357362] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/30/2013] [Indexed: 01/01/2023]
Abstract
Study Design Systematic review. Study Rationale One of the most consistent indications for a Chiari decompression is tonsillar descent meeting the radiographic criteria and an associated syrinx in a symptomatic patient. In counseling patients about surgery, it would be advantageous to have information regarding the expected outcome with regard to the syrinx and other possible treatments available if the result is suboptimal. Clinical Questions The clinical questions include: (1) What is the average rate of recurrent or residual syringomyelia following posterior fossa decompression as a result of Chiari malformation with associated syringomyelia? (2) What treatment methods have been reported in the literature for managing recurrent or residual syringomyelia after initial posterior fossa decompression? Materials and Methods Available search engines were utilized to identify publications dealing with recurrent or residual syrinx after Chiari decompression and/or management of the syrinx. Rates of residual or recurrent syrinx were extracted and management strategies were recorded. Overall strength of evidence was quantified. Results Of the 72 citations, 11 citations met inclusion criteria. Rates of recurrent/residual syringomyelia after decompression in adults range from 0 to 22% with an average of 6.7%. There were no studies that discussed specifically management of the remaining syrinx. Conclusion Rates of recurrent/residual syringomyelia after Chiari decompression in adults range from 0 to 22% (average 6.7%). Although no studies describing the optimal management of residual syrinx were found, there is general agreement that the aim of the initial surgery is to restore relatively unimpeded flow of cerebrospinal across the craniocervical junction. Large holocord syrinx may induce a component of spinal cord injury even with adequate decompression and reduction in the caliber of the syrinx, resulting in permanent symptoms of injury.
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Affiliation(s)
- James M Schuster
- Department of Neurological Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Fangyi Zhang
- Department of Orthopedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, United States ; Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, United States
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Arnautovic KI, Muzevic D, Splavski B, Boop FA. Association of increased body mass index with Chiari malformation Type I and syrinx formation in adults. J Neurosurg 2013; 119:1058-67. [DOI: 10.3171/2013.4.jns122011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper the authors describe an association between increased body mass index (BMI) and Chiari malformation Type I (CM-I) in adults, as well as its relationship to the development of syringomyelia.
Methods
In the period between January 2004 and December 2011, the senior author reviewed the data for all CM-I patients with or without syringomyelia and neurological deficit. Analyzed factors included clinical status (headaches and neurological signs), radiological characteristics of syringomyelia (diameter and vertical extent of syrinx), BMI, and relationship of age to BMI, syrinx diameter, and vertical extent of syrinx.
Results
Sixty consecutive adults had CM-I, 26 of whom also had syringomyelia. The mean BMI among all patients was 30.35 ± 7.65, which is Class I obesity (WHO), and was similar among patients with or without syringomyelia. Extension of the vertical syrinx was greater in overweight patients (p = 0.027) than in those with a normal body weight. Evidence of de novo syrinx formation was found in 2 patients who gained an average BMI of 10.8 points. After repeated decompression and no change in holocord syrinx width or vertical extent, a reduction in the syrinx was seen after BMI decreased 11.7 points in one individual. No correlation was found between patient age and BMI, age and vertical extension of the syrinx, and age and diameter of the syrinx.
Conclusions
An association between increased BMI and CM-I in adults was recognized. Gaining weight may influence the de novo creation of a syrinx in adults who previously had minimally symptomatic or asymptomatic CM-I, and reducing weight can improve a syrinx after unsuccessful surgical decompression. Therefore, a reduction in body weight should be recommended for all overweight and obese patients with CM-I.
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Affiliation(s)
- Kenan I. Arnautovic
- 1Semmes-Murphey Clinic
- 2Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Dario Muzevic
- 3Department of Neurosurgery, Osijek University School of Medicine, Clinical Hospital Center, Osijek, Croatia
| | - Bruno Splavski
- 3Department of Neurosurgery, Osijek University School of Medicine, Clinical Hospital Center, Osijek, Croatia
| | - Frederick A. Boop
- 1Semmes-Murphey Clinic
- 2Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee; and
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Brandão RACS, Costa BS, Dellaretti MA, de Carvalho GTC, Faria MP, de Sousa AA. Efficacy and Safety of a Porcine Collagen Sponge for Cranial Neurosurgery: A Prospective Case-Control Study. World Neurosurg 2013; 79:544-50. [DOI: 10.1016/j.wneu.2011.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 08/04/2011] [Indexed: 10/15/2022]
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Hayashi T, Ueta T, Kubo M, Maeda T, Shiba K. Subarachnoid-subarachnoid bypass: a new surgical technique for posttraumatic syringomyelia. J Neurosurg Spine 2013; 18:382-7. [PMID: 23432327 DOI: 10.3171/2013.1.spine12828] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The origin of posttraumatic syringomyelia is not completely understood. With respect to posttraumatic syringomyelia, the optimum management strategy for patients with spinal cord injury has also not been established. The authors hypothesized that reconstruction of the subarachnoid channels would reestablish CSF flow, thereby addressing the underlying cause of the syrinx formation. The authors performed a new type of surgery, subarachnoid-subarachnoid bypass (S-S bypass), in which an attempt was made to reestablish normal CSF circulation around the spinal cord. The purpose of this study was to evaluate the effectiveness of S-S bypass for posttraumatic syringomyelia. METHODS Twenty consecutive patients with symptomatic posttraumatic syringomyelia who had progressive neurological symptoms and underwent S-S bypass were included in the study. The surgical procedure was as follows: a laminectomy was performed at the level of trauma, and a midline dural opening was made under a microscope. The arachnoid was exposed up to the area of normal arachnoid mater with normal CSF circulation. After dissection of the normal arachnoid mater at the cephalic and caudal sites, 1 or 2 tubes made of medical-grade silicone were inserted into the cephalic and caudal ends of the normal subarachnoid space. Bypass tubes were laid in the subdural space, and a watertight dural closure was accomplished using running sutures. The mean follow-up period was 48.2 months (range 12-93 months). The preoperative status and postoperative clinical course were assessed according to 3 grading systems: the Frankel grading system for global neurological status, the American Spinal Injury Association motor score for motor weakness, and the Klekamp system for bladder function. The major presenting symptoms or signs were assessed in terms of symptom improvement, stabilization, or deterioration. Preoperative and postoperative MRI was used to analyze the size and craniocaudal extension of the cavity. RESULTS Twelve patients showed clinical improvement, 4 were stable, and 4 showed deterioration. The mean length of the syrinx observed on preoperative MRI was 9.9 spinal levels, and the mean Vaquero index was 62.3%. The mean length of the syrinx observed on postoperative MRI was 5.3 spinal levels, and the mean Vaquero index was 28.4%. These values were significantly lower than the preoperative values (p = 0.01 and p < 0.01, respectively). CONCLUSIONS This study showed that interference with CSF flow was the major cause of syrinx development and that reconstruction of CSF flow is the most important treatment strategy based on the cause of the syrinx. Subarachnoid-subarachnoid bypass, which can be performed without myelotomy, was not only a safe and effective surgical technique, but may also be a more physiological way of treating posttraumatic syringomyelia.
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Vaquero J, Ferreira E, Parajón A. Spontaneous resolution of syrinx: report of two cases in adults with Chiari malformation. Neurol Sci 2011; 33:339-41. [DOI: 10.1007/s10072-011-0670-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 06/14/2011] [Indexed: 11/30/2022]
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Aghakhani N, Baussart B, David P, Lacroix C, Benoudiba F, Tadie M, Parker F. Surgical Treatment of Posttraumatic Syringomyelia. Neurosurgery 2010; 66:1120-7; discussion 1127. [PMID: 20495426 DOI: 10.1227/01.neu.0000369609.30695.ab] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
The present study evaluates the effectiveness of 2 surgical procedures, shunting and untethering, for posttraumatic syringomyelia.
METHODS
We retrospectively reviewed the medical charts of all surgical patients with posttraumatic syringomyelia in our department. Shunting was performed before 1997; after 1997, we used arachnoidolysis and untethering.
RESULTS
Shunting was performed in 15 patients, and 19 patients underwent arachnoidolysis. Statistical analysis found that the 2 groups did not differ in age or initial clinical or radiological presentation. All patients suffered from progressively worsening symptoms. Reconstruction of the subarachnoid space by arachnoidolysis and untethering the cord allowed us to improve or stabilize 94% of our patients. Shunting exposed the patients to a higher rate of clinical recurrence and reoperation. Comparisons between the 2 groups found a significant difference (better results) in favor of arachnoidolysis for the McCormick classification (P = .03), American Spinal Injury Association motor score of the lower extremities (P = .02), and subjective grading (P = .001). There was no significant difference in the evolution of pain or the Vaquero index between the 2 groups; however, a tendency appeared in favor of arachnoidolysis for cyst evolution in regard to the extent of the cyst and the Vaquero index (P = .05).
CONCLUSION
Our results confirmed that arachnoidolysis is an effective and safe treatment for posttraumatic syringomyelia. Because the majority of patients were stabilized, we concluded that surgery should be performed as soon as possible in patients with clearly progressing clinical features.
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Affiliation(s)
- Nozar Aghakhani
- Department of Neurosurgery, Bicetre University Hospital, Bicetre, France
| | - Bertrand Baussart
- Department of Neurosurgery, Bicetre University Hospital, Bicetre, France
| | - Philippe David
- Department of Neurosurgery, Bicetre University Hospital, Bicetre, France
| | - Catherine Lacroix
- Department of Neurology, Bicetre University Hospital, Bicetre, France
| | - Farida Benoudiba
- Department of Neuroradiology, Bicetre University Hospital, Bicetre, France
| | - Marc Tadie
- Department of Neurosurgery, Bicetre University Hospital, Bicetre, France
| | - Fabrice Parker
- Department of Neurosurgery, Bicetre University Hospital, Bicetre, France
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Surgical outcomes of foramen magnum decompression for syringomyelia associated with Chiari I malformation: relation between the location of the syrinx and body pain. J Orthop Sci 2010; 15:299-304. [PMID: 20559796 DOI: 10.1007/s00776-010-1462-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 02/05/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND There have been few reports about the relation between the morphology of syrinxes and body pain in syringomyelia associated with Chiari I malformation. To investigate this phenomenon, the relation between the location of the syrinx and body pain before and after foramen magnum decompression (FMD) were evaluated. METHODS The subjects were 20 patients with Chiari I malformation associated with syringomyelia who underwent FMD. The morphology of the syrinxes was classified into three types - enlarged type, which was a distended syrinx at the central spinal cord; deviated type, which was a deviated syrinx posterolaterally within the spinal cord; central type, which was a small syrinx at the central canal of the spinal cord - based on axial magnetic resonance imaging (MRI). Preoperative and postoperative clinical symptoms and the body pain were evaluated by the Japanese Orthopaedic Association (JOA) score and a visual analogue scale (VAS) prospectively. RESULTS Preoperative and postoperative JOA scores showed no statistically significant differences between the three syrinx types. Intensity of body pain evaluated by the VAS showed that patients with a deviated-type syrinx on pre- and postoperative MRI tended to be associated with more intense pain than the other two types. CONCLUSIONS It was indicated that pain before and after surgery is more intense when the syrinx is deviated toward the spinal dorsal horn as seen on MRI.
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Cerda-Gonzalez S, Olby NJ, Broadstone R, McCullough S, Osborne JA. Characteristics of cerebrospinal fluid flow in Cavalier King Charles Spaniels analyzed using phase velocity cine magnetic resonance imaging. Vet Radiol Ultrasound 2009; 50:467-76. [PMID: 19788029 DOI: 10.1111/j.1740-8261.2009.01571.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Syringomyelia is an important morbidity source in Cavalier King Charles Spaniels. Although abnormal cerebrospinal fluid (CSF) flow secondary to Chiari malformations is thought to cause syringomyelia in humans, this relationship is unknown in dogs. We used phase-contrast magnetic resonance (MR) imaging to evaluate CSF flow in dogs. Fifty-nine Cavalier King Charles Spaniels were assigned a neurologic grade reflecting their neurologic status. Five normal control dogs of other breeding were imaged for comparison. The presence of syringomyelia was noted from sagittal MR images. The pattern and velocity of CSF flow were assessed using phase-contrast cine MRI at the foramen magnum, C2-C3 disc space, and within syrinxes. Flow was measured most easily with the neck flexed to mimic standing. CSF flow velocity in the dorsal aspect of the subarachnoid space at the foramen magnum was significantly higher in control dogs than Cavalier King Charles Spaniels (P = 0.035). Flow was obstructed at the foramen magnum in 41 of 59 Cavalier King Charles Spaniels. Turbulent flow and jets were associated with syringomyelia presence and severity, and CSF flow velocity at C2/3 dorsally was inversely related to the presence of syringomyelia (P = 0.0197). Peak dorsal subarachnoid space CSF flow velocity at the foramen magnum and C2-C3 were together highly predictive of syringomyelia. CSF flow can be assessed in dogs using phase-contrast cine MRI. Obstruction to flow at the foramen magnum is common in Cavalier King Charles Spaniels and CSF flow pattern and velocity are related to the presence of syringomyelia.
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Affiliation(s)
- Sofia Cerda-Gonzalez
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Kumar R, Kalra SK, Vaid VK, Mahapatra AK. Chiari I malformation: surgical experience over a decade of management. Br J Neurosurg 2009; 22:409-14. [DOI: 10.1080/02688690801894638] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Moskowitz SI, Liu J, Krishnaney AA. Postoperative complications associated with dural substitutes in suboccipital craniotomies. Neurosurgery 2009; 64:ons28-33; discussion ons33-4. [PMID: 19240570 DOI: 10.1227/01.neu.0000334414.79963.59] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Dural replacements are used in cranial surgery when primary closure of native dura is not possible. The goal is to recreate a watertight barrier to prevent cerebrospinal fluid leakage with few associated complications. We reviewed a single-institution experience with a variety of dural substitutes in posterior fossa neurosurgery, for which higher complication rates are well described. METHODS Patients were screened for suboccipital posterior fossa neurosurgery between November 2005 and April 2007. Surgical logs were reviewed for diagnosis, procedure, and use of dural replacement. Clinical courses were reviewed for hydrodynamic complications, including delayed hydrocephalus, clinically significant pseudomeningocele, aseptic meningitis, and persistent cerebrospinal leakage. RESULTS One hundred twenty-eight patients were included, and a dural replacement was used in 106. Overall, the complication rate was 21.9% (28 patients). Complications were seen for acellular human dermis in 33.3%, for collagen matrix in the original formulation in 18.2%, for the reformulation in 16.9%, for the suturable formulation in 50%, for nonautologous materials in 24%, and for no dural replacement in 16.7%. Univariate and multivariate analysis demonstrated that hydrodynamic complications were associated with use of the suturable collagen matrix (odds ratio, 10.8; 95% confidence interval, 2.5-46.1; P = 0.0014) and trended with use of acellular human dermis (odds ratio, 4.6; 95% confidence interval, 0.9-23.1; P = 0.06). CONCLUSION The increased risk of hydrodynamic complications associated with suboccipital neurosurgery is modified by choice of dural replacement. Similar complication rates were seen for most materials with a variety of primary abnormalities, with the exception of suturable bovine collagen matrix, with hydrodynamic complications in 50% of patients.
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Affiliation(s)
- Shaye I Moskowitz
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Aghakhani N, Parker F, David P, Morar S, Lacroix C, Benoudiba F, Tadie M. Long-term follow-up of Chiari-related syringomyelia in adults: analysis of 157 surgically treated cases. Neurosurgery 2009; 64:308-15; discussion 315. [PMID: 19190458 DOI: 10.1227/01.neu.0000336768.95044.80] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the long-term outcome of surgically treated Chiari-related syringomyelia. METHODS The medical charts of 157 consecutive surgically treated patients with Chiari-related syringomyelia were retrospectively analyzed. Factors predicting outcome, either clinical or radiological, are discussed, and our results are compared with those of other large series in the literature. RESULTS The study included 74 men and 83 women (age range, 16-75 years; mean age at surgery, 38.3 years). Pain and sensory disturbance were the most frequent initial symptoms. The average duration of preoperative symptoms was 8.2 years. The follow-up period ranged from 82 to 204 months (median, 88 months). At the end of the study, 99 patients (63.06%) had improved, 48 (30.58%) had stabilized, 9 (5.73%) had worsened, and 1 (0.63%) had died during the postoperative period. Factors predicting improvement or stabilization were young age at the time of surgery and clinical signs of paroxysmal intracranial hypertension. Factors associated with a poor outcome were older age at the time of surgery, arachnoiditis, and a clinical feature of long-tract impairment syndrome. The presence of arachnoiditis or of basilar invagination was associated with poor clinical presentation (P = 0.05 and 0.0001, respectively). The extent of the cyst on postoperative magnetic resonance imaging was a predictor of poor clinical outcome (P = 0.002). CONCLUSION Our results confirmed that surgery is an effective and safe treatment of Chiari-related syringomyelia, with a 90% chance of long-term stabilization or improvement on average. Surgery should be proposed as soon as possible in patients with clearly progressing clinical features.
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Affiliation(s)
- Nozar Aghakhani
- Department of Neurosurgery, Bicêtre University Hospital, Bicêtre, France.
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Sindou M, Gimbert E. Decompression for Chiari type I-malformation (with or without syringomyelia) by extreme lateral foramen magnum opening and expansile duraplasty with arachnoid preservation: comparison with other technical modalities (Literature review). Adv Tech Stand Neurosurg 2009; 34:85-110. [PMID: 19368082 DOI: 10.1007/978-3-211-78741-0_4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Posterior craniocervical decompression is the procedure most currently used for treating Chiari I malformation (alone or in association with syringomyelia in the absence of hydrocephalus). We reviewed the various technical modalities reported in the literature. We present a personal series of 44 patients harboring Chiari type I malformation (CM-I) operated with a suboccipital craniectomy and a C1 (or C1/C2) laminectomy, plus an extreme lateral Foramen Magnum opening, a "Y" shaped dural incision with preservation of the arachnoid membrane, and an expansile duraplasty employing autogenous periosteum. Outcomes were analyzed with follow-up ranging from 1 to 10 years (4 years on average). The presented technique was compared with the other surgical modalities reported in the literature. This comparative study shows that this type of craniocervical decompression achieved the best results with minimal complications and side-effects. Syringomyelia associated with CM-I must be treated by craniocervical decompression alone. Shunting no longer appears to be an appropriate method of treatment for syringomyelia.
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Affiliation(s)
- M Sindou
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, University of Lyon, Lyon, France
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Sung WS, Chen YY, Dubey A, Hunn A. Spontaneous regression of syringomyelia – review of the current aetiological theories and implications for surgery. J Clin Neurosci 2008; 15:1185-8. [DOI: 10.1016/j.jocn.2007.08.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 08/27/2007] [Accepted: 08/29/2007] [Indexed: 10/21/2022]
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Ono A, Suetsuna F, Ueyama K, Yokoyama T, Aburakawa S, Takeuchi K, Numasawa T, Wada K, Toh S. Cervical spinal motion before and after surgery in patients with Chiari malformation type I associated with syringomyelia. J Neurosurg Spine 2007; 7:473-7. [PMID: 17977187 DOI: 10.3171/spi-07/11/473] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There have been few reports about the cervical spinal motion in patients with Chiari malformation Type I (CM-I) associated with syringomyelia. To investigate this phenomenon, the relationship between the preoperative cervical range of motion (ROM) and the stage of cerebellar tonsillar descent as well as the cervical ROM before and after foramen magnum decompression (FMD) were evaluated. METHODS Thirty patients who had CM-I associated with syringomyelia and who underwent FMD participated in the study. The ROM and lordosis angle of the cervical spine were measured on x-ray films. In addition, the relationship between preoperative degree of cerebellar tonsillar descent and the ROM between the levels of the occiput (Oc) and C2 was investigated. RESULTS The mean flexion-extension ROM at Oc-C2 was 15.5 degrees before and 14.1 degrees after surgery, and the mean flexion-extension ROM of C2-7 was 55.1 degrees before and 52.8 degrees after surgery. The mean pre- and postoperative lordosis angles at C2-7 were 16.8 and 19.1 degrees, respectively. There was no significant difference between the values measured before and after surgery. There was no correlation between the degree of cerebellar tonsillar descent and the ROM at Oc-C2. CONCLUSIONS. Foramen magnum decompression is an excellent surgical technique that has no effect on the postoperative cervical ROM and cervical alignment.
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Affiliation(s)
- Atsushi Ono
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Japan.
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Ono A, Suetsuna F, Ueyama K, Yokoyama T, Aburakawa S, Numasawa T, Wada K, Toh S. Surgical outcomes in adult patients with syringomyelia associated with Chiari malformation Type I: the relationship between scoliosis and neurological findings. J Neurosurg Spine 2007; 6:216-21. [PMID: 17355020 DOI: 10.3171/spi.2007.6.3.216] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The clinical characteristics of pediatric scoliosis associated with syringomyelia have been reported in previous studies, but scoliosis associated with syringomyelia in adults is rarely treated, and there is a paucity of detailed studies. In the present study of adult syringomyelia associated with Chiari malformation Type I, the authors investigated the relationships among the syrinx, scoliosis, and neurological data.
Methods
The population was composed of 27 patients (≥ 20 years of age) who underwent foramen magnum decompression for the treatment of syringomyelia. The patients were divided into two groups: those with scoliosis of 10° or more (Group A) and those without scoliosis (Group B). The authors assessed the length of the syrinx, duration of morbidity, and clinical status before and after surgery based on the Japanese Orthopaedic Association (JOA) Scale.
There were 15 cases in Group A and 12 in Group B. The mean length of the syrinx was 12.8 vertebral bodies (VBs) in Group A and 7.2 VBs in Group B. The mean duration of morbidity was 14.2 years in Group A and 6.8 years in Group B. The mean preoperative JOA score was 10.1 in Group A and 14.4 in Group B, whereas the mean postoperative JOA scores were 11.9 and 15.8, respectively. There were significant differences between Groups A and B in length of the syrinx, duration of morbidity, and pre- and postoperative JOA scores.
Conclusions
In patients with syringomyelia and scoliosis the syringes spanned a greater number of VBs, the duration of morbidity was greater, neurological dysfunction was more severe, and surgical results were poorer. Scoliosis could be a predicting factor of the prognosis in patients with syringomyelia and Chiari malformation Type I.
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Affiliation(s)
- Atsushi Ono
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Japan.
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Malformazioni della cerniera craniocervicale e siringomielie. Neurologia 2007. [DOI: 10.1016/s1634-7072(07)70554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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McGirt MJ, Nimjee SM, Fuchs HE, George TM. Relationship of cine phase-contrast magnetic resonance imaging with outcome after decompression for Chiari I malformations. Neurosurgery 2006; 59:140-6; discussion 140-6. [PMID: 16823310 DOI: 10.1227/01.neu.0000219841.73999.b3] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Many patients with symptomatic Chiari I malformations experience symptom recurrence after surgical decompression. Identification of predictors of outcome is needed to better select patients most likely to benefit from surgical intervention. We examined whether or not cerebrospinal fluid (CSF) flow dynamics assessed by cine phase contrast magnetic resonance imaging could independently predict response to posterior fossa decompression for Chiari I malformations. METHODS Pre- and postoperative CSF flow dynamics were assessed by cine phase-contrast magnetic resonance imaging in 130 consecutive patients receiving posterior fossa decompression for a Chiari I malformation between 1997 and 2003. CSF flow was classified as "abnormal" if biphasic flow was either absent or decreased through the aqueduct, fourth ventricle and its outlets, the foramen magnum, or ventral or dorsal to the cervical spinal cord. If no evidence of decreased flow was noted, CSF flow was classified as "normal." The association between preoperative CSF flow dynamics, all recorded variables, and long-term outcome was assessed using multivariate proportional hazards regression analysis. RESULTS All patients had tonsil herniation more than 5 mm below the foramen magnum (average, 11 +/- 5 mm). Abnormal hindbrain CSF flow was observed in 81% of patients (43% complete obstruction, 38% reduced flow). Normal CSF flow was observed in 19% of patients. In multivariate analysis, patients with normal preoperative hindbrain CSF flow were 4.8-fold more likely to experience symptom recurrence after surgery (relative risk, 4.85; 95% confidence interval, 1.88-12.5; P < 0.001) regardless of degree of tonsillar ectopia or presence of syringomyelia. Isolated frontal headache (relative risk, 4.16; 95% confidence interval, 1.7-9.8; P < 0.05) and scoliosis (relative risk, 9.2; 95% confidence interval, 1.7-10.5; P < 0.001) also were independent risk factors for symptom recurrence. CONCLUSION Normal preoperative hindbrain CSF flow was an independent risk factor for treatment failure after decompression for Chiari I malformation regardless of the degree of tonsillar ectopia. Cine phase-contrast magnetic resonance imaging may be a valuable tool in identifying patients who are less likely to respond to surgical decompression for Chiari I malformation.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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McGirt MJ, Nimjee SM, Fuchs HE, George TM. Relationship of Cine Phase-Contrast MRI to Outcome after Decompression for Chiari I Malformation. Neurosurgery 2006; 59:140-146. [PMID: 28180603 DOI: 10.1227/01.neu.0000243293.46319.35] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2005] [Accepted: 02/10/2006] [Indexed: 11/19/2022] Open
Affiliation(s)
- Matthew J McGirt
- Pediatric Neurosurgery Service, Division of Neurosurgery, Duke University Medical Center, BOX 3708, Duke Medical Center, Durham, NC 27710
| | - Shahid M Nimjee
- Pediatric Neurosurgery Service, Division of Neurosurgery, Duke University Medical Center, BOX 3708, Duke Medical Center, Durham, NC 27710
| | - Herbert E Fuchs
- Pediatric Neurosurgery Service, Division of Neurosurgery, Duke University Medical Center, BOX 3708, Duke Medical Center, Durham, NC 27710
| | - Timothy M George
- Pediatric Neurosurgery Service, Division of Neurosurgery, Duke University Medical Center, BOX 3708, Duke Medical Center, Durham, NC 27710
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McGirt MJ, Nimjee SM, Floyd J, Bulsara KR, George TM. Correlation of cerebrospinal fluid flow dynamics and headache in Chiari I malformation. Neurosurgery 2006; 56:716-21; discussion 716-21. [PMID: 15792510 DOI: 10.1227/01.neu.0000156203.20659.14] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2004] [Accepted: 11/06/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The management of patients with a Chiari I malformation who present with headaches alone remains unclear. We studied the cerebrospinal fluid (CSF) flow dynamics of Chiari I malformation patients presenting with headaches alone so as to identify headache types that are associated with CSF flow obstruction versus those that may be unrelated to Chiari I malformations. METHODS Preoperative cine phase-contrast magnetic resonance imaging of the craniocervical junction was prospectively performed in 33 patients presenting with headaches alone and a Chiari I malformation (tonsillar ectopia >5 mm below the foramen magnum). Headaches were classified as frontal, occipital, or generalized. CSF flow dynamics were then prospectively compared with presenting symptomatology. A subgroup of 17 patients underwent surgical decompression of the Chiari I malformations. RESULTS Patients with frontal or generalized headaches were 10-fold less likely to demonstrate obstructed CSF flow (odds ratio, 0.10; 95% confidence interval, 0.02-0.52) and 8-fold less likely to have tonsillar descent greater than 7 mm (odds ratio, 0.12; 95% confidence interval, 0.03-0.62) compared with patients with occipital headaches. Adjusting for degree of tonsillar herniation in multivariate analysis, frontal and generalized headaches remained independently associated with nonobstructed CSF flow pathological findings, whereas occipital headaches remained associated with obstructed CSF flow independent of tonsil location (odds ratio, 5.84; 95% confidence interval, 1.01-34.28). In the surgical group, all patients with obstructed CSF flow did well compared with the group with normal flow, regardless of headache location. CONCLUSION Regardless of the degree of tonsillar ectopia, occipital headaches were strongly associated with hindbrain CSF flow abnormalities, whereas frontal and generalized headaches were not. Normal magnetic resonance imaging-cine CSF flow in the setting of a Chiari I malformation and frontal headaches alone suggests that frontal headaches are not pathologically or causatively associated with the Chiari I malformation in the vast majority of patients. Frontal headaches with obstructed flow may respond to surgery.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurosurgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
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Danish SF, Samdani A, Hanna A, Storm P, Sutton L. Experience with acellular human dura and bovine collagen matrix for duraplasty after posterior fossa decompression for Chiari malformations. J Neurosurg 2006; 104:16-20. [PMID: 16509475 DOI: 10.3171/ped.2006.104.1.16] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Posterior fossa decompression with duraplasty is routinely used for the treatment of Chiari malformations. It has been traditionally believed that this procedure requires a watertight seal with primary closure of the dura with either pericranium or allograft. In this study, the authors evaluated two synthetic dural substitutes in this patient population for feasibility of use and identification of perioperative morbidity. METHODS The authors evaluated 56 patients who underwent duraplasty with a synthetic collagen matrix (DuraGen) after suboccipital craniectomy and C-1 laminectomy, and 45 patients in whom the dural closure involved acellular human dermis (AlloDerm). Patients in both groups were assessed for the presence of a pseudomeningocele, wound infection, cerebrospinal fluid (CSF) leak, and the need for repeated operation either for wound revision or the placement of a ventriculoperitoneal shunt. Operative times for which DuraGen duraplasty was used were compared with those for AlloDerm closure. In the DuraGen group, complications included five pseudomeningoceles (8.9%), two wound infections (3.6%), one CSF leak (1.8%), and four repeated operations (three shunt revisions and one reexploration; 7.1%) in nine patients. In the AlloDerm group, there were five pseudomeningoceles (11.1%), one wound infection (2.2%), one CSF leak (2.2%), and two repeated operations (two shunt revisions; 4.4%) in seven patients. The operative time associated with DuraGen was significantly shorter than that of duraplasty that required closure with sutures (92 minutes compared with 128 minutes, p < 0.01). CONCLUSIONS The synthetic dural substitutes DuraGen and AlloDerm provide a suitable alternative duraplasty with comparable complication rates. DuraGen requires a significantly shorter operative time than AlloDerm.
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Affiliation(s)
- Shabbar F Danish
- Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania, USA.
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Attal N, Bouhassira D. Chapter 47 Pain in syringomyelia/bulbia. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:705-713. [PMID: 18808869 DOI: 10.1016/s0072-9752(06)80051-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Davids JR, Chamberlin E, Blackhurst DW. Indications for magnetic resonance imaging in presumed adolescent idiopathic scoliosis. J Bone Joint Surg Am 2004; 86:2187-95. [PMID: 15466727 DOI: 10.2106/00004623-200410000-00009] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of magnetic resonance imaging has led to the diagnosis of abnormalities of the central nervous system associated with apparent idiopathic scoliosis. The indications for magnetic resonance imaging for presumed adolescent idiopathic scoliosis have not been established. METHODS One thousand, two hundred and eighty children with presumed adolescent idiopathic scoliosis were evaluated over a ten-year period. Magnetic resonance imaging of the central nervous system (brainstem and spinal cord) was performed for specific patients, on the basis of the presence of selected indicators determined from the clinical history, physical examination, and plain radiographic examination of the spine. The medical records were reviewed to determine the specific indicators, the results of the imaging studies, and the subsequent treatment. RESULTS Magnetic resonance imaging was ordered for 274 (21%) of the 1280 children who were evaluated. Abnormal findings were seen in twenty-seven (10%) of the 274 patients who underwent imaging, or 2% of the entire cohort. The most valuable single indicator of an abnormal finding on magnetic resonance imaging was absence of thoracic apical segment lordosis: eight of thirty-nine patients with that indicator had an abnormal finding on magnetic resonance imaging. The optimal diagnostic yield for a single category of indicators occurred when an atypical curve pattern was the only indicator: six of fifty-eight patients in whom this was the case had an abnormal finding on magnetic resonance imaging. None of the twenty children in whom pain was the only indicator category had an abnormal imaging study. The optimal diagnostic yield occurred when both an atypical curve pattern and neurological indicators were present: thirteen (25%) of fifty-three patients in whom this was the case had an abnormal finding on magnetic resonance imaging. Thirteen of the twenty-seven patients received surgical treatment for the abnormality of the central nervous system revealed by the imaging. CONCLUSIONS The correct use of diagnostic tests is an important component of effective medical practice. An abnormality of the central nervous system is present in approximately 10% of patients with presumed adolescent idiopathic scoliosis in whom only subtle abnormalities are identified on the basis of the clinical history, physical examination, or radiographic examination. Knowledge of the diagnostic value of the specific clinical indicators, considered individually and in combination, can help the clinician to determine more effectively when advanced imaging of the central nervous system should be performed.
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Affiliation(s)
- Jon R Davids
- Motion Analysis Laboratory, Shriners Hospital for Children, 950 West Faris Road, Greenville, SC 29605, USA.
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Attal N, Parker F, Tadié M, Aghakani N, Bouhassira D. Effects of surgery on the sensory deficits of syringomyelia and predictors of outcome: a long term prospective study. J Neurol Neurosurg Psychiatry 2004; 75:1025-30. [PMID: 15201364 PMCID: PMC1739115 DOI: 10.1136/jnnp.2003.026674] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To quantify the effects of surgery on the thermal deficits of syringomyelia and assess the predictors for such effects. METHODS The subjects were 16 consecutive patients (12 men, 4 women; mean (SD) duration of sensory symptoms, 5.1 (4.5) years) presenting with the typical symptoms of syringomyelia related to Chiari I malformation or trauma, and requiring surgical treatment. They were evaluated before surgery, then at six months and two years. Sensory evaluation included determination of the extent of thermal deficits and quantitative assessment of thermal, mechanical, vibration detection, and pain thresholds. Neuropathic pain intensity was evaluated on visual analogue scales. Magnetic resonance imaging was done before and after surgery to measure syrinx dimensions. RESULTS The magnitude and extent of thermal deficits improved in a subgroup of patients and this was best predicted by the duration of sensory symptoms: patients operated on less than two years after the onset of their symptoms tended to improve, while those operated on later were stabilised or deteriorated slightly. The effect of surgery on thermal deficits was correlated with the duration of sensory symptoms. Surgery also affected vibration deficits in patients with the Chiari malformation, neuropathic pain on effort, and syrinx dimensions. CONCLUSIONS The duration of sensory deficits is the best predictive factor of the efficacy of surgery for the thermal symptoms of syringomyelia. Early surgery is required if these deficits are to be minimised.
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Affiliation(s)
- N Attal
- INSERM E-332, Centre d'Evaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne-Billancourt, France.
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Kyoshima K, Kuroyanagi T, Toriyama T, Takizawa T, Hirooka Y, Miyama H, Tanabe A, Oikawa S. Surgical experience of syringomyelia with reference to the findings of magnetic resonance imaging. J Clin Neurosci 2004; 11:273-9. [PMID: 14975416 DOI: 10.1016/j.jocn.2003.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2002] [Accepted: 02/19/2003] [Indexed: 10/26/2022]
Abstract
We present our surgical experience of 20 patients with syringomyelia, who were divided into two groups based on the findings of magnetic resonance (MR) imaging: a "non-visible cisterna magna" group, in which MR imaging did not reveal cerebrospinal fluid (CSF) in the cisterna magna, and a "visible cisterna magna" group. Patients with non-visible cisterna magna were associated with Chiari malformation (14 patients) or tight cisterna magna (4 patients) and underwent craniocervical decompression. Intradural exploration was performed when CSF movement in the cisterna magna or CSF outflow from the fourth ventricle appeared to be insufficient. It is important to confirm CSF outflow from the foramen of Magendie. Patients with visible cisterna magna were associated with tuberculous meningitis (2 patients) and underwent shunting procedures. Postoperatively, improvement in symptoms and a reduction in syrinx size were demonstrated in all patients except one. Two patients experienced recurrence of symptoms and syrinx dilatation.
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Affiliation(s)
- Kazuhiko Kyoshima
- Department of Neurosurgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
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Nakamura M, Chiba K, Nishizawa T, Maruiwa H, Matsumoto M, Toyama Y. Retrospective study of surgery-related outcomes in patients with syringomyelia associated with Chiari I malformation: clinical significance of changes in the size and localization of syrinx on pain relief. J Neurosurg Spine 2004; 100:241-4. [PMID: 15029911 DOI: 10.3171/spi.2004.100.3.0241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Pain is one of the major symptoms in patients with syringomyelia; however, its origin is not fully understood, and postoperative improvement of pain is difficult to predict. The objectives of this study were to assess the surgery-related results obtained in patients who underwent treatment for syringomyelia associated with Chiari I malformation, particularly related to pain status, and to identify factors that may influence improvement in postoperative pain by comparing pre- and postoperative magnetic resonance (MR) imaging findings.
Methods. The correlation between pre- and postoperative changes in the size and the location of the syrinx and pain improvement was investigated in 25 patients. The shapes of the syringes were classified into three types: central, enlarged, and deviated. In most cases in which the syrinx deviated toward the posterolateral aspect of the spinal cord at the level corresponding to dermatomal distribution of preoperative pain, the lesion remained at the same position postoperatively, and improvement in pain was poor. On the other hand, enlarged-type syringes were the most frequently observed prior to surgery, exhibited diverse changes postoperatively, and improvement in pain status was difficult to predict. When postoperative MR imaging revealed a transformation to the deviated type, poor pain improvement was noted.
Conclusions. Neurons in the dorsal horn were thought to be involved in the development of pain as a result of the deafferentiation mechanism in cases of syringomyelia.
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Affiliation(s)
- Masaya Nakamura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.
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Abstract
More than a quarter of spinal cord injured patients develop syringes and many of these patients suffer progressive neurological deficits as a result of cyst enlargement. The mechanism of initial cyst formation and progressive enlargement are unknown, although arachnoiditis and persisting cord compression with disturbance of cerebrospinal fluid flow appear to be important aetiological factors. Current treatment options include correction of bony deformity, decompression of the spinal cord, division of adhesions, and shunting. Long-term improvement occurs in fewer than half of patients treated. Imaging evidence of a reduction in syrinx size following treatment does not guarantee symptomatic resolution or even prevention of further neurological loss. A better understanding of the causal mechanisms of syringomyelia is required to develop more effective therapy.
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Affiliation(s)
- A R Brodbelt
- Prince of Wales Medical Research Institute, University of New South Wales, NSW, Randwick, Australia
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Akay KM, Gönül E, Ocal E, Timurkaynak E. The initial treatment of meningocele and myelomeningocele lesions in adulthood: experiences with seven patients. Neurosurg Rev 2003; 26:162-7. [PMID: 12845543 DOI: 10.1007/s10143-002-0230-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2001] [Accepted: 01/22/2002] [Indexed: 10/22/2022]
Abstract
This is a retrospective study of patients having undergone surgical treatment of spina bifida cystica (SBC) lesions in adulthood. The objectives were to assess the clinical, radiological, and surgical characteristics of SBC lesions in adults. There is almost no study assessing these characteristics. Seven adult male patients with SBC lesions, ages between 20 and 23 (mean 21.1), had their primary evaluations between 1995 and 1999 in the Military Hospital, Yzmir, and Gülhane Military Medical Academy, Ankara. A temporary cerebrospinal fluid leak in the patient with the thoracic lesion and a temporary partial urinary incontinence in the patient with the lumbosacral lesion occurred. The most common preoperative complaint was low back pain. This improved in three of four patients (75%) but did not disappear. Although it is rare, an adult with an untreated SBC is a possible entity. These lesions should be included in the differential diagnosis of dorsal midline lesions in adults. Even though they appear as a simple spinal meningocele clinically, preoperative MR imaging and CT are necessary and helpful in the precise diagnosis and surgical planning.
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Affiliation(s)
- Kamil Melih Akay
- Department of Neurosurgery, Gülhane Military Medical Academy, 06010 Ankara, Turkey.
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Abstract
BACKGROUND Chiari type I malformations (Chiari I) are congenital deformities where caudal migration of the cerebellar tonsils through the foramen magnum compresses the cerebellum and cervicomedullary junction (lower brainstem and upper cervical spinal cord). Associations with chronic fatigue syndrome, fibromyalgia, orthostatic intolerance, and other neurologic syndromes have been proposed along with the current plethora of known symptoms of this disease process. In advanced cases, Chiari I malformations can lead to significant neurologic deficit and be the cause of permanent nervous system damage. REVIEW SUMMARY This article focuses on the clinical diagnosis and treatment of patients with Chiari I, including a discussion on the possible mechanisms of Chiari I with a review of present diagnostic tests, indications for treatment, and appraisal of surgical outcome. CONCLUSIONS Future radiological advances and research will undoubtedly be directed to better understanding of the pathology of the Chiari malformation and more effective medical and surgical treatment.
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Affiliation(s)
- Joseph S Cheng
- Section of Spinal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2380, USA.
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Kyoshima K, Kuroyanagi T, Oya F, Kamijo Y, El-Noamany H, Kobayashi S. Syringomyelia without hindbrain herniation: tight cisterna magna. Report of four cases and a review of the literature. J Neurosurg 2002; 96:239-49. [PMID: 12450289 DOI: 10.3171/spi.2002.96.2.0239] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Idiopathic syringomyelia, which is not associated with any definite pathogenic lesions, has been treated mainly by shunting of the syrinx and rarely by craniocervical decompression. The authors report four cases of syringomyelia thought to be idiopathic syringomyelia but treated by craniocervical decompression with favorable results. Syringomyelia was present without hindbrain herniation. In such cases, the subarachnoid space anterior to the brainstem at the level of the foramen magnum is usually open but the cisterna magna is impacted by the tonsils, a condition the authors term "tight cisterna magna." All patients underwent foramen magnum decompression and C-1 laminectomy, and the outer layer of the dura was peeled off. Further intradural exploration was performed when outflow of cerebrospinal fluid (CSF) from the fourth ventricle was deemed to be insufficient. Postoperatively, improvement in symptoms and a reduction in syrinx size were demonstrated in three patients, and a reduction in ventricle size was shown in two. Syringomyelia associated with tight cisterna magna should not be classified as idiopathic syringomyelia; rather, it belongs to the category of organic syringomyelia such as Chiari malformation. A possible pathogenesis of cavitation is obstruction of the CSF outflow from the foramen of Magendie, and the cavity may be a communicating dilation of the central canal. Ventricular dilation may depend on the extent to which CSF drainage is impaired from the foramina of Luschka. These cavities may respond to craniocervical decompression if it results in sufficient CSF outflow from the foramen of Magendie, even in cases with concomitant hydrocephalus.
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Affiliation(s)
- Kazuhiko Kyoshima
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
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Ono A, Ueyama K, Okada A, Echigoya N, Yokoyama T, Harata S. Adult scoliosis in syringomyelia associated with Chiari I malformation. Spine (Phila Pa 1976) 2002; 27:E23-8. [PMID: 11805676 DOI: 10.1097/00007632-200201150-00011] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In adult syringomyelia associated with Chiari I malformation, the spinal deformity, the configuration of cerebellar tonsillar descent, the configuration of syrinx, and the clinical evaluation before and after surgery were investigated. OBJECTIVES To investigate the characteristics of the scoliosis in syringomyelia associated with Chiari I malformation. SUMMARY OF BACKGROUND DATA In previous studies, the clinical characteristics of pediatric scoliosis associated with syringomyelia have been reported. METHODS In this study, 42 patients with syringomyelia were treated. All the patients were 20 years of age or older. They were divided into three groups: Group 1 comprising those without scoliosis, Group 2 composed of those with scoliosis of 10 degrees or more but less than 20 degrees, and Group 3 consisting of those with scoliosis of 20 degrees or more. Investigations conducted with the three groups included determining the curve patterns of scoliosis, the degree of thoracic kyphosis, the configuration of cerebellar tonsillar descent, the configuration of syrinx, the morbidity period, and the clinical evaluation before and after surgery. RESULTS There were 12 patients in Group 1, 21 patients in Group 2, and 9 patients in Group 3. The concomitant rate of adult syringomyelia with scoliosis was 71.4%. As scoliosis advanced, the kyphotic angle also increased. The concordance in laterality between the cerebellar tonsil and curve convex was 70%. Findings showed that the more advanced the scoliosis was, the more aggravated the neurologic symptoms were, and the poorer the surgical outcomes tended to be. CONCLUSIONS In adult syringomyelia with scoliosis, the morbidity period is long, the syrinx is long, the neurologic symptoms are aggravated, and the surgical outcomes tend to be poor.
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Affiliation(s)
- Atsushi Ono
- Department of Orthopaedics Surgery, Hirosaki University School of Medicine, Japan.
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Iwasaki Y, Hida K, Koyanagi I, Abe H. Reevaluation of syringosubarachnoid shunt for syringomyelia with Chiari malformation. Neurosurgery 2000; 46:407-12; discussion 412-3. [PMID: 10690730 DOI: 10.1097/00006123-200002000-00026] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the effectiveness of syringosubarachnoid (S-S) shunting for syringomyelia with Chiari malformation. The authors describe the technical methods of performing the S-S shunt and the clinical results, including shunt malfunction. METHODS Forty-nine patients underwent S-S shunting. These patients were divided into three groups according to differences in the surgical technique used. Group I patients underwent laminectomy plus midline myelotomy and had a shunt tube placed in the dorsal subarachnoid space. Group II patients underwent laminectomy plus dorsal root entry zone myelotomy and had a shunt tube placed in the dorsolateral subarachnoid space. Group III patients underwent hemilaminectomy plus dorsal root entry zone myelotomy and had a shunt tube placed in the ventrolateral subarachnoid space. RESULTS Clinical results were generally satisfactory, especially in terms of pain relief, in all three groups. However, 10 patients among Groups I and II required follow-up surgery because of shunt problems; no second surgery was necessary for any patient in Group III. CONCLUSION The S-S shunt was very effective in deflating the syrinx, and the clinical results were satisfactory. Therefore, even though foramen magnum decompression is a very effective treatment, S-S shunting should be reevaluated and not rejected; it should be considered as one of the major surgical options. To prevent the possibility of cord injury by myelotomy or shunt malfunction, the dorsal root entry zone should be selected as the myelotomy site, and the shunt tube should be inserted into the ventral subarachnoid space at the cervical level.
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Affiliation(s)
- Y Iwasaki
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Caldarelli M, Di Rocco C, La Marca F. Treatment of hydromyelia in spina bifida. SURGICAL NEUROLOGY 1998; 50:411-20. [PMID: 9842864 DOI: 10.1016/s0090-3019(97)00457-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cavitation of the spinal cord (hydrosyringomyelia) seems to be common in spina bifida patients, although the overall clinical and radiological incidence has very rarely been analyzed. The real incidence of the condition is, in fact, difficult to assess as patients with this complication may remain relatively asymptomatic. The mechanisms accounting for the occurrence of hydrosyringomyelia in myelodysplasia are still a subject of debate. Similarly, the indications for the surgical treatment are still to be defined and its results to be assessed. METHODS In this study, 142 patients with spina bifida were screened with magnetic resonance imaging (MRI) to determine the incidence of hydromyelia. Thirty-two patients presented a cavitating lesion on MRIs of which 18 were not a cause of symptoms and 14 were. Clinical characteristics of the lesions and their correlation to the radiological picture were analyzed. All the symptomatic children underwent surgical treatment. Outcomes were evaluated and correlated also with the MRI findings. RESULTS A correlation between the presence of symptomatology and the extension and/or dilation of the hydromyelia was observed. A significant relationship between the presence of symptoms and adequate control of associated hydrocephalus was also noted. No correlation was observed between the presence of hydromyelia and the level of the myelomeningocele or the degree of ventricular dilation in those cases that presented with hydrocephalus. The mean age at hydromyelia diagnosis for all patients affected was 3.9 years and, in particular, 4 years for those patients who presented with symptoms. A total of 15 operations were performed in the 14 symptomatic patients. Seven direct procedures were carried out to drain the hydromyelia: five hydroperitoneal shunt insertions and two hydrosubarachnoid shunting procedures. Eight indirect treatments were performed to eliminate the filling mechanism of the hydromyelia: five posterior fossa decompressions, two ventriculoperitoneal shunt revisions, and one spinal cord untethering procedure with terminal syringostomy. All patients improved postoperatively, except one who remained clinically stable at follow-up. This patient had undergone a posterior fossa decompression followed by a hydrosubarachnoid shunting procedure. CONCLUSIONS The incidence of syringohydromyelia is actually higher than that reported in the literature, although not all lesions are symptomatic. The radiological picture may be helpful in planning a more careful follow-up program for patients theoretically at risk for neurologic deterioration. Surgical treatment is possible with good results in the majority of cases and should be carried out as soon as possible before further deterioration occurs. Not all symptoms respond equally to treatment. Generally, improvement of clinical status correlates with a reduction in size of the hydromyelic cavity on MRI.
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Affiliation(s)
- M Caldarelli
- Department of Neurosurgery, Catholic University Medical School, Rome, Italy
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Emery E, Hort-Legrand C, Hurth M, Metral S. [Correlations between clinical deficits, motor and sensory evoked potentials and radiologic aspects of MRI in malformative syringomyelia. 27 Cases]. Neurophysiol Clin 1998; 28:56-72. [PMID: 9562999 DOI: 10.1016/s0987-7053(97)89578-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Twenty-seven patients (15 males, 12 females, age range: 16-66 years) were admitted for malformative syringomyelia diagnosed on MRI with measures of syrinx extending and transverse diameter. Posterior tibial somatosensory evoked potentials (PT SEP), median (M SEP), trigeminal (V3 SEP), brain stem auditory evoked potentials (BEAP), cortical and cervical motor evoked potentials (MEP) were correlated with clinical and radiological findings. SEP abnormalities were not correlated with the duration of symptoms. PT SEP proved to be more sensitive than M SEP. MEP abnormalities were very frequent (87% of the cases), even without clinical motor deficits. Trigeminal SEP were more sensitive than BEAP which were not related to the presence of associated cranio-vertebral abnormalities. We found no significative relationship between clinical and radiological results. Moreover, there was a positive relationship between electrophysiological and radiological results: abnormal trigeminal SEP were detected in 85% of the patients with high cervical syringomyelia. In all cases, trigeminal SEP and MEP should be done in association with M and PT SEP as both of them detect subclinical evidence of spinal cord dysfunction in syringomyelia.
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Affiliation(s)
- E Emery
- Service de neurochirurgie, hôpital Beaujon, Clichy, France
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Bowen JD, Malanga GA. Spondylolysis associated with Arnold-Chiari malformation and syringomyelia. A report of two cases. Spine (Phila Pa 1976) 1997; 22:2458-63. [PMID: 9355230 DOI: 10.1097/00007632-199710150-00026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN This is a report of two cases. OBJECTIVE To document the occurrence and association of spondylolysis and Arnold-Chiari malformation Type I. SUMMARY OF BACKGROUND DATA The association of spinal dysraphism has been reported with Arnold-Chiari Type II, but not with Arnold-Chiari Type I. METHODS The senior author was involved in the care of these patients. All medical records, laboratory and radiologic investigations, and related literature were reviewed. RESULTS The presence of cephalic and caudal neuropore maldevelopment may be present in various combinations. The presence of spondylolysis, with or without spina bifida occulta, associated with Arnold-Chiari malformation type I and syringohydromyelia, is demonstrated. CONCLUSIONS In some patients, the presence of spondylolysis may represent a congenital anomaly and may be associated with cephalic neuropore maldevelopment, such as cerebromedullary malformation syndrome (i.e., Arnold-Chiari malformation Type I).
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Affiliation(s)
- J D Bowen
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
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Lund-Johansen M, Wester K. Syringomyelia treated with a nonvalved syringoperitoneal shunt: a follow-up study. Neurosurgery 1997; 41:858-64; discussion 864-5. [PMID: 9316047 DOI: 10.1097/00006123-199710000-00018] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Eighteen patients with syringomyelia received nonvalved syringoperitoneal shunts during the years 1987 through 1996. In 15 cases, the fistulae were multicompartmental, either separated by segments of normal cord or septated. METHOD Even in the multicystic cases, only one syringeal catheter was introduced, usually into the caudalmost cavity. Access to the fistula was obtained via a midline myelotomy, which was performed in an area at which the spinal cord overlying the fistula was at its thinnest. RESULTS The progressive clinical course of syringomyelia was arrested in all patients. Surgery resulted in improvement for 11 patients. Five patients remained unchanged without further progression. Two patients became worse as the result of new deficits caused by surgery. In four patients, the myelotomy lead to new but discrete sensory loss of minor importance. Postoperative magnetic resonance images showed a rapid and persistent collapse of all fistulae in all patients. CONCLUSIONS We conclude that syringoperitoneal shunting is favorable in patients with large fistulae. In patients with Chiari malformations, the procedure may be a second alternative to foramen magnum decompression.
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Affiliation(s)
- M Lund-Johansen
- Department of Neurosurgery, Haukeland Hospital, Bergen, Norway
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