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Pattisapu JV, Ackerman LL, Infinger LK, Maher CO, Quinsey C, Rocque BG, Silberstein H, Jackson EM, Jernigan S, Niazi T, Qaiser R, Raskin JS, Vachhrajani S, Bauer DF. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions. Neurosurgery 2023; 93:731-735. [PMID: 37646504 DOI: 10.1227/neu.0000000000002635] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Chiari malformation type I (CIM) diagnoses have increased in recent years. Controversy regarding the best operative management prompted a review of the literature to offer guidance on surgical interventions. OBJECTIVE To assess the literature to determine (1) whether posterior fossa decompression or posterior fossa decompression with duraplasty is more effective in preoperative symptom resolution; (2) whether there is benefit from cerebellar tonsillar resection/reduction; (3) the role of intraoperative neuromonitoring; (4) in patients with a syrinx, how long should a syrinx be observed for improvement before additional surgery is performed; and 5) what is the optimal duration of follow-up care after preoperative symptom resolution. METHODS A systematic review was performed using the National Library of Medicine/PubMed and Embase databases for studies on CIM in children and adults. The most appropriate surgical interventions, the use of neuromonitoring, and clinical improvement during follow-up were reviewed for studies published between 1946 and January 23, 2021. RESULTS A total of 80 studies met inclusion criteria. Posterior fossa decompression with or without duraplasty or cerebellar tonsil reduction all appeared to show some benefit for symptom relief and syrinx reduction. There was insufficient evidence to determine whether duraplasty or cerebellar tonsil reduction was needed for specific patient groups. There was no strong correlation between symptom relief and syringomyelia resolution. Many surgeons follow patients for 6-12 months before considering reoperation for persistent syringomyelia. No benefit or harm was seen with the use of neuromonitoring. CONCLUSION This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. In patients with CIM with or without syringomyelia, treatment options include bone decompression with or without duraplasty or cerebellar tonsil reduction. Improved syrinx resolution may potentially be seen with dural patch grafting. Symptom resolution and syrinx resolution did not correlate directly. Reoperation for a persistent syrinx was potentially beneficial if the syrinx had not improved 6 to 12 months after the initial operation. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions .
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Affiliation(s)
- Jogi V Pattisapu
- Pediatric Neurosurgery, University of Central Florida College of Medicine, Orlando , Florida , USA
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University Health, Indianapolis , Indiana , USA
| | - Libby Kosnik Infinger
- Department of Neurosurgery, Medical University of South Carolina (MUSC), Charleston , South Carolina , USA
| | - Cormac O Maher
- Department of Neurosurgery, Stanford Medicine, Palo Alto , California , USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina Chapel Hill, Chapel Hill , North Carolina , USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , Alabama , USA
| | - Howard Silberstein
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester , New York , USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Sarah Jernigan
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
| | - Toba Niazi
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami , Florida , USA
| | - Rabia Qaiser
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Shobhan Vachhrajani
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton , Ohio , USA
| | - David F Bauer
- Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston , Texas , USA
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Tran TM, Lee MS, McClelland CM. Downbeat nystagmus: a clinical review of diagnosis and management. Curr Opin Ophthalmol 2021; 32:504-514. [PMID: 34456290 DOI: 10.1097/icu.0000000000000802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN). RECENT FINDINGS Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies. SUMMARY DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic.
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Affiliation(s)
- Tu M Tran
- Department of Ophthalmology and Visual Neurosciences
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences
- Department of Neurology
- Department of Neurosurgery, University of Minnesota, Minneapolis, USA
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Wang K, Wu H, Fengzeng J, Zeng G. Opinion for different centers: surgical experience with Chiari malformation type I in children at Xuanwu Hospital, China. Childs Nerv Syst 2019; 35:1915-1919. [PMID: 31214817 DOI: 10.1007/s00381-019-04230-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 05/24/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the presenting symptoms, surgical strategy, and outcome in children with Chiari malformation type I (CM-I). METHODS The medical records of children who were diagnosed with CM-I under 14 years old and subsequently underwent surgery for CM-I between 2014 and 2018 were reviewed. The medical records for presentation, radiological image, surgical intervention, and outcome were evaluated. RESULTS Twelve children with CM-I and syringomyelia were included. All of the children were symptomatic. The most common presenting symptom was weakness, followed by scoliosis. All of them underwent posterior fossa decompression with/without duraplasty. Relief of preoperative pathologies and syringomyelia was experienced by all of them. CONCLUSIONS The presenting symptoms of CM-I in children may be neurological deficits and scoliosis, which have a relationship with syringomyelia. Early recognition and a tailored operative procedure of CM-I in children could lead to good outcomes. Additional therapies for syringomyelia and scoliosis could be avoided.
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Affiliation(s)
- Kai Wang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Jian Fengzeng
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.
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