Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I

OBJECTIVEThe Chiari Severity Index (CSI) and points-based algorithm of Thakar et al. are two prognostic tools that have been developed to predict the likelihood of improvement after suboccipital decompression in adult patients with Chiari malformation type I (CM-I). This study aimed to externally validate and critically evaluate these algorithms in the interest of guiding the development of improved prediction systems.METHODSA consecutive cohort of CM-I patients undergoing suboccipital decompression between September 2006 and September 2018 were included. The CSI and Thakar point score were computed for all patients, and associations with improvement were analyzed. The ability of both prediction systems to predict improvement as measured by different Chicago Chiari Outcome Scale (CCOS) cutoffs was assessed using receiver operating curve analysis. Post hoc correlations between the algorithms and different CCOS subcomponents were also assessed.RESULTSThe surgical cohort was composed of 149 adult CM-I patients, of whom 39 (26%) had a syrinx. Most patients experienced improvement after surgery (80% CCOS ≥ 13; 96% CCOS ≥ 11). The proportion of patients improving decreased with increasing CSI, but the results were not statistically significant (p = 0.246). No statistically significant difference in the mean Thakar point score was identified between improved and nonimproved patients using both CCOS cutoffs (p = 0.246 for a cutoff of 13 and p = 0.480 for a cutoff of 11). The CSI had a poor ability in identifying improved patients at a CCOS cutoff of 13 (area under the curve [AUC] 0.582) and 11 (AUC 0.646). The Thakar point score similarly had poor discrimination at a cutoff of 13 (AUC 0.467) and 11 (AUC 0.646). Neither algorithm had significant correlation with any of the CCOS subcomponents except for CSI and nonpain symptom improvement (coefficient = −0.273, p = 0.001).CONCLUSIONSPreviously published algorithms failed to provide prediction value with regard to clinically meaningful improvement following suboccipital decompression in adult CM-I patients. Future models and practical scoring systems are still required to improve the decision-making process.

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Effect of symptomatic pseudomeningocele on improvement in pain, disability, and quality of life following suboccipital decompression for adult Chiari malformation Type I

Journal of Neurosurgery ◽

10.3171/2013.8.jns122106 ◽

2013 ◽

Vol 119 (5) ◽

pp. 1159-1165 ◽

Cited By ~ 14

Author(s):

Scott L. Parker ◽

Saniya S. Godil ◽

Scott L. Zuckerman ◽

Stephen K. Mendenhall ◽

Noel B. Tulipan ◽

...

Keyword(s):

Quality Of Life ◽

Chiari Malformation ◽

Type I ◽

Complication Rates ◽

Chiari Malformation Type I ◽

Long Term Outcome ◽

Pain Disability ◽

Patient Reported ◽

Suboccipital Decompression

Object Suboccipital decompression is a common procedure for patients with Chiari malformation Type I (CMI). Published studies have reported complication rates ranging from 3% to 40%, with pseudomeningocele being one of the most common complications. To date, there are no studies assessing the effect of this complication on long-term outcome. Therefore, the authors set out to assess the effect of symptomatic pseudomeningocele on patient outcomes following suboccipital decompression for CM-I. Methods The study comprised 50 adult patients with CM-I who underwent suboccipital craniectomy and C-1 laminectomy with or without duraplasty. Clinical presentation, radiological studies, operative variables, and complications were assessed for each case. Baseline and 1-year postoperative patient-reported outcomes were assessed to determine improvement in pain, disability, and quality of life. The extent of improvement was compared for patients with and without development of a postoperative symptomatic pseudomeningocele. Results A symptomatic pseudomeningocele developed postoperatively in 9 patients (18%). There was no difference with regard to clinical, radiological, or operative variables for patients with or without a postoperative pseudomeningocele. Patients without a pseudomeningocele had significant improvement in all 9 patient-reported outcome measures assessed. On the other hand, patients with pseudomeningocele only had significant improvement in headache (as measured on the Numeric Rating Scale) and headache-related disability (as measured on the Headache Disability Index) but no improvement in quality of life. Twenty-nine (71%) of 41 patients without a pseudomeningocele reported improvement in health status postoperatively compared with only 3 (33%) of 9 patients with a postoperative pseudomeningocele (p = 0.05). Conclusions Surgical management of CM-I in adults provides significant and sustained improvement in pain, disability, general health, and quality of life. Development of a postoperative symptomatic pseudomeningocele has lingering effects at 1 year, and it significantly diminishes the overall benefit of suboccipital decompression for CM-related symptoms. Further research is needed to accurately predict which patients may benefit from decompression alone without duraplasty.

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Time to Resolution of Symptoms After Suboccipital Decompression with Duraplasty in Children with Chiari Malformation Type I

World Neurosurgery ◽

10.1016/j.wneu.2018.06.073 ◽

2018 ◽

Vol 117 ◽

pp. e544-e551 ◽

Cited By ~ 5

Author(s):

Eveline Teresa Hidalgo ◽

Yosef Dastagirzada ◽

Cordelia Orillac ◽

Svetlana Kvint ◽

Emily North ◽

...

Keyword(s):

Chiari Malformation ◽

Type I ◽

Chiari Malformation Type I ◽

Suboccipital Decompression

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Suboccipital decompression for Chiari malformation–associated scoliosis: risk factors and time course of deformity progression

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/1/6/456 ◽

2008 ◽

Vol 1 (6) ◽

pp. 456-460 ◽

Cited By ~ 35

Author(s):

Frank J. Attenello ◽

Matthew J. McGirt ◽

April Atiba ◽

Muraya Gathinji ◽

Ghazala Datoo ◽

...

Keyword(s):

Cobb Angle ◽

Spinal Deformity ◽

Chiari Malformation ◽

Time Course ◽

Thoracolumbar Junction ◽

Type I ◽

Chiari Malformation Type I ◽

Severe Scoliosis ◽

Suboccipital Decompression ◽

Deformity Progression

Object Chiari malformation Type I (CM-I) is often associated with scoliosis. It remains unclear which subgroups of patients are most likely to experience progression of spinal deformity after cervicomedullary decompression. The authors' goal was to determine the time frame of curvature progression and assess which patient subgroups are at greatest risk for progression of spinal deformity after surgery. Methods The authors retrospectively reviewed the records of all pediatric patients with significant scoliosis in whom suboccipital decompression was performed to treat for CM-I during a 10-year period at a single academic institution. Clinical, radiological, and operative variables were assessed as independent factors for failure (worsening of scoliosis) by using a univariate regression analysis. Results Twenty-one children (mean age 9 ± 3 years; 4 male) underwent hindbrain decompression for CM-I–associated scoliosis and were followed for a mean of 39 months. All patients harbored a syrinx. Eight patients (38%) experienced improvement in scoliosis curvature, whereas 10 (48%) suffered a progression. Thoracolumbar junction scoliosis (p = 0.04) and failure of the syrinx to improve (p = 0.05) were associated with 5- and 4-fold respective increases in the likelihood of deformity progression. Each increasing degree of preoperative Cobb angle was associated with an 11% increase in the likelihood of scoliotic curve progression (p < 0.05). Conclusions Over one third of patients with CM-I–associated scoliosis will improve after cervicomedullary decompression alone. Cervicomedullary decompression is a good first-line option, particularly in children with concordant posterior fossa symptoms. Patients presenting with more severe scoliosis (increasing Cobb angle) or scoliosis that crosses the thoracolumbar junction may benefit from earlier orthopedic involvement and should be monitored regularly for curvature progression after cervicomedullary decompression. In cases in which there is a failure of the syrinx to show improvement after suboccipital decompression, the patients are also more likely to develop curvature progression.

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Resolution of syndromic craniosynostosis-associated Chiari malformation Type I without suboccipital decompression after posterior cranial vault release

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.11.peds11268 ◽

2012 ◽

Vol 9 (2) ◽

pp. 111-115 ◽

Cited By ~ 17

Author(s):

Michael R. Levitt ◽

Toba N. Niazi ◽

Richard A. Hopper ◽

Richard G. Ellenbogen ◽

Jeffrey G. Ojemann

Keyword(s):

Chiari Malformation ◽

Watchful Waiting ◽

Cranial Vault ◽

Type I ◽

Crouzon Syndrome ◽

Csf Flow ◽

Chiari Malformation Type I ◽

Syndromic Craniosynostosis ◽

Suboccipital Decompression

Chiari malformation Type I (CM-I) is associated with syndromic and nonsyndromic craniosynostosis in pediatric patients, and the surgical management of CM-I in such cases is controversial. Previous guidelines have recommended simultaneous cranial vault expansion and suboccipital decompression. However, spontaneous resolution of CM-I has been observed, and the combined procedure carries additional surgical risks. The authors report the case of a 6-month-old boy with Crouzon syndrome, CM-I, and a cervical syrinx who underwent posterior cranial vault release without suboccipital decompression. Imaging at the 3-month follow-up visit demonstrated complete resolution of the CM-I, improvement in CSF flow, and reduction in the size of the syrinx. This case suggests that up-front suboccipital decompression may not be necessary in patients with craniosynostosis and CM-I. A strategy of initial cranial vault release, followed by watchful waiting and radiographic surveillance, is proposed.

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Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation Type I

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/2/7/052 ◽

2008 ◽

Vol 2 (1) ◽

pp. 52-57 ◽

Cited By ~ 69

Author(s):

Matthew J. McGirt ◽

Frank J. Attenello ◽

Ghazala Datoo ◽

Muraya Gathinji ◽

April Atiba ◽

...

Keyword(s):

Chiari Malformation ◽

Intraoperative Ultrasonography ◽

Type I ◽

Tonsillar Herniation ◽

Chiari Malformation Type I ◽

Lower Cranial Nerve ◽

Cerebrospinal Fluid Flow ◽

Subarachnoid Spaces ◽

Suboccipital Decompression ◽

Symptom Recurrence

Object Indications for duraplasty in treatment of Chiari malformation Type I (CM-I) remain unclear. In the present study, the authors evaluate their surgical experience to determine whether intraoperative ultrasonography is effective in the selection of patients with CM-I who can be adequately treated with craniectomy alone without duraplasty. Methods The authors reviewed the records of 256 children who underwent first-time hindbrain decompression for CM-I. Craniectomy alone (without duraplasty) was performed when intraoperative ultrasonography suggested adequate decompression of the subarachnoid spaces ventral and dorsal to the tonsils after suboccipital craniectomy alone. Duraplasty was performed if intraoperative ultrasonography demonstrated persistent dural compression of the tonsils following craniectomy. Symptom recurrence as a function of time was compared between cases of duraplasty versus suboccipital decompression alone stratified by extent of tonsillar herniation. Results Duraplasty was performed in 140 patients (55%), and suboccipital decompression alone was performed in 116 patients (45%). Patients underwent follow-up for 29 ± 15 months. Symptoms included headache in 192 patients (75%) and lower cranial nerve and brainstem dysfunction in 68 (27%). In 38 patients (15%) there was tonsillar herniation rostral to the C-1 lamina, in 195 (76%) it extended between the C-1 and C-2 lamina, and in 23 patients (9%) there was herniation caudal to the lower border of the C-2 lamina. In children with tonsillar herniation caudal to C-1, ultrasonography-guided suboccipital decompression alone was associated with a 2-fold increase in the risk of symptom recurrence compared with those who also underwent duraplasty (p = 0.01). In children with tonsillar herniation rostral to C-1, outcome was equivalent between suboccipital decompression alone and duraplasty (p = 0.41). Conclusions In the setting of moderate-to-severe tonsillar CM-I, intraoperative ultrasonography demonstrating decompression of the subarachnoid spaces ventral and dorsal to the tonsils may not effectively select patients in whom bone decompression alone is sufficient. Duraplasty may be warranted in cases of tonsillar herniation that extends below the C-1 lamina regardless of intraoperative ultrasonography findings. More objective cerebrospinal fluid flow or volumetric measures may be needed intraoperatively to guide duraplasty in patients with more pronounced tonsillar herniation.

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Resolution of neurogenic arterial hypertension after suboccipital decompression for Chiari malformation

Journal of Neurosurgery ◽

10.3171/jns.2005.102.6.1147 ◽

2005 ◽

Vol 102 (6) ◽

pp. 1147-1150 ◽

Cited By ~ 4

Author(s):

Sait Naderi ◽

Feridun Acar ◽

Göksemin Acar ◽

Süleyman Men

Keyword(s):

Arterial Hypertension ◽

Chiari Malformation ◽

Experimental Studies ◽

Ventrolateral Medulla ◽

Vascular Compression ◽

Type I ◽

Chiari Malformation Type I ◽

Content Type ◽

Suboccipital Decompression ◽

Fine Print

✓ A Chiari malformation Type I may remain asymptomatic until the patient has reached adulthood and acute presentation of symptoms occurs. In several clinical and experimental studies it has been shown that essential hypertension is associated with vascular compression of the brainstem, particularly of the rostral ventrolateral medulla oblongata. Nevertheless, two cases of Chiari malformation and neurogenic arterial hypertension have been reported. In this article the authors describe a patient with Chiari malformation Type I and neurogenic arterial hypertension. A simple suboccipital decompression not only provided neurological improvement, but also led to resolution of the hypertension. In cases of Chiari malformation and concomitant neurogenic arterial hypertension careful preoperative clinical and neuroimaging assessments may reveal the cause of the arterial hypertension. Resolution of neurogenic arterial hypertension may be expected even in a case of simple suboccipital decompression.

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Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery

Scientific Reports ◽

10.1038/s41598-021-94179-4 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Artur Balasa ◽

Przemysław Kunert ◽

Tomasz Dziedzic ◽

Mateusz Bielecki ◽

Sławomir Kujawski ◽

...

Keyword(s):

Chiari Malformation ◽

Clinical Results ◽

Graft Fixation ◽

Fixation Method ◽

Decompression Surgery ◽

Type I ◽

Chiari Malformation Type I ◽

Suboccipital Decompression

AbstractSuboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.

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