Posterior Fossa Decompression With or Without Duraplasty in the Treatment of Paediatric Chiari Malformation Type I: A Literature Review and Meta-Analysis

Neurosurgery ◽  
2019 ◽  
Vol 84 (5) ◽  
pp. E270-E270 ◽  
Author(s):  
Susan I Honeyman ◽  
William Warr
Keyword(s):  
Posterior Fossa ◽  
Current Literature ◽  
Chiari Malformation ◽  
Statistical Power ◽  
Definitive Treatment ◽  
Current Evidence ◽  
Csf Leak ◽  
Structural Abnormality ◽  
Posterior Fossa Decompression ◽  
Type I

Abstract INTRODUCTION Chiari malformation I (CM-1) is a posterior fossa structural abnormality, characterized by caudal displacement of cerebellar tonsils, through the foramen magnum. Posterior fossa decompression (PFD), involving a suboccipital craniectomy and C1 laminectomy, remains the definitive treatment. Both PFD alone (PFDO) and PFD with additional duraplasty (PFDD) are used in surgical practices. This review evaluates the current literature comparing outcomes of CM-1 treatment using PFDO and PFDD. METHODS A literature search of EMBASE and MEDLINE was conducted. References from January 1980 to January 2018 were retrieved. Only papers containing original data, comparing the use of PFDD and PFDO in paediatric CM-1 patients, were included. RESULTS Eighteen relevant papers were identified, with a resulting cohort of 4030 patients, 46.1% underwent PFDD and 53.9% PFDO. PFDD was associated with 60 min longer mean operation duration, and longer mean hospital stays by 0.7 d. PFDD provided greater symptomatic improvement (OR: 2.13; 95% CI: 1.31-3.45; P = .002). However, PFDD was also associated with increased postoperative complications (OR: 1.71, 95% CI: 1.41-2.08; P = .0001), in particular CSF leak and meningitis. PFDD was not significantly associated with incidence of syrinx improvement or revision surgery, relative to PFDO. CONCLUSION From the current literature, PFDD is associated with greater clinical improvement but higher risk of postsurgical complications, in comparison to PFDO for the treatment of paediatric CM-1. The requirement for a large cohort prospective study, adjusting for case-mix, which evaluates the relative efficacy of these 2 techniques have been identified. Current evidence is low quality, with limited statistical power.

Outcomes for various dural graft materials after posterior fossa decompression with duraplasty for Chiari malformation type I: a systematic review and meta-analysis

2021 ◽  
pp. 1-14
Author(s):  
Alexander T Yahanda ◽  
Laura E Simon ◽  
David D. Limbrick
Keyword(s):  
Posterior Fossa ◽  
Systematic Reviews ◽  
Revision Surgery ◽  
Chiari Malformation ◽  
Meta Analysis ◽  
Current Evidence ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Chiari Malformation Type I ◽  
Dural Graft

OBJECTIVE Posterior fossa decompression with duraplasty (PFDD) is often used for Chiari malformation type I (CM-I), but outcomes associated with different dural graft materials are not well characterized. In this meta-analysis, the authors examined complication rates and outcomes after PFDD for CM-I for autografts and four types of nonautologous grafts. METHODS A literature search of numerous electronic databases (Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, NHS Economic Evaluation Database, and ClinicalTrials.gov) was performed to identify articles detailing complications for dural graft materials after PFDD. Whenever available, data were also extracted regarding the need for revision surgery, symptom changes after PFDD, and syrinx size changes after PFDD. All searches were compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Institute of Medicine, Standards for Systematic Reviews, Cochrane Handbook for Systematic Reviews of Interventions, and Peer Review of Electronic Search Strategies guidelines. There were no exclusion criteria based on patient age or presence or absence of syringomyelia. RESULTS The current evidence surrounding outcomes for various dural graft materials was found to be of low or very low quality. Twenty-seven studies were included, encompassing 1461 patients. Five types of dural graft materials were included: autograft (n = 404, 27.6%), synthetic (n = 272, 18.6%), bovine pericardium (n = 181, 12.4%), collagen-based (n = 397, 27.2%), and allograft (n = 207, 14.2%). Autograft was associated with a significantly lower rate of pseudomeningocele compared to collagen-based grafts, allografts, and nonautologous grafts in aggregate. Autograft was also associated with the lowest rates of aseptic meningitis, infectious meningitis, and need for revision PFDD, though these associations did not reach statistical significance. No other graft comparisons yielded significant results. Autograft and nonautologous graft materials yielded similar rates of revision surgery and produced similar improvements in postoperative symptoms and syrinx size. CONCLUSIONS Autograft was the dural graft material that most frequently had the lowest rate of complications and was associated with significantly lower rates of pseudomeningocele compared to collagen-based graft, allograft, and nonautologous graft materials. Autografts and nonautologous grafts yielded similar outcomes for revision surgery, symptoms, and syrinx size. Large prospective studies comparing different graft materials are needed to accurately and precisely characterize outcomes for individual graft types.

Radiological and clinical associations with scoliosis outcomes after posterior fossa decompression in patients with Chiari malformation and syrinx from the Park-Reeves Syringomyelia Research Consortium

2020 ◽  
Vol 26 (1) ◽  
pp. 53-59 ◽  
Author(s):  
Jennifer M. Strahle ◽  
Rukayat Taiwo ◽  
Christine Averill ◽  
James Torner ◽  
Jordan I. Gewirtz ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Chiari Malformation ◽  
Craniocervical Junction ◽  
Curve Progression ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Younger Age ◽  
Curve Magnitude ◽  
The Mean

OBJECTIVEIn patients with Chiari malformation type I (CM-I) and a syrinx who also have scoliosis, clinical and radiological predictors of curve regression after posterior fossa decompression are not well known. Prior reports indicate that age younger than 10 years and a curve magnitude < 35° are favorable predictors of curve regression following surgery. The aim of this study was to determine baseline radiological factors, including craniocervical junction alignment, that might predict curve stability or improvement after posterior fossa decompression.METHODSA large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and a syrinx (≥ 3 mm in width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°) in patients who underwent posterior fossa decompression and who also had follow-up imaging.RESULTSOf 825 patients with CM-I and a syrinx, 251 (30.4%) were noted to have scoliosis present at the time of diagnosis. Forty-one (16.3%) of these patients underwent posterior fossa decompression and had follow-up imaging to assess for scoliosis. Twenty-three patients (56%) were female, the mean age at time of CM-I decompression was 10.0 years, and the mean follow-up duration was 1.3 years. Nine patients (22%) had stable curves, 16 (39%) showed improvement (> 5°), and 16 (39%) displayed curve progression (> 5°) during the follow-up period. Younger age at the time of decompression was associated with improvement in curve magnitude; for those with curves of ≤ 35°, 17% of patients younger than 10 years of age had curve progression compared with 64% of those 10 years of age or older (p = 0.008). There was no difference by age for those with curves > 35°. Tonsil position, baseline syrinx dimensions, and change in syrinx size were not associated with the change in curve magnitude. There was no difference in progression after surgery in patients who were also treated with a brace compared to those who were not treated with a brace for scoliosis.CONCLUSIONSIn this cohort of patients with CM-I, a syrinx, and scoliosis, younger age at the time of decompression was associated with improvement in curve magnitude following surgery, especially in patients younger than 10 years of age with curves of ≤ 35°. Baseline tonsil position, syrinx dimensions, frontooccipital horn ratio, and craniocervical junction morphology were not associated with changes in curve magnitude after surgery.

scholarly journals Syrinx resolution after posterior fossa decompression in patients with scoliosis secondary to Chiari malformation type I

2011 ◽  
Vol 21 (6) ◽  
pp. 1143-1150 ◽  
Author(s):  
Tao Wu ◽  
Zezhang Zhu ◽  
Jian Jiang ◽  
Xin Zheng ◽  
Xu Sun ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Chiari Malformation ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Chiari Malformation Type I

Comparison of posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation Type I in pediatric patients: a meta-analysis

2008 ◽  
Vol 2 (1) ◽  
pp. 42-49 ◽  
Author(s):  
Susan R. Durham ◽  
Kristina Fjeld-Olenec
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Treatment ◽  
Clinical Improvement ◽  
Posterior Fossa ◽  
Chiari Malformation ◽  
Meta Analysis ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Chiari Malformation Type I ◽  
Patient Age

Object Surgery for Chiari malformation Type I (CM-I) is one of the most common neurosurgical procedures performed in children, although there is clearly no consensus among practitioners about which surgical method is preferred. The objective of this meta-analysis was to compare the outcome of posterior fossa decompression with duraplasty (PFDD) and posterior fossa decompression without duraplasty (PFD) for the treatment of CM-I in children. Methods The authors searched Medline–Ovid, The Cochrane Library, and the conference proceedings of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons (2000–2007) for studies meeting the following inclusion criteria: 1) surgical treatment of CM-I; 2) surgical techniques of PFD and PFDD being reported in a single cohort; and 3) patient age < 18 years. Results Five retrospective and 2 prospective cohort studies involving a total of 582 patients met the criteria for inclusion in the meta-analysis. Of the 582 patients, 316 were treated with PFDD and 266 were treated with PFD alone. Patient age ranged from 6 months to 18 years. Patients undergoing PFDD had a significantly lower reoperation rate (2.1 vs 12.6%, risk ratio [RR] 0.23, 95% confidence interval [CI] 0.08–0.69) and a higher rate of cerebrospinal fluid–related complications (18.5 vs 1.8%, RR 7.64, 95% CI 2.53–23.09) than those undergoing PFD. No significant differences in either clinical improvement (78.6 vs 64.6%, RR 1.23, 95% CI 0.95–1.59) or syringomyelia decrease (87.0 vs 56.3%, RR 1.43, 95% CI 0.91–2.25) were noted between PFDD and PFD. Conclusions Posterior fossa decompression with duraplasty is associated with a lower risk of reoperation than PFD but a greater risk for cerebrospinal fluid–related complications. There was no significant difference between the 2 operative techniques with respect to clinical improvement or decrease in syringomyelia.

Patients with Chiari malformation Type I presenting with acute neurological deficits: case series

2011 ◽  
Vol 7 (3) ◽  
pp. 244-247 ◽  
Author(s):  
Chester K. Yarbrough ◽  
Alexander K. Powers ◽  
Tae Sung Park ◽  
Jeffrey R. Leonard ◽  
David D. Limbrick ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Posterior Fossa ◽  
Neurological Deficit ◽  
Chiari Malformation ◽  
Acute Onset ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Chiari Malformation Type I ◽  
Sensory Deficits ◽  
Operative Notes

Object A subset of patients with Chiari malformation Type I (CM-I) presented with acute onset of a neurological deficit. In this study the authors summarize their experience with these patients' clinical presentation, imaging results, timing of surgery, and outcome following decompression. Methods The authors reviewed clinical records, imaging studies, and operative notes from all patients undergoing posterior fossa decompression for CM-I at St. Louis Children's Hospital from 1990 to 2008. Of the 189 patients who underwent surgery, 6 were identified with the acute onset of a neurological deficit at presentation. Results All 6 children (age range 3–14 years, 3 boys and 3 girls) had either syringomyelia (5 patients) or T2 signal changes in the spinal cord (1 patient) and CM-I on initial MR imaging. Three patients presented after minor trauma (1 with paraparesis, 2 with sensory deficits). Three patients presented without a clear history of trauma (1 with abrupt onset of spontaneous dysphagia and ataxia, 2 with sensory deficits). Decompression was performed at a mean 7.7 ± 4.9 days after symptom onset (7.0 ± 1.6 days after neurosurgical evaluation). In 1 patient, symptoms had resolved by the time of surgery; in the remainder of the patients, clear improvements were noted within 2 weeks of surgery, with complete resolution of symptoms by 12 months postoperatively. Follow-up MR images were obtained in 4 patients, demonstrating improvement in the extent of the syrinx in each patient. Conclusions Children with CM-I and syringomyelia can develop acute spinal cord or bulbar deficits with relatively minor head or neck injuries. The prognosis for symptomatic improvement in the observed deficit is good, with each patient in our series showing resolution of deficits over time. However, based on this relatively limited experience, the authors suggest that patients who present with an acute neurological deficit and are found to have CM-I be managed with early posterior fossa decompression. Patients with CM-I and syringomyelia may be at higher risk of acute neurological deficit than those without a syrinx.

Complications following decompression of Chiari malformation Type I in children: dural graft or sealant?

2011 ◽  
Vol 8 (2) ◽  
pp. 177-183 ◽  
Author(s):  
Stephen R. Parker ◽  
Peggy Harris ◽  
Thomas J. Cummings ◽  
Timothy George ◽  
Herbert Fuchs ◽  
...  
Keyword(s):  
Aseptic Meningitis ◽  
Complication Rate ◽  
Chiari Malformation ◽  
Csf Leak ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Complication Rates ◽  
Chiari Malformation Type I ◽  
Dural Graft ◽  
Tissue Sealant

Object Posterior fossa decompression with duraplasty for Chiari malformation Type I (CM-I) is a common pediatric neurosurgery procedure. Published series report a complication rate ranging from 3% to 40% for this procedure. Historically, many dural substitutes have been used, including bovine grafts, human cadaveric pericardium, synthetic dura, and autologous pericranium. The authors hypothesized that a recently observed increase in complications was dependent on the graft used. Methods Between January 2004 and January 2008, 114 consecutive patients ≤ 18 years old underwent primary CM-I decompression using duraplasty. Records were retrospectively reviewed for short- and intermediate-term complications and operative technique, focusing on the choice of duraplasty graft with or without application of a tissue sealant. Results The average age of the patients was 8.6 years. The dural graft used was variable: 15 were treated with cadaveric pericardium, 12 with Durepair, and 87 with EnDura. Tisseel was used in 75 patients, DuraSeal in 12, and no tissue sealant was used in 27 patients. The overall complication rate was 21.1%. The most common complications included aseptic meningitis, symptomatic pseudomeningocele, or a CSF leak requiring reoperation. The overall complication rates were as follows: cadaveric pericardium 26.7%, Durepair 41.7%, and EnDura 17.2%; reoperation rates were 13%, 25%, and 8.1%, respectively. Prior to adopting a different graft product, the overall complication rate was 18.1%; following the change the rate increased to 35%. Complication rates for tissue sealants were 14.8% for no sealant, 18.7% for Tisseel, and 50% for DuraSeal. Nine patients were treated with the combination of Durepair and DuraSeal and this subgroup had a 56% complication rate. Conclusions Complication rates after CM-I decompression may be dependent on the dural graft with or without the addition of tissue sealant. The complication rate at the authors' institution approximately doubled following the adoption of a different graft product. Tissue sealants used in combination with a dural substitute to augment a duraplasty may increase the risk of aseptic meningitis and/or CSF leak. The mechanism of the apparent increased inflammation with this combination remains under investigation.

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