Heterotopic ossification following suboccipital craniectomy decompression surgery for Chiari malformation type I: case report

Suboccipital craniectomy with duraplasty is a commonly performed procedure for children with symptomatic Chiari malformation type I (CM-I). Several dural substitutes are used for duraplasty, ranging from pericranium to synthetic materials. When available, autologous pericranium is often preferred due to its low cost, performance in obtaining a watertight closure, ease of suturing, and absence of immune reaction. Long-term follow-up data on the durability of various dural substitutes are lacking. The authors report a rare, long-term complication of duraplasty performed using an autologous pericranial graft, and they conduct a literature review of similar complications. Heterotopic ossification of an autologous pericranial graft is a rare complication of duraplasty. This dystrophic bone growth can be symptomatic due to compression of neural structures, and it requires reoperation for removal. Surgeons should consider this rare long-term complication in patients presenting with unusual symptoms after duraplasty with pericranium.

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PedsQL for Prediction of Postoperative Patient-Reported Outcomes following Chiari Decompression Surgery

Proceedings of IMPRS ◽

10.18060/23419 ◽

2019 ◽

Vol 2 (1) ◽

Author(s):

Shawyon Baygani, BS ◽

Kristin Zieles,BS ◽

Andrew Jea, MD, MHA

Keyword(s):

Chiari Malformation ◽

Patient Reported Outcomes ◽

Rank Test ◽

Decompression Surgery ◽

Type I ◽

Postoperative Patient ◽

Disability Score ◽

Chiari Malformation Type I ◽

Patient Reported

Background and Hypothesis: Chiari malformation type I (CM-I) is a common pediatric disorder in which the cerebellar tonsils herniate the foramen magnum with associated spinal symptoms. The purpose of this study is to determine if the preoperative Pediatric Quality of Life Inventory (PedsQL) score is predictive of intermediate-term PedsQL outcomes following Chiari decompression surgery. The utility of preoperative patient-reported outcomes (PROs) to postoperative PROs has been previously demonstrated in adult spine surgery. However, to our knowledge, there is currently no widely accepted tool to predict short-, intermediate-, or long-term outcomes after pediatric Chiari decompression surgery. Project Methods: A prospectively maintained database was retrospectively reviewed. Patients who underwent first-time decompression for symptomatic Chiari malformation were identified and grouped by their preoperative PedsQL scores: mild disability (score 80–100), moderate disability (score 60–80); and severe disability (score < 60). PedsQL outcomes were collected at 6-week, 3-month, and 6-month follow-up. Preoperative PedsQL subgroups were tested for an association with demographic, perioperative characteristics, and improvements between groups by one-way ANOVA, chi-square, or Wilcoxon signed rank test, where appropriate. Results: The postoperative patient- and parent-reported PedsQL values were significantly different between all three groups at 6-weeks, 3-months, and 6-months after surgery (p < 0.05), except at the 6-month timepoint for parent-reported outcomes (p = 0.111). Patients with higher preoperative disability demonstrated statistically significant greater improvements (compared to preoperative score) in parent-reported PedsQL at all timepoints after surgery, except at the 6-month parent-reported outcomes (p = 0.133). Conclusion: Patients with worse preoperative disability, as assessed by PedsQL, experienced lower absolute PedsQL scores at all timepoints after surgery but had greater improvement in short- and intermediate-term PROs. We conclude that PedsQL is an efficient and accurate tool that can quickly assess patient disability in the preoperative period and predict both short-term and long-term surgical outcomes.

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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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Resolution of Tachyarrhythmia Following Posterior Fossa Decompression Surgery for Chiari Malformation Type I

World Neurosurgery ◽

10.1016/j.wneu.2017.12.119 ◽

2018 ◽

Vol 111 ◽

pp. 154-156 ◽

Cited By ~ 3

Author(s):

Christopher Elia ◽

James Brazdzionis ◽

Vartan Tashjian

Keyword(s):

Posterior Fossa ◽

Chiari Malformation ◽

Decompression Surgery ◽

Posterior Fossa Decompression ◽

Type I ◽

Chiari Malformation Type I

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Ossified pseudomeningocele following Chiari decompression surgery in a patient with Kleeblattschädel deformity

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/2/9/203 ◽

2008 ◽

Vol 2 (3) ◽

pp. 203-206 ◽

Cited By ~ 5

Author(s):

Matthew R. Reynolds ◽

Spiros L. Blackburn ◽

Matthew D. Smyth

Keyword(s):

Genetic Basis ◽

Rare Complication ◽

Decompression Surgery ◽

Posterior Fossa Decompression ◽

Type I ◽

Lumbosacral Region ◽

Chiari Malformation Type I ◽

History Of ◽

Ossification Process ◽

Skull Deformity

The authors present the case of a 3-year-old child with Kleeblattschädel, or cloverleaf skull deformity, and a Chiari malformation Type I who developed an ossified pseudomeningocele after posterior fossa decompression. To their knowledge, this is the first report of a postoperative ossified pseudomeningocele in a patient with Kleeblattschädel and the only case of an ossified pseudomeningocele located outside the lumbosacral region. A genetic basis for the ossification process seems likely given the child's history of premature cranial suture closure. The authors draw attention to this rare complication and review the available body of literature on this topic.

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Nonoperative management of enlarging syringomyelia in clinically stable patients after decompression of Chiari malformation type I

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.12.peds20621 ◽

2021 ◽

Vol 28 (1) ◽

pp. 28-33

Author(s):

Nicholas S. Szuflita ◽

Tiffany N. Phan ◽

Jason H. Boulter ◽

Robert F. Keating ◽

John S. Myseros

Keyword(s):

Chiari Malformation ◽

Nonoperative Management ◽

Posterior Fossa Decompression ◽

Type I ◽

Chiari Malformation Type I ◽

Suboccipital Craniectomy ◽

Close Observation ◽

Lost To Follow Up ◽

Serial Mri

OBJECTIVE The authors aimed to describe the natural history and optimal management of persistent syringomyelia after suboccipital craniectomy for Chiari malformation type I (CM-I). METHODS A cohort of all patients who presented to a tertiary pediatric hospital with newly diagnosed CM-I between 2009 and 2017 was identified. Patients with persistent or worsened syringomyelia were identified on the basis of a retrospective review of medical records and imaging studies. The management of these patients and their clinical courses were then described. RESULTS A total of 153 children with CM-I and syringomyelia were evaluated between 2009 and 2017. Of these, 115 (68.8%) patients underwent surgical intervention: 40 patients underwent posterior fossa decompression (PFD) alone, 43 underwent PFD with duraplasty, and 32 underwent PFD with duraplasty and fourth ventricle stent placement. Eleven (7.19%) patients had increased syringomyelia on subsequent postoperative imaging. Three of these patients underwent revision surgery because of worsening scoliosis or pain, 2 of whom were lost to follow-up, and 4 were managed nonoperatively with close surveillance and serial MRI evaluations. The syringes decreased in size in 3 patients and resolved completely in 1 patient. CONCLUSIONS Persistent or worsened syringomyelia after CM-I decompression is uncommon. In the absence of symptoms, nonoperative management with close observation is safe for patients with persistent syrinx.

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Interlayer Dural Split Technique for Chiari I Malformation Treatment in Adult -- Technical Note

10.22541/au.161131388.84631753/v1 ◽

2021 ◽

Author(s):

Ioan Alexandru Florian ◽

Mihaela Maria Pop ◽

Teodora Larisa Timis ◽

Ioan Stefan Florian

Keyword(s):

Chiari Malformation ◽

Chiari I Malformation ◽

Sensory Loss ◽

Posterior Arch ◽

Type I ◽

Chiari Malformation Type I ◽

Control Series ◽

Suboccipital Craniectomy ◽

Chiari I ◽

Split Technique

Objective: To present an alternative surgical technique in treating cases of Chiari I Malformation with mild-to-moderate syringomyelia after decompressive suboccipital craniectomy: incising only the outer layer of the dura mater, then dissecting it from the inner layer without opening the latter. Methods and Results: We utilized this technique in a short series of three cases who were admitted in our department for mild symptoms such as intermittent headache and dissociated sensory loss in the upper limbs, caused by a Chiari Malformation Type I. The patients were placed in the sitting position. We performed a reduced median suboccipital craniectomy and resection of the posterior arch of C1 adapted to the level of tonsil descent, from a limited superior half to a complete resection. Afterwards, we incised the outer dural layer, while sparing the inner one. Using a fine dissector, we then split apart the outer and inner layers to the margin of the craniectomy. Through the transparency of the inner layer and the arachnoid, the cerebellum and the medulla were visible and pulsating. An autologous fascia duraplasty was then performed. The postoperative course was favorable in all cases, patients being discharged without any deficits and with complete symptom resolution. Conclusions: Interlayer dural split technique can be used effectively in treating symptomatic cases of type I Chiari malformation in adults, with mild-to-moderate syringomyelia. It is less invasive than opening the dura and possibly more effective than decompressive craniectomy and C1 laminectomy alone. This technique must be validated in a larger case-control series.

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Case Report: Acute obstructive hydrocephalus associated with infratentorial extra-axial fluid collection following foramen magnum decompression and durotomy for Chiari malformation type I

F1000Research ◽

10.12688/f1000research.7627.1 ◽

2016 ◽

Vol 5 ◽

pp. 33 ◽

Cited By ~ 3

Author(s):

Sunil Munakomi ◽

Binod Bhattarai ◽

Pramod Chaudhary

Keyword(s):

Chiari Malformation ◽

Fourth Ventricle ◽

Rare Complication ◽

Obstructive Hydrocephalus ◽

Fluid Collection ◽

Foramen Magnum ◽

Type I ◽

Foramen Magnum Decompression ◽

Chiari Malformation Type I ◽

Definitive Role

Acute obstructive hydrocephalus due to infratentorial extra-axial fluid collection (EAFC) is an extremely rare complication of foramen magnum decompression (FMD) and durotomy for Chiari malformation type I. Presence of infratentorial EAFC invariably causes obstruction at the level of the fourth ventricle or aqueduct of Silvius, thereby indicating its definitive role in hydrocephalus. Pathogenesis of EAFC is said to be a local arachnoid tear as a result of durotomy, as this complication is not described in FMD without durotomy. Controversy exists in management. Usually EAFC is said to resolve with conservative management; so hydrocephalus doesn’t require treatment. However, in this case EAFC was progressive and ventriculo-peritoneal shunting (VPS) was needed for managing progressive and symptomatic hydrocephalus.

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Quadriparesis due to the delayed formation of a compressive epidural cerebrospinal fluid collection following suboccipital craniectomy with duraplasty for Chiari malformation Type I

Journal of Neurosurgery Spine ◽

10.3171/spi-07/10/450 ◽

2007 ◽

Vol 7 (4) ◽

pp. 450-453 ◽

Cited By ~ 2

Author(s):

Daniel M. Oberer ◽

Oran S. Aaronson ◽

Joseph S. Cheng

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Hypotension ◽

Chiari Malformation ◽

Fluid Collection ◽

Spontaneous Intracranial Hypotension ◽

Type I ◽

Chiari Malformation Type I ◽

Suboccipital Craniectomy ◽

Neurological Insult

✓ The authors describe a previously undocumented complication of suboccipital craniectomy combined with duraplasty for the treatment of Chiari malformation Type I and propose techniques to prevent its occurrence. Although there have been reports of epidural pseudomeningoceles in the setting of spontaneous intracranial hypotension and intracranial hygromas following suboccipital craniectomy with duraplasty, the authors believe this case to be the first instance of quadriparesis caused by the delayed formation of a compressive epidural cerebrospinal fluid collection after suboccipital craniectomy with duraplasty. This complication is significant and must be recognized given the potential severity of neurological insult and the number of these procedures performed yearly in both the pediatric and adult populations.

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Chiari malformation Type I surgery in pediatric patients. Part 1: validation of an ICD-9-CM code search algorithm

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.10.peds15370 ◽

2016 ◽

Vol 17 (5) ◽

pp. 519-524 ◽

Cited By ~ 9

Author(s):

Travis R. Ladner ◽

Jacob K. Greenberg ◽

Nicole Guerrero ◽

Margaret A. Olsen ◽

Chevis N. Shannon ◽

...

Keyword(s):

Treatment Outcomes ◽

Chiari Malformation ◽

Large Scale ◽

Pediatric Patients ◽

Search Algorithm ◽

Decompression Surgery ◽

Type I ◽

Discharge Diagnosis ◽

Billing Data ◽

Chiari Malformation Type I

OBJECTIVE Administrative billing data may facilitate large-scale assessments of treatment outcomes for pediatric Chiari malformation Type I (CM-I). Validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code algorithms for identifying CM-I surgery are critical prerequisites for such studies but are currently only available for adults. The objective of this study was to validate two ICD-9-CM code algorithms using hospital billing data to identify pediatric patients undergoing CM-I decompression surgery. METHODS The authors retrospectively analyzed the validity of two ICD-9-CM code algorithms for identifying pediatric CM-I decompression surgery performed at 3 academic medical centers between 2001 and 2013. Algorithm 1 included any discharge diagnosis code of 348.4 (CM-I), as well as a procedure code of 01.24 (cranial decompression) or 03.09 (spinal decompression or laminectomy). Algorithm 2 restricted this group to the subset of patients with a primary discharge diagnosis of 348.4. The positive predictive value (PPV) and sensitivity of each algorithm were calculated. RESULTS Among 625 first-time admissions identified by Algorithm 1, the overall PPV for CM-I decompression was 92%. Among the 581 admissions identified by Algorithm 2, the PPV was 97%. The PPV for Algorithm 1 was lower in one center (84%) compared with the other centers (93%–94%), whereas the PPV of Algorithm 2 remained high (96%–98%) across all subgroups. The sensitivity of Algorithms 1 (91%) and 2 (89%) was very good and remained so across subgroups (82%–97%). CONCLUSIONS An ICD-9-CM algorithm requiring a primary diagnosis of CM-I has excellent PPV and very good sensitivity for identifying CM-I decompression surgery in pediatric patients. These results establish a basis for utilizing administrative billing data to assess pediatric CM-I treatment outcomes.

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