Comparison of posterior fossa decompression with or without duraplasty in children with Type I Chiari malformation

Lee, Amy; Yarbrough, Chester K.; Greenberg, Jacob K.; Barber, Jason; Limbrick, David D.; Smyth, Matthew D.

doi:10.1007/s00381-014-2424-5

Cited by 70 publications

(53 citation statements)

References 27 publications

(56 reference statements)

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“…The authors recommended the more invasive PFDD as first-line treatment for more severe patients with rapidly progressive symptoms or severe neurological deficits. 16 Our data echoes these results in that even though there was no difference with overall clinical outcome between the 2 techniques, patient who underwent dural splitting had a quicker and easier recovery.…”

Section: Discussionsupporting

confidence: 80%

Natural and surgical history of Chiari malformation Type I in the pediatric population

Pomeraniec

Ksendzovsky

Awad

et al. 2016

PED

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OBJECT The natural and surgical history of Chiari malformation Type I (CM-I) in pediatric patients is currently not well described. In this study the authors discuss the clinical and radiological presentation and outcomes in a large cohort of pediatric CM-I patients treated with either conservative or surgical management. METHODS The authors retrospectively reviewed 95 cases involving pediatric patients with CM-I who presented between 2004 and 2013. The patients ranged in age from 9 months to 18 years (mean 8 years) at presentation. The cohort was evenly split between the sexes. Twenty-five patients underwent posterior fossa decompression (PFD) with either dural splitting or duraplasty. Seventy patients were managed without surgery. Patients were followed radiologically (mean 44.8 months, range 1.2–196.6 months) and clinically (mean 66.3 months, range 1.2–106.5 months). RESULTS Seventy patients were treated conservatively and followed with serial outpatient neurological and radiological examinations, whereas 25 patients were treated with PFD. Of these 25 surgical patients, 11 were treated with duraplasty (complete dural opening) and 14 were treated with a dura-splitting technique (incomplete dural opening). Surgical intervention was associated with better clinical resolution of symptoms and radiological resolution of tonsillar ectopia and syringomyelia (p = 0.0392). Over the course of follow-up, 20 (41.7%) of 48 nonsurgical patients who were symptomatic at presentation experienced improvement in symptoms and 18 (75%) of 24 symptomatic surgical patients showed clinical improvement (p = 0.0117). There was no statistically significant difference in resolution of symptoms between duraplasty and dura-splitting techniques (p = 0.3572) or between patients who underwent tonsillectomy and tonsillopexy (p = 0.1667). Neither of the 2 patients in the conservative group with syrinx at presentation showed radiological evidence of resolution of the syrinx, whereas 14 (87.5%) of 16 patients treated with surgery showed improvement or complete resolution of syringomyelia (p = 0.0392). In the nonsurgical cohort, 3 patients (4.3%) developed new or increased syrinx. CONCLUSIONS The overwhelming majority of CM-I patients (92.9%) managed conservatively do not experience clinical or radiological progression, and a sizeable minority (41.7%) of those who present with symptoms improve. However, appropriately selected symptomatic patients (sleep apnea and dysphagia) and those presenting with syringomyelia should be considered surgical candidates because of the high rates of clinical (75%) and radiological improvement (87.5%).

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Section: Discussionsupporting

confidence: 80%

Natural and surgical history of Chiari malformation Type I in the pediatric population

Pomeraniec

Ksendzovsky

Awad

et al. 2016

PED

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“…It was found that 60.1% of all CM-1 were managed with PFD, which is consistent with the current trend favoring conservative surgical management based on the theoretical advantages of this less invasive approach [2,3]. Recent studies further support this argument and have shown that PFD produces comparable rates of clinical and radiological improvements in CM-1 patients without syringomyelia [4,5]. Additionally, the national data set indicates that recent trends have less likely favored an upper cervical laminectomy with PFD than with PFDD (41.7 vs. 49.1%, p = 0.03).…”

Section: Discussionsupporting

confidence: 71%

National Trends, Complications, and Hospital Charges in Pediatric Patients with Chiari Malformation Type I Treated with Posterior Fossa Decompression with and without Duraplasty

et al. 2015

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Background: The treatment of type 1 Chiari malformation (CM-1) with posterior fossa decompression without (PFD) or with duraplasty (PFDD) is controversial. The authors analyze both options in a national sample of pediatric patients. Methods: Utilizing the Kids' Inpatient Database, CM-1 patients undergoing PFD or PFDD from 2000 through 2009 were analyzed. Results: 1,593 patients with PFD and 1,056 with PFDD were evaluated. The average age was 10.3 years, slightly younger in PFD (9.8 vs. 10.9 years, p = 0.001). PFDD patients were more likely White (81.2 vs 75.6%, p = 0.04) and less likely admitted emergently (8.4 vs. 13.8%, p = 0.007). They also underwent more reoperations (2.1 vs. 0.7%, p = 0.01), had more procedure-related complications (2.3 vs. 0.8%, p = 0.003), a longer length of stay (4.4 vs. 3.8 days, p = 0.001) and higher charges (USD 35,321 vs. 31,483, p = 0.01). Conclusions: This large national study indicates that PFDD is performed more often in Caucasians, less so emergently, and associated with significantly more complications and immediate reoperations, while PFD is more frequent in those with syringomyelia and more economical, requiring fewer hospital resources. Overall, PFD is more favorable for CM-1, though it would be prudent to conduct a prospective trial, as this analysis is limited by data on preoperative presentations and long-term outcomes.

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“…We decided to use the CCOS as the primary clinical outcome score as it provides a more objective comparison of clinical outcome than other Gestalt methods [22,23] . Our results support the previous findings of Lee et al [24] that the clinical outcome in children with CM1, as judged by CCOS, did not differ between patients who had undergone duroplasty versus extradural decompression only.…”

Section: Discussionsupporting

confidence: 83%

“…To our knowledge, this is the first report of this in the literature. A few studies have compared the results of 2 procedures for CM1 in children, particularly BD only versus BD and DOPD [18,20,24] ; however, all but one of these reports share an important limitation, i.e., they lack a standardized and validated method to assess the clinical outcome [24] . We decided to use the CCOS as the primary clinical outcome score as it provides a more objective comparison of clinical outcome than other Gestalt methods [22,23] .…”

Section: Discussionmentioning

confidence: 99%

“…It also remains controversial, amongst the authors who advocate dural opening, whether or not a watertight expansile duroplasty (DOPD) should be performed [21] . The lack of a simple, quantifiable, and validated outcome tool until the recent introduction of the Chicago Chiari Outcome Scale (CCOS) has largely contributed to this controversy and also prevented an objective comparison being made of the different surgical series outcomes reported in the literature [22][23][24] .…”

Section: Introductionmentioning

confidence: 99%

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Comparison of Three Different Cranio-Cervical Decompression Procedures in Children with Chiari Malformation Type I: Does the Surgical Technique Matter?

et al. 2017

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Background/Aims: A broad spectrum of cranio-cervical decompression techniques (CCD) is employed for the treatment of Chiari malformation type I (CM1). The aim of this study was to compare the clinical and radiological outcome of 3 different CCD performed in a single paediatric centre. Methods: A retrospective analysis of children treated between 2008 and 2014 was performed. Three different surgical techniques were offered to the patients: an extradural osseo-ligamentous bony decompression (BD), or a BD plus opening of the dura either without duroplasty (DOWD) or with watertight expansile duroplasty (DOPD). The primary clinical outcome was measured by utilizing the Chicago Chiari Outcome Scale (CCOS). Results: Forty-six children underwent 51 CCD: 17 BD, 17 DOWD, and 17 DOPD. The median follow-up period was 46 months (16-98 months). Patients who underwent BD had a shorter length of hospital stay than those who underwent DPTC and DOWD. Clinical improvement, defined by the mean CCOS score, was comparable in patients receiving BD (n = 14.6) and DOPD (n = 14.5), but lower in patients with DOWD (n = 12). Post-operative complications were noted in 7 DOWD patients (41%) and 3 DOPD patients (17.6%). Conclusions: BD is a safe and effective procedure with comparable clinical and radiological outcomes to DOPD in children with CM1. The risk of post-operative complications and worse clinical outcome was noted to be higher when performing a DOWD.

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Comparison of posterior fossa decompression with or without duraplasty in children with Type I Chiari malformation

Cited by 70 publications

References 27 publications

Natural and surgical history of Chiari malformation Type I in the pediatric population

Natural and surgical history of Chiari malformation Type I in the pediatric population

National Trends, Complications, and Hospital Charges in Pediatric Patients with Chiari Malformation Type I Treated with Posterior Fossa Decompression with and without Duraplasty

Comparison of Three Different Cranio-Cervical Decompression Procedures in Children with Chiari Malformation Type I: Does the Surgical Technique Matter?

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