Efficacy of Posterior Fossa Decompression with Duraplasty for Patients with Chiari Malformation Type I: A Systematic Review and Meta-Analysis

Chai, Zhi; Xue, Xiaoming; Fan, Huijie; Sun, Lin; Cai, Hongyu; Ma, Yan-Miao; Ma, Cun‐Gen; Zhou, Ran

doi:10.1016/j.wneu.2018.02.092

Cited by 59 publications

(42 citation statements)

References 27 publications

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“…We fully agree that the coexistence of BI and AAD with CM should not be missed with the available data nowadays [13,84]. However, previous studies clearly demonstrated clinical efficacy with decompression alone and probably remains a suitable treatment option for CM with no signs of instability [11,54]. In summary, we agree with Deora and colleagues that in patients with pure CM with symmetrical C1/2 joints and no signs of instability, PFD and duraplasty is an established, effective, and safe treatment option with excellent long-term outcome [18,28,62,89].…”

Section: Chiari Malformation Type I-discussion Of Evidencesupporting

confidence: 82%

“…PFD with or without duraplasty (PFDD) has been and is still widely used. To date, the largest meta-analysis dealing with PFD +/-PFDD by Chai et al demonstrated that both procedures are effective options in most cases [11]. PFDD is associated with a larger reduction in syrinx size, but with a higher incidence of CSF leakage and aseptic meningitis.…”

Section: Chiari Malformation Type I-discussion Of Evidencementioning

confidence: 99%

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Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis

et al. 2020

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Introduction Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction (CVJ) abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective. In turn, C1-2 fusion is proposed as a single solution for all CVJ abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead relying on the intraoperative assessment of the atlantoaxial joints to confirm instability. Methods The authors conducted a comprehensive narrative review of literature and evidence covering this recently emerged hypothesis. The proposed pathomechanisms are discussed and contextualized with published literature. Conclusion The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with CVJ abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression, occipitocervical fusion, and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor for CVJ abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.

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Section: Chiari Malformation Type I-discussion Of Evidencesupporting

confidence: 82%

Section: Chiari Malformation Type I-discussion Of Evidencementioning

confidence: 99%

Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis

et al. 2020

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“…In the largest meta-analysis to date of posterior fossa decom-pression for Chiari I malformation, Chai et al, 28 compared posterior fossa decompression with or without duroplasty. Fourteen cohort studies comprising 3,666 patients with Chiari malformation type I were analyzed.…”

Section: Evidence On Posterior Fossa Decompression: Is It Actually Efmentioning

confidence: 99%

Is Cervical Stabilization for All Cases of Chiari-I Malformation an Overkill? Evidence Speaks Louder Than Words!

et al. 2019

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Chiari I malformation is characterized by the downward displacement of cerebellar tonsils through the foramen magnum. While discussing the treatment options for Chiari I malformation, the points of focus include: (1) Has the well-established procedure of posterior fossa decompression become outdated and has been replaced by posterior C1-2 stabilization in every case? (2) In case posterior stabilization is required, should a C1-2 stabilization, rather than an occipitocervical fusion, be the only procedure recommended? The review of literature revealed that when there is bony instability like atlantoaxial dislocation (AAD), occipito-atlanto-axial facet joint asymmetry or basilar invagination (BI) associated with Chiari I malformation, one should address the anterior bony compression as well as perform stabilization. This takes care of the compromised canal at the foramen magnum and re-establishes the cerebrospinal fluid flow along the craniospinal axis; and also provides treatment for CVJ instability. In the cases with a pure Chiari I malformation without AAD or BI and with completely symmetrical C1-2 joints, however, posterior fossa decompression with or without duroplasty is sufficient to bring about neurological improvement. The latter subset of cases with pure Chiari I malformation have, thus, shown significant (> 70%) rates of neurological improvement with posterior fossa decompression alone. A C1-2 posterior stabilization is a more stable construct due to the strong bony purchase provided by the C1-2 lateral masses and the short lever arm of the construct. However, in the cases with significant bleeding from paravertebral venous plexus; a very high BI, condylar hypoplasia and occipitalized atlas; gross C1-2 rotation or vertical C1-2 joints with unilateral C1 or C2 facet hypoplasia, as well as the presence of subaxial scoliosis; maldevelopment of the lateral masses and facet joints (as in very young patients); or, the artery lying just posterior to the C1-2 facet joint capsule (being endangered by the C1-2 stabilization procedure), it may be safer to perform an occipitocervical rather than a C1-2 fusion.

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“…Reduction in the syrinx cavity appears to be better in patients undergoing posterior fossa decompression with duraplasty, than in patients undergoing bone decompression only. 20 The material used for duraplasty also varies widely and includes allograft, autologous tissue, and synthetic material. Our own practice is to use a combination of nonstretchable synthetic material together with autologous pericranium.…”

Section: Adult Chiari Surgerymentioning

confidence: 99%

Chiari malformation and syringomyelia

Holly¹,

Batzdorf²

2019

Journal of Neurosurgery: Spine

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Chiari malformation was first described over a century ago, and consists of posterior fossa anomalies that generally share the feature of cerebellar tonsillar descent through the foramen magnum. Our understanding of this disorder was initially based on autopsy studies, and has been greatly enhanced by the advent of MRI. The surgical management of Chiari anomalies has also evolved in a parallel fashion. Although the exact surgical technique varies among individual surgeons, the goals of surgery remain constant and consist of relieving brainstem compression and cranial nerve distortion, restoring the normal flow of CSF across the foramen magnum, and reducing the size of any associated syrinx cavity. Syrinx cavities are most commonly associated with Chiari anomalies, yet primary spinal syringomyelia (PSS) can be caused by traumatic, infectious, degenerative, and other etiologies that cause at least a partial CSF flow obstruction in the spinal subarachnoid space. As with syringomyelia associated with Chiari anomalies, the main goal of PSS surgery is to reestablish CSF flow across the area of obstruction. In addition to MRI, myelography with CT can be very helpful in the evaluation and management of these patients by identifying focal regions of CSF obstruction that may be amenable to surgical intervention. Future directions for the treatment of Chiari anomalies and syringomyelia include the application of advanced imaging techniques, more widespread use of genetic evaluation, large-scale outcome studies, and the further refinement of surgical technique.

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Efficacy of Posterior Fossa Decompression with Duraplasty for Patients with Chiari Malformation Type I: A Systematic Review and Meta-Analysis

Cited by 59 publications

References 27 publications

Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis

Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis

Is Cervical Stabilization for All Cases of Chiari-I Malformation an Overkill? Evidence Speaks Louder Than Words!

Chiari malformation and syringomyelia

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