Multidimensional, patient-reported outcome after posterior fossa decompression in 79 patients with Chiari malformation type I

Vlieger, Jan De; Dejaegher, Joost; Calenbergh, Frank Van

doi:10.25259/sni_377_2019

Cited by 8 publications

(6 citation statements)

References 16 publications

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“…Of the 760 abstracts, 680 did not meet inclusion criteria or were off-topic, and the remaining 80 were selected 7-77 for systematic review (Appendix III, https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions).…”

Section: Resultsmentioning

confidence: 99%

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions

Pattisapu,

Ackerman,

Infinger

et al. 2023

Neurosurgery

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BACKGROUND: Chiari malformation type I (CIM) diagnoses have increased in recent years. Controversy regarding the best operative management prompted a review of the literature to offer guidance on surgical interventions. OBJECTIVE: To assess the literature to determine (1) whether posterior fossa decompression or posterior fossa decompression with duraplasty is more effective in preoperative symptom resolution; (2) whether there is benefit from cerebellar tonsillar resection/reduction; (3) the role of intraoperative neuromonitoring; (4) in patients with a syrinx, how long should a syrinx be observed for improvement before additional surgery is performed; and 5) what is the optimal duration of follow-up care after preoperative symptom resolution. METHODS: A systematic review was performed using the National Library of Medicine/PubMed and Embase databases for studies on CIM in children and adults. The most appropriate surgical interventions, the use of neuromonitoring, and clinical improvement during follow-up were reviewed for studies published between 1946 and January 23, 2021. RESULTS: A total of 80 studies met inclusion criteria. Posterior fossa decompression with or without duraplasty or cerebellar tonsil reduction all appeared to show some benefit for symptom relief and syrinx reduction. There was insufficient evidence to determine whether duraplasty or cerebellar tonsil reduction was needed for specific patient groups. There was no strong correlation between symptom relief and syringomyelia resolution. Many surgeons follow patients for 6–12 months before considering reoperation for persistent syringomyelia. No benefit or harm was seen with the use of neuromonitoring. CONCLUSION: This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. In patients with CIM with or without syringomyelia, treatment options include bone decompression with or without duraplasty or cerebellar tonsil reduction. Improved syrinx resolution may potentially be seen with dural patch grafting. Symptom resolution and syrinx resolution did not correlate directly. Reoperation for a persistent syrinx was potentially beneficial if the syrinx had not improved 6 to 12 months after the initial operation. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions.

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Section: Resultsmentioning

confidence: 99%

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions

Pattisapu,

Ackerman,

Infinger

et al. 2023

Neurosurgery

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“…In addition, since the suboccipital muscles are innervated from the dorsal ramus of the C1 spinal nerve, it is possible that a feedback loop is created whereby damage to the C1 nerve causes spasticity of the suboccipital muscles, which then transmits even more tension to the cervical dura through the MDBC and increases the pulse pressure correspondingly. It is interesting to note that decompression surgery is reported to improve neck pain only 52–66% of the time [ 41 - 42 ], perhaps indicating residual instability or permanent nerve damage.…”

Section: Discussionmentioning

confidence: 99%

A new hypothesis for the pathophysiology of symptomatic adult Chiari malformation Type I

Labuda¹,

Nwotchouang

Ibrahimy

et al. 2022

Medical Hypotheses

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Chiari malformation Type I (CMI) is characterized by herniation of the cerebellar tonsils through the foramen magnum. The pathophysiology of CMI is not well elucidated; however, the prevailing theory focuses on the underdevelopment of the posterior cranial fossa which results in tonsillar herniation. Symptoms are believed to be due to the herniation causing resistance to the natural flow of cerebrospinal fluid (CSF) and exerting a mass effect on nearby neural tissue. However, asymptomatic cases vastly outnumber symptomatic ones and it is not known why some people become symptomatic. Recently, it has been proposed that CMI symptoms are primarily due to instability of either the atlanto-axial (AA) or the atlanto-occipital (AO) joint and the cerebellar tonsils herniate to prevent mechanical pinching. However, only a small percentage of patients exhibit clinical instability and these theories do not account for asymptomatic herniations. We propose that the pathophysiology of adult CMI involves a combination of craniocervical abnormalities which leads to tonsillar herniation and reduced compliance of the cervical spinal canal. Specifically, abnormal AO and/or AA joint morphology leads to chronic cervical instability, often subclinical, in a large portion of CMI patients. This in turn causes overwork of the suboccipital muscles as they try to compensate for the instability. Over time, the repeated, involuntary activation of these muscles leads to mechanical overload of the myodural bridge complex, altering the mechanical properties of the dura it merges with. As a result, the dura becomes stiffer, reducing the overall compliance of the cervical region. This lower compliance, combined with CSF resistance at the same level, leads to intracranial pressure peaks during the cardiac cycle (pulse pressure) that are amplified during activities such as coughing, sneezing, and physical exertion. This increase in pulse pressure reduces the compliance of the cervical subarachnoid space which increases the CSF wave speed in the spinal canal, and further increases pulse pressure in a feedback loop. Finally, the abnormal pressure environment induces greater neural tissue motion and strain, causing microstructural damage to the cerebellum, brainstem, and cervical spinal cord, and leading to symptoms. This hypothesis explains how the combination of craniocervical bony abnormalities, anatomic CSF restriction, and reduced compliance leads to symptoms in adult CMI.

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“…For long time very unspecific patient reported outcome measures (PROMs) were used for CM-I patients, including Patient Global Impression of Change, Odom’s criteria and EQ-5D-5L ( 25 ). Whereas the use of CM-I specific tools allowed surgeons to focus on patients’ appreciation of postoperative clinically important differences.…”

Section: Introductionmentioning

confidence: 99%

Precise Management of Chiari Malformation with Type I

Guo

Turğut

2022

Front. Surg.

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Diagnosis of Chirai malformation type I (CM-I) is based on magnetic resonance imaging of the brain or cervical spinal cord. The main goal of surgery is to relieve the blockage to the free pulsatile flow of cerebrospinal fluid beyond the foramen magnum and to stop the progression of a syringomyelia. Despite recent advances in imaging and surgery, even today, there is no consensus on optimal management of CM-I. Ongoing focus is devoted to a better consideration of the pathophysiology of CM-I and the development of more effective medical and surgical treatments. It is hoped that proposed algorithm helps the neurosurgeon to provide a precise management for patients with CM-I in advance.

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Multidimensional, patient-reported outcome after posterior fossa decompression in 79 patients with Chiari malformation type I

Cited by 8 publications

References 16 publications

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions

A new hypothesis for the pathophysiology of symptomatic adult Chiari malformation Type I

Precise Management of Chiari Malformation with Type I

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