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Vazquez S, Dominguez JF, Das A, Soldozy S, Kinon MD, Ragheb J, Hanft SJ, Komotar RJ, Morcos JJ. Treatment of Chiari malformations with craniovertebral junction anomalies: Where do we stand today? World Neurosurg X 2023; 20:100221. [PMID: 37456684 PMCID: PMC10338356 DOI: 10.1016/j.wnsx.2023.100221] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/14/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Chiari malformation type 1 (CM-1) is characterized by cerebellar tonsil herniation through the foramen magnum and can be associated with additional craniovertebral junction anomalies (CVJA). The pathophysiology and treatment for CM-1 with CVJA (CM-CVJA) is debated. Objective To evaluate the trends and outcomes of surgical interventions for patients with CM-CVJA. Methods A systematic review of the literature was performed to obtain articles describing surgical interventions for patients with CM-CVJA. Articles included were case series describing surgical approach; reviews were excluded. Variables evaluated included patient characteristics, approach, and postoperative outcomes. Results The initial query yielded 403 articles. Twelve articles, published between 1998-2020, met inclusion criteria. From these included articles, 449 patients underwent surgical interventions for CM-CVJA. The most common CVJAs included basilar invagination (BI) (338, 75.3%), atlantoaxial dislocation (68, 15.1%) odontoid process retroflexion (43, 9.6%), and medullary kink (36, 8.0%). Operations described included posterior fossa decompression (PFD), transoral (TO) decompression, and posterior arthrodesis with either occipitocervical fusion (OCF) or atlantoaxial fusion. Early studies described good results using combined ventral and posterior decompression. More recent articles described positive outcomes with PFD or posterior arthrodesis in combination or alone. Treatment failure was described in patients with PFD alone that later required posterior arthrodesis. Additionally, reports of treatment success with posterior arthrodesis without PFD was seen. Conclusion Patients with CM-CVJA appear to benefit from posterior arthrodesis with or without decompressive procedures. Further definition of the pathophysiology of craniocervical anomalies is warranted to identify patient selection criteria and ideal level of fixation.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Merritt D. Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - John Ragheb
- Department of Neurosurgery, Brian Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Simon J. Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ricardo J. Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacques J. Morcos
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Sasun AR, Qureshi MI. A Pragmatic Neuro-Rehabilitation Approach for Basilar Invagination: A Case Report. Cureus 2023; 15:e41921. [PMID: 37583726 PMCID: PMC10424607 DOI: 10.7759/cureus.41921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/15/2023] [Indexed: 08/17/2023] Open
Abstract
Basilar invagination is a rare pathology of the occipital bone, along with prolapsing of the vertebral column. It is a narrowing in the opening of the foramen magnum of the odontoid process. It is a well-known cause of pain and tingling in the upper limbs. However, only a few afflictions requiring physiotherapy rehabilitation in basilar invaginations have been reported. Thus, this study was carried out to investigate a case of basilar invagination. A 51-year-old female visited the neuro-outpatient department. The chief complaints of the patient were restricted overhead activities, restricted neck and shoulder movements, upper limb weakness, and tingling of bilateral upper limbs for the past two months. Clinical examination revealed pain thresholds for the neck and shoulder at nine by ten on activity and five by ten on rest. Manual muscle testing revealed a significant reduction in the strength of muscles around the neck and shoulder at three by five on bilateral upper limbs. The patient was advised to have computed tomography (CT), magnetic resonance imaging (MRI), and a bone density test to confirm the diagnosis of the condition. Investigations revealed a case of basilar invagination. But due to the financial burden, surgery couldn't be opted for; therefore, she opted for physiotherapy rehabilitation. The patient was managed with neuro-physiotherapy rehabilitation exercises like neural tissue stretch, which included nerve gliding and nerve stretching exercises, vestibular rehabilitation exercises, and gaze stabilization exercises. The strengthening of weakened muscles was done using Delorme's technique. Cervical traction, electrotherapy, and moist heat modalities like interferential therapy and hydrocollator packs were given. It also included deep breathing exercises like diaphragmatic breathing and thoracic expansion exercises. The exercise was planned according to the frequency, intensity, time, and type (FITT) principle. Frequency: five days/week; intensity: slow to moderate pace with rest intervals; time: 60 minutes/day; type of exercise: strength training along with other exercises for a total of thirty days. The patient was able to resume her job after receiving physiotherapy rehabilitation, which played a pivotal role in decreasing her symptoms.
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Affiliation(s)
- Anam R Sasun
- Department of Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Moh'd Irshad Qureshi
- Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, IND, Wardha, IND
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3
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Wang S, Zhang D, Wu K, Fan W, Fan T. Potential association among posterior fossa bony volume and crowdedness, tonsillar hernia, syringomyelia, and CSF dynamics at the craniocervical junction in Chiari malformation type I. Front Neurol 2023; 14:1069861. [PMID: 36891476 PMCID: PMC9986261 DOI: 10.3389/fneur.2023.1069861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/26/2023] [Indexed: 02/22/2023] Open
Abstract
Objective The characteristic morphological parameters (bony posterior fossa volume (bony-PFV), posterior fossa crowdness, cerebellar tonsillar hernia, and syringomyelia) and CSF dynamics parameters at the craniocervical junction (CVJ) in Chiari malformation type I (CMI) were measured. The potential association between these characteristic morphologies and CSF dynamics at CVJ was analyzed. Methods A total of 46 cases of control subjects and 48 patients with CMI underwent computed tomography and phase-contrast magnetic resonance imaging. Seven morphovolumetric measures and four CSF dynamics at CVJ measures were performed. The CMI cohort was further divided into "syringomyelia" and "non-syringomyelia" subgroups. All the measured parameters were analyzed by the Pearson correlation. Results Compared with the control, the posterior cranial fossa (PCF) area, bony-PFV, and CSF net flow were significantly smaller (P < 0.001) in the CMI group. Otherwise, the PCF crowdedness index (PCF CI, P < 0.001) and the peak velocity of CSF (P < 0.05) were significantly larger in the CMI cohort. The mean velocity (MV) was faster in patients with CMI with syringomyelia (P < 0.05). In the correlation analysis, the degree of cerebellar tonsillar hernia was correlated with PCF CI (R = 0.319, P < 0.05), MV (R = -0.303, P < 0.05), and the net flow of CSF (R = -0.300, P < 0.05). The Vaquero index was well correlated with the bony-PFV (R= -0.384, P < 0.05), MV (R = 0.326, P < 0.05), and the net flow of CSF (R = 0.505, P < 0.05). Conclusion The bony-PFV in patients with CMI was smaller, and the MV was faster in CMI with syringomyelia. Cerebellar subtonsillar hernia and syringomyelia are independent indicators for evaluating CMI. Subcerebellar tonsillar hernia was associated with PCF crowdedness, MV, and the net flow of CSF at CVJ, while syringomyelia was associated with bony-PFV, MV, and the net flow of CSF at the CVJ. Thus, the bony-PFV, PCF crowdedness, and the degree of CSF patency should also be one of the indicators of CMI evaluation.
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Affiliation(s)
- Shengxi Wang
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Dongao Zhang
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Kun Wu
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Wayne Fan
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada
| | - Tao Fan
- Department of Spinal Spine Surgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
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4
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Dastagirzada YM, Kurland DB, Hankinson TC, Anderson RCE. Craniovertebral Junction Instability in the Setting of Chiari Malformation. Neurosurg Clin N Am 2023; 34:131-142. [DOI: 10.1016/j.nec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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He Q, Cao J, Tian H, Chen B, Fan X, Wang S, Zhao Y, Wei J, Nie L, Pan X, Cheng L. The Classification of Axial Deformity in Patients with Basilar Invagination. Orthop Surg 2022; 14:3150-3158. [PMID: 36222216 PMCID: PMC9732616 DOI: 10.1111/os.13487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/21/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To summarize the variation types of the axis in patients with basilar invagination (BI), then propose a classification scheme of the axis deformity. METHODS From December 2013 to September 2020, 92 patients (male 42, female 50) who were diagnosed with BI were studied retrospectively. Based on the imaging data of CT, the width and height of the axis pedicle and the sagittal diameter of the lateral mass were measured in each patient. According to the development of axis pedicle and lateral mass, the types of axis variation were summarized, and then the classification scheme of axis deformity was put forward. RESULTS All cases were analyzed and axis deformities were divided into four types. Type I: the axis is basically normal (53 cases, 57.6%). Type II: axis lateral mass is dysplasia (eight cases, 8.7%), which includes two subtypes: type IIA, the axis unilateral lateral mass is dysplasia (three cases); type IIB, the axis bilateral lateral masses are all dysplasia (five cases). Type III: axis pedicle is dysplasia (11 cases, 12%), which is subdivided into two subtypes: type IIIA, the axis unilateral pedicle is dysplasia (six cases); type IIIB, the axis bilateral pedicles are all dysplasia (five cases). Type IV: axis pedicle and lateral mass are all dysplasia (20 cases, 21.7%), this type contains the following four subtypes: type IVA, the unilateral axis pedicle and unilateral lateral mass (contralateral or ipsilateral) are all hypoplasia (four cases); type IVB, the unilateral axis pedicle and bilateral lateral masses are all hypoplasia (five cases); type IVC, the bilateral axis pedicles and unilateral lateral mass are all dysplasia (seven cases); type IVD, the bilateral axis pedicles and bilateral lateral masses are all dysplasia (four cases). The left and right abnormal lateral mass sagittal diameter (Type II) was (7.23 ± 1.39) mm and (5.96 ± 1.37) mm, respectively, the left and right abnormal pedicle width (Type III) was (2.61 ± 1.01) mm and (3.23 ± 0.66) mm, respectively, left and right abnormal pedicle height (Type III) was (5.43 ± 2.19) mm and (4.92 ± 1.76) mm, respectively. Moreover, the classification scheme has good repeatability and credibility. CONCLUSIONS The classification about axis deformity could provide personalized guidance for axis screw placement in the BI and other upper cervical surgery, and axis screw placement errors would be effectively avoided.
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Affiliation(s)
- Qiting He
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Jiankang Cao
- Department of Pain, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Huichao Tian
- Department of Orthopedic SurgeryLiaocheng People's HospitalLiaochengChina
| | - Bin Chen
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Xincheng Fan
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina,Department of Orthopedic SurgeryTaian City Central HospitalTaianChina
| | - Shaoyi Wang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Yunpeng Zhao
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Jianlu Wei
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Lin Nie
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Xin Pan
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Lei Cheng
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
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Saletti V, Farinotti M, Peretta P, Massimi L, Ciaramitaro P, Motta S, Solari A, Valentini LG. The management of Chiari malformation type 1 and syringomyelia in children: a review of the literature. Neurol Sci 2021; 42:4965-4995. [PMID: 34591209 DOI: 10.1007/s10072-021-05565-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
In anticipation of the "Chiari and Syringomyelia Consensus Conference" held in Milan in 2019, we performed a systematic literature review on the management of Chiari malformation type 1 (CM1) and syringomyelia (Syr) in children.We aimed to summarize the available evidence and identify areas where consensus has not been reached and further research is needed.In accordance with PRISMA guidelines, we formulated seven questions in Patients-Interventions-Comparators-Outcomes (PICO) format. Six PICOs concerned CM1 children with/without additional structural anomalies (Syr, craniosynostosis, hydrocephalus, tethered cord, and cranio-vertebral junction anomalies), and one PICO Syr without CM1. We searched Medline, Embase, Cochrane, and NICE databases from January 1, 1999, to May 29, 2019. Cohort studies, controlled and randomized clinical trials (CCTs, RCTs), and systematic reviews were included, all pertinent only to patients ≤ 18 years of age.For CM1, 3787 records were found, 460 full texts were assessed and 49 studies (46 cohort studies, one RCT, and two systematic reviews) were finally included. For Syr, 376 records were found, 59 full texts were assessed, and five studies (one RCT and four cohort studies) were included. Data on each PICO were synthetized narratively due to heterogeneity in the inclusion criteria, outcome measures, and length of follow-up of the included studies.Despite decades of experience on CM1 and Syr management in children, the available evidence remains limited. Specifically, there is an urgent need for collaborative initiatives focusing on the adoption of shared inclusion criteria and outcome measures, as well as rigorous prospective designs, particularly RCTs.
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Affiliation(s)
- Veronica Saletti
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria, 11, 20133, Milan, Italy.
| | - Mariangela Farinotti
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paola Peretta
- Pediatric Neurosurgery Unit, Ospedale Infantile Regina Margherita, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Massimi
- Pediatric Neurosurgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Ciaramitaro
- Clinical Neurophysiology, Department of Neuroscience, Presidio CTO, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Grazia Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Hong ZH, Jin DH, Yuan XJ, Zhao Y, Lin HW, Chen J. Association of neural tube defects with congenital abnormalities of the urogenital system in a Chinese cohort. BMC Pediatr 2021; 21:66. [PMID: 33546634 PMCID: PMC7863264 DOI: 10.1186/s12887-021-02492-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/04/2021] [Indexed: 11/22/2022] Open
Abstract
Background This study aimed to retrospectively analyze the correlation between congenital abnormality of the urogenital system and various factors in children with neural tube defects (NTDs). Methods A total of 190 children with congenital NTDs, who were admitted to a hospital from May 2013 to May 2018, were included into the present study. All admitted children with congenital NTDs were carried out routine abdominal B-ultrasound examinations to determine the malformations of the abdominal organs, including the urinary system. Children with a B-ultrasound result of suspected and unsure malformation underwent intravenous pyelography (IVP) and voiding cysto-urethrography (VCU), and this was further confirmed by the CT results. Results The incidence of urogenital malformation was 12.1% (23/190) in children with congenital NTDs. For the 23 children with urogenital malformations, most of these children had no definite urinary system symptoms, while some of these children had multiple incidences of urinary system infections. Conclusions Congenital NTDs are often combined with urogenital malformations, if not specifically searched these may be overlooked. The early detection of these malformations is beneficial to reduce the risk of operation and improve the prognosis.
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Affiliation(s)
- Zhi-Hua Hong
- Department of Pediatric Surgery, Jiaxing Maternity and Child Health Care Hospital, No. 2468, Zhonghuan East Road, Nanhu District, 314051, Jiaxing, China.
| | - Dong-Hui Jin
- Department of Pediatric Surgery, Jiaxing Maternity and Child Health Care Hospital, No. 2468, Zhonghuan East Road, Nanhu District, 314051, Jiaxing, China
| | - Xiao-Jian Yuan
- Department of Pediatric Surgery, Jiaxing Maternity and Child Health Care Hospital, No. 2468, Zhonghuan East Road, Nanhu District, 314051, Jiaxing, China
| | - Yang Zhao
- Department of Pediatric Surgery, Jiaxing Maternity and Child Health Care Hospital, No. 2468, Zhonghuan East Road, Nanhu District, 314051, Jiaxing, China.,Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Jiaxing Branch, Shanghai Jiaotong University, 314051, Jiaxing, China
| | - Hou-Wei Lin
- Department of Pediatric Surgery, Jiaxing Maternity and Child Health Care Hospital, No. 2468, Zhonghuan East Road, Nanhu District, 314051, Jiaxing, China.,Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Jiaxing Branch, Shanghai Jiaotong University, 314051, Jiaxing, China
| | - Jie Chen
- Department of Pediatric Surgery, Jiaxing Maternity and Child Health Care Hospital, No. 2468, Zhonghuan East Road, Nanhu District, 314051, Jiaxing, China.,Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Jiaxing Branch, Shanghai Jiaotong University, 314051, Jiaxing, China
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Wang S, Huang Z, Xu R, Liao Z, Yan Y, Tang W, Xia Y. Chiari Malformations Type I without Basilar Invagination in Adults: Morphometric and Volumetric Analysis. World Neurosurg 2020; 143:e640-e647. [PMID: 32791229 DOI: 10.1016/j.wneu.2020.08.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/05/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chiari malformation type I (CMI) cases are frequently associated with basilar invagination (BI), which complicates the understanding of the pathology of CMI. We specifically evaluated the morphometric and volumetric alterations in the bony structures of CMI patients without BI. METHODS Fifty adult CMI patients without BI treated at our institution from January 2015 to December 2019 were retrospectively studied. The morphometric and volumetric characteristics of the posterior cranial fossa (PCF) were analyzed using thin-slice computed tomography images. RESULTS Compared with the controls, the clivus length (P < 0.001), supraoccipital length (P < 0.001), Klaus height index (P < 0.001), axial length (P < 0.001), clivo-axial angle (P < 0.001), tentorial angle (P < 0.05), and bony PCF volume (P < 0.001) of the CMI-only group were significantly smaller, and the distance between the Chamberlain line and the dens axis (P < 0.001), clivus angle (P < 0.001), and basal angle (P < 0.001) of the CMI-only group were significantly larger, while the distance between the McRae line and the dens axis, McRae line, anteroposterior diameter of the PCF, occipital angle, occipital canal angle, and tentorial Twining line angle showed no significant difference between the 2 groups. CONCLUSIONS Hypoplasia of the clivus and occipital bone were confirmed in CMI patients without BI, thus providing further evidence for the notion that CMI is secondary to the underdevelopment of the PCF.
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Affiliation(s)
- Shengxi Wang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhijian Huang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Xu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengbu Liao
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Yan
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenyuan Tang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yongzhi Xia
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Tonsillectomy with modified reconstruction of the cisterna magna with and without craniectomy for the treatment of adult Chiari malformation type I with syringomyelia. Acta Neurochir (Wien) 2020; 162:1585-1595. [PMID: 31897729 DOI: 10.1007/s00701-019-04177-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In light of the controversies regarding the surgical treatment of adult Chiari malformation type I (CM-I) with syringomyelia, a retrospective study was conducted to evaluate the safety and efficacy of tonsillectomy followed by modified reconstruction of the cisterna magna with or without craniectomy. METHODS Between 2008 and 2017, 78 adult CM-I patients (36 males and 42 females, mean age 40.6 years old) with syringomyelia were treated with posterior fossa decompression (PFD) with tonsillectomy and modified reconstruction of the cisterna magna. Patients were divided into two study groups: group A (n = 40) underwent cranioplasty with replacement of the bone flap; group B (n = 38) underwent suboccipital craniectomy. Neurological outcomes were evaluated by traditional physician assessment (improved, unchanged, and worsened) and the Chicago Chiari Outcome Scale (CCOS). Syringomyelia outcomes were assessed radiologically. RESULTS The procedure was successfully performed in all patients, and restoration of normal cerebrospinal fluid (CSF) flow was confirmed by intraoperative ultrasonography. The median postoperative follow-up was 20.3 months (range 18-60 months). Clinical improvement was evident in 66 (84.6%) patients, with no significant differences between the two groups (85.0% vs. 84.2%, P = 0.897). According to the CCOS, 36 patients (90.0%) in group A were labeled as "good" outcome, compared with that of 34 (86.8%) in group B (P = 0.734). Improvement of syringomyelia was also comparable between the groups, which was observed in 35 (87.5%) vs. 33 (86.8%) patients (P = 0.887). The postoperative overall (7.5% vs. 23.7%, P = 0.048) and CSF-related (2.5% vs. 18.4%, P = 0.027) complication rates were significantly lower in group A than group B. CONCLUSIONS Tonsillectomy with modified reconstruction of the cisterna magna without craniectomy seems to be a safe and effective surgical option to treat adult CM-I patients with syringomyelia, though future well-powered prospective randomized studies are warranted to validate these findings.
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10
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Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis. Acta Neurochir (Wien) 2020; 162:1553-1563. [PMID: 32504118 PMCID: PMC7295832 DOI: 10.1007/s00701-020-04429-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 12/27/2022]
Abstract
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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11
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Visocchi M, Mattogno PP. Chiari malformations: the impact of clinical and surgical features on a journal reviewer's evaluation protocol. J Neurosurg Sci 2019; 64:578-579. [PMID: 31601066 DOI: 10.23736/s0390-5616.19.04796-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Pier P Mattogno
- Institute of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
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12
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Hentati A, Badri M, Bahri K, Zammel I. Acquired Chiari I malformation due to lumboperitoneal shunt: A case report and review of literature. Surg Neurol Int 2019; 10:78. [PMID: 31528416 PMCID: PMC6744799 DOI: 10.25259/sni-234-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/04/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Type I malformations are supposed to be the result of mesodermal defects that create a congenitally small posterior fossa. However, Chiari malformation could be also "iatrogenic" and then called "acquired" Chiari I malformation. In this study, the authors report the clinical feature of a patient who developed a Chiari I malformation after lumboperitoneal shunt. CASE DESCRIPTION A 35-year-old woman has been suffering from idiopathic intracranial hypertension and rhinorrhea due to an anterior skull base defect. A valveless lumboperitoneal shunt followed by surgical closure of the defect was performed. Six months later, she suffered from major continuous occipital headaches. The neurological examination found a mild cerebellar gait ataxia and cerebellar dysarthria. The cerebral magnetic resonance imaging (MRI) showed a ptosis of the cerebellar tonsils and a disappearance of the cisterna magna; there was no syringomyelia. This herniation was not present before shunt was performed. A replacement of the lumboperitoneal shunt with a pressure-regulated valve chamber was performed. After a 1-year follow-up, the patient reports a marked decrease of the headache as well as the ataxia, and the last cerebral MRI showed resolution of the Chiari I malformation. CONCLUSIONS Symptomatic acquired Chiari malformation with or without syringomyelia as a delayed complication after lumbar shunting is a rare complication, particularly reported in the pediatric population, but could also occur to adult patients. Treating these patients by correcting the shunt's valve could be enough, but should be monitored, as it may fail to resolve the Chiari malformation even years after treatment.
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Affiliation(s)
- Aslam Hentati
- Department of Neurosurgery, Burns and Trauma Center, Ben Arous, Tunis, Tunisia
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