Pain improvement in patients with syringomyelia and Chiari I malformation treated with suboccipital decompression and tonsillar coagulation

Three-Dimensional Volumetric Magnetic Resonance Imaging Analysis of Syringomyelia Evolution After Posterior Fossa Decompression for Chiari Malformation Type1

OBJECTIVE

This study aims to introduce a method of three-dimensional (3D) volume magnetic resonance imaging (MRI) measurements to evaluate the evolution of syringomyelia (SM) in adults with Chiari malformation type 1 (CM-1) after posterior fossa decompression (PFD), to provide reproducible and accurate measurements.

METHODS

Radiologic and clinical data were obtained for 28 patients. MRI 3D syrinx volumes were evaluated by 2 observers using Philips Healthcare Tumor Tracking tool.

RESULTS

The mean SM preoperative volume was 9.1 ± 15.3 cm3 versus 4.6 ± 8.7 cm3 postoperatively, corresponding to a volume variation reduced by -50% ± 33.4%. A total of 21 patients (75%) showed >25% reduction in SM volume postoperatively and 25 patients (89.2%) showed good to excellent postoperative clinical outcomes. Very high interobserver and intraobserver agreement was noted for 3D volumetric analysis with Cohen weighted κ coefficients (0.899-0.991). A negative correlation was found between the number of involved metameres and the postoperative SM volume reduction (Pearson correlation coefficient = 0.378; P = 0.047). Patients with better clinical outcomes had fewer syrinx septae (F = 8.830; P = 0.001). Similarly, better syrinx volume reduction was associated with fewer septae (F = 1.554; P = 0.233). A positive relationship was observed between clinical outcomes and postoperative syrinx volume reduction (F = 1.554; P= 0.233), with data similar to the reported literature.

CONCLUSIONS

This study shows that 3D volume measurement of the syrinx cavity on MRI is a reproducible and accurate method to assess the postoperative evolution of SM in CM-1 after PFD. Most patients (75%) showed a reduction of SM volume, with a mean volume decrease of 50%. The reliability is yet to be validated in further larger studies.

Comparative Assessment of Three Posterior Fossa Decompression Techniques and Evaluation of the Evidence Supporting the Efficacy of Syrinx Shunting and Filum Terminale Sectioning in Chiari Malformation Type I. A Systematic Review and Network Meta-Analysis

BACKGROUND

This study aimed to compare the effectiveness of posterior fossa decompression (PFD), posterior fossa decompression with duraplasty (PFDD), and posterior fossa decompression with resection of tonsils (PFDRT) in Chiari malformation type I (CMI). Furthermore, we aimed to evaluate the evidence supporting the efficacy of filum terminale sectioning (FTS), syringosubarachnoid shunting (SSS), and syringoperitoneal shunting (SPS) in CMI.

METHODS

PubMed, Cochrane, and Embase databases were screened for English-language studies published from inception until August 11, 2020. A total of 3593 studies were identified through the searching process. Fifteen cohort studies were included in the systematic review and network meta-analysis.

RESULTS

No studies concerning FTS, SSS, and SPS were found eligible. Therefore, only PFD, PFDD, and PFDRT were compared. PFDD showed significantly higher incidence of complications (relative risk [RR], 3.79; 95% confidence interval [CI], 2.54-5.64) cerebrospinal fluid leak (RR, 9.74; 95% CI, 2.33-40.78) and neurologic deficit (RR, 8.76; 95% CI, 2.08-36.90) than did PFD. Both PFDD and PFDRT achieved higher syringomyelia improvement (RR, 1.23, 95% CI, 1.09-1.39 and RR, 1.32, 95% CI, 1.15-1.51, respectively) and greater clinical improvement (RR, 1.24, 95% CI, 1.10-1.39 and RR, 1.24, 95% CI, 1.08-1.44, respectively) than did PFD. No differences were found between PFDD and PFDRT.

CONCLUSIONS

PFDD and PFDRT are superior to PFD, especially in patients with syringomyelia-Chiari complex, because of greater syringomyelia reduction and better clinical improvement. However, PFDD and PFDRT can be considered equally efficient. There is no evidence pleading in favor of SFT, SSS, and SPS over any PFD technique.

The 270° Circumferential Microsurgical Decompression of the Foramen Magnum in Adult Chiari Malformation Type I: Single Surgeon Series of 130 Patients with Syringomyelia, Neurologic, and Headache Outcomes

OBJECTIVE

Chiari malformation type I (CM-I) is a craniocervical junction disorder associated with descent of the cerebellar tonsils >5 mm. The prevalence of CM-I is common, including 0.5%-3.5% in the general population, 0.56%-0.77% on magnetic resonance imaging, and 0.62% in anatomic dissection studies. We sought to measure our surgical outcomes related to resolution/improvement of headaches, neurologic outcomes, and syringomyelia compared with reported adult CM-I studies from 2000-2019.

METHODS

From December 2003 to June 2018, the first author (K.I.A.) performed 270° circumferential decompression on adult (>18 years) patients with CM-I. At admission and follow-up, all parameters were numerically evaluated; headaches were self-reported on the visual analog scale, neurologic condition was evaluated using Karnofsky Performance Status and European Myelopathy Score, and syrinx width (if present) was measured on magnetic resonance imaging by grades I-IV. All parameters were analyzed, compared, and statistically tested. We compared results with our previously reported and updated systematic review of operative adult CM-I studies (studies from 2000 to 2019).

RESULTS

In our series, 118/121 (98%) experienced headache improvements and 100% experienced neurologic improvements. Complete syrinx resolution was experienced by 35/43 (81%); 8 (19%) showed significant improvement. In data from reported studies (2000-2019), only 79% experienced headache resolution, 77% improvement of neurologic status, and 74% resolution/improvement of syrinx (mean).

CONCLUSIONS

Our modified 270° circumferential microsurgical foramen magnum decompression for adult CM-I appears to be beneficial in improvement of outcomes, namely in resolution of the syrinx, neurologic symptoms, and headaches. We also confirm the association of body mass index with CM-I. Further studies are needed to confirm our results.

Radiological outcome after surgical treatment of syringomyelia-Chiari I complex in adults: a systematic review and meta-analysis

Foramen magnum decompression (FMD) is widely accepted as the standard treatment for syringomyelia associated with Chiari type I malformation (CMI). Despite extensive clinical investigations, relevant surgical details are still matter of debate. The authors performed a systematic review and meta-analysis of the literature examining the radiological outcome of syringomyelia in adult patients with CMI after different surgical strategies. PRISMA guidelines were followed. A systematic search of three databases was performed for studies published between 1990 and 2018. Our systematic review included 13 studies with a total of 276 patients with CMI associated with syringomyelia. Overall, the rate of post-operative radiological improvement at last follow-up was 81.1% (95% CI 73.3-88.9%; p < 0.001; I² = 71.4%). The rate of post-operative syrinx shrinkage did not differ significantly among both groups of decompression with the extra-arachnoidal technique and arachnoid dissection (90%, 95% CI 85.1-94.8%, I² = 0% vs 79.8%, 95% CI 61.7-98%, I² = 85.5%). A lower rate of post-operative radiological syrinx shrinkage was observed after decompression with splitting of the outer layer of the dura (55.6% 95% CI 40.5-70.8%, I² = 0%). CSF-related complications and infections were similar among the different groups. Our meta-analysis found that FMD with the extra-arachnoidal technique and arachnoid dissection provides similar results in terms of post-operative shrinkage of syringomyelia. Patients undergoing decompression with splitting of the dura presented the lower rate of syrinx reduction. These data should be considered when choosing the surgical approach in adult patients with CMI associated with syringomyelia.

Pediatric and adult Chiari malformation Type I surgical series 1965-2013: a review of demographics, operative treatment, and outcomes

OBJECT

Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia.

METHODS

The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included.

RESULTS

The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series.

CONCLUSIONS

Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.

Are Established Methods of Physiotherapeutic Management for Long-term Neurological Conditions Applicable to 'Orphan' Conditions such as Syringomyelia?

BACKGROUND AND PURPOSE

Syringomyelia is a rare or 'orphan' condition with the potential to cause significant disability and detrimental effects to quality of life. Syringomyelia shares similar symptoms to those common in other long-term neurological conditions, including spinal cord injury and multiple sclerosis. In these more prevalent conditions, physiotherapy is utilized widely and is effective in optimizing physical, psychological and social parameters. Therefore, we theorized that physiotherapy might be transferable to, and beneficial to syringomyelia patients. As a paucity of literature exists in this area, we aimed to evaluate the existing uptake and perceived efficacy of physiotherapy.

METHODS

An exploratory, mixed methodology was selected to derive sufficient qualitative data for analysis. Specifically designed questionnaires and semi-structured interviews yielded data on uptake and perceived physiotherapy efficacy. One hundred patients from a National Health Service tertiary syringomyelia service were invited to participate.

RESULTS

The questionnaire and interviews were completed by 49 and 20 patients, respectively. Of the small number of patients receiving physiotherapy, the majority reported beneficial effects on pain modulation and quality of life. Stretching and hydrotherapy were deemed effective for relief of pain and stiffness. Additionally, physiotherapy was reported to provide similar benefits to surgical intervention.

DISCUSSION

Syringomyelia patients report physiotherapy to provide benefits for symptom management and quality of life. Such findings suggest that established rehabilitation techniques in more common conditions may be transferable to those less prevalent. Uptake of physiotherapy was limited, seemingly because of inadequate information, knowledge and resources. To address these deficiencies, further studies should be planned investigating the effectiveness of physiotherapy modalities, such as hydrotherapy, in parallel or in conjunction with surgery and/or pharmacology. Additionally, syringomyelia could be represented alongside similar pathologies in research trials to initiate further research questions and drivers for funding.

Outcome methods used in clinical studies of Chiari malformation Type I: a systematic review

OBJECT

Chiari malformation Type I (CM-I) is a common and often debilitating neurological disease. Efforts to improve treatment of CM-I are impeded by inconsistent and limited methods of evaluating clinical outcomes. To understand current approaches and lay a foundation for future research, the authors conducted a systematic review of the methods used in original published research articles to evaluate clinical outcomes in patients treated for CM-I.

METHODS

The authors searched PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov , and Cochrane databases to identify publications between January 2003 and August 2013 that met the following criteria: 1) reported clinical outcomes in patients treated for CM-I; 2) were original research articles; 3) included at least 10 patients or, if a comparative study, at least 5 patients per group; and 4) were restricted to patients with CM-I.

RESULTS

Among the 74 papers meeting inclusion criteria, there was wide variation in the outcome methods used. However, all approaches were broadly grouped into 3 categories: 1) "gestalt" impression of overall symptomatic improvement (n=45 papers); 2) postoperative change in specific signs or symptoms (n=20); or 3) results of various standardized assessment scales (n=22). Among standardized scales, 11 general function measures were used, compared with 6 disease-specific tools. Only 3 papers used scales validated in patients with CM-I. To facilitate a uniform comparison of these heterogeneous approaches, the authors appraised articles in multiple domains defined a priori as integral to reporting clinical outcomes in CM-I. Notably, only 7 articles incorporated patient-response instruments when reporting outcome, and only 22 articles explicitly assessed quality of life.

CONCLUSIONS

The methods used to evaluate clinical outcomes in CM-I are inconsistent and frequently not comparable, complicating efforts to analyze results across studies. Development, validation, and incorporation of a small number of disease-specific patient-based instruments will improve the quality of research and care of CM-I patients.

The quality of life and psychiatric morbidity in patients operated for Arnold-Chiari malformation type I

BACKGROUND

There are some case reports that highlight the association of Arnold-Chiari malformation (ACM) with psychiatric symptoms. We assessed the association between ACM and psychiatric symptoms and risk factors in terms of psychiatric morbidity and evaluated the quality of life after surgery.

METHODS

This study consisted of sixteen patients who underwent decompression operation at the Department of Neurosurgery of Sisli Etfal Hospital. The MINI plus, Short-Form McGill Pain Questionnaire and WHOQOL-BREF-TR were administered to patients.

RESULTS

About 43.8% of the patients had a psychiatric disorder. About 50% of the patients had co-existing syringomyelia of which 50% with syringomyelia had a psychiatric disorder. Patients with syringomyelia without any psychiatric disorder had significantly lower scores on physical domain of WHOQOL-BREF-TR (p = 0.02) than the patients without syringomyelia and psychiatric disorder. Subjects with a psychiatric disorder had lower scores on four domains of WHOQOL-BREF-TR. The patients with psychiatric diagnoses had significantly higher scores on affective pain index (p = 0.021) and total pain index (p = 0.037) than the patients without any psychiatric disorder.

CONCLUSION

The presence of a psychiatric condition influences not only the physical aspect but also deteriorates the psychological and social relations and environmental aspect. Moreover the presence of a psychiatric disorder increases the perception of pain and causes more discomfort.

Glossopharyngeal neuralgia in the context of a Chiari type I malformation

A 34-year-old woman presented with disabling right-sided glossopharyngeal neuralgia. MRI revealed a Chiari I malformation with an asymmetric herniation of the right tonsil. Surgical inspection of the lower cranial nerves through a suboccipital approach showed no vascular compromise. The patient was pain free for three months before the same symptoms recurred. MRI showed a persisting crowding at the level of the foramen magnum. A second intervention with extension of the suboccipital craniectomy and resection of the right tonsil achieved definitive pain relief. To our knowledge this is the fourth report of a glossopharyngeal neuralgia caused by a Chiari I malformation. Recurrence of the pain after incomplete decompression of the posterior fossa underlines the importance of tonsillectomy in these patients.

Chiari type I malformation in children

The diagnosis of Chiari type I malformation (CIM) is more and more frequent in clinical practice due to the wide diffusion of magnetic resonance imaging. In many cases, such a diagnosis is made incidentally in asymptomatic patients, as including children investigated for different reasons such as mental development delay or sequelae of brain injury. The large number of affected patients, the presence of asymptomatic subjects, the uncertainties surrounding the pathogenesis of the malformation, and the different options for its surgical treatment make the management of CIM particularly controversial.This paper reports on the state of the art and the recent achievements about CIM aiming at providing further information especially on the pathogenesis, the natural history, and the management of the malformation, which are the most controversial aspects. A historial review introduces and explains the current classification. Furthermore, the main clinical, radiological, and neurophysiological findings of CIM are described to complete the picture of this heterogeneous and complex disease.