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Moniruzzaman S, Kaipainen A, Tervonen J, Huttunen J, Jyrkkänen HK, Huuskonen TJ, Rantala S. Long-term outcome of operated Chiari I patients between 2005 and 2020 in Eastern Finland. Acta Neurochir (Wien) 2024; 166:115. [PMID: 38416251 PMCID: PMC10902000 DOI: 10.1007/s00701-024-05999-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE The purpose of our study was to examine the long-term outcomes of operated Chiari malformation type 1 (CM1) patients and evaluate whether different duraplasty techniques affected outcome after surgery in Kuopio University Hospital catchment area. METHODS In this retrospective study, a total of 93 patients were diagnosed with CM1 and underwent posterior fossa decompression surgery with or without duraplasty between 2005 and 2020. All patients' medical records were examined for baseline characteristics, surgical details, and long-term follow-up data after operation. RESULTS The mean age of CM1 patients was 25.9 years (SD 19.2 years), with female preponderance 69/93 (73.4%). The mean clinical follow-up time was 26.5 months (SD 33.5 months). The most common presenting symptoms were headache, symptoms of extremities, and paresthesia. Posterior fossa decompression with duraplasty was performed in 87 (93.5%) patients and bony decompression in 6 (6.5%) patients. After surgery, preoperative symptoms alleviated in 84.9% (79/93) and the postoperative syringomyelia regression rate was 89.2% (33/37) of all patients. The postoperative complication rate was 34.4% (32/93), with aseptic meningitis being the most common, 25.8% (24/93). Revision surgery was required in 14% (13/93) of patients. No significant correlation between postoperative outcome and extent of dural decompression, or type of duraplasty performed was found. CONCLUSION This is the largest reported series of surgically treated CM1 patients in Finland. Posterior fossa decompression is an effective procedure for CM1 symptomology. Duraplasty technique had no significant difference in complication rate or long-term outcomes.
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Affiliation(s)
- Samir Moniruzzaman
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
| | - Aku Kaipainen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Henna-Kaisa Jyrkkänen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Terhi J Huuskonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Susanna Rantala
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Pattisapu JV, Ackerman LL, Infinger LK, Maher CO, Quinsey C, Rocque BG, Silberstein H, Jackson EM, Jernigan S, Niazi T, Qaiser R, Raskin JS, Vachhrajani S, Bauer DF. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions. Neurosurgery 2023; 93:731-735. [PMID: 37646504 DOI: 10.1227/neu.0000000000002635] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 09/01/2023] Open
Abstract
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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Affiliation(s)
- Jogi V Pattisapu
- Pediatric Neurosurgery, University of Central Florida College of Medicine, Orlando , Florida , USA
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University Health, Indianapolis , Indiana , USA
| | - Libby Kosnik Infinger
- Department of Neurosurgery, Medical University of South Carolina (MUSC), Charleston , South Carolina , USA
| | - Cormac O Maher
- Department of Neurosurgery, Stanford Medicine, Palo Alto , California , USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina Chapel Hill, Chapel Hill , North Carolina , USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , Alabama , USA
| | - Howard Silberstein
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester , New York , USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Sarah Jernigan
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
| | - Toba Niazi
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami , Florida , USA
| | - Rabia Qaiser
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Shobhan Vachhrajani
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton , Ohio , USA
| | - David F Bauer
- Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston , Texas , USA
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Tochigi S, Isoshima A, Ohashi H, Kawamura D, Karagiozov K, Hatano K, Ohashi S, Nagashima H, Murayama Y, Abe T. Preoperative assessment of dominant occipital sinus in patients with Chiari malformation type I: anatomical variations and implications for preventing potentially life-threatening surgical complications. J Neurosurg 2023; 138:540-549. [PMID: 35901697 DOI: 10.3171/2022.5.jns212973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The surgical treatment of Chiari malformation type I (CM-I) frequently involves dural incision at the posterior cranial fossa. In cases of persistent patent occipital sinus (OS), the sinus is usually obliterated and divided. However, there are some patients whose OS is prominent and requires crucial modification of the operative planning to avoid potentially life-threatening massive hemorrhage and disturbance of cerebral venous circulation. In the present study, the anatomical variations of the dominant OS in patients with CM-I were analyzed and the authors attempted to develop treatment recommendations for patients with CM-I with dominant OS. METHODS The study included 213 patients with CM-I who underwent MR venography (MRV) prior to surgical treatment. OS dominance was assessed using 2D time-of-flight MRV or 3D phase-contrast MRV. Particular attention was paid to the pattern of venous outflow channels. The characteristics of the patients with dominant OS and the surgical outcomes were retrospectively reviewed. RESULTS Dominant OS was identified in 7 patients (3.3%). The age in those with dominant OS was significantly younger than in those without (p = 0.0202). The incidence of concurrent scoliosis in the patients with dominant OS was significantly higher than in those without (p = 0.0366). All the dominant OSs were found to be of the oblique type. Unilateral oblique OS (OOS) with normal ipsilateral transverse sinus (TS) and hypoplastic contralateral TS was found in 2 patients (0.9%). The authors found 1 patient each (0.5%) who had unilateral OOS with hypoplastic ipsilateral TS and normal contralateral TS, unilateral OOS with bilateral hypoplastic TSs, and bilateral OOSs with bilateral normal TSs. Bilateral OOSs with bilateral hypoplastic TSs were found in 2 patients (0.9%). All these patients had syringomyelia. Instead of performing Y-shaped dural incision and duraplasty, surgical procedures were modified depending on the types of the OOSs to preserve their venous drainage routes. Although massive bleeding from the dominant OS during dural incision occurred in 1 patient, none suffered neurological deterioration. The syrinx volume decreased in all but 1 of the patients postoperatively. CONCLUSIONS Assessment of the venous drainage pattern using MRV is indispensable for safe surgical treatment in patients with CM-I. The surgical procedure should be modified based on the type of dominant OS to minimize the surgical risks.
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Affiliation(s)
- Satoru Tochigi
- 1Department of Neurosurgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba
| | - Akira Isoshima
- 2Department of Neurosurgery, Omori Red Cross Hospital, Tokyo
| | - Hiroki Ohashi
- 3Department of Neurosurgery, The Jikei University School of Medicine, Tokyo
| | - Daichi Kawamura
- 3Department of Neurosurgery, The Jikei University School of Medicine, Tokyo
| | | | - Keisuke Hatano
- 3Department of Neurosurgery, The Jikei University School of Medicine, Tokyo
| | - So Ohashi
- 4Department of Neurosurgery, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa
| | - Hiroyasu Nagashima
- 5Department of Neurosurgery, The Jikei University Katsushika Medical Center, Tokyo; and
| | - Yuichi Murayama
- 3Department of Neurosurgery, The Jikei University School of Medicine, Tokyo
| | - Toshiaki Abe
- 3Department of Neurosurgery, The Jikei University School of Medicine, Tokyo.,6Department of Neurosurgery, Mishima Central Hospital, Mishima, Shizuoka, Japan
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Naylor RM, Rotter J, Proctor MR, Bite U, Ahn ES. Above-The-Hairline Suboccipital Transverse Approach for the Treatment of Chiari I Malformation. Oper Neurosurg (Hagerstown) 2023; 24:542-547. [PMID: 36716002 DOI: 10.1227/ons.0000000000000619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/08/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Chiari I malformation is a common pediatric neurosurgical disorder with an established treatment paradigm. Posterior fossa decompression and duraplasty (PFDD) is associated with symptom improvement but it carries postoperative risk, particularly cerebrospinal fluid (CSF) leak and wound complications. In addition, the cosmetic outcomes of PFDD have been overlooked in the literature. OBJECTIVE To describe a novel approach for PFDD in which the transverse surgical incision is completely hidden above the hairline and to report early outcomes in a prospective patient cohort. METHODS Clinical and cosmetic outcomes were recorded for 15 consecutive pediatric patients who underwent PFDD for Chiari I malformation via the above-the-hairline transverse suboccipital approach. RESULTS The median clinical follow-up time was 6 months (range 1-12 months), and the majority of patients experienced significant improvement of their preoperative symptoms. Three patients (20%) experienced complications associated with surgery, which included injury to the greater occipital nerve, CSF hypotension and subfascial pseudomeningocele, and superficial wound dehiscence that resolved spontaneously with oral antibiotics. Zero patients (0%) returned to the operating room for persistent CSF leak, deep wound infection, or revision decompression. An excellent cosmetic outcome was achieved in 12 patients (80%). No patient had a poor cosmetic outcome. CONCLUSION The above-the-hairline transverse suboccipital approach for PFDD in patients with Chiari I malformation offers favorable cosmetic outcomes and fascial closure while permitting adequate decompression.
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Affiliation(s)
- Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juliana Rotter
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Uldis Bite
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Center for Aesthetic Medicine & Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward S Ahn
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Gilna GP, Clarke JE, Silva M, Saberi RA, Parreco JP, Thorson CM, McCrea HJ. Assessment of neuromonitoring use and postoperative readmission rates in pediatric Chiari I malformation with syrinx. Childs Nerv Syst 2022; 39:1021-1027. [PMID: 36411360 DOI: 10.1007/s00381-022-05746-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION While operative intervention for Chiari malformation type I (CMI) with syringomyelia is well established, there is limited data on outcomes of intraoperative neuromonitoring (IONM). This study sought to explore differences in procedural characteristics and their effects on postoperative readmission rates. METHODS The Nationwide Readmission Database was queried from 2010 to 2014 for patients ≤ 18 years of age with CMI and syringomyelia who underwent cranial decompression or spinal decompression. Demographics, hospital characteristics, and outcomes were analyzed. RESULTS Over the 5-year period, 2789 patients were identified that underwent operative treatment for CMI with syringomyelia. Mean age was 10 ± 4 years with 55% female. During their index hospitalization 14% of the patients had IONM. Patients receiving IONM had no significant difference in Charleston Comorbidity Index ≥ 1 (16% vs. 15% without, p = 0.774). IONM was more often used in those with private insurance (63% vs. 58% without, p = 0.0004) and less likely in those with Medicaid (29% vs. 37% without, p = 0.004). Patients receiving IONM were more likely to have a postoperative complication (23% vs 17%, p = 0.004) and were more likely to have hospital lengths of stay > 7 days (9% vs. 5% without, p = 0.005). Readmission rates for CMI were 9% within 30 days and 15% within the year. The majority (89%) of readmissions were unplanned. 25% of readmissions were for infection and 27% of readmissions underwent a CMI reoperation. The 30-day readmission rate was higher for those with IONM (12% vs. 8% without, p = 0.010). Median cost for hospitalization was significantly higher for patients with IONM ($26,663 ($16,933-34,397)) vs. those without ($14,577 ($11,538-18,392)), p < 0.001. CONCLUSION The use of intraoperative neuromonitoring for operative repair of CMI is associated with higher postoperative complications and readmissions. In addition, there are disparities in its use and increased cost to the healthcare system. Further studies are needed to elucidate the factors underlying this association.
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Affiliation(s)
- Gareth P Gilna
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, FL, Miami, USA
| | - Jamie E Clarke
- Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Michael Silva
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Memorial Health System, FL, Miami, USA
| | - Rebecca A Saberi
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, FL, Miami, USA
| | - Joshua P Parreco
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, USA
| | - Chad M Thorson
- DeWitt-Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, FL, Miami, USA
| | - Heather J McCrea
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Memorial Health System, FL, Miami, USA.
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Karras CL, Murthy NK, Trybula SJ, Alden TD. Chiari malformation type 1 presenting as isolated unilateral foot drop with rapid recovery following posterior fossa decompression. Childs Nerv Syst 2022; 38:821-825. [PMID: 34235553 DOI: 10.1007/s00381-021-05275-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/22/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chiari malformation (CM) type 1 is characterized by descent of the cerebellar tonsils resulting from crowding of the posterior fossa. In 30% of cases, it is associated with syringomyelia. When symptomatic, it may result in a classic constellation of symptoms. CASE PRESENTATION Here we describe a case of a 16-year-old male who presented with isolated, unilateral foot drop due to CM type 1 and holosyrinx. This unique presentation is extremely rare, and we additionally present a review of all other reported cases in the literature. After undergoing posterior fossa decompression with C1 laminectomy and duraplasty, our patient made a complete neurological recovery within 2 weeks postoperatively and his MRI entire spine at 3 months postoperatively demonstrated a nearly complete resolution of the holosyrinx with significant decompression of the foramen magnum. CONCLUSION This rare presentation highlights the importance of maintaining a broad differential, particularly in pediatric patients, and expediting the workup in order to offer a surgical decompression within 1-2 months of foot weakness to maximize the probability of a full neurological recovery.
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Affiliation(s)
| | - Nikhil K Murthy
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Siting J Trybula
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Tord D Alden
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA. .,Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, USA.
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Guo F, Turgut M. Precise Management of Chiari Malformation with Type I. Front Surg 2022; 9:850879. [PMID: 35558380 PMCID: PMC9088844 DOI: 10.3389/fsurg.2022.850879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/10/2022] [Indexed: 11/21/2022] Open
Abstract
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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Affiliation(s)
- Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan International Joint Laboratory of Nervous System Malformation, Zhengzhou, China
- Correspondence: Fuyou Guo
| | - Mehmet Turgut
- Henan International Joint Laboratory of Nervous System Malformation, Zhengzhou, China
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Efeler, Aydın, Turkey
- Department of Histology and Embryology, Aydın Adnan Menderes University Health Sciences Institute, Efeler, Aydın, Turkey
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