1
|
Erol G, Çavuşoğlu N, Sevgi UT, Fidan S, Canbolat Ç, Doğruel Y, Luzzi S, Cohen Gadol AA, Güngor A. Occipital Sinus-Sparing Linear Paramedian Dural Incision: A Technical Note and Case Series for Median Suboccipital Approach. World Neurosurg 2024; 184:e121-e128. [PMID: 38244681 DOI: 10.1016/j.wneu.2024.01.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Durotomies, traditionally used during the midline suboccipital approach, involve sacrificing the occipital sinus (OS) with consequent shrinking of the dura, risk of venous complications, difficulty performing watertight closure, and a higher rate of postoperative cerebrospinal fluid (CSF) leaks. The present technical note describes the OS-sparing linear paramedian dural incision, which leads to a decrease in the risk of complications during the median suboccipital approach in our case series. METHODS The OS-sparing linear incision technique involves a dural incision placed 1 cm lateral to the OS. The angle of view of the microscope is frequently changed to overcome the narrowed exposure of the linear durotomy. Copious irrigation with saline prevents drying of the dura. A running watertight closure of the dura is performed. The overall results of 5 cases are reviewed. RESULTS The cases were 3 tumors and 2 cavernomas. The OS was preserved in all 5, and no duraplasty was needed. The average dura closure time was 16.8 minutes. No CSF leak occurred, and no wound complications were observed. A gross total resection of the lesion was achieved in all the patients. The mean follow-up was 10.2 months, and there were no late complications related to the dura closure. CONCLUSIONS In comparison to the types of durotomies conventionally used for the midline suboccipital approach, the OS-sparing linear paramedian dural incision entails lower risks of bleeding, venous complications, CSF leaks, and infections by avoiding duraplasty. Validation of this technical note on a larger patient cohort is needed.
Collapse
Affiliation(s)
- Gökberk Erol
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Neslihan Çavuşoğlu
- Department of Neurosurgery, Bakırköy Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Umut Tan Sevgi
- Department of Neurosurgery, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Semih Fidan
- Department of Neurosurgery, Bakırköy Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Çağrı Canbolat
- Department of Neurosurgery, Liv Hospital Vad istanbul, Istanbul, Turkey
| | - Yücel Doğruel
- The Neurosurgical Atlas, Carmel, Indiana, USA; Department of Neurosurgery, Tunceli State Hospital, Tunceli, Turkey
| | - Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Aaron A Cohen Gadol
- The Neurosurgical Atlas, Carmel, Indiana, USA; Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Abuzer Güngor
- Department of Neurosurgery, Liv Hospital Vad istanbul, Istanbul, Turkey; Faculty of Medicine, Department of Neurosurgery, Istinye University, Istanbul, Turkey.
| |
Collapse
|
2
|
Tavakol S, Zieles K, Peters M, Omini M, Chen S, Jea A. The impact of social determinants of health on early outcomes after adult Chiari surgery. GeroScience 2024; 46:1451-1459. [PMID: 37996723 PMCID: PMC10828512 DOI: 10.1007/s11357-023-01021-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/19/2023] [Indexed: 11/25/2023] Open
Abstract
We sought to identify social determinants of health (SDoH) for adult patients undergoing Chiari decompression surgery and to analyze their association with postoperative outcomes, including length of stay (LOS), return to the system within 30 days, and the Chicago Chiari Outcomes Score (CCOS). This is a retrospective study of adult patients who underwent Chiari decompression surgery between June 2021 and January 2023. Data was gathered through electronic medical record review and telephone surveys. Descriptive statistics were used to evaluate demographics of all patients meeting inclusion criteria. Fisher's exact tests and logistic regression were used for data analysis. A total of 37 patients underwent Chiari decompression (23 CCOS/SDoH survey respondents): 48% bony decompression only, 30% bony decompression plus intradural exploration, and 22% occipitocervical fusion. Seven patients (30%) had a LOS > 2 days, 1 patient (4%) required inpatient rehabilitation postoperatively, 4 patients (17%) returned to the system within 30 days, 10 patients (43%) had an extremely favorable CCOS (15-16), and 11 patients (48%) reported interaction with a Chiari support group. Mean follow-up was 9.5 months. Patients with occipitocervical fusion were more likely to have a LOS > 2 days (p = 0.03), patients who exercised ≥ 3 days per week were more likely to have a favorable CCOS (p = 0.04), and patients who participated in a Chiari support group were less likely to have a favorable CCOS (p = 0.03). Chiari decompression plus occipitocervical fusion may be associated with increased LOS. While more frequent exercise may be associated with better post-surgical outcomes, participation in a Chiari support group may be correlated with worse outcomes.
Collapse
Affiliation(s)
- Sherwin Tavakol
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Kristin Zieles
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mikayla Peters
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael Omini
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Andrew Jea
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| |
Collapse
|
3
|
Gecici NN, Gurses ME, Isikay AI, Bilginer B, Hanalioglu S. Duraplasty with autologous cervical fascia in pediatric posterior fossa tumor surgery: a single-center experience with 214 cases. Childs Nerv Syst 2024:10.1007/s00381-024-06351-6. [PMID: 38498171 DOI: 10.1007/s00381-024-06351-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/01/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Posterior fossa surgeries for pediatric tumors pose challenges in achieving optimal dural repair and duraplasty is usually required. Autografts, allografts, xenografts, and synthetic substitutes can be used for duraplasty. Autologous cervical fascia can be a safe and reliable graft option for duraplasty after posterior fossa surgeries. This study aims to investigate the outcomes of duraplasty with autologous cervical fascial graft in children after posterior fossa surgery for pediatric brain tumors. METHODS Pediatric patients with posterior fossa tumor who underwent surgery between March 2001 and August 2022 were retrospectively reviewed. Data on demographics, preoperative symptoms, diagnosis, tumor characteristics, hydrocephalus history, and postoperative complications, including cerebrospinal fluid (CSF) leakage, pseudomeningocele, and meningitis were collected. Logistic regression analysis was performed to explore risk factors for postoperative complications. RESULTS Patient cohort included 214 patients. Autologous cervical fascia was used in all patients for duraplasty. Mean age was 7.9 ± 5.3 years. Fifty-seven patients (26.6%) had preoperative hydrocephalus and 14 patients (6.5%) received VPS or EVD perioperatively. Postoperative hydrocephalus was present in 31 patients (14.5%). Rates of CSF leak, pseudomeningocele, and meningitis were 4.2%, 2.8%, and 4.2% respectively. Logistic regression analysis revealed that postoperative EVD and VPS placement were the factors associated with postoperative complications. CONCLUSION Autologous cervical fascia is a safe and reliable option for duraplasty with minimal risk of postoperative complications. The straightforward surgical technique and with no additional cost for harvesting the graft renders autologous cervical fascia a favorable alternative for resource-limited countries or surgical settings.
Collapse
Affiliation(s)
- Neslihan Nisa Gecici
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muhammet Enes Gurses
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ahmet Ilkay Isikay
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Burcak Bilginer
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| |
Collapse
|
4
|
Rosa M, Parise M, Ferreira-Pinto PH, Nigri F. Bovine Pericardium Treated with Polyethylene Glycol and Ethanol Versus Pericranium for Duraplasty: A Pilot Study in Supratentorial Neurosurgery. World Neurosurg 2024; 183:e871-e876. [PMID: 38218446 DOI: 10.1016/j.wneu.2024.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Watertight closure of dura mater after intracranial surgery can avoid cerebrospinal fluid leakage and central nervous system infection and herniation. When primary closure is not possible, the pericranium is the preferential choice. When it is not available, a dural substitute becomes necessary. Bovine pericardium treated with polyethylene glycol and ethanol is herein tested as a dural substitute. METHODS A pilot study comparing bovine pericardium with pericranium in supratentorial neurosurgery was performed. RESULTS Twenty patients were initially allocated into a bovine pericardium group (group 1) or a pericranium group (group 2). Three patients from group 1 and 2 from group 2 had a loss of follow-up, being excluded. In the remaining 15 patients, epidemiological analysis demonstrated a male:female ratio of 3:4 and 4:4 for groups 1 and 2. Ages varied from 28 to 68 (Mean = 49.6) in group 1 and 40-80 (Mean = 61.2) in group 2, with a mean difference of 11.68 years (P = 0.09). Two cases of surgical site infection and 1 of hydrocephalus were observed. Although the calculated relative risk for complications was higher in group 1 (Relative Risk = 1.08), Fisher exact test demonstrated no statistically significant difference between groups (P = 1.00). Procedure mean time was 23 minutes and 11 seconds in group 1 versus 27 minutes and 55 seconds in group 2 (P = 0.47). Mean graft area was 13.17 and 6.23 cm2 in groups 1 and 2 (P = 0.02). CONCLUSIONS Bovine pericardium treated with polyethylene glycol and ethanol was comparable to pericranium as a dural substitute. More studies are encouraged to certify our findings.
Collapse
Affiliation(s)
- Magno Rosa
- Neurosurgery Teaching and Assistance Unit, Department of Surgical Specialties, Pedro Ernesto University Hospital, University of State of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Maud Parise
- Neurosurgery Teaching and Assistance Unit, Department of Surgical Specialties, Pedro Ernesto University Hospital, University of State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Henrique Ferreira-Pinto
- Neurosurgery Teaching and Assistance Unit, Department of Surgical Specialties, Pedro Ernesto University Hospital, University of State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flavio Nigri
- Neurosurgery Teaching and Assistance Unit, Department of Surgical Specialties, Pedro Ernesto University Hospital, University of State of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
5
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
6
|
Li Z, Ge S, Zhao T, Zhang X, Zhao L, Qu Y. Trans-Defect Underlay Watertight Duraplasty for Traumatic Anterior Skull Base Dural Defect: Technical Report. World Neurosurg 2024; 186:1-6. [PMID: 38395353 DOI: 10.1016/j.wneu.2024.02.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Watertight duraplasty is essential for surgical management of traumatic anterior skull base (ASB) dural defect but challenging in the deep and narrow operative corridor. Here, the authors report a trans-defect underlay watertight duraplasty (TDUWD) technique for traumatic ASB dural defect. METHODS TDUWD was performed by inserting a free pericranium graft under the dural defect. The diameter of the pericranium graft was larger than the dural defect. The pericranium graft was sutured to the dural defect watertightly in an "inside-to-outside" direction, with the needle not penetrating the inner layer of pericranium graft. The pedicled pericranium flap was used as a second layer of reconstruction. The characteristics, complications, and outcomes of patients who received TDUWD are reported. RESULTS A total of 29 patients received TDUWD. Immediate postoperative cessation of cerebrospinal fluid (CSF) leak occurred in 28 patients. One patient recovered after lumber drainage. No patient needed a second operation or reported delayed recurrence of CSF leak. No complication related to the surgical technique was observed. CONCLUSIONS Use of TDUWD for traumatic ASB dural defect results in an immediate, 1-stage, and definitive correction of CSF leak and seems to be simple, safe, and reliable for large and deeply located dural defects.
Collapse
Affiliation(s)
- Zhihong Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Xingye Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Lanfu Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China.
| |
Collapse
|
7
|
Knafo S, Aghakhani N, Parker F. Laminoplasty with tented duraplasty for Hirayama disease. Acta Neurochir (Wien) 2024; 166:5. [PMID: 38214785 DOI: 10.1007/s00701-024-05893-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Hirayama disease (HD) is a characterized by progressive amyotrophy of the upper limbs due to a forward displacement of the cervical dura during neck flexion. METHODS Unlike other treatment options aiming at preventing cervical flexion (e.g., collar or arthrodesis), laminoplasty with tented duraplasty addresses dural dysplasia. Technically, the procedure consists in enlarging the dural sac by performing an expansile duraplasty that is secured to the yellow ligaments, in association with an open-book laminoplasty. CONCLUSION Laminoplasty with tented duraplasty is a surgical option addressing the cause of HD to prevent further neurological deterioration while preserving cervical motion.
Collapse
Affiliation(s)
- Steven Knafo
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicetre, France.
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicetre, France.
| | - Nozar Aghakhani
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicetre, France
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicetre, France
| | - Fabrice Parker
- Department of Neurosurgery, Bicêtre Hospital, AP-HP, Le Kremlin-Bicetre, France
- Faculty of Medicine, University Paris-Saclay, Le Kremlin-Bicetre, France
| |
Collapse
|
8
|
Fioravanti A, Badaloni F, Tubbs RS, Donofrio CA. How I do it - The "drum skin" duraplasty technique after foramen magnum decompression for Chiari malformations. Acta Neurochir (Wien) 2023; 165:3045-3050. [PMID: 37060375 DOI: 10.1007/s00701-023-05576-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Chiari malformations are a spectrum of posterior cranial fossa anomalies characterized by herniation of the cerebellar tonsils through the foramen magnum. Surgery is the treatment of choice for selected patients with good postoperative outcomes. METHODS We describe foramen magnum decompression (FMD) with dural opening and a "drum skin" duraplasty technique. CONCLUSIONS In our experience, FMD with "drum skin" duraplasty is a safe and effective procedure, reducing the risk of CSF leakage and arachnoidal adhesions and yielding better long-term clinical and radiological outcomes than other traditional techniques.
Collapse
Affiliation(s)
- Antonio Fioravanti
- Neurosurgery Department, ASST Cremona, Viale Concordia 1, 26100, Cremona, Italy
| | - Filippo Badaloni
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
- University of Queensland, Brisbane, Australia
| | - Carmine Antonio Donofrio
- Neurosurgery Department, ASST Cremona, Viale Concordia 1, 26100, Cremona, Italy.
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Faculty of Medicine, University of Brescia, Viale Europa 11, 25123, Brescia, Italy.
| |
Collapse
|
9
|
Saadoun S, Grassner L, Belci M, Cook J, Knight R, Davies L, Asif H, Visagan R, Gallagher MJ, Thomé C, Hutchinson PJ, Zoumprouli A, Wade J, Farrar N, Papadopoulos MC. Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial. Trials 2023; 24:497. [PMID: 37550727 PMCID: PMC10405486 DOI: 10.1186/s13063-023-07454-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/13/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Cervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone. METHODS This is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results). DISCUSSION We anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care. TRIAL REGISTRATION IRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021).
Collapse
Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK.
| | - Lukas Grassner
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
- Institute of Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Maurizio Belci
- National Spinal Injury Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, Bucks, UK
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Ruth Knight
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Lucy Davies
- Surgical Intervention Trials Unit, University of Oxford, Oxford, UK
| | - Hasan Asif
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Ravindran Visagan
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Mathew J Gallagher
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Claudius Thomé
- Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | | | - Argyro Zoumprouli
- Neuro-Intensive Care Unit, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, London, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Farrar
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
- Neurosurgery, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
10
|
Nguyen A, Reddy A, Sharaf R, Ladehoff L, Diaz MJ, Lucke-Wold B. Outcomes of surgical management and implant consideration for depressed skull fractures: A systematic review. Adv Neurol (Singap) 2023; 2:247. [PMID: 36846546 PMCID: PMC9948107 DOI: 10.36922/an.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Traumatic brain injuries (TBIs) are associated with high mortality and morbidity. Depressed skull fractures (DSFs) are a subset of fractures characterized by either direct or indirect brain damage, compressing brain tissue. Recent advances in implant use during primary reconstruction surgeries have shown to be effective. In this systematic review, we assess differences in titanium mesh, polyetheretherketone (PEEK) implants, autologous pericranial grafts, and methyl methacrylate (PMMA) implants for DSF treatment. Methods A literature search was conducted in PubMed, Scopus, and Web of Science from their inception to September 2022 to retrieve articles regarding the use of various implant materials for depressed skull fractures. Inclusion criteria included studies specifically describing implant type/material within treatment of depressed skull fractures, particularly during duraplasty. Exclusion criteria were studies reporting only non-primary data, those insufficiently disaggregated to extract implant type, those describing treatment of pathologies other than depressed skull fractures, and non-English or cadaveric studies. The Newcastle-Ottawa Scale was utilized to assess for presence of bias in included studies. Results Following final study selection, 18 articles were included for quantitative and qualitative analysis. Of the 177 patients (152 males), mean age was 30.8 years with 82% implanted with autologous graft material, and 18% with non-autologous material. Data were pooled and analyzed with respect to the total patient set, and additionally stratified into those treated through autologous and non-autologous implant material.There were no differences between the two cohorts regarding mean time to encounter, pre-operative Glasgow coma scale (GCS), fracture location, length to cranioplasty, and complication rate. There were statistically significant differences in post-operative GCS (p < 0.0001), LOS (p = 0.0274), and minimum follow-up time (p = 0.000796). Conclusion Differences in measurable post-operative outcomes between implant groups were largely minimal or none. Future research should aim to probe these basic results deeper with a larger, non-biased sample.
Collapse
Affiliation(s)
- Andrew Nguyen
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Akshay Reddy
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ramy Sharaf
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Lauren Ladehoff
- College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
11
|
De Marco R, Piatelli G, Portonero I, Fiaschi P, Secci F, Pacetti M, Pavanello M. Transient meningism in children after non-autologous duraplasty for Chiari Malformation surgery: A case series. Neurochirurgie 2023; 69:101423. [PMID: 36775120 DOI: 10.1016/j.neuchi.2023.101423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/14/2023] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Increasing the posterior fossa volume is the mainstay of treatment for Chiari type 1 Malformation (C1M) and type 1.5 (C1.5M). Different options to restore CSF flow have been described but no consensus has been reached yet. Bony decompression of posterior cranial fossa with dural opening provides good results but at the price of complications such as pseudomeningocele and aseptic meningitis. A single center retrospective analysis was conducted to find any relationships between outcome and perioperative factors. As a second goal a specific analysis was conducted on the complications and their hypothetical causes. METHODS All the pediatric patients who underwent to posterior fossa bony decompression and dural opening for C1M or C1.5M in the period 2008-2020 were included in the study. A minimum period of three-months follow-up was considered among the inclusion criteria. RESULTS A population of fifty-three consecutive patients was collected. Pseudomeningocele and a mild meningeal irritation resulted the most frequent complications. Considering preoperative and intraoperative factors, the type of dural graft showed a relatively strong correlation (P<.01) with pseudomeningocele appearance and the development of meningism. In the latter case, a short course of steroids was the only treatment required to control symptoms. CONCLUSIONS Different factors could influence the outcome in Chiari Malformation surgery and eventually the development of complications. An adequate dural graft selection is of paramount importance when a dural opening for posterior fossa augmentation is planned. In case of mild meningeal irritation, a trial with short course steroids could avoid revision surgery.
Collapse
Affiliation(s)
- R De Marco
- Department of Neurosurgery, Istituto Giannina Gaslini Children's Hospital, Genova, Italy; Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", "Città della Salute e della Scienza" University Hospital, University of Turin, Turin, Italy.
| | - G Piatelli
- Department of Neurosurgery, Istituto Giannina Gaslini Children's Hospital, Genova, Italy
| | - I Portonero
- Department of Neurosurgery, Istituto Giannina Gaslini Children's Hospital, Genova, Italy; Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", "Città della Salute e della Scienza" University Hospital, University of Turin, Turin, Italy
| | - P Fiaschi
- Section of Neurosurgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Dipertimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Università di Genova, Genova, Italy
| | - F Secci
- Department of Neurosurgery, Istituto Giannina Gaslini Children's Hospital, Genova, Italy
| | - M Pacetti
- Department of Neurosurgery, Istituto Giannina Gaslini Children's Hospital, Genova, Italy
| | - M Pavanello
- Department of Neurosurgery, Istituto Giannina Gaslini Children's Hospital, Genova, Italy
| |
Collapse
|
12
|
Mohammed K, Iqbal J, Arshad M, Abu-Dayeh AS, Albozom I, Alyafei A, Ben Zabih T, Belkhair S. Extensive Foreign Body Reaction to Synthetic Dural Replacement After Decompressive Craniectomy with Radiological and Histopathology Evidence: Observational Case Series. World Neurosurg 2023; 172:e585-e592. [PMID: 36754353 DOI: 10.1016/j.wneu.2023.01.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Though the indications are quite varied, decompressive craniectomy is considered a life-saving procedure. Maximal effectiveness of craniectomy is achieved when, in addition to bone removal, the dura mater is opened properly and is augmented with duraplasty. Different synthetic materials have been used over the decades to replace the dura during decompressive craniectomy. We have used different synthetic dural replacements at our institution, including Neuro-Patch, DuraGen, and Lyoplant. In this case series, we described 4 cases that had excessive granulation tissue formation in response to a newly used synthetic dural substitute (ReDura) after emergent decompressive craniectomy. During follow-up brain imaging at different intervals, these cases were found to have foreign body reaction in the form of excessive granulation tissue formation; additionally, 1 case had a sterile pus-like collection. The granulation tissue diagnosis was affirmed by histopathology in all 4 cases. METHODS This study was an observational retrograde case series, with data obtained from electronic medical records. RESULTS The study showed extensive foreign body giant cell reactions on preoperative computed tomography scans, indicating a very high occurrence rate of 72.4%, when ReDura was used as dural replacement. CONCLUSIONS Our experience showed that patients are prone to develop severe foreign body giant cell reactions with ReDura. Neurosurgical centers using this material should monitor patients for possible abnormal foreign body reaction and report it to establish the safety and efficacy profile of this material.
Collapse
Affiliation(s)
- Kazim Mohammed
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar; Department of Neurosurgery, University of Qatar, Doha, Qatar.
| | - Javeed Iqbal
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Mohsin Arshad
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Ala Saleem Abu-Dayeh
- Department of Pathology, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Issam Albozom
- Department of Pathology, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Abdulnasser Alyafei
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Tarek Ben Zabih
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar
| | - Sirajeddin Belkhair
- Department of Neurosurgery, Hamad Medical Corporation, Hamad General Hospital, Doha, Qatar; Department of Neurosurgery, Weill Cornell medicine-Qatar, Ar-Rayyan, Qatar; Department of Neurosurgery, University of Qatar, Doha, Qatar
| |
Collapse
|
13
|
Giannakaki V, Wildman J, Thejasvin K, Pexas G, Nissen J, Ross N, Mitchell P. Foramen Magnum Decompression for Chiari Malformation Type 1: Is There a Superior Surgical Technique? World Neurosurg 2023; 170:e784-90. [PMID: 36455845 DOI: 10.1016/j.wneu.2022.11.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Foramen magnum decompression is a common operation used to treat Chiari malformation. There are different surgical techniques; however, some are anecdotally more effective than others. Our aim was to determine whether there is a superior technique in relation to revision rates, presence of persistent postoperative headache and nausea, and syrinx reduction. METHODS This was a retrospective analysis of foramen magnum decompressions performed between 2012 and 2017 for Chiari 1 in a single institution. Three types of operations were performed: 1) bony decompression alone; 2) bony decompression with durotomy and dura left open; 3) bony decompression with opening of dura and duraplasty. We compared postoperative symptoms and revision rates between these 3 operations. RESULTS In 168 patients, 185 foramen magnum decompressions were performed. Among the 168 primary operations, in 66 the dura was not opened, in 86 the dura was opened without a duraplasty, and in 16 a duraplasty was performed. Of 185 operations, 17 were revision surgery. For primary procedures, the revision rates were 12 (18%) where the dura was not opened, 4 (5%) where the dura was left open, and 1 (6%) when duraplasty was performed. Severe postoperative headache and nausea occurred in 2 (3%) patients where the dura was not opened, 4 (25%) patients after primary duraplasty, and 64 (74%) patients after primary durotomy. CONCLUSIONS In this study, rate of revision surgery was highest in patients who had bony decompression without dural opening. Rate of postoperative headache and nausea was highest in the durotomy group. Overall duraplasty had the best results.
Collapse
|
14
|
Sommer F, Brand M, Scheithauer MO, Hoffmann TK, Theodoraki MN, Weber R. [Diagnosis and Treatment in frontobasal fractures]. HNO 2023; 71:35-47. [PMID: 36525033 DOI: 10.1007/s00106-022-01256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 12/23/2022]
Abstract
Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.
Collapse
Affiliation(s)
- F Sommer
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland.
| | - M Brand
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - M O Scheithauer
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - T K Hoffmann
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - M-N Theodoraki
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - R Weber
- Hals-Nasen-Ohrenklinik des Städtischen Klinikums Karlsruhe, Karlsruhe, Deutschland
| |
Collapse
|
15
|
Valentini LG, Galbiati TF, Saletti V, Farinotti M, Erbetta A, Croci C, Vetrano IG. Evaluation of Adult and Pediatric Chiari Type 1 Malformation Patients: Do Consensus Documents Fit Everyday Practice? Acta Neurochir Suppl 2023; 135:147-155. [PMID: 38153463 DOI: 10.1007/978-3-031-36084-8_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
The management of Chiari 1 malformation (CM1) and Syringomyelia (Syr) has shown many changes in surgical indications and techniques over time. The dedicated neurosurgical and neurological community recently planned to analyze the state of the art and find conduct uniformity. This led to international consensus documents on diagnostic criteria and therapeutic strategies. We aimed to evaluate, in a large, monocentric surgical series of adult and children CM1 patients, if the daily clinical practice reflects the consensus documents. Our series comprises 190 pediatric and 220 adult Chiari patients submitted to surgery from 2000 to 2021. The main indications for the treatment were the presence of Syr and symptoms related to CM1. While there is great correspondence with the statements derived from the consensus documents about what to do for Syr and symptomatic CM1, the accordance is less evident in CM1 associated with craniosynostosis or hydrocephalus, especially when considering the early part of the series. However, we think that performing such studies could increase the homogeneity of surgical series, find a common way to evaluate long-term outcomes, and reinforce the comparability of different strategies adopted in different referral centers.
Collapse
Affiliation(s)
- Laura Grazia Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Veronica Saletti
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mariangela Farinotti
- Neuroepidemiology Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Erbetta
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carolina Croci
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| |
Collapse
|
16
|
Jbarah OF, Aburayya BI, Shatnawi AR, Alkhasoneh MA, Toubasi AA, Alharahsheh SM, Nukho SK, Nassar AS, Jamous MA. Risk of meningitis after posterior fossa decompression with duraplasty using different graft types in patients with Chiari malformation type I and syringomyelia: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:3537-3550. [PMID: 36180807 DOI: 10.1007/s10143-022-01873-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/24/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022]
Abstract
Several complications have been reported after the use of grafts for duraplasty following posterior fossa decompression for the treatment of Chiari malformation type I. This study aims to investigate the rate of meningitis after posterior fossa decompression using different types of grafts in patients with Chiari malformation type I and associated syringomyelia. The search was conducted using multiple databases, including PubMed, Scopus, Web of Science, and Embase. Data on the rate of meningitis, syrinx change, and rate of reoperation were extracted and investigated. Quality of evidence was assessed using the Newcastle-Ottawa scale. Nineteen studies were included in the final meta-analysis, encompassing 1404 patients and investigating autografts, synthetic grafts, allografts, and xenografts (bovine collagen, bovine pericardium, and pig pericardium). Autografts were associated with the lowest rate of meningitis (1%) compared to allografts, synthetic grafts, and xenografts (2%, 5%, and 8% respectively). Autografts were also associated with the lowest rate of reoperation followed by xenografts, allografts, and synthetic grafts (4%, 5%, 9%, and 10% respectively). On the other hand, allografts were associated with the highest rate of syrinx improvement (83%) in comparison to autografts and synthetic grafts (77%, and 79% respectively). Autografts were associated with the lowest meningitis, reoperation, and syrinx improvement rates. Furthermore, synthetic grafts were associated with the highest reoperation and xenografts with the highest rate of meningitis, whereas allografts were associated with the best syrinx improvement rate and second-best meningitis rate. Future studies comparing autografts and allografts are warranted to determine which carries the best clinical outcome.
Collapse
Affiliation(s)
- Omar F Jbarah
- Department of Neurosurgery, Faculty Of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, zip code 22110, Jordan
| | - Bahaa I Aburayya
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Ayman R Shatnawi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Mohab A Alkhasoneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Ahmad A Toubasi
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Sondos M Alharahsheh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Saleem K Nukho
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Asil S Nassar
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Mohammad A Jamous
- Department of Neurosurgery, Faculty Of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, zip code 22110, Jordan.
| |
Collapse
|
17
|
Kubota Y, Ogiwara T, Kitamura S, Nishikawa A, Fujii Y, Hanaoka Y, Yokota A, Higashiyama F, Oya F, Goto T, Hongo K, Horiuchi T. Novel method of rugby headgear for managing postoperative cerebrospinal fluid leakage following craniotomy. Neurochirurgie 2022; 68:550-552. [PMID: 35697526 DOI: 10.1016/j.neuchi.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Y Kubota
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - T Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan.
| | - S Kitamura
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - A Nishikawa
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Y Fujii
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Y Hanaoka
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - A Yokota
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan; Department of Neurosurgery, Shinshu Ueda Medical Center, Ueda, Nagano, Japan
| | - F Higashiyama
- Department of Neurosurgery, Shinshu Ueda Medical Center, Ueda, Nagano, Japan
| | - F Oya
- Department of Neurosurgery, Shinshu Ueda Medical Center, Ueda, Nagano, Japan
| | - T Goto
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - K Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - T Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| |
Collapse
|
18
|
Hu Z, Liao G, Lu Y, Wang C, Mei J. Comparison of Dural Graft Types and Graft Fixation Methods in Chiari Malformation Type I Decompression Surgery. World Neurosurg 2022; 164:e458-e462. [PMID: 35526814 DOI: 10.1016/j.wneu.2022.04.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Suboccipital decompression with duraplasty is being increasingly accepted for treating patients with Chiari malformation type I (CM-1). To date, the optimal duraplasty for CM-I has not been delineated. This study aims to compare the clinical and radiologic effects of duraplasty performed using 2 types of grafts and 2 graft fixation methods in 3 combinations. METHODS In this retrospective study, 84 consecutive decompressions with duraplasty were analyzed. Two types of grafts (nonautologous [Non-Auto G], 90.5% and autologous [Auto G], 9.5%) and 2 graft fixations (suturing [S], 31.0%; and suturing plus gluing [S + G], 69.0%) were used in 3 different combinations: Non-Auto G S: 31.0%; Non-Auto G S + G: 59.5%, and Auto G S + G: 9.5%. All patients were followed up for 3 months. Clinical results were evaluated using the Gestalt scale, and syringomyelia results were evaluated using magnetic resonance imaging. RESULTS According to the Gestalt scale, 82.1% of the patients showed improvement 3 months post operation, and the improvement was not related to the type of graft (P = 0.90), fixation (P = 0.90), or duraplasty (P = 0.81). Decreased syringomyelia was observed in 76.4% of the patients. It was not associated with the graft (P = 0.53), fixation (P = 0.72), or duraplasty (P = 0.80). Meningitis occurred in the Auto G S + G, Non-Auto G S + G and Non-Auto G S groups (25%, 48%, and 23.1%, respectively; P = 0.30), and their formations were not related to the k graft type (P = 0.57) or fixation (P = 0.19). CONCLUSIONS Autologous and nonautologous dural grafts can be performed using either sutures or sutures plus glue, as both result in similar outcomes.
Collapse
Affiliation(s)
- Zuli Hu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Gang Liao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuzhao Lu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chunliang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Jinhong Mei
- Department of Pathology, The First Affiliated Hospital of Nanchang University, Nanchang, China; Institute of Molecular Pathology, Nanchang University, Nanchang, China
| |
Collapse
|
19
|
Cavelier S, Quarrington RD, Jones CF. Mechanical properties of porcine spinal dura mater and pericranium. J Mech Behav Biomed Mater 2021; 126:105056. [PMID: 34953436 DOI: 10.1016/j.jmbbm.2021.105056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The objective of this study was to characterize and compare the mechanical properties of porcine pericranium and spinal dura mater, to evaluate the mechanical suitability of pericranium as a dural graft. METHOD Eighty-eight spinal dura (cervical, thoracic, and lumbar regions, in ventral longitudinal, dorsal longitudinal and circumferential orientations) and eighteen pericranium samples (ventral-dorsal, and lateral orientations) from four pigs, were harvested and subjected to uniaxial loading while hydrated. The stiffness, strain at toe-linear regions transition, strain at linear-yield regions transition and other structural and mechanical properties were measured. Stress-strain curves were fitted to a one-term Ogden model and Ogden parameters were calculated. Linear regression models with cluster-robust standard errors were used to assess the effect of region and orientation on material and structural properties. RESULTS Both spinal dura and pericranium exhibited distinct anisotropy and were stiffer in the longitudinal direction. The tissues exhibited structural and mechanical similarities especially in terms of stiffness and strains in the linear region. Stiffness ranged from 1.28 to 5.32 N/mm for spinal dura and 2.42-3.90 N/mm for pericranium. In the circumferential and longitudinal directions, the stiffness of spinal dura specimens was statistically similar to that of pericranium in the same orientation. The strain at the upper bound of the linear region of longitudinal pericranium (28.0%) was statistically similar to that of any spinal dura specimens (24.4-32.9%). CONCLUSIONS Autologous pericranium has advantageous physical properties for spinal duraplasty. The present study demonstrated that longitudinally oriented pericranium is mechanically compatible with spinal duraplasty procedures. Autologous pericranium grafts will likely support the mechanical loads transmitted from the spinal dura, but further biomechanical analyses are required to study the effect of the lower yield strain of circumferential pericranium compared to spinal dura. Finally, the Ogden parameters calculated for pericranium, and the spinal dura at each spinal level, will be useful for computational models incorporating these soft tissues.
Collapse
Affiliation(s)
- S Cavelier
- Spinal Research Group & Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5005, Australia; Department of Mechanical Engineering, McGill University, 817 Rue Sherbrooke Ouest, Montréal, QC, H3A 0C3, Canada
| | - R D Quarrington
- Spinal Research Group & Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - C F Jones
- Spinal Research Group & Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5005, Australia; School of Mechanical Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia.
| |
Collapse
|
20
|
Mozaffari K, Davidson L, Chalif E, Phan TN, Sparks AD, Myseros JS, Oluigbo CO, Keating RF. Long-term outcomes of posterior fossa decompression for Chiari malformation type 1: which patients are most prone to failure? Childs Nerv Syst 2021; 37:2891-2898. [PMID: 34232379 DOI: 10.1007/s00381-021-05280-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The role of an osseous-only posterior fossa decompression (PFD) for Chiari malformation type 1 (CM1) remains controversial. We reviewed long-term outcomes for patients with CM1 undergoing a PFD to evaluate if there was any difference for failure when compared to patients undergoing a PFD with duraplasty (PFDD). METHODS Consecutive patients surgically treated at a single tertiary pediatric neurosurgery clinic over a 25-year period with at least 5 years of follow-up were evaluated. PFD patients were compared to those that initially received a PFDD. Demographics, surgical indications, surgical approach, outcomes, and complications were reviewed. RESULTS A total of 60 patients were included in this study of which 25 (41.67%) underwent PFD and 35 (58.33%) underwent PFDD. Mean age at surgery was 7.41 years (range 0.4 to 18 years) with a mean follow-up of 8.23 years (range 5 to 21 years). Those that received a PFD had a lower rate of radiographic syrinx improvement (p = 0.03), especially in the setting of holocord syringes. Failure rate was significantly higher in the PFD group (20% vs 2.90%, p = 0.03). However, complications were significantly higher in the PFDD group (17.14% vs 4.0%, p = 0.04). CONCLUSIONS PFD provides a safe treatment option with similar clinical improvements and lower post-operative complication rate compared to PFDD, albeit at the cost of greater chance of reoperation, especially in the setting of a holocord syrinx. Patients with a holocord syrinx should be considered for a PFDD as their initial procedure.
Collapse
Affiliation(s)
- Khashayar Mozaffari
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Laurence Davidson
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Eric Chalif
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tiffany N Phan
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, The George Washington University Hospital, Washington, DC, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| |
Collapse
|
21
|
Antkowiak L, Tabakow P. 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. World Neurosurg 2021; 152:31-43. [PMID: 34098134 DOI: 10.1016/j.wneu.2021.05.124] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lukasz Antkowiak
- Department of Pediatric Neurosurgery, Medical University of Silesia, Katowice, Poland.
| | - Pawel Tabakow
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
22
|
Fuentes AM, Chiu RG, Nie J, Mehta AI. Inpatient outcomes of posterior fossa decompression with or without duraplasty for Chiari malformation type I. Clin Neurol Neurosurg 2021; 207:106757. [PMID: 34230005 DOI: 10.1016/j.clineuro.2021.106757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 05/05/2021] [Accepted: 06/06/2021] [Indexed: 12/09/2022]
Abstract
OBJECTIVE Chiari malformation type 1 (CM-1) is a congenital neurologic condition in which the cerebellar tonsils herniate below the foramen magnum, resulting in symptoms such as headache and neck pain. Two common surgical treatment approaches are posterior fossa decompression with (PFDD) and without duraplasty (PFD). Previous single-center studies have demonstrated increased neurologic complications after PFDD compared to PFD. The goal of this study is to determine differences in inpatient complications and hospitalization data among patients treated with these surgical techniques using a nationwide sample. METHODS The National Inpatient Sample (NIS) was queried for years 2012-2015 for all patients with a primary diagnosis of CM-1 who underwent PFD or PFDD. Differences in baseline demographics and comorbidities were accounted for in subsequent analysis using propensity score matching. Hospitalization measures and inpatient complications of the two cohorts were compared using Chi-squared tests and t-tests when appropriate. RESULTS A total of 2395 patients with CM-1 were included in this study, with 750 (31.3%) undergoing PFD and 1645 (68.7%) undergoing PFDD. PFDD was associated with higher total hospital costs than PFD. There were no significant differences in other hospitalization or discharge data, non-neurologic complications, or CNS complications (CSF leak, pseudomeningocele, abscess, meningitis, stroke) between the two surgical groups. CONCLUSIONS This study represents the largest national analysis to date of adult CM-1 patients undergoing PFD or PFDD. Our findings suggest that whether the decision is made to perform the less invasive PFD or more invasive PFDD, inpatient complications and hospitalization data will not significantly differ.
Collapse
Affiliation(s)
- Angelica M Fuentes
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ryan G Chiu
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - James Nie
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
| |
Collapse
|
23
|
Özlen F, Kucukyuruk B, Alizada O, Guler H, Akgun MY, Kafadar AM, Tuzgen S, Sanus GZ, Hanci M. Comparison of two surgical techniques in Chiari Malformation Type 1 Patients: Duraplasty alone vs duraplasty with arachnoid dissection. Clin Neurol Neurosurg 2021; 206:106686. [PMID: 34053804 DOI: 10.1016/j.clineuro.2021.106686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECT Optimal surgical technique to restore the cerebrospinal fluid flow through the foramen magnum remains to be debated in Chiari malformation type 1 (CM-1) patients. METHOD This study included 46 patients with CM-1 who underwent surgical treatment by one of two methods: posterior fossa bone decompression (BD) with arachnoid preserving duraplasty (Group 1) and BD with duraplasty and arachnoid dissection (Group 2). Complaints of the patient population and neurological findings were assessed with Neck Disability Index (NDI) and Europe Quality of Life 5 Dimensions (EQ-5D) in pre- and postoperative periods. RESULTS NDI and EQ-5D scores improved in overall patient population and in each individual surgical group. Both groups showed a significant decrease in size of syringomyelia cavity. Complications resulting in recurrent treatments and re-operations occurred in 15% of patients (n = 7); six of them were from Group 2. CONCLUSION CM-1 patients benefit significantly from surgical treatment. Duraplasty should be included to surgical technique. Avoiding arachnoid dissection may lead to better results regarding complication rates.
Collapse
Affiliation(s)
- Fatma Özlen
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Baris Kucukyuruk
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey.
| | - Orkhan Alizada
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Huseyin Guler
- Department of Anesthesiology and Intensive Care Medicine, Evangelisches Waldkrankenhaus Spandau, Berlin, Germany
| | | | - Ali Metin Kafadar
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Saffet Tuzgen
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Murat Hanci
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| |
Collapse
|
24
|
Saadoun S, Papadopoulos MC. Acute, Severe Traumatic Spinal Cord Injury: Monitoring from the Injury Site and Expansion Duraplasty. Neurosurg Clin N Am 2021; 32:365-376. [PMID: 34053724 DOI: 10.1016/j.nec.2021.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We discuss 2 evolving management options for acute spinal cord injury that hold promise to further improve outcome: pressure monitoring from the injured cord and expansion duraplasty. Probes surgically implanted at the injury site can transduce intraspinal pressure, spinal cord perfusion pressure, and cord metabolism. Intraspinal pressure is not adequately reduced by bony decompression alone because the swollen, injured cord is compressed against the dura. Expansion duraplasty may be necessary to effectively decompress the injured cord. A randomized controlled trial called DISCUS is investigating expansion duraplasty as a novel treatment for acute, severe traumatic cervical spinal cord injury.
Collapse
Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK.
| | - Marios C Papadopoulos
- Department of Neurosurgery, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
| |
Collapse
|
25
|
Tam SKP, Brodbelt A, Bolognese PA, Foroughi M. Posterior fossa decompression with duraplasty in Chiari malformation type 1: a systematic review and meta-analysis. Acta Neurochir (Wien) 2021; 163:229-238. [PMID: 32577895 DOI: 10.1007/s00701-020-04403-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Surgery for symptomatic Chiari type I malformation (CM-I) patients include posterior fossa decompression (PFD) involving craniectomy with or without dural opening, and posterior fossa decompression with duraplasty (PFDD). This review aims to examine the evidence to aid surgical decision-making. METHODS A medical database search was expanded to include article references to identify all relevant published case series. Animal studies, editorials, letters, and review articles were excluded. A systemic review and meta-analysis were performed to assess clinical and radiological improvement, complications, and reoperation rates. RESULTS Seventeen articles, containing data on 3618 paediatric and adult participants, met the inclusion criteria. In the group, 5 papers included patients that had the dura left open. PFDD is associated with better clinical outcomes (RR 1.24, 95% CI, 1.07 to 1.44; P = 0.004), but has a higher complication rate (RR 4.51, 95% CI, 2.01 to 10.11; P = 0.0003). In adults, clinical outcomes differences did not reach statistical significance (P = 0.07) but re-operation rates were higher with PFD (RR 0.17, 95% CI 0.03 to 0.86; P = 0.03), whilst in children re-operation rates were no different (RR 0.97, 95% CI 0.41 to 2.30; P = 0.94). Patients with a syrinx did better with PFDD (P = 0.02). No significant differences were observed concerning radiological improvement. CONCLUSIONS In the absence of hydrocephalus and craniocervical region instability, PFDD provides better clinical outcomes but with higher risk. The use of PFD may be justified in some cases in children, and in the absence of a syrinx. To help with future outcome assessments in patients with a CM-I, standardization of clinical and radiological grading systems are required. TRIAL REGISTRATION not required.
Collapse
|
26
|
Chang TW, Zhang X, Maoliti W, Yuan Q, Yang XP, Wang JC. Outcomes of Dura Splitting Decompression Versus Posterior Fossa Decompression With Duraplasty in the Treatment of Chiari I Malformation: A Systematic Review and Meta-analysis. World Neurosurg 2020; 147:105-114. [PMID: 33290896 DOI: 10.1016/j.wneu.2020.11.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgery is the definitive treatment option for symptomatic Chiari malformation I (CMI), but there is no clear consensus as to the preferred surgical method. This study aimed to quantitatively assess and compare the effect and safety of dura splitting decompression (DSD) and posterior fossa decompression with duraplasty (PFDD) in treating patients with CMI. METHODS A literature search of EMBASE, MEDLINE, PubMed, Cochrane Library, and Web of Science databases was conducted. References from January 1990 to September 2020 were retrieved. We only included papers containing original data, comparing the use of DSD and PFDD in CMI patients. RESULTS Overall, 11 relevant studies were identified, wherein 443 patients treated for CMI by DSD were compared with 261 patients treated by PFDD. No difference was observed between PFDD and PFD in terms of clinical improvement (P = 0.69), syringomyelia improvement (P = 0.90), or reoperation (P = 0.22). DSD was associated with shorter operation durations (P = 0.0007), shorter length of stay (P = 0.0007), and shorter overall postoperative complications (P < 0.0001) (especially cerebrospinal fluid [CSF] leak [P = 0.005], meningitis [P = 0.002], and pseudomeningocele [P = 0.002]), as compared with PFDD. CONCLUSIONS This study confirmed that dura splitting decompression has clinical and syringomyelia improvement outcomes comparable to posterior fossa decompression with duraplasty. Compared with PFDD, DSD not only significantly shortened the operation time and length of stay, but also significantly reduced the overall complication rate, especially those related to incidence of CSF-related complications. More evidence from advanced multicenter studies are needed to require to validate the findings.
Collapse
Affiliation(s)
- Teng-Wu Chang
- Department of Neurosurgery, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, People's Republic of China
| | - Xv Zhang
- Department of Neurosurgery, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, People's Republic of China
| | - Wulabeike Maoliti
- Department of Neurosurgery, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, People's Republic of China
| | - Qv Yuan
- Department of Imaging, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, People's Republic of China
| | - Xiao-Peng Yang
- Department of Neurosurgery, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, People's Republic of China
| | - Ji-Chao Wang
- Department of Neurosurgery, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, People's Republic of China.
| |
Collapse
|
27
|
Gallo P, Copley PC, McAllister S, Kaliaperumal C. The impact of neurosurgical technique on the short- and long-term outcomes of adult patients with Chiari I malformation. Clin Neurol Neurosurg 2020; 200:106380. [PMID: 33387726 DOI: 10.1016/j.clineuro.2020.106380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study is aimed to compare and evaluate any differences in clinical and radiological outcomes of different operative techniques of cranio-cervical decompression (CCD) performed in adults with symptomatic Chiari malformation type I (CM-1) within a single tertiary neurosurgical center. METHODS A retrospective review using the Hospital theatre management system (ORSOS) and records of patients who underwent CCD for CM-1 between January 2011 and October 2019 was performed. Patients were divided in three cohorts according to the operative technique used: an extradural osteo-ligamentous decompression (BD), BD followed by dural opening either without duraplasty (DOWD) or plus duroplasty (DOPD). The primary clinical outcome was measured by utilizing the Chicago Chiari Outcome Scale (CCOS). Syrinx outcome was measured on post-op MRI. Statistical analysis was performed using IBM SPSS 24 with α = 0.05. RESULTS 67 adults underwent 69 CCD: 10 BD, 29 DOWD and 30 DOPD. Median follow-up was 47.3 months (Interquartile Range (IQR) 26.3-73.7). Patients who underwent DOPD had a shorter median hospital stay (p-value 0.001), fewer unplanned readmissions (p-value 0.015), a higher median CCOS (p-value 0.001) and a lower post-operative complications rate (p-value 0.001) compared to patients who underwent DOWD. BD revealed a 40 % failure rate and was ineffective in cases with syringomyelia. CONCLUSION Better clinical outcomes, lower complication risk, and short duration of hospital stay were associated with patients who underwent dural opening with augmentative watertight duraplasty. Bony decompression alone despite being a very safe technique, does not appear to be reliable and effective in controlling and relieving the clinical symptoms and the syringomyelia of adult patients with CM-1.
Collapse
Affiliation(s)
- Pasquale Gallo
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom.
| | - Phillip Correia Copley
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom
| | - Shannon McAllister
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom
| | - Chandrasekaran Kaliaperumal
- Department of Clinical Neurosciences, 50 Little France Crescent, Edinburgh BioQuarter, Edinburgh, EH16 4TJ, United Kingdom
| |
Collapse
|
28
|
Adeleye AO. Posttraumatic leptomeningeal cyst capsule as a cost-free autograft for its repair: case illustrated technical reports. Neurosurg Rev 2020; 44:1775-1778. [PMID: 32772295 DOI: 10.1007/s10143-020-01364-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/03/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
The surgical treatment of traumatic leptomeningeal cyst (LMC) is repair of the dural defect with or without cranioplasty. The dural substitutes used are either autografts (which may not be enough) or artificial grafts (which are foreign-body implantations and which also may be too expensive in a low-resource practice). In this report from a developing country, we present the surgical description of the use of the cyst capsule as a cost-free autologous graft in the surgical repair of the dural defects of two cases of traumatic leptomeningeal cyst.
Collapse
Affiliation(s)
- Amos O Adeleye
- Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria. .,Department of Neurological Surgery, University College Hospital, UCH, Ibadan, Nigeria.
| |
Collapse
|
29
|
Butensky S, Rodgers S, Baron S, Schneider S, Mittler M. Comparison of surgical outcomes in patients with Chiari Type I malformation receiving posterior fossa decompression with and without duraplasty. Childs Nerv Syst 2020; 36:1399-1405. [PMID: 32451665 DOI: 10.1007/s00381-020-04667-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The goals of this study were to compare clinical outcomes in patients with Chiari Malformation Type I (CMI) receiving posterior fossa decompression with (PFDD) or without duraplasty (PFD). METHODS We conducted a retrospective analysis of 178 consecutive cases of 157 patients undergoing PFDD or PFD for CMI at Cohen Children's Medical Center between 2007 and 2017. Clinical improvement was defined as a clear reduction of preoperative symptoms after surgery as reported by patients and parents. An improvement of syrinx was derived from radiologic comparison of pre- and postoperative MR imaging. Chi-square analysis was performed to analyze the association between duraplasty and clinical parameters (alpha = 0.05). RESULTS The primary presenting complaint was headache (142/178; 80%), followed by neck, back, and upper extremity pain, and numbness or tingling (49/178; 28%). Seventy patients (78/178; 44%) underwent PFD, and 100 patients (100/178; 56%) underwent PFDD. Overall, 143 patients (143/178; 80%) experienced subjective improvement with no statistically significant difference between the two surgical techniques (p = 0.705). The number of patients receiving PFDD with syrinx improvement or stabilization (55/59; 93%) was statistically larger than those that received PFD (8/13; 62%) (p = 0.008). PFDD was associated with greater complications than PFD alone. There were 35 cases of reoperation overall (35/178; 19%), and there was no statistically significant difference in reoperation rate between PFD and PFDD (p = 0.255). CONCLUSIONS There appears to be a role for PFDD in patients with severe syringomyelia, but overall, PFD alone may be safely offered as the initial surgical intervention for symptomatic CMI patients.
Collapse
Affiliation(s)
- Samuel Butensky
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA
| | - Shaun Rodgers
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA. .,Division of Pediatric Neurosurgery, Cohen Children's Medical Center of New York, New Hyde Park, NY, 11040, USA.
| | - Shanna Baron
- Division of Pediatric Neurosurgery, Cohen Children's Medical Center of New York, New Hyde Park, NY, 11040, USA
| | - Steven Schneider
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA.,Division of Pediatric Neurosurgery, Cohen Children's Medical Center of New York, New Hyde Park, NY, 11040, USA
| | - Mark Mittler
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA.,Division of Pediatric Neurosurgery, Cohen Children's Medical Center of New York, New Hyde Park, NY, 11040, USA
| |
Collapse
|
30
|
Tavallaii A, Keykhosravi E, Rezaee H, Abouei Mehrizi MA, Ghorbanpour A, Shahriari A. Outcomes of dura-splitting technique compared to conventional duraplasty technique in the treatment of adult Chiari I malformation: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:1313-29. [PMID: 32567026 DOI: 10.1007/s10143-020-01334-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
Chiari malformation type I is a developmental abnormality with an array of surgical techniques introduced for the management of it. The most common technique is foramen magnum decompression with duraplasty. Dura-splitting technique as one of the non-dura-opening techniques is a less known procedure that spares the internal layer of the dura and can theoretically result in fewer complications compared to duraplasty. So, we performed a review of literature and meta-analysis on different clinical and radiological aspects of this technique and compared its outcomes to duraplasty. MOOSE guidelines were followed. A systematic search of three databases based on predefined search strategy and inclusion/exclusion criteria was performed. After quality assessment and data extraction by two authors, summarized data were presented in form of tables, and meta-analysis results were illustrated in forest plots. A review of 10 included studies consisting of 370 patients revealed significantly shorter operation duration and less intraoperative blood loss in the dura-splitting technique compared to duraplasty. Interestingly, there was no significant difference between these two techniques in terms of clinical and radiological outcomes. Overall complication rate and incidence of CSF-related complications or infections were significantly in favor of the dura-splitting technique. Dura-splitting technique can be considered as a safe and effective surgical procedure for Chiari I malformation with comparable outcomes and fewer complications compared to duraplasty, although this interpretation is derived from retrospective observational studies and lack of a prospective clinical trial is evident.
Collapse
|
31
|
Maehara N, Morioka T, Shimogawa T, Suzuki SO, Mizoguchi M, Haga S. Massive Ossification with Hematopoietic Marrow on Both Surfaces of the Expanded Polytetrafluoroethylene Artificial Dura Mater. World Neurosurg 2020; 139:405-409. [PMID: 32339733 DOI: 10.1016/j.wneu.2020.04.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Artificial dural substitute made from an expanded polytetrafluoroethylene (ePTFE) sheet has been widely used in surgical application. CASE DESCRIPTION We describe a 19-year-old woman in whom massive ossification with hematopoietic marrow was noted on both surfaces of an ePTFE sheet during epilepsy surgery. At age 8, she underwent decompressive craniectomy for a ruptured arteriovenous malformation in the right frontal lobe, followed by duraplasty with an ePTFE sheet and autologous cranioplasty fixed with titanium miniplates. CONCLUSIONS Since the ossification was prominent in the wrinkle dents of the ePTFE sheet and fibrotic membrane with repetitive hemorrhagic events was noted under the ePTFE sheet, the most plausible mechanism of ossification development is the organization of epiartificial and subartificial dural hematoma. Surgeons should be aware of the possibility of ossification development when working with ePTFE sheets for duraplasty.
Collapse
Affiliation(s)
- Naoki Maehara
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan; Department of Neurosurgery, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyusyu University, Fukuoka, Japan
| | - Sei Haga
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Japan.
| |
Collapse
|
32
|
Sinurat R. The Glasgow Outcome Scale-Extended Pediatric Scores of Intracranial Bleeding Patients with Acquired Prothrombin Complex Deficiency Post Craniotomy and Duraplasty. Pediatr Neurosurg 2020; 55:254-258. [PMID: 33171478 DOI: 10.1159/000511020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 08/15/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical evacuation of intracranial bleeding in pediatric patients due to acquired prothrombin complex deficiency (APCD) is a life-saving surgery when conservative treatment insufficient and impending brain herniation. This study aimed to evaluate the Glasgow outcome scale-extended pediatric (GOS-ePed) score of the pediatric intracranial bleeding patients with APCD after craniotomy and duraplasty. METHOD This was a retrospective study in the last 5 years of our experience. All of the pediatric patients with intracranial bleeding due to APCD who needed surgery were investigated. The data were collected from medical records after their parents have given their written informed concern and approved by the Ethics Review Committee, Faculty of Medicine, Universitas Kristen Indonesia. The inclusion criteria were patients who operated on by craniotomy and duraplasty. The patient with a second disease was excluded. Blood tests include hemoglobin, prothrombin time, activated prothrombin time, and platelets were investigated before and after intravenous vitamin K injection, transfusion packed red cells (PRCs), and fresh frozen plasma (FFP) administration. The Glasgow coma scale (GCS) pre- and postoperatively was evaluated using a modified GCS for infants and children. The outcome was evaluated by the GOS-ePed score. All data were analyzed with the normality test and paired t test. RESULTS There were 5 patients age between 37 and 60 days, and all patients did not get vitamin K prophylaxis after birth. The blood tests of all patients revealed anemia, prothrombin, and activated prothrombin time increased, but platelets were normal. All these values returned to normal after vitamin K injection, transfusion of PRCs, and FFP. The paired t tests were p < 0.05. The GCS of all patients before surgery was 8 or below. After surgery, the GCS of 4 patients was increased become 12 and 15. One patient did not change significantly. The GOS-ePed score showed 4 patients (80%) had upper or lower good recovery, and 1 patient (20%) was in a vegetative state. CONCLUSIONS The GOS-ePed score of the pediatric intracranial bleeding with APCD after craniotomy and duraplasty was mostly in upper or lower good recovery.
Collapse
Affiliation(s)
- Robert Sinurat
- Surgery Department, Medical Faculty of Universitas Kristen Indonesia, Jakarta, Indonesia,
| |
Collapse
|
33
|
Abstract
PURPOSE Surgical decision-making in Chiari malformation type I (CM-I) patients tends to depend on the presence of neurological signs and symptoms, syringomyelia, and/or scoliosis, but significant variability exists from center to center. Here, we review the symptoms of CM-I in children and provide an overview of the differences in opinion regarding surgical indications, preferred surgical techniques, and measures of outcome. METHODS A review of the literature was performed to identify publications relevant to the surgical management of pediatric CM-I patients. RESULTS Most surgeons agree that asymptomatic patients without syringomyelia should not undergo prophylactic surgery, while symptoms of brainstem compression and/or lower cranial nerve dysfunction warrant surgery. Patients between these extremes, however, remain controversial, as does selection of the most appropriate surgical technique. CONCLUSIONS The optimal surgical procedure for children with CM-I remains a point of contention, and widespread variability exists between and within centers.
Collapse
Affiliation(s)
- David S Hersh
- Semmes-Murphey Neurologic & Spine Institute, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Frederick A Boop
- Semmes-Murphey Neurologic & Spine Institute, Memphis, TN, USA. .,Le Bonheur Children's Hospital, Memphis, TN, USA. .,Semmes-Murphey Neurologic & Spine Institute, Memphis, TN, 38120, USA.
| |
Collapse
|
34
|
Wang K, Wu H, Fengzeng J, Zeng G. Opinion for different centers: surgical experience with Chiari malformation type I in children at Xuanwu Hospital, China. Childs Nerv Syst 2019; 35:1915-1919. [PMID: 31214817 DOI: 10.1007/s00381-019-04230-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 05/24/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the presenting symptoms, surgical strategy, and outcome in children with Chiari malformation type I (CM-I). METHODS The medical records of children who were diagnosed with CM-I under 14 years old and subsequently underwent surgery for CM-I between 2014 and 2018 were reviewed. The medical records for presentation, radiological image, surgical intervention, and outcome were evaluated. RESULTS Twelve children with CM-I and syringomyelia were included. All of the children were symptomatic. The most common presenting symptom was weakness, followed by scoliosis. All of them underwent posterior fossa decompression with/without duraplasty. Relief of preoperative pathologies and syringomyelia was experienced by all of them. CONCLUSIONS The presenting symptoms of CM-I in children may be neurological deficits and scoliosis, which have a relationship with syringomyelia. Early recognition and a tailored operative procedure of CM-I in children could lead to good outcomes. Additional therapies for syringomyelia and scoliosis could be avoided.
Collapse
Affiliation(s)
- Kai Wang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Jian Fengzeng
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing, 100053, China.
| |
Collapse
|
35
|
Alexander H, Tsering D, Myseros JS, Magge SN, Oluigbo C, Sanchez CE, Keating RF. Management of Chiari I malformations: a paradigm in evolution. Childs Nerv Syst 2019; 35:1809-1826. [PMID: 31352576 DOI: 10.1007/s00381-019-04265-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation. METHODS A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC. RESULTS The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02). CONCLUSION While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.
Collapse
Affiliation(s)
- H Alexander
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - D Tsering
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - J S Myseros
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - S N Magge
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C E Sanchez
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA. .,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA.
| |
Collapse
|
36
|
Massimi L, Frassanito P, Bianchi F, Tamburrini G, Caldarelli M. Bony decompression vs duraplasty for Chiari I malformation: does the eternal dilemma matter? Childs Nerv Syst 2019; 35:1827-1838. [PMID: 31209642 DOI: 10.1007/s00381-019-04218-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE The management of Chiari I malformation (CIM) still raises the problem of the optimal surgical treatment, with special regard to the "eternal dilemma" of the posterior fossa bony decompression alone (PFBD) or with duraplasty (PFBDD). The goal of the present review is to update the results (outcome and complications) of both techniques to better understand the correct indication for each of them. METHODS A review of the literature has been performed, focusing on the articles and the meta-analyses specifically addressing the problem of PFBD vs PFBDD. Also, the personal authors' experience is briefly discussed. RESULTS PFBD (usually with C1 laminectomy, often with delamination of the external dural layer) is the most commonly used technique in children, especially if syringomyelia is absent. It ensures a high success rate, with > 80% clinical improvement and about 75% reduction of the syringomyelia, and a very low risk of complications, hospital stay, and costs. A certain risk of recurrence is present (2-12%). PFBDD (with autologous tissues or dural substitutes), on the other hand, is mostly used not only in adults but also in children with large syringomyelia. It is burdened by a higher risk of complications (namely, the CSF-related ones), longer hospital stay, and higher costs; however, it warrants a better clinical improvement (> 85%) and a lower risk of reoperation (2-3.5%). Eight meta-analyses of the literature (three on pediatric series and five in adult series) and one prospective study in children, published in the last decade, largely confirm these findings. CONCLUSION PFBD and PFBDD are different techniques that are indicated for different types of patients. In children, PFBD has been demonstrated to represent the best choice, although some patients may require a more aggressive treatment. Therefore, the success in the management of CIM, with or without syringomyelia, depends on the correct indication to surgery and on a patient-tailored choice rather than on the surgical technique.
Collapse
Affiliation(s)
- Luca Massimi
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy. .,Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy.
| | - P Frassanito
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - F Bianchi
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - G Tamburrini
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy
| | - M Caldarelli
- Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy
| |
Collapse
|
37
|
Caffo M, Cardali SM, Caruso G, Fazzari E, Abbritti RV, Barresi V, Germanò A. Minimally invasive posterior fossa decompression with duraplasty in Chiari malformation type I with and without syringomyelia. Surg Neurol Int 2019; 10:88. [PMID: 31528426 PMCID: PMC6744795 DOI: 10.25259/sni-70-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 04/02/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Posterior fossa decompression (PFD), with and without duraplasty, represents a valid treatment in Chiari malformation Type I (CM-I) with and without syringomyelia. Despite a large amount of series reported in literature, several controversies exist regarding the optimal surgical approach yet. In this study, we report our experience in the treatment of CM-I, with and without syringomyelia, highlighting how the application of some technical refinements could lead to a good outcome and a lesser rate of complications. Methods: Twenty-six patients with CM-I, with and without syringomyelia, underwent PFD through a 3 cm × 3 cm craniectomy with the removal of the most median third of the posterior arch of C1 and duraplasty. Signs and symptoms included sensory deficits, motor deficits, neck pain, paresthesias, headache, dizziness, lower cranial nerve deficits, and urinary incontinence. Postoperative magnetic resonance (MR) was performed in all patients. Results: Signs and symptoms improved in 76.9% of cases. Postoperative MR revealed a repositioning of cerebellar tonsils and the restoration of cerebrospinal fluid circulation. In our experience, the rate of complication was 23% (fistula, worsening of symptoms, and respiratory impairment). Conclusion: PFD through a 3 cm × 3 cm craniectomy and the removal of the most median third of posterior arch of C1 with duraplasty represents a feasible and valid surgical alternative to treat patients with CM-I, with and without syringomyelia, achieving a good outcome and a low rate of complications.
Collapse
Affiliation(s)
- Maria Caffo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Salvatore M Cardali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Gerardo Caruso
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Elena Fazzari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Rosaria V Abbritti
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Antonino Germanò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| |
Collapse
|
38
|
Matsumoto H, Minami H, Yamaura I, Yoshida Y. Postoperative subdural hematoma with blood flow from an epidural hematoma through a tear at the suture point of an artificial dura substitute. Acta Neurochir (Wien) 2019; 161:755-60. [PMID: 30762126 DOI: 10.1007/s00701-019-03830-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We have recently seen cases of postoperative epidural and subdural hematomas after duraplasty with an artificial dura substitute. In these cases, the epidural hematoma flowed into the subdural space through a tear at the suture point of the artificial dura substitute. In this study, whether such hematomas are specific to a certain artificial dura substitute was investigated, and the cause and risk factors were examined. METHODS In our institute, 46 patients underwent brain tumor extirpation with duraplasty with an artificial dura substitute; Gore-Tex and SEAMDURA were used as the artificial dura substitutes. Patients with postoperative hemorrhage after brain tumor extirpation with duraplasty with an artificial dura substitute were retrospectively analyzed. Moreover, suture strength was compared experimentally between Gore-Tex and SEAMDURA. RESULTS In patients who underwent brain tumor extirpation with duraplasty with an artificial dura substitute, the rate of postoperative hemorrhage was 8.6%. Epidural and subdural hematomas were seen in four patients after tumor extirpation with duraplasty with SEAMDURA, but there were none with Gore-Tex. Exposure of the superior sagittal sinus at craniotomy, older age, and longer operative time were seen more frequently in patients with hematoma than in patients without hematoma. The strength of the suture point was significantly weaker with SEAMDURA than with Gore-Tex (P = 0.00016). CONCLUSIONS Postoperative epidural and subdural hematomas seem to be specific for SEAMDURA and may be caused by the weak suture strength of SEAMDURA. In cases of duraplasty, a nonabsorbable artificial dura substitute may be suitable.
Collapse
|
39
|
Takeshima Y, Matsuda R, Nishimura F, Nakagawa I, Motoyama Y, Park YS, Nakase H. Sequential Enlargement of Posterior Fossa After Duraplasty for Chiari Malformation Type 1. World Neurosurg X 2019; 2:100004. [PMID: 31218279 PMCID: PMC6580881 DOI: 10.1016/j.wnsx.2018.100004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022] Open
Abstract
Objective There are several material options for duraplasty in surgery for foramen magnum decompression (FMD). We retrospectively analyzed surgical results and the impact of sequential alteration of posterior fossa (PF) size in patients with Chiari malformation type 1 after duraplasty using local fascia. Methods The patients with Chiari malformation type 1 who underwent FMD with duraplasty using local fascia at our institution between 2004 and 2015 were included in the study. Some pediatric patients who underwent FMD without duraplasty and patients with insufficient follow-up data were excluded. Improvement of clinical signs, regression of syrinx, and temporal alteration of PF size were analyzed with perioperative magnetic resonance imaging. Postoperative clinical outcomes were evaluated at the final follow-up using the Chicago Chiari Outcome Scale. Correlations between the PF size alteration and size of dural patch or Chicago Chiari Outcome Scale were statistically analyzed. Results Twelve patients were included in this study. The mean age of the patients was 31.9 (range, 18–48) years. Syrinx was incorporated in 11 patients and regressed postoperatively in all patients. The PF was significantly enlarged sequentially over time (P < 0.05). The degree of enlargement was positively correlated with size of the fascial patch (r = 0.540). Postoperative clinical outcomes at final follow-up were positively correlated with the degree of PF enlargement (r = 0.678). Conclusions The PF was enlarged sequentially over time after duraplasty using local fascia. The degree of enlargement was positively correlated with the size of the fascial patch and the likelihood of a favorable postoperative outcome.
Collapse
Affiliation(s)
- Yasuhiro Takeshima
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| |
Collapse
|
40
|
Villa A, Imperato A, Maugeri R, Visocchi M, Iacopino DG, Francaviglia N. Surgical Treatment in Symptomatic Chiari Malformation Type I: A Series of 25 Adult Patients Treated with Cerebellar Tonsil Shrinkage. Acta Neurochir Suppl 2019; 125:125-131. [PMID: 30610312 DOI: 10.1007/978-3-319-62515-7_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The variety of symptoms and radiological findings in patients with Chiari malformation type I makes both the indication for surgery and the technical modality controversial. We report our 5-year experience, describing our technique and critically evaluating the clinical results. METHODS Between 2012 and 2016, 25 patients (15 female and 10 male; mean age 39.2 years) underwent posterior fossa decompression for Chiari malformation type I. Their clinical complaints included headache, nuchalgia, upper limb weakness or numbness, instability, dizziness and diplopia. Syringomyelia was present in 12 patients (48%). Suboccipital craniectomy was completed in all cases with C1 laminectomy and shrinkage of the cerebellar tonsils by bipolar coagulation; duraplasty was performed with a suturable dura substitute. RESULTS Gratifying results were observed in our series. Symptoms and signs were resolved in 52% of patients, and 20% of patients had an improvement in their preoperative deficits. The symptoms of six patients (24%) were essentially unchanged, and one patient (4%) deteriorated despite undergoing surgery. Generally, patients with syringomyelia on magnetic resonance imaging (MRI) showed less symptomatic improvement after surgery. The syrinx disappeared in seven of 12 patients, and complications occurred in three patients (12%). CONCLUSION Cerebellar tonsil reduction and restoration of cerebrospinal fluid (CSF) circulation provided clinical improvement and a stable reduction in the syrinx size in the vast majority of treated patients, with a low rate of complications.
Collapse
Affiliation(s)
- Alessandro Villa
- Division of Neurosurgery, ARNAS Civico Hospital, Palermo, Italy.
| | | | - Rosario Maugeri
- Neurosurgical Clinic, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | | | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | | |
Collapse
|
41
|
Massimi L, Frassanito P, Chieffo D, Tamburrini G, Caldarelli M. Bony Decompression for Chiari Malformation Type I: Long-Term Follow-Up. Acta Neurochir Suppl 2019; 125:119-124. [PMID: 30610311 DOI: 10.1007/978-3-319-62515-7_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several surgical techniques are used for the management of Chiari malformation type I (CM-I). Bony posterior fossa decompression is considered a good option in children, though with a higher risk of requiring reoperation. However, there is not enough evidence from the series in the literature, which are often limited by inadequate follow-up. The goal of this study was to assess the effectiveness of suboccipital craniectomy alone in children after long-term follow-up. METHODS Forty-two children (25 female and 17 male; mean age 6.7 years), operated on with bony decompression alone, were retrospectively reviewed. All patients underwent suboccipital craniectomy. Thirty-eight children required C1 laminectomy, and 21 also underwent dural delamination on the basis of intraoperative ultrasound investigations. The outcome was assessed using the traditional measurement and the Chicago Chiari Outcome Scale (CCOS). The mean follow-up period was 11.3 years (range 5-15 years). RESULTS Headache was the most frequent preoperative symptom (81%), followed by neck pain (40%), vertigo (40%), ataxia (26%), and upper and lower extremity paraesthesia (26%). Syringomyelia was present in 19 patients (45%). Resolution and significant improvement of preoperative clinical symptoms were observed in 36.5% and 21.5% of cases, respectively. Three children required adjunctive surgery for symptom recurrence (7%). The tonsil position and syringomyelia were normalized or improved in 50% and 79% of cases, respectively. No complications occurred. According to the CCOS scores, 69.5% of children had an excellent outcome, 28.5% had a functional outcome and 2% had an impaired outcome. CONCLUSION Bony decompression alone is an effective, safe and long-lasting treatment for children with CM-I. A certain risk of symptom recurrence requiring new surgery exists, but it is widely counterbalanced by the low risk of complications. Careful patient selection is crucial for a good outcome. Prospective and randomized studies are needed for further validation.
Collapse
Affiliation(s)
- Luca Massimi
- Paediatric Neurosurgery, Agostino Gemelli Hospital Foundation, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
| | - Paolo Frassanito
- Paediatric Neurosurgery, Agostino Gemelli Hospital Foundation, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Daniela Chieffo
- Paediatric Neuropsychology, Agostino Gemelli Hospital Foundation, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Gianpiero Tamburrini
- Paediatric Neurosurgery, Agostino Gemelli Hospital Foundation, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Massimo Caldarelli
- Paediatric Neurosurgery, Agostino Gemelli Hospital Foundation, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| |
Collapse
|
42
|
Entezami P, Gooch MR, Poggi J, Perloff E, Dupin M, Adamo MA. Current management of pediatric chiari type 1 malformations. Clin Neurol Neurosurg 2018; 176:122-126. [PMID: 30557765 DOI: 10.1016/j.clineuro.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/09/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated. PATIENTS AND METHODS We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6-12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months. RESULTS One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%). CONCLUSIONS Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.
Collapse
Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jonathan Poggi
- Department of Neurosurgery, Brown University, Providence, RI, USA
| | - Eric Perloff
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Melissa Dupin
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| |
Collapse
|
43
|
Zipfel J, da Silva Freitas R, Lafitte LM, Kural C, Schuhmann MU. U-shaped durotomy for midline posterior fossa tumor removal: technical note and evaluation of results. Childs Nerv Syst 2018; 34:2299-303. [PMID: 30054807 DOI: 10.1007/s00381-018-3922-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The classical dura opening for midline posterior fossa tumors in and around the 4th ventricle and the craniocervical junction is a Y-shaped incision. Several potential problems are associated with this technique. We used a technical variant, the U-shaped durotomy, previously described by Rhoton, offering several advantages. We report on the surgical results of the technique in a consecutive series of posterior fossa cases in children and adolescents. METHODS In all midline posterior fossa approaches, a U-shaped dural incision is standard in our institution. All cases were retrospectively analyzed regarding hydrocephalus, placement of EVD or lumbar drain, need for ETV or shunting during follow-up, and frequency of duraplasty, of pseudomeningocele, of primary watertight dural closure, of CSF leakage, and of venous sinus hemorrhage at opening. RESULTS Fifty pediatric patients were included. In all easy occipital sinus, control was achieved and no additional dural retraction for tumor exposure required. In 49/50 patients, a primary watertight dura closure without duraplasty was achieved, also in re-do cases with previous U-shaped opening. One patient received a small periostium graft after having had a duraplasty following Y-shaped opening beforehand. No CSF fistula ever occurred and no pseudomeningocele was detected in any follow-up MRI. CONCLUSION The U-shaped durotomy for dorsal midline approach to the 4th ventricle and craniocervical junction provides wide exposure to all tumors and allows for primary and watertight dura closure. Compared to published results and complications of classic Y-shaped dural opening, this method of durotomy and closure seems most advantageous.
Collapse
|
44
|
Geng LY, Liu X, Zhang YS, He SX, Huang QJ, Liu Y, Hu XH, Zou YJ, Liu HY. Dura-splitting versus a combined technique for Chiari malformation type I complicated with syringomyelia. Br J Neurosurg 2018; 32:479-483. [PMID: 30146911 DOI: 10.1080/02688697.2018.1498448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Surgical approaches for Chiari malformation type I (CM-I) complicated with syringomyelia (SM) are controversial, so we assessed the efficacy and safety of two widely used procedures. METHODS We retrospectively analyzed results from posterior fossa decompression (PFD) using bony decompression with dura-splitting or a combined technique (duraplasty with arachnoid dissection and coagulation of the herniated tonsils) for CM-I associated with SM between Jan 2008 and Feb 2016. Patients were followed up for at least one year. General data, primary outcomes (symptom improvement, syrinx reductions, and complications) and secondary outcomes (operating time, blood loss, postoperative hospital stay) for each procedure were compared. RESULTS Of the 49 patients treated, 17 had dura-splitting decompression and 32 had the combined technique. There were no significant differences in general data. The combined technique was significantly superior to dura-splitting for long-term syrinx reductions (length, 100.03 ± 44.79 vs 72.73 ± 34.79 mm, p = 0.040; diameter, 8.09 ± 3.46 vs 5.73 ± 3.02 mm, p = 0.026) and symptom improvement (75.00% vs 47.06%, p = 0.036). No postoperative complications occurred during dura-splitting cases; however, complications occurred in 9 combined technique cases (31.25%, p = 0.010) and surgical time was longer for the combined technique (248.03 ± 60.12 vs 167.94 ± 60.11 min, p < 0.001). CONCLUSIONS The combined technique improved long-term symptoms and reduced syringes compared to dura-splitting; however, postoperative complications are more likely.
Collapse
Affiliation(s)
- Liang-Yuan Geng
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Xiang Liu
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Yan-Song Zhang
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Sheng-Xue He
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Qing-Jiu Huang
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Yong Liu
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Xin-Hua Hu
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Yuan-Jie Zou
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| | - Hong-Yi Liu
- a Department of Neurosurgery, Affiliated Nanjing Brain Hospital , Nanjing Medical University , Nanjing , People's Republic of China
| |
Collapse
|
45
|
Farber H, McDowell MM, Alhourani A, Agarwal N, Friedlander RM. Duraplasty Type as a Predictor of Meningitis and Shunting After Chiari I Decompression. World Neurosurg 2018; 118:e778-e783. [PMID: 30026145 DOI: 10.1016/j.wneu.2018.07.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Expansile duraplasty is frequently performed during Chiari I decompression. Aseptic and bacterial meningitis are possible complications of this procedure. We sought to compare the rates of meningitis and subsequent need for cerebrospinal fluid (CSF) diversion with duraplasty using bovine pericardial (BPC) xenograft and allograft. METHODS We conducted a retrospective review of 112 patients who underwent Chiari I decompression. All patients underwent duraplasty with either allograft or BPC. Occurrence of postoperative lumbar punctures and associated data were recorded to determine rates of meningitis. Rates of subsequent shunting were also recorded. RESULTS Overall, 112 patients were included in the study: 30 underwent duraplasty with allograft (27%) and 82 received BPC (73%). A total of 26 patients developed postoperative meningitis (23 cases of chemical meningitis and 3 of bacterial meningitis). Rates of meningitis were higher in patients who received BPC than patients who received allograft (28% vs. 10%, respectively; P = 0.047). The rate of shunting was greater in patients with meningitis compared with patients without meningitis (56.5% vs. 5.75%, respectively; P < 0.0001). Moreover, 13 of the 15 patients (87%) in the BPC cohort who were shunted were found to have meningitis compared with 0 of the 3 shunted patients (0%) in the allograft cohort (P = 0.044). CONCLUSIONS We found that rates of total meningitis were greater in patients who underwent Chiari I decompression and duraplasty with BPC compared with an allograft. The rate of shunting was significantly higher for patients who developed meningitis after decompression compared with patients without meningitis.
Collapse
Affiliation(s)
- Harrison Farber
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ahmad Alhourani
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
46
|
Hidalgo ET, Dastagirzada Y, Orillac C, Kvint S, North E, Bledea R, McQuinn MW, Redel-Traub G, Rodriguez C, Wisoff JH. Time to Resolution of Symptoms After Suboccipital Decompression with Duraplasty in Children with Chiari Malformation Type I. World Neurosurg 2018; 117:e544-e551. [PMID: 29933088 DOI: 10.1016/j.wneu.2018.06.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Duraplasty is a technique successfully used to treat Chiari malformation type I (CM-I). This study describes the timely manner of clinical outcomes and the postoperative course after craniectomy and duraplasty for the treatment of symptomatic CM-I in children. METHODS A retrospective chart review was performed in 105 consecutive children who underwent surgical decompression of symptomatic CM-I with dural opening by a single surgeon between 1999 and 2015. RESULTS In 16 of 28 children (57%) with typical Valsalva-related/tussive and mixed headaches, the symptoms resolved before discharge; by 6 months, all children were headache-free. Two of 28 children (7%) had recurrent headaches 9 months after surgery. Among the 78 children with syrinx, syrinx resolved or decreased in 68 (87%), recurred in 8 (10%), and was stable in 2 children (3%). Syrinx was resolved or decreased by 3 months in 51 children (65%) and by 6 months in 62 children (79%). Complications included aseptic meningitis requiring reoperation in 3 children (3%) and infection in one child (1%). Twelve children underwent reoperation, none within the first 30 days. No child had a major morbidity or mortality. CONCLUSIONS In carefully selected children with CM-I, a high success rate can be achieved with suboccipital decompression and duraplasty. Valsalva-related/tussive headaches resolved by the time of discharge from the hospital in the majority of children, and syrinx resolved or decreased in two-thirds of the children by 3 months. By 6 months, headaches were resolved in all cases, and syrinx was resolved or decreased in 79% of cases.
Collapse
Affiliation(s)
- Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA.
| | - Yosef Dastagirzada
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Cordelia Orillac
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Svetlana Kvint
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Emily North
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Ramona Bledea
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Michelle W McQuinn
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Gabriel Redel-Traub
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Crystalann Rodriguez
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| |
Collapse
|
47
|
Azzam D, Romiyo P, Nguyen T, Sheppard JP, Alkhalid Y, Lagman C, Prashant GN, Yang I. Dural Repair in Cranial Surgery Is Associated with Moderate Rates of Complications with Both Autologous and Nonautologous Dural Substitutes. World Neurosurg 2018; 113:244-248. [PMID: 29374609 DOI: 10.1016/j.wneu.2018.01.115] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Duraplasty, a common neurosurgical intervention, involves synthetic or biological graft placement to ensure dural closure. The objective of this study is to advance our understanding of the use of dural substitutes in cranial surgery. METHODS The PubMed database was systematically searched to identify studies published over the past decade (2007-2017) that described duraplasty procedures. Clinical data were disaggregated and analyzed for the comparisons of biological versus synthetic grafts. RESULTS A total of 462 cases were included in the quantitative synthesis. Overall, the most common indication for duraplasty was tumor resection (53%). Allografts were more frequently used in decompression for Chiari malformations compared with xenografts and synthetic grafts (P < 0.001). Xenografts were more frequently used in decompressive hemicraniectomy procedures for evacuation of acute subdural hematomas over allografts and synthetics (P < 0.001). Synthetic grafts were more frequently used in tumor cases than biological grafts (P = 0.002). The cumulative complication rate for dural substitutes of all types was 11%. There were no significant differences in complication rates among the 3 types of dural substitutes. CONCLUSIONS Dural substitutes are commonly used to ensure dural closure in a variety of cranial procedures. This study provides greater insight into duraplasty practices and highlights the moderate complication rate associated with the procedure. Future studies are needed to determine the safety and efficacy of such procedures in larger prospective cohorts.
Collapse
Affiliation(s)
- Daniel Azzam
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Yasmine Alkhalid
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, California, USA; Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA.
| |
Collapse
|
48
|
Giammattei L, Borsotti F, Parker F, Messerer M. Chiari I malformation: surgical technique, indications and limits. Acta Neurochir (Wien) 2018; 160:213-7. [PMID: 29130121 DOI: 10.1007/s00701-017-3380-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Chiari malformation type I (CM-I) is a rare disease characterised by herniation of cerebellar tonsils below the foramen magnum with associated anomalies of posterior fossa. We describe here the surgical technique, indications and limits of surgical treatment. METHOD The authors describe the surgical technique, including: posterior fossa decompression, opening of the foramen of Magendie and duraplasty in case of CM-I. CONCLUSIONS Posterior fossa decompression plus duraplasty is a safe and effective procedure for patients with CM-I malformation.
Collapse
|
49
|
Lin W, Duan G, Xie J, Shao J, Wang Z, Jiao B. Comparison of Results Between Posterior Fossa Decompression with and without Duraplasty for the Surgical Treatment of Chiari Malformation Type I: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 110:460-474.e5. [PMID: 29138073 DOI: 10.1016/j.wneu.2017.10.161] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/27/2017] [Accepted: 10/28/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Posterior fossa decompression without (PFD) or with duraplasty (PFDD) for the treatment of type 1 Chiari malformation (CM-1) is controversial. We thus performed a systematic review and meta-analysis of studies to assess the effect on clinical and imaging improvement, operative time, complications, and recurrence rate between PFD and PFDD in patients with CM-1. METHODS We systematically searched PubMed, Embase, Cochrane, Web of Knowledge, and ClinicalTrials.gov for retrospective or prospective studies comparing PFD with PFDD. Our main end points were clinical and imaging improvement, operative time, complications, and recurrence rate. We assessed pooled data by use of a fixed-effects or random-effects model according to the between-study heterogeneity. RESULTS Of 214 identified studies, 13 were eligible and were included in our analysis (N = 3481 patients). Compared with PFD, PFDD led to a mean greater increase in operative time than did PFD [standardized mean difference, -2.35; 95% confidence interval [CI], (-2.70 to -1.99)], a higher likelihood of clinical improvement in patients with syringomyelia (relative risk [RR], 0.70; 95% CI, 0.49-0.98), no increased RR of clinical improvement in patients without syringomyelia, no increased RR of imaging improvement, but an increased RR of cerebrospinal fluid-related complications (RR, 0.29; 95% CI, 0.15-0.58), cerebrospinal fluid leak, aseptic meningitis, pseudomeningocele, and a decreased likelihood of recurrence rate. CONCLUSIONS PFDD can be an optimal surgical strategy because of its higher clinical improvement and lower recurrence rate in the patients with syringomyelia. In patients without syringomyelia, PFD can be a preferred choice because of its similar clinical improvement and lower costs. Future randomized studies with large numbers and the power to provide illumination for surgical decision making in CM-1 are warranted.
Collapse
|
50
|
Alkhamees A, Proust F. Idiopathic Spinal Cord Herniation: A Case Report. Int J Health Sci (Qassim) 2016; 10:592-595. [PMID: 27833524 PMCID: PMC5085354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive spinal myelopathy, which frequently presents as Brown-Sequard syndrome. A 50 year old woman consulted for difficulty in walking. On examination, the patient reported sensory deficit of temperature on the left side, associated with diminished anal sensitivity. Nine months before consultation, a walking disorder began disturbing the activities of everyday life. A single case report with surgical treatment outcome. Idiopathic spinal cord herniation is a potentially treatable condition, which should be diagnosed early and treated. The surgical operation contributed clinical improvement in functional autonomy with modification in McCormick classification in our patient. Despite the existence of growing number of ISCH cases in the literature, misdiagnosis and choice of treatment remains a major concern. SCH is a rare clinical entity that seems to be increasing with the accessibility of MRI imaging. Preoperative diagnosis can be made with magnetic resonance imaging (MRI). ISCH should be considered as differential diagnosis of Brown-Sequard syndrome, especially after fourth decade of life. Although progression of neurologic deficits can be gradually slow, reducing surgically the cord hernia and repair of the defect are vital factors in preventing the deterioration and display reversible improvement. In recent reviews, patients who underwent surgery had better outcomes as with our case.
Collapse
Affiliation(s)
- Abdullah Alkhamees
- Department of Neurosurgery, C.H.U. Rouen University Hospital and Rouen University, Rouen, FRANCE
| | - Francois Proust
- Head of Neurosurgery Department, C.H.U. Hôpitaux Universitaires de Strasbourg, Strasbourg, FRANCE
| |
Collapse
|