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Published on: July 5, 2011
Complications following decompression of Chiari malformation Type I in children: dural graft or sealant?
Stephen R Parker1, Peggy Harris, Thomas J Cummings
1Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
Insights
The choice of dural graft and tissue sealant significantly impacts complication rates in pediatric Chiari malformation Type I (CM-I) decompression surgery. Certain graft materials and sealant combinations may increase risks such as CSF leaks and aseptic meningitis.
Area of Science:
- Neurosurgery
- Pediatric Surgery
- Biomaterials Science
Background:
- Posterior fossa decompression with duraplasty is a standard procedure for Chiari malformation Type I (CM-I) in children.
- Published complication rates for CM-I surgery vary widely (3-40%), with historical use of diverse dural substitutes.
- An observed increase in complications prompted an investigation into the role of specific graft materials.
Purpose of the Study:
- To investigate the hypothesis that complications following CM-I decompression are dependent on the type of dural graft used.
- To evaluate the impact of different dural substitutes and tissue sealants on short- and intermediate-term complication rates.
Main Methods:
- Retrospective review of 114 pediatric patients (≤18 years) undergoing primary CM-I decompression with duraplasty (Jan 2004-Jan 2008).
- Analysis focused on dural graft type (cadaveric pericardium, Durepair, EnDura) and use of tissue sealants (Tisseel, DuraSeal, none).
- Complications including aseptic meningitis, CSF leak, and pseudomeningocele were recorded and analyzed in relation to surgical materials.
Main Results:
- Overall complication rate was 21.1%. EnDura (17.2%) had lower complication rates than cadaveric pericardium (26.7%) and Durepair (41.7%).
- Complication rates varied significantly with tissue sealants: 14.8% (none), 18.7% (Tisseel), and 50% (DuraSeal).
- The combination of Durepair and DuraSeal resulted in a 56% complication rate. A shift in graft product correlated with an increase in overall complication rates from 18.1% to 35%.
Conclusions:
- Dural graft choice and the use of tissue sealants are critical factors influencing complication rates in pediatric CM-I decompression.
- Certain synthetic grafts and tissue sealants, particularly DuraSeal, may be associated with increased risks of CSF leak and aseptic meningitis.
- Further investigation is warranted to understand the mechanisms behind increased inflammation when tissue sealants are combined with dural substitutes.
Object:
Posterior fossa decompression with duraplasty for Chiari malformation Type I (CM-I) is a common pediatric neurosurgery procedure. Published series report a complication rate ranging from 3% to 40% for this procedure. Historically, many dural substitutes have been used, including bovine grafts, human cadaveric pericardium, synthetic dura, and autologous pericranium. The authors hypothesized that a recently observed increase in complications was dependent on the graft used.
Methods:
Between January 2004 and January 2008, 114 consecutive patients ≤ 18 years old underwent primary CM-I decompression using duraplasty. Records were retrospectively reviewed for short- and intermediate-term complications and operative technique, focusing on the choice of duraplasty graft with or without application of a tissue sealant.
Results:
The average age of the patients was 8.6 years. The dural graft used was variable: 15 were treated with cadaveric pericardium, 12 with Durepair, and 87 with EnDura. Tisseel was used in 75 patients, DuraSeal in 12, and no tissue sealant was used in 27 patients. The overall complication rate was 21.1%. The most common complications included aseptic meningitis, symptomatic pseudomeningocele, or a CSF leak requiring reoperation. The overall complication rates were as follows: cadaveric pericardium 26.7%, Durepair 41.7%, and EnDura 17.2%; reoperation rates were 13%, 25%, and 8.1%, respectively. Prior to adopting a different graft product, the overall complication rate was 18.1%; following the change the rate increased to 35%. Complication rates for tissue sealants were 14.8% for no sealant, 18.7% for Tisseel, and 50% for DuraSeal. Nine patients were treated with the combination of Durepair and DuraSeal and this subgroup had a 56% complication rate.
Conclusions:
Complication rates after CM-I decompression may be dependent on the dural graft with or without the addition of tissue sealant. The complication rate at the authors' institution approximately doubled following the adoption of a different graft product. Tissue sealants used in combination with a dural substitute to augment a duraplasty may increase the risk of aseptic meningitis and/or CSF leak. The mechanism of the apparent increased inflammation with this combination remains under investigation.
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