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Published on: September 13, 2024
Outcomes after suboccipital decompression without dural opening in children with Chiari malformation Type I
Benjamin C Kennedy1, Kathleen M Kelly1, Michelle Q Phan1
1Department of Neurological Surgery, Columbia University, New York, New York;
Insights
Posterior fossa decompression without dural opening offers good outcomes for pediatric Chiari malformation Type I. This approach avoids complications, though partial C-2 laminectomy may increase reoperation risk.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Craniovertebral Junction Abnormalities
Background:
- Symptomatic pediatric Chiari malformation Type I (CM-I) is commonly treated with posterior fossa decompression (PFD).
- The necessity of dural opening during PFD for CM-I remains a debated topic, with potential benefits for symptom resolution versus increased complication risks.
Purpose of the Study:
- To present the largest series of outcomes for pediatric CM-I treated with PFD without dural opening.
- To identify risk factors associated with symptom recurrence and the need for reoperation in this patient cohort.
Main Methods:
- Retrospective review of 156 pediatric patients undergoing PFD without dural opening between 2003 and 2013.
- Analysis included patient demographics, clinical presentation, radiographic and intraoperative ultrasound findings, and neuromonitoring.
- Univariate and multivariate regression analyses were used to identify risk factors for reoperation.
Main Results:
- Over 90% of patients experienced symptom improvement or resolution at a mean follow-up of 32 months.
- No major complications were reported, with a mean hospital stay of 2.0 days.
- Partial C-2 laminectomy (p = 0.037) and motor weakness (p = 0.075) were associated with reoperation. Patients with < 8 mm tonsillar herniation did not require reoperation.
Conclusions:
- PFD without dural opening is a safe and effective treatment for the majority of pediatric symptomatic CM-I patients.
- This approach is associated with a low complication rate and good clinical outcomes.
- Risk factors for reoperation include partial C-2 laminectomy and, to a lesser extent, motor weakness; herniation at or below C-2 indicates a higher risk of failure.
Abstract:
OBJECT Symptomatic pediatric Chiari malformation Type I (CM-I) is most often treated with posterior fossa decompression (PFD), but controversy exists over whether the dura needs to be opened during PFD. While dural opening as a part of PFD has been suggested to result in a higher rate of resolution of CM symptoms, it has also been shown to lead to more frequent complications. In this paper, the authors present the largest reported series of outcomes after PFD without dural opening surgery, as well as identify risk factors for recurrence. METHODS The authors performed a retrospective review of 156 consecutive pediatric patients in whom the senior authors performed PFD without dural opening from 2003 to 2013. Patient demographics, clinical symptoms and signs, radiographic findings, intraoperative ultrasound results, and neuromonitoring findings were reviewed. Univariate and multivariate regression analyses were performed to determine risk factors for recurrence of symptoms and the need for reoperation. RESULTS Over 90% of patients had a good clinical outcome, with improvement or resolution of their symptoms at last follow-up (mean 32 months). There were no major complications. The mean length of hospital stay was 2.0 days. In a multivariate regression model, partial C-2 laminectomy was an independent risk factor associated with reoperation (p = 0.037). Motor weakness on presentation was also associated with reoperation but only with trend-level significance (p = 0.075). No patient with < 8 mm of tonsillar herniation required reoperation. CONCLUSIONS The vast majority (> 90%) of children with symptomatic CM-I will have improvement or resolution of symptoms after a PFD without dural opening. A non-dural opening approach avoids major complications. While no patient with tonsillar herniation < 8 mm required reoperation, children with tonsillar herniation at or below C-2 have a higher risk for failure when this approach is used.
