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Published on: June 6, 2020
Decompressive surgery for Chiari I malformation in children without dural repair: a still effective and safe
Arthur R Kurzbuch1,2, Jayaratnam Jayamohan3, Shailendra Magdum3
1Department of Pediatric Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. kurzbuch@web.de.
Insights
Foramen magnum decompression without dural repair (FMDWDR) is a safe and effective surgical option for pediatric Chiari I malformation. This technique showed a low complication rate and positive clinical outcomes in a recent study.
Area of Science:
- Neurosurgery
- Pediatric Neurosurgery
- Surgical Techniques
Background:
- Chiari I malformation involves cerebellar tonsil herniation, often requiring surgical decompression.
- Numerous surgical variations exist for foramen magnum decompression, with ongoing debate on optimal techniques.
- Foramen magnum decompression without dural repair (FMDWDR) is one such technique with varying reported outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of foramen magnum decompression without dural repair (FMDWDR) in pediatric patients with Chiari I malformation.
- To assess the complication rates and clinical outcomes associated with the FMDWDR technique.
- To determine if FMDWDR is a viable surgical option for children with Chiari I malformation.
Main Methods:
- Retrospective review of 65 pediatric patients who underwent FMDWDR for Chiari I malformation between 2009 and 2016.
- Analysis of patient demographics, clinical data, surgical specifics, complications, and outcomes.
- Specific focus on complication rates and clinical improvement post-surgery.
Main Results:
- Sixty-five patients underwent FMDWDR; complications included aseptic meningitis, subdural hematoma, CSF collections, and CSF leaks.
- A technical modification significantly reduced the CSF leak rate.
- Seven patients required revision surgery; no cases of hydrocephalus or infection were noted.
- 52 patients reported improvement, 10 were unchanged, and 3 experienced worsening symptoms; no mortality or long-term morbidity.
Conclusions:
- Foramen magnum decompression without dural repair (FMDWDR), particularly with a "T"-shaped fascial incision for watertight closure, is a safe and effective treatment for pediatric Chiari I malformation.
- The technique demonstrates a favorable clinical outcome profile with manageable complications.
- FMDWDR remains a valuable surgical option for managing Chiari I malformation in children.
Purpose:
There are numerous publications about the technical aspects of decompressive surgery for Chiari I malformation highlighting many variations of this procedure. Each approach has its followers. Bony decompression of the foramen magnum alone or with the removal of a portion of the posterior arch of C1, dural splitting with keeping arachnoid intact, and durotomy are described. Dural closure is done with various materials. We retrospectively reviewed foramen magnum decompression without dural repair (FMDWDR) following the technique used by Gardener and Williams as an option in pediatric patients with Chiari I malformation in terms of complication rate and clinical outcome.
Methods:
The surgical database of our unit identified 65 consecutive children who underwent FMDWDR surgery for Chiari I malformation between 2009 and 2016. The retrospective assessment included patient demographics, clinical data, surgical technique, revision rate, complications, and clinical outcome.
Results:
Durotomy without repair was performed in 65 patients. Complications included aseptic meningitis and subdural hematoma respectively in three cases, intradiploic CSF collections in three patients, and CSF leaks in six children. The CSF leak rate has reduced dramatically after introducing a technical modification. Revision surgery was performed in seven cases. None of the patients was identified with postoperative hydrocephalus or infection. There was no mortality and no long-term surgical morbidity. In terms of clinical outcome, 52 patients reported postoperative improvement, 10 were clinically unchanged, and three noticed worsening of symptoms.
Conclusion:
Applying a "T"-shaped fascial incision which allows a watertight closure of the fascia FMDWDR is still a safe and effective treatment option for Chiari I malformation in children.
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