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Decompression with or without Duraplasty for Chiari I and Syringomyelia
David D Limbrick1, Chevis N Shannon2, Emine O Bayman3
1Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond.
Insights
Posterior fossa decompression with duraplasty (PFD-D) showed no significant difference in surgical complications compared to PFD alone for children with Chiari malformation. Further research is needed to clarify the benefits and risks of PFD-D.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Medical Devices
Background:
- Chiari type I malformation with syringomyelia affects children, often treated with posterior fossa decompression (PFD).
- The addition of duraplasty (PFD-D) to PFD is of unclear benefit for improving outcomes.
Purpose of the Study:
- To compare the outcomes of PFD with duraplasty (PFD-D) versus PFD alone in pediatric patients with Chiari type I malformation and syringomyelia.
- To assess surgical complications, clinical improvement, syrinx reduction, and quality of life.
Main Methods:
- A multicenter, cluster-randomized controlled trial involving 162 participants (≤21 years) with Chiari type I malformation and syringomyelia.
- Participants were assigned to either PFD-D or PFD alone.
- Primary outcome was surgical complications within 6 months; secondary outcomes included clinical improvement, syrinx reduction, and quality of life up to 24 months.
Main Results:
- No significant difference in surgical complications within 6 months between PFD-D (14%) and PFD alone (6%).
- At 24 months, PFD-D showed higher rates of clinical improvement (58% vs. 46%) and syrinx reduction (3.08 mm vs. 1.22 mm) compared to PFD alone.
- Lower rates of repeat decompression were observed with PFD-D (3% vs. 14%).
Conclusions:
- Surgical complication rates did not significantly differ between PFD-D and PFD alone.
- While PFD-D showed trends toward improved clinical outcomes and syrinx reduction, larger trials are necessary to confirm these findings and assess relative benefits and risks.
Background:
In children with Chiari type I malformation and syringomyelia, neurosurgical posterior fossa decompression (PFD) provides clinical improvement, but whether duraplasty (incising the dura and placing a dural graft) improves outcomes is unclear.
Methods:
We conducted a multicenter, cluster-randomized, controlled trial of PFD with duraplasty (PFD-D) as compared with PFD alone. Persons 21 years of age or younger with cerebellar tonsillar ectopia of at least 5 mm and a maximum syrinx diameter of 3.0 to 9.9 mm were enrolled at 38 centers. Centers were cluster-randomized: all the participants within each center underwent the same intervention. The primary outcome was surgical complications within 6 months. Secondary outcomes were clinical improvement, syrinx reduction, and repeat decompression at 10 to 24 months and the change in overall health-related quality of life at 6 to 24 months.
Results:
A total of 162 participants were included in the trial, of whom 78 were assigned to undergo PFD-D and 84 to undergo PFD alone. The percentage of participants with complications within 6 months was 14% with PFD-D and 6% with PFD (adjusted odds ratio, 2.59; 95% confidence interval [CI], 0.86 to 7.84; P = 0.11). At 24 months, the percentage of participants with clinical improvement was 58% with PFD-D and 46% with PFD; the mean (±SD) syrinx reduction was 3.08±2.33 mm and 1.22±1.79 mm, respectively; and the percentage of participants with repeat decompression was 3% and 14%. Changes in health-related quality of life were similar in the two groups.
Conclusions:
The percentage of participants with surgical complications did not differ significantly between those who underwent PFD-D and and those who underwent PFD alone. Larger trials are needed to determine the relative benefits and risks of these two procedures. (Funded by the Patient-Centered Outcomes Research Institute and others; ClinicalTrials.gov number, NCT02669836.).