Skip to main content
SpringerLink
Log in

Decompressive surgery for Chiari I malformation in children without dural repair: a still effective and safe procedure?

  • Special Annual Issue
  • Published:
Child's Nervous System Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Aboulezz AO, Sartor K, Geyer CA, Gado MH (1985) Position of cerebellar tonsils in the normal population and in patients with Chiari malformation: a quantitative approach with MR imaging. J Comput Assist Tomogr 9(6):1033–1036

    Article  CAS  PubMed  Google Scholar 

  2. Aliaga L, Hekman KE, Yassari R, Straus D, Luther G, Chen J, Sampat A, Frim D (2012) A novel scoring system for assessing Chiari malformation type I treatment outcomes. Neurosurgery 70(3):656–665

    Article  PubMed  Google Scholar 

  3. Chai Z, Xue X, Fan H, Sun L, Cai H, Ma Y, Ma C, Zhou R (2018) Efficacy of posterior Fossa decompression with Duraplasty for patients with Chiari malformation type I: a systematic review and meta-analysis. World Neurosurg 113:357–365

    Article  PubMed  Google Scholar 

  4. Del Gaudio N, Vaz G, Duprez T, Raftopoulos C (2018) Comparison of dural peeling versus duraplasty for surgical treatment of Chiari type I malformation: results and complications in a monocentric patients’ cohort. World Neurosurg 117:e595–e602

    Article  PubMed  Google Scholar 

  5. Duddy JC, Allcutt D, Crimmins D, O'Brien D, O'Brien DF, Rawluk D, Sattar MT, Young S, Caird J (2014) Foramen magnum decompression for Chiari I malformation: a procedure not to be underestimated. Br J Neurosurg 28(3):330–334

    Article  PubMed  Google Scholar 

  6. Durham SR, Fjeld-Olenec K (2008) Comparison of posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation type I in pediatric patients: a meta-analysis. J Neurosurg Pediatr 2(1):42–49

    Article  PubMed  Google Scholar 

  7. Felbaum DR, Mueller K, Anaizi A, Mason RB, Jean WC, Voyadzis JM (2016) Preservation of the myofascial cuff during posterior fossa surgery to reduce the rate of pseudomeningocele formation and cerebrospinal fluid leak: a technical note. Cureus 8(12):e946

  8. Galarza M, Sood S, Ham S (2007) Relevance of surgical strategies for the management of pediatric Chiari type I malformation. Childs Nerv Syst 23(6):691–696

    Article  PubMed  Google Scholar 

  9. Gardner WJ, Goodall RJ (1950) The surgical treatment of Arnold-Chiari malformation in adults; an explanation of its mechanism and importance of encephalography in diagnosis. J Neurosurg 7(3):199–206

    Article  CAS  PubMed  Google Scholar 

  10. Goel A, Gore S, Shah A, Dharurkar P, Vutha R, Patil A (2018) Atlantoaxial fixation for Chiari 1 formation in pediatric age-group patients: report of treatment in 33 patients. World Neurosurg 111:e668–e677

    Article  PubMed  Google Scholar 

  11. Gonzalez-Lopez P, Harput MV, Türe H, Atalay B, Türe U (2014) Efficacy of placing a thin layer of gelatin sponge over the subdural space during dural closure in preventing meningo-cerebral adhesion. World Neurosurg 83(1):93–101

    Article  PubMed  Google Scholar 

  12. Hankinson T, Tubbs RS, Wellons JC (2011) Duraplasty or not? An evidence-based review of the pediatric Chiari I malformation. Childs Nerv Syst 27(1):35–40

    Article  PubMed  Google Scholar 

  13. Isu T, Sasaki H, Takamura H, Kobayashi N (1993) Foramen magnum decompression with removal of the outer layer of the dura as treatment for syringomyelia occurring with Chiari I malformation. Neurosurgery 33(5):845–849

    CAS  PubMed  Google Scholar 

  14. Jiang E, Sha S, Yuan X, Zhu W, Jiang J, Ni H, Liu Z, Qiu Y, Zhu Z (2018) Comparison of clinical and radiographic outcomes for posterior fossa decompression with and without furaplasty for treatment of pediatric Chiari I malformation: a prospective study. World Neurosurg 110:e465–e472

    Article  PubMed  Google Scholar 

  15. Klekamp J (2012) Neurological deterioration after foramen magnum decompression for Chiari malformation type I: old or new pathology? J Neurosurg Pediatr 10(6):538–547

    Article  PubMed  Google Scholar 

  16. Klekamp J, Batzdorf U, Samii M, Bothe HW (1996) The surgical treatment of Chiari I malformation. Acta Neurochir 138(7):788–801

    Article  CAS  PubMed  Google Scholar 

  17. Krieger MD, McComb JG, Levy ML (1999) Toward a simpler surgical management of Chiari I malformation in a pediatric population. Pediatr Neurosurg 30(3):113–121

    Article  CAS  PubMed  Google Scholar 

  18. Krieger MD, Falkinstein Y, Bowen IE, Tolo VT, McComb JG (2011) Scoliosis and Chiari malformation type I in children. J Neurosurg Pediatr 7(1):25–29

    Article  PubMed  Google Scholar 

  19. Kumar A, Bhattacharjee S, Sahu BP (2014) Importance of C1 laminectomy in foramen magnum decompression surgery: a technical note. Asian J Neurosurg 9(4):235

    PubMed  PubMed Central  Google Scholar 

  20. Lee A, Yarbrough CK, Greenberg JK, Barber J, Limbrick DD, Smyth MD (2014) Comparison of posterior fossa decompression with or without duraplasty in children with type I Chiari malformation. Childs Nerv Syst 30(8):1419–1424

    Article  PubMed  PubMed Central  Google Scholar 

  21. Limonadi FM, Selden NR (2004) Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg 101(2 Suppl):184–188

    PubMed  Google Scholar 

  22. Lin W, Duan G, Xie J, Shao J, Wang Z, Jiao B (2018) 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 110:460–474

    Article  PubMed  Google Scholar 

  23. Lu VM, Phan K, Crowley SP, Daniels DJ (2017) The addition of duraplasty to posterior fossa decompression in the surgical treatment of pediatric Chiari malformation type I: a systematic review and meta-analysis of surgical and performance outcomes. J Neurosurg Pediatr 20(5):439–449

    Article  PubMed  Google Scholar 

  24. Mitsuyama T, Aihara Y, Taira T, Eguchi S, Kawamata T (2017) Re-evaluation of foramen magnum decompression with dura left open for Chiari I malformation. Interdiscip Neurosurg 10:150–154

    Article  Google Scholar 

  25. Munshi I, Frim D, Stine-Reyes R, Weir BK, Hekmatpanah J, Brown F (2000) Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery 46(6):1384–1389

    Article  CAS  PubMed  Google Scholar 

  26. Mutchnick IS, Janjua RM, Moeller K, Moriarty TM (2010) Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr 5(5):474–478

    Article  PubMed  Google Scholar 

  27. Ozdol C, Alagoz F, Yildirim AE, Korkmaz M, Daglioglu E, Atilla P, Muftuoglu S, Belen AD (2015) Use of Spongostan™ for prevention of cranial subdural adhesions following craniotomy in an experimental rabbit model. Turk Neurosurg 25(5):707–711

    PubMed  Google Scholar 

  28. Perrini P (2015) Technical nuances of autologous pericranium harvesting for dural closure in Chiari malformation surgery. J Neurol Surg B Skull Base 76(2):90–93

    PubMed  Google Scholar 

  29. Perrini P, Benedetto N, Tenenbaum R, Di Lorenzo N (2007) Extra-arachnoidal cranio-cervical decompression for syringomyelia associated with Chiari I malformation in adults: technique assessment. Acta Neurochir 149(10):1015–1022

    Article  CAS  PubMed  Google Scholar 

  30. Sakas DE, Korfias SI, Wayte SC, Beale DJ, Papapetrou KP, Stranjalis GS, Whittaker KW, Whitwell HL (2005) Chiari malformation: CSF flow dynamics in the craniocervical junction and syrinx. Acta Neurochir 147(12):1223–1233

    Article  CAS  PubMed  Google Scholar 

  31. Singhal A, Cheong A, Steinbok P (2018) International survey on the management of Chiari 1 malformation and syringomyelia: evolving worldwide opinions. Childs Nerv Syst 34(6):1177–1182

    Article  PubMed  Google Scholar 

  32. Tubbs RS, Wellons JC 3rd, Oakes WJ (2002) Asymmetry of tonsillar ectopia in Chiari I malformation. Pediatr Neurosurg 37(4):199–202

    Article  PubMed  Google Scholar 

  33. Tubbs RS, Beckman J, Naftel RP, Chern JJ, Wellons JC 3rd, Rozzelle CJ, Blount JP, Oakes WJ (2011) Institutional experience with 500 cases of surgically treated pediatric Chiari malformation type I. J Neurosurg Pediatr 7(3):248–256

    Article  PubMed  Google Scholar 

  34. Williams B (1990) Syringomyelia. Neurosurg Clin N Am 1(3):653–685

    Article  CAS  PubMed  Google Scholar 

  35. Williams B (1994) A blast against grafts--on the closing and grafting of the posterior fossa dura. Br J Neurosurg 8(3):275–278

    Article  CAS  PubMed  Google Scholar 

  36. Xu H, Chu L, He R, Ge C, Lei T (2017) Posterior fossa decompression with and without duraplasty for the treatment of Chiari malformation type I - a systematic review and meta-analysis. Neurosurg Rev 40(2):213–221

    Article  PubMed  Google Scholar 

  37. Zhao JL, Li MH, Wang CL, Meng W (2016) A systematic review of Chiari I malformation: techniques and outcomes. World Neurosurg 88:7–14

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pediatric Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK

    Arthur R. Kurzbuch, Jayaratnam Jayamohan & Shailendra Magdum

  2. Hôpital du Valais - Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland

    Arthur R. Kurzbuch

Authors
  1. Arthur R. Kurzbuch
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jayaratnam Jayamohan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shailendra Magdum
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Arthur R. Kurzbuch.

Ethics declarations

Conflict of interest

The authors report no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kurzbuch, A.R., Jayamohan, J. & Magdum, S. Decompressive surgery for Chiari I malformation in children without dural repair: a still effective and safe procedure?. Childs Nerv Syst 35, 1839–1846 (2019). https://doi.org/10.1007/s00381-019-04241-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00381-019-04241-w

Keywords

Search

Navigation