Abstract
Purpose
The management of Chiari I malformation (CIM) still raises the problem of the optimal surgical treatment, with special regard to the “eternal dilemma” of the posterior fossa bony decompression alone (PFBD) or with duraplasty (PFBDD). The goal of the present review is to update the results (outcome and complications) of both techniques to better understand the correct indication for each of them.
Methods
A review of the literature has been performed, focusing on the articles and the meta-analyses specifically addressing the problem of PFBD vs PFBDD. Also, the personal authors’ experience is briefly discussed.
Results
PFBD (usually with C1 laminectomy, often with delamination of the external dural layer) is the most commonly used technique in children, especially if syringomyelia is absent. It ensures a high success rate, with > 80% clinical improvement and about 75% reduction of the syringomyelia, and a very low risk of complications, hospital stay, and costs. A certain risk of recurrence is present (2–12%). PFBDD (with autologous tissues or dural substitutes), on the other hand, is mostly used not only in adults but also in children with large syringomyelia. It is burdened by a higher risk of complications (namely, the CSF-related ones), longer hospital stay, and higher costs; however, it warrants a better clinical improvement (> 85%) and a lower risk of reoperation (2–3.5%). Eight meta-analyses of the literature (three on pediatric series and five in adult series) and one prospective study in children, published in the last decade, largely confirm these findings.
Conclusion
PFBD and PFBDD are different techniques that are indicated for different types of patients. In children, PFBD has been demonstrated to represent the best choice, although some patients may require a more aggressive treatment. Therefore, the success in the management of CIM, with or without syringomyelia, depends on the correct indication to surgery and on a patient-tailored choice rather than on the surgical technique.
Similar content being viewed by others
References
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 70:656–665
Attenello FJ, McGirt MJ, Garcés-Ambrossi GL, Chaichana KL, Carson B, Jallo GI (2009) Suboccipital decompression for Chiari I malformation: outcome comparison of duraplasty with expanded polytetrafluoroethylene dural substitute versus pericranial autograft. Childs Nerv Syst 25:183–190
Badie B, Mendoza D, Batzdorf U (1995) Posterior fossa volume and response to suboccipital decompression in patients with Chiari I malformation. Neurosurg 37:214–218
Bejjani GK, Zabramski J (2007) Safety and efficacy of the porcine small intestinal submucosa dural substitute: results of a prospective multicenter study and literature review. J Neurosurg 106:1028–1033
Bond AE, Jane JA Sr, Liu KC, Oldfield EH (2015) Changes in cerebrospinal fluid flow assessed using intraoperative MRI during posterior fossa decompression for Chiari malformation. J Neurosurg 122:1068–1075
Caldarelli M, Novegno F, Massimi L, Romani R, Tamburrini G, Di Rocco C (2007) The role of limited posterior fossa craniectomy in the surgical treatment of Chiari malformation type I: experience with a pediatric series. J Neurosurg 106(3 Suppl Pediatrics):187–195
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
Chauvet D, Carpentier A, George B (2009) Dura splitting decompression in Chiari type 1 malformation: clinical experience and radiological findings. Neurosurg Rev 32:465–470
Chotai S, Medhkour A (2014) Surgical outcomes after posterior fossa decompression with and without duraplasty in Chiari malformation-I. Clin Neurol Neurosurg 125:182–188
Cools MJ, Quinsey CS, Elton SW (2018) Chiari decompression outcomes using ligamentum nuchae harvest and duraplasty in pediatric patients with Chiari malformation type I. J Neurosurg Pediatr 22:47–51
Danish SF, Samdani A, Hanna A, Storm P, Sutton L (2006) Experience with acellular human dura and bovine collagen matrix for duraplasty after posterior fossa decompression for Chiari malformations. J Neurosurg 104(1 Suppl):16–20
De Vlieger J, Dejaegher J, Van Calenbergh F (2019) Posterior fossa decompression for Chiari malformation type I: clinical and radiological presentation, outcome and complications in a retrospective series of 105 procedures. Acta Neurol Belg 2019 Feb 8
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
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 2:42–49
Förander P, Sjåvik K, Solheim O, Riphagen I, Gulati S, Salvesen Ø, Jakola AS (2014) The case for duraplasty in adults undergoing posterior fossa decompression for Chiari I malformation: a systematic review and meta-analysis of observational studies. Clin Neurol Neurosurg 125:58–64
Foreman P, Safavi-Abbasi S, Talley MC, Boeckman L, Mapstone TB (2012) Perioperative outcomes and complications associated with allogeneic duraplasty for the management of Chiari malformations type I in 48 pediatric patients. Neurosurg Pediatr 10:142–149
Furtado SV, Thakar S, Hegde AS (2011) Correlation of functional outcome and natural history with clinicoradiological factors in surgically managed pediatric Chiari I malformation. Neurosurgery 68:319–327
Gallo P, Sokol D, Kaliaperumal C, Kandasamy J (2017) Comparison of three different cranio-cervical decompression procedures in children with Chiari malformation type I: does the surgical technique matter? Pediatr Neurosurg 52:289–297
Genitori L, Peretta P, Nurisso C, Macinante L, Mussa F (2000) Chiari type I anomalies in children and adolescents: minimally invasive management in a series of 53 cases. Child’s Nerv System 16:707–718
Greenberg JK, Milner E, Yarbrough CK, Lipsey K, Piccirillo JF, Smyth MD, Park TS, Limbrick DD Jr (2015) Outcome methods used in clinical studies of Chiari malformation type I: a systematic review. J Neurosurg 122: 262–272
Gürbüz MS, Berkman MZ, Ünal E, Akpınar E, Gök Ş, Orakdöğen M, Aydın S (2015) Foramen magnum decompression and duraplasty is superior to only foramen magnum decompression in Chiari malformation type 1 associated with syringomyelia in adults. Asian Spine J 9:721–727
Hankinson T, Tubbs RS, Wellons JC (2011) Duraplasty or not? An evidence-based review of the pediatric Chiari I malformation. Childs Nerv Syst 27:35–40
Hida K, Iwasaki Y, Koyanagi I, Sawamura Y, Abe H (1995) Surgical indication and resu1ts of foramen magnum decompression versus syringo-subarachnoid shunting for syringomyelia associated with Chiari I malformation. Neurosurg 37:673–679
Hidalgo ET, Dastagirzada Y, Orillac C, Kvint S, North E, Bledea R, McQuinn MW, Redel-Traub G, Rodriguez C, Wisoff JH (2018) Time to resolution of symptoms after suboccipital decompression with duraplasty in children with Chiari malformation type I. World Neurosurg 117:e544–e551
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. Neurosurg 33:845–849
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 duraplasty for treatment of pediatric Chiari I malformation: a prospective study. World Neurosurg 110:e465–e472
Kennedy BC, Kelly KM, Phan MQ, Bruce SS, McDowell MM, Anderson RC, Feldstein NA (2015) Outcomes after suboccipital decompression without dural opening in children with Chiari malformation type I. J Neurosurg Pediatr 16:150–158
Khalsa SSS, Siu A, DeFreitas TA, Cappuzzo JM, Myseros JS, Magge SN, Oluigbo CO, Keating RF (2017) Comparison of posterior fossa volumes and clinical outcomes after decompression of Chiari malformation type I. J Neurosurg Pediatr 19:511–517
Korshunov AE, Kushel' YV (2016) Posterior decompression of the craniovertebral junction in children with Chiari malformation: a surgery extent issue. Zh Vopr Neirokhir Im N N Burdenko 80:13–20 Article in Russian
Krieger MD, McComb JG, Levy ML (1999) Toward a simpler surgical management of Chiari I malformation in a pediatric population. Pediatr Neurosurg 30:113–121
Lacy M, DeDios-Stern S, Fredrickson S, Parikh S, Nader T, Frim DM (2018) Prevalence of psychiatric diagnoses in pediatric Chiari malformation type 1. Pediatr Neurosurg 53:371–378
Lam FC, Kasper E (2012) Augmented autologous pericranium duraplasty in 100 posterior fossa surgeries—a retrospective case series. Neurosurgery 71(2 Suppl Operative):ons302–ons307
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 30:1419–1424
Lee S, Wang KC, Cheon JE, Phi JH, Lee JY, Cho BK, Kim SK (2014) Surgical outcome of Chiari I malformation in children: clinico-radiological factors and technical aspects. Childs Nerv Syst 30:613–623
Leon TJ, Kuhn EN, Arynchyna AA, Smith BP, Tubbs RS, Johnston JM, Blount JP, Rozzelle CJ, Oakes WJ, Rocque BG (2019) Patients with “benign” Chiari I malformations require surgical decompression at a low rate. J Neurosurg Pediatr 4:1–9
Levy WJ, Mason L, Hahn JF (1983) Chiari malformation presenting in adults: a surgical experience in 127 cases. Neurosurg 12:377–390
Limonadi FM, Selden NRJ (2004) Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg 101:184–188
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
Litvack ZN, Lindsay RA, Selden NR (2013) Dura splitting decompression for Chiari I malformation in pediatric patients: clinical outcomes, healthcare costs, and resource utilization. Neurosurgery 72:922–928
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 20:439–449
Ma J, You C, Chen H, Huang S, Ieong C (2012) Cerebellar tonsillectomy with suboccipital decompression and duraplasty by small incision for Chiari I malformation (with syringomyelia): long term follow-up of 76 surgically treated cases. Turk Neurosurg 22:274–279
Martínez-Lage JF, Pérez-Espejo MA, Palazón JH, López Hernández F, Puerta P (2006) Autologous tissues for dural grafting in children: a report of 56 cases. Childs Nerv Syst 22:139–144
Massimi L, Caldarelli M, Paternoster G, Novegno F, Tamburrini G, Di Rocco C (2008) Mini-invasive surgery for Chiari type I malformation. Neuroradiol J 21:65–70
Massimi L, Frassanito P, Chieffo D, Tamburrini G, Caldarelli M (2019) Bony decompression for Chiari malformation type I: long-term follow-up. Acta Neurochir Suppl 125:119–124
Mazzola CA, Fried AH (2003) Revision surgery for Chiari malformation decompression. Neurosurg Focus 15:E3
McGirt MJ, Attenello FJ, Datoo G, Gathinji M, Atiba A, Weingart JD, Carson B, Jallo GI (2008) Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation type I. J Neurosurg Pediatr 2:52–57
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 46:1384–1389
Mutchnick IS, Janjua RM, Moeller K, Moriarty TM (2010) Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr 5:474–488
Narenthiran G, Parks C, Pettorini B (2015) Management of Chiari I malformation in children: effectiveness of intra-operative ultrasound for tailoring foramen magnum decompression. Childs Nerv Syst 31:1371–1376
Nathoo N, Narotam PK (2010) Posterior fossa duraplasty and hydrodynamic complications. Neurosurgery 66:E1030
Navarro R, Olavarria G, Seshadri R, Gonzales-Portillo G, McLone DG, Tomita T (2004) Surgical results of posterior fossa decompression for patients with Chiari I malformation. Childs Nerv Syst 20:349–356
Noguchi-Shinohara M, Hamaguchi T, Kitamoto T, Sato T, Nakamura Y, Mizusawa H, Yamada M (2007) Clinical features and diagnosis of dura mater graft associated Creutzfeldt Jakob disease. Neurology 69:360–367
Novegno F, Caldarelli M, Massa A, Chieffo D, Massimi L, Pettorini B, Tamburrini G, Di Rocco C (2008) The natural history of the Chiari type I anomaly. J Neurosurg Pediatrics 2:179–187
Oral S, Yilmaz A, Kucuk A, Tumturk A, Menku A (2018) Comparison of dural splitting and duraplasty in patients with Chiari type I malformation: relationship between tonsillo-dural distance and syrinx cavity. Turk Neurosurg 2018 Jun 21
Ostendorf AP, Connolly AM (2013) Medical management of eosinophilic meningitis following bovine graft duraplasty for Chiari malformation type I repair: case report. J Neurosurg Pediatr 12:357–359
Park JK, Gleason PL, Madsen JR, Goumnerova LC, Scott RM (1997) Presentation and management of Chiari I malformation in children. Pediatr Neurosurg 26:190–196
Pomeraniec IJ, Ksendzovsky A, Awad AJ, Fezeu F, Jane JA Jr (2016) Natural and surgical history of Chiari malformation type I in the pediatric population. J Neurosurg Pediatr 17: 343–352
Poretti A, Ashmawy R, Garzon-Muvdi T, Jallo GI, Huisman TA, Raybaud C (2016) Chiari type 1 deformity in children: pathogenetic, clinical, neuroimaging, and management aspects. Neuropediatrics 47:293–307
Quon JL, Grant RA, Di Luna ML (2015) Multimodal evaluation of CSF dynamics following extradural decompression for Chiari malformation type I. J Neurosurg Spine 22:622–630
Radmanesh A, Greenberg J, Chatterjee A, Smyth MD, Limbrick DD, Sharma A (2015) Tonsillar pulsatility before and after surgical decompression for children with Chiari malformation type 1: an application for true fast imaging with steady state precession. Neuroradiology 57:387–393
Raza-Knight S, Mankad K, Prabhakar P, Thompson D (2017) Headache outcomes in children undergoing foramen magnum decompression for Chiari I malformation. Arch Dis Child 102:238–243
Rehman L, Akbar H, Bokhari I, Babar AK, M Hashim AS, Arain SH (2015) Posterior fossa decompression with duraplasty in Chiari-1 malformations. J Coll Physicians Surg Pak 25:254–258
Rosen DS, Wollman R, Frim DM (2003) Recurrence of symptoms after Chiari decompression and duraplasty with nonautologous graft material. Pediatr Neurosurg 38:186–190
Shetty J, Kandasamy J, Sokol D, Gallo P (2019) Clinical deterioration despite syringomyelia resolution after successful foramen magnum decompression for Chiari malformation - case series. Eur J Paediatr Neurol 23(2019):333–337
Shweikeh F, Sunjaya D, Nuno M, Drazin D, Adamo MA (2015) National trends, complications, and hospital charges in pediatric patients with Chiari malformation type I treated with posterior fossa decompression with and without duraplasty. Pediatr Neurosurg 50:31–37
Sindou M, Gimbert E (2009) Decompression for Chiari type I-malformation (with or without syringomyelia) by extreme lateral foramen magnum opening and expansile duraplasty with arachnoid preservation: comparison with other technical modalities (literature review). Adv Tech Stand Neurosurg 34:85–110
Sindou M, Chávez-Machuca J, Hashish H (2002) Cranio-cervical decompression for Chiari type I-malformation, adding extreme lateral foramen magnum opening and expansile duroplasty with arachnoid preservation. Technique and long-term functional results in 44 consecutive adult cases -- comparison with literature data. Acta Neurochir 144:1005–1019
Soleman J, Bartoli A, Korn A, Constantini S, Roth J (2018) Treatment failure of syringomyelia associated with Chiari I malformation following foramen magnum decompression: how should we proceed? Neurosurg Rev 2018 Dec 15
Stevens EA, Powers AK, Sweasey TA, Tatter SB, Ojemann RG (2009) Simplified harvest of autologous pericranium for duraplasty in Chiari malformation type I. Technical note. J Neurosurg Spine 11:80–83
Tubbs RS, Wellons JC III, Blount JP, Oakes WJ (2002) Posterior atlantooccipital membrane for duraplasty. Technical note. J Neurosurg 97(2 Suppl):266–268
Tubbs RS, McGirt MJ, Oakes WJ (2003) Surgical experience in 130 pediatric patients with Chiari 1 malformations. J Neurosurg 99:291–296
Vidal CHF, Brainer-Lima AM, Valença MM, Farias RL (2019) Chiari 1 malformation surgery: comparing non-violation of the arachnoid versus arachnoid opening and thermocoagulation of the tonsils. World Neurosurg 121:e605–e613
Wilkinson DA, Johnson K, Garton HJ, Muraszko KM, Maher CO (2017) Trends in surgical treatment of Chiari malformation type I in the United States. J Neurosurg Pediatr 19:208–216
Williams B (1994) A blast against grafts--on the closing and grafting of the posterior fossa dura. Br J Neurosurg 8:275–278
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 40:213–221
Yeh DD, Koch B, Crone KR (2006) Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation type I. J Neurosurg 105(1 Suppl):26–32
Yundt KD, Park TS, Tantuwaya VS, Kaufman BA (1996) Posterior fossa decompression without duraplasty in infants and young children for treatment of Chiari malformation. Pediatr Neurosurg 25:221–226
Zhang L, Yi Z, Duan H, Li L (2017) A novel autologous duraplasty in situ technique for the treatment of Chiari malformation type I. J Neurosurg 126:91–97
Zhao JL, Li MH, Wang CL, Meng W (2016) A systematic review of Chiari I malformation: techniques and outcomes. World Neurosurg 88:7–14
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
No conflict of interest to disclose.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Massimi, L., Frassanito, P., Bianchi, F. et al. Bony decompression vs duraplasty for Chiari I malformation: does the eternal dilemma matter?. Childs Nerv Syst 35, 1827–1838 (2019). https://doi.org/10.1007/s00381-019-04218-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00381-019-04218-9