Intraoperative neurophysiological monitoring in paediatric Chiari surgery—help or hindrance?
The role of intraoperative neurophysiological monitoring (IONM) during surgery for Chiari I malformation has not been fully elucidated. Questions remain regarding its utility as an adjunct to foramen magnum decompression surgery, specifically, does IONM improve the safety profile of foramen magnum decompression surgery and can IONM parameters help in intraoperative surgical decision-making. This study aimed to describe a single institution experience of IOM during paediatric Chiari I surgery.
The methodology comprised a retrospective review of prospectively collected electronic neurosurgical departmental operative database. Inclusion criteria were children under 16 years of age who had undergone foramen magnum decompression for Chiari I malformation with IONM. In addition to basic demographic data, details pertaining to presenting features and post-operative outcomes were obtained. These included primary symptoms of Chiari I malformation and indications for surgery. MRI findings, including the presence of syringomyelia on pre-and post-operative imaging, were reviewed. Details of the surgical technique for each patient were recorded. Only patients with either serial brainstem auditory evoked potential (BAEP) and/or upper limb somatosensory evoked potential (SSEP) recordings were included. Two time points were used for the purposes of analysing IONM data; initial baseline before skin incision and final at the time of skin closure.
Thirty-seven children underwent foramen magnum decompression (FMD) with IONM. Mean age was 10.5 years (range 1–16 years) with a male:female ratio 13:24. The commonest clinical features on presentation included headaches (15) and scoliosis (13). Twenty-four patients had evidence of associated syringomyelia (24/37 = 64.9%). A reduction in the SSEP latency was observed in all patients. SSEP amplitude was more variable, with a decrease seen in 18 patients and an increase observed in 12 patients. BAEP recordings decreased in 13 patients and increased in 4 patients. There were no adverse neurological events following surgery; the primary symptom was resolved or improved in all patients at 3-month follow-up. Resolution or improvement in syringomyelia was observed in 19/24 cases.
Our data shows that FMD for Chiari malformation (CM) is associated with changes in SSEPs and BAEPs. However, we did not identify a definite link between clinical outcomes and IONM, nor did syrinx outcome correlate with IONM. There may be a role for IONM in CM surgery but more robust data with better-defined parameters are required to further understand the impact of IONM in CM surgery.
KeywordsChiari Neurophysiology Intraoperative monitoring Foramen magnum decompression
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
The study was registered as a Service Evaluation study with the Great Ormond Street Hospital for Children NHS Foundation Trust.
Informed consent was not sought, as this was a retrospective study.
- 2.Attenello FJ, McGirt MJ, Garces-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. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 25:183–190CrossRefGoogle Scholar
- 4.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 20:439–449CrossRefPubMedGoogle Scholar
- 5.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. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 30:1419–1424CrossRefGoogle Scholar
- 6.McGirt MJ, Attenello FJ, Atiba A, Garces-Ambrossi G, Datoo G, Weingart JD, Carson B, Jallo GI (2008) Symptom recurrence after suboccipital decompression for pediatric Chiari I malformation: analysis of 256 consecutive cases. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 24:1333–1339CrossRefGoogle Scholar
- 7.Narenthiran G, Parks C, Pettorini B (2015) Management of Chiari I malformation in children: effectiveness of intra-operative ultrasound for tailoring foramen magnum decompression. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 31:1371–1376CrossRefGoogle Scholar
- 9.Zamel K, Galloway G, Kosnik EJ, Raslan M, Adeli A (2009) Intraoperative neurophysiologic monitoring in 80 patients with Chiari I malformation: role of duraplasty. Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society 26:70–75CrossRefGoogle Scholar