Abstract
Introduction: Posterior fossa decompression (PFD) is the treatment of choice for symptomatic Chiari I malformation (CIM) patients; however, controversy exists regarding specific surgical techniques needed to accomplish this goal. While a variety of methods have been described, an ongoing central debate exists regarding the need for duraplasty (PFDD) in addition to bony posterior fossa decompression for CIM.Materials and Methods: We performed a systematic review, including articles from 2000 to 2018, following the PRISMA statement, to study outcomes of CIM patients who underwent PFD with or without duraplasty. Information on demographic data, the type of procedure, study design, the presence of a syrinx, follow-up duration, and various clinical outcomes were collected. We conducted a meta-analysis to assess outcomes, such as clinical improvement, syringomyelia resolution, complications and reoperation rate.Results: Nine studies (including 212 and 315 patients undergoing PFD and PFDD, respectively) were included in the meta-analysis. Regarding clinical outcomes, PFDD showed higher clinical and syrinx improvement rates compared to PFD (p>0.05, <0.05, respectively). PFDD yielded a higher complication rate than PFD (p<0.05), particularly in CSF fistula and aseptic meningitis (p<0.05). No differences were found in wound infection and pseudomeningocele rates. PFD showed a higher reoperation rate compared to PFDD (p<0.05). In PFD, reoperations were related to a lack of resolution of clinical symptoms and syringomyelia, while in PFDD, were due to persistence of symptoms, or repair of a CSF fistula.Conclusions: We found no significant difference in outcome with respect to postoperative clinical improvement, rate of wound infection, or pseudomeningocele occurrence between PFD and PFDD. Although the clinical response was similar between the groups, the rate of syrinx regression was higher in patients undergoing PFDD compared to PFD. And while the reoperation rate was higher in the PFD subgroup, complications as a whole were more frequent in patients undergoing PFDD.
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References
Massimi L, Peppucci E, Peraio S, Di Rocco C. History of Chiari type I malformation. Neurol Sci. 2011;32(Suppl 3):S263–5.
Chiari H. Concerning alterations in the cerebellum resulting from cerebral hydrocephalus. 1891. Pediatr Neurosci. 1987;13(1):3–8.
Doberstein CA, Torabi R, Klinge PM. Current concepts in the pathogenesis, diagnosis, and management of type I Chiari malformations. R I Med J (2013). 2017;100(6):47–9.
Milhorat TH, Chou MW, Trinidad EM, Kula RW, Mandell M, Wolpert C, et al. Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery. 1999;44(5):1005–17.
Sgouros S, Kountouri M, Natarajan K. Skull base growth in children with Chiari malformation type I. J Neurosurg. 2007;107(3 Suppl):188–92.
Azahraa Haddad F, Qaisi I, Joudeh N, Dajani H, Jumah F, Elmashala A, et al. The newer classifications of the chiari malformations with clarifications: an anatomical review. Clin Anat. 2018;31(3):314–22.
Elster AD, Chen MY. Chiari I malformations: clinical and radiologic reappraisal. Radiology. 1992;183(2):347–53.
Brockmeyer DL, Spader HS. Complex Chiari malformations in children: diagnosis and management. Neurosurg Clin N Am. 2015;26(4):555–60.
Meadows J, Kraut M, Guarnieri M, Haroun RI, Carson BS. Asymptomatic Chiari Type I malformations identified on magnetic resonance imaging. J Neurosurg. 2000;92(6):920–6.
Bejjani GK, Cockerham KP. Adult Chiari Malformation. Contempor Neurosurg. 2001;23(26):1–7.
Speer MC, Enterline DS, Mehltretter L, Hammock P, Joseph J, Dickerson M, et al. Review article: Chiari type I malformation with or without Syringomyelia: prevalence and genetics. J Genet Couns. 2003;12(4):297–311.
Greenlee JDW, Donovan KA, Hasan DM, Menezes AH. Chiari I malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years. Pediatrics. 2002;110(6):1212–9.
Tubbs RS, Lyerly MJ, Loukas M, Shoja MM, Oakes WJ. The pediatric Chiari I malformation: a review. Childs Nerv Syst. 2007;23(11):1239–50.
Zhao JL, Li MH, Wang CL, Meng W. A systematic review of Chiari I malformation: techniques and outcomes. World Neurosurg. 2016;88:7–14.
Xu H, Chu L, He R, Ge C, Lei T. Posterior fossa decompression with and without duraplasty for the treatment of Chiari malformation type I-a systematic review and meta-analysis. Neurosurg Rev. 2017;40(2):213–21.
Durham SR, Fjeld-Olenec K. 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. 2008;2(1):42–9.
Forander P, Sjavik K, Solheim O, Riphagen I, Gulati S, Salvesen O, et al. 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. 2014;125:58–64.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.
McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6.
Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94.
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.
Chen J, Li Y, Wang T, Gao J, Xu J, Lai R, et al. Comparison of posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation type I in adult patients: a retrospective analysis of 103 patients. Medicine (Baltimore). 2017;96(4):e5945.
Erdogan E, Cansever T, Secer HI, Temiz C, Sirin S, Kabatas S, et al. The evaluation of surgical treatment options in the Chiari malformation type I. Turk Neurosurg. 2010;20(3):303–13.
Gurbuz MS, Karaaslan N, Caliskan T, Unal E, Berkman MZ. Comparison of the surgical results for foramen magnum decompression with and without duraplasty in Chiari malformation type 1. Turk Neurosurg. 2015;25(3):419–24.
Jiang E, Sha S, Yuan X, Zhu W, Jiang J, Ni H, et al. 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. 2018;110:e465–e72.
Limonadi FM, Selden NR. Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome. J Neurosurg. 2004;101(2 Suppl):184–8.
Mutchnick IS, Janjua RM, Moeller K, Moriarty TM. Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr. 2010;5(5):474–8.
Munshi I, Frim D, Stine-Reyes R, Weir BK, Hekmatpanah J, Brown F. Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery. 2000;46(6):1384–9; discussion 9–90.
Romero FR, Pereira CA. Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? Arq Neuropsiquiatr. 2010;68(4):623–6.
Yilmaz A, Kanat A, Musluman AM, Colak I, Terzi Y, Kayaci S, et al. When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale? World Neurosurg. 2011;75(2):307–13.
Aliaga L, Hekman KE, Yassari R, Straus D, Luther G, Chen J, et al. A novel scoring system for assessing Chiari malformation type I treatment outcomes. Neurosurgery. 2012;70(3):656–64; discussion 64-5.
Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–15.
Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 7. Rating the quality of evidence--inconsistency. J Clin Epidemiol. 2011;64(12):1294–302.
Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 8. Rating the quality of evidence--indirectness. J Clin Epidemiol. 2011;64(12):1303–10.
Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. GRADE guidelines 6. Rating the quality of evidence--imprecision. J Clin Epidemiol. 2011;64(12):1283–93.
Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, et al. GRADE guidelines: 5. Rating the quality of evidence--publication bias. J Clin Epidemiol. 2011;64(12):1277–82.
Shweikeh F, Sunjaya D, Nuno M, Drazin D, Adamo MA. 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. 2015;50(1):31–7.
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The authors would like to thank Carrie Price for her invaluable support in developing the search strategy.
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Perdomo-Pantoja, A., Iyer, R.R., Cohen, A.R. (2019). Chiari Malformation: Posterior Fossa Decompression With or Without Duraplasty?. In: Bartels, R., Rovers, M., Westert, G. (eds) Evidence for Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-030-16323-5_9
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