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  • Minimally Invasive Occipitoce​rvical Decompress​ion Preserving Posterior Muscular-L​igamentous Tension Band for Surgical Management of Type I Chiari Malformati​on: A Prospectiv​e Clinical and Radiolog

    Final Number:
    1615

    Authors:
    Silvia Tatiana Quintero Olivero MD; Roberto C. Diaz MD; Miguel E. Berbeo; OSCAR HERNANDO FEO - LEE MD; Oscar Zorro MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Type I Chiari malformation is a frequent neurosurgical entity that presents in most of cases with affection of cerebrospinal fluid circulation and spinal tracts. Therapy of choice is decompression achieved by performing a suboccipital craniectomy and cervical posterior osteotomies with durotomy and duraplasty. Traditional approaches have an increased risk of bleeding and post-operative pain; they also disrupt the the posterior cervical muscular-ligamentous tension band which affects spinal biomechanics. There are no reports about minimally invasive surgery (M.I.S.) for these patients; we sought to describe a new minimally invasive approach through a small suboccipital incision without lesion to the posterior cervical muscles and ligamentum nuchae while obtaining optimal decompression margins, performing adequate repair of the dura mater, and reducing perioperative morbidity. Eleven surgical cases are presented to illustrate the procedure.

    Methods: An occipitoatlantal decompression was performed through an incision above the occipital hair insertion line. A muscle splitting technique was performed by the use of a minimally invasive retractor (MaXcess – Nuvasive Inc.). Craniectomy was performed with Kerrison rongeours, under microscopical guidance. A vertical durotomy was performed and dura repair was made with a synthetic dura mater patch, fixated in six patients with manual suture and in five patients with fibrin sealant; skin closure was performed in standard fashion. Patients were followed prospectively with visits at one, three, six and twelve months after surgery

    Results: Eleven patients with type I Chiari were included for analysis. Average surgical time was 140.5 minutes with an estimated blood loss of 120.9 cc. All patients were discharged the day after surgery with minimal pain; one patient developed a csf fistula which required surgical revision; computerized tomography scans showed adequate decompression; no infectious complications were noted.

    Conclusions: A minimally invasive approach to the craniocervical junction is feasible in order to preserve as much normal anatomy as possible to avoid alterations in spinal biomechanics. This work presents a novel procedure which can help to reduce operative morbidity and mortality as well as promoting earlier recovery in patients with Chiari I malformation.

    Patient Care: small suboccipital incision without lesion to the posterior cervical muscles and ligamentum nuchae while obtaining optimal decompression margins, reducing perioperative morbidity

    Learning Objectives: to describe a new minimally invasive approach through a small suboccipital incision without lesion to the posterior cervical muscles and ligamentum nuchae while obtaining optimal decompression margins

    References: Disinserting muscles from C7 produces axial pain. Hosono N, Sakaura H, Mukai Y, et al. C3–6 laminoplasty takes over C3–7 laminoplasty with significantly lower incidence of axial neck pain. Eur Spine J 2006;15:1375–9. Disinserting muscles from the C2 spinous process deteriorates spinal sagital balance. Nolan JP Jr, Sherk HH. Biomechanical evaluation of the extensor musculature of the cervical spine. Spine 1988;13:9–11. Cervical laminectomies from C1, C2 or subaxial levels can lead to deformity. Steinbok P, Boyd M, Cochrane D. Cervical spinal deformity following craniotomy and upper cervical laminectomy for posterior fossa tumors in children. Childs Nerv Syst 1989;5:25–8. The preservation of the muscular insertions at C2 decreases post operative loss of lordosis when compared to laminoplasty. Takeshita K, Seichi A, Akune T, et al. Can laminoplasty maintain the cervical alignment even when the C2 lamina is contained? Spine 2005;30:1294–8.

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