In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Surgical Treatment of Chiari I Malformations: Advantage of Linear Autologous Duraplasty

    Final Number:

    Juanita Garces MD; Edison Valle MD; Tyler Scullen BS; Ascher B Kaufmann BS; John Franklin Berry; Jonathan William Riffle MD; Cuong Bui MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: Chiari malformation type I (CMI) exhibit an incidence of approximately 1 in 1000 births but often poses a significant diagnostic and treatment challenge for neurosurgeons. Although treatment outcomes are favorable, controversy remains as to the ideal surgical treatment paradigm. Recent experiences and data suggest that bony decompression alone without duraplasty is favored due to the lower incidence of pseudomeningocele and aseptic meningitis. We believe that technical nuisances such as linear dural opening and use of autologous pericranium duraplasty maximize favorable outcome without significant concern of pseudomeningocele and/or aseptic meningitis.

    Methods: We retrospectively reviewed 50 CMI patients surgically treated and followed by senior author. We report long-term (>1 year) outcome and complication rate. We also discuss the current literature and controversies surrounding Chiari treatment paradigms.

    Results: The female to male ratio was approximately 3:1 (37 females and 13 males) and median age was 22. Primary outcomes of significant improvement of exertion-headache and/or spinal syringomyelia were achieved in 96% (48/50) of patients at 1 year. Two patients developed pseudomeningoceles but only one required surgical re-exploration and repair while the other patient was asymptomatic and resolved at 1 year. No return ER visit or readmission for post-operative aseptic meningitis was seen.

    Conclusions: The ideal surgical approach for CMI has yet to be elucidated. Suboccipital decompression and C1 laminectomy alone offers some advantages but it may miss 4th ventricular outlet obstructions such as arachnoid veils requiring re-operation in up to 10% of cases. Furthermore, it prevents direct tonsilar manipulation. Techniques allowing for simpler and more watertight duraplasty closure may off set risks of pseudomeningocele and aseptic meningitis. For symptomatic CMI patients, suboccipital craniectomy with linear autologous duraplasty is a safe and viable surgical treatment option that can provide excellent outcome without increased risk of surgery-related complications.

    Patient Care: By providing our experience and outcomes with linear autologous duraplasty for posterior fossa decompression, other neurosurgeons have the opportunity to add this to their armamentarium of Chairi

    Learning Objectives: 1) Understand potential surgical advantages of linear, autologous duraplasty 2) Review various treatment options for CIM 3) Identify an effective treatment for posterior fossa decompression in CIM patients

    References: 1. Hadley DM. The chiari malformations. J Neurol Neurosurg Psychiatry. 2002. 2. Markunas CA, Tubbs RS, Moftakhar R, et al. Clinical, radiological, and genetic similarities between patients with chiari type I and type 0 malformations. J Neurosurg Pediatr. 2012;9(4):372-378. 3. Tubbs RS, Muhleman M, Loukas M, Oakes WJ. A new form of herniation: The chiari V malformation. Childs Nerv Syst. 2012;28(2):305-307. 4. Cama A, Tortori-Donati P, Piatelli GL, Fondelli MP, Andreussi L. Chiari complex in children--neuroradiological diagnosis, neurosurgical treatment and proposal of a new classification (312 cases). Eur J Pediatr Surg. 1995;5 Suppl 1:35-38. 5. Alden TD, Ojemann JG, Park TS. Surgical treatment of chiari I malformation: Indications and approaches. Neurosurg Focus. 2001;11(1):E2. 6. Novegno F, Caldarelli M, Massa A, et al. The natural history of the chiari type I anomaly. J Neurosurg Pediatr. 2008;2(3):179-187. 7. Massimi L, Della Pepa GM, Tamburrini G, Di Rocco C. Sudden onset of chiari malformation type I in previously asymptomatic patients. J Neurosurg Pediatr. 2011;8(5):438-442. 8. Massimi L, Caldarelli M, Paternoster G, Novegno F, Tamburrini G, Di Rocco C. Mini-invasive surgery for chiari type I malformation. Neuroradiol J. 2008;21(1):65-70. 9. Wellons JC,3rd, Tubbs RS, Bui CJ, Grabb PA, Oakes WJ. Urgent surgical intervention in pediatric patients with chiari malformation type I. report of two cases. J Neurosurg. 2007;107(1 Suppl):49-52. 10. Chang CZ, Howng SL. Surgical outcome of chiari I malformations--an experience sharing and literature review. Kaohsiung J Med Sci. 1999;15(11):659-664. 11. Menezes AH. Chiari I malformations and hydromyelia--complications. Pediatr Neurosurg. 1991;17(3):146-154. 12. Rhoton AL,Jr. Microsurgery of arnold-chiari malformation in adults with and without hydromyelia. J Neurosurg. 1976;45(5):473-483. 13. Pollack IF, Pang D, Albright AL, Krieger D. Outcome following hindbrain decompression of symptomatic chiari malformations in children previously treated with myelomeningocele closure and shunts. J Neurosurg. 1992;77(6):881-888. 14. Tubbs RS, Bui CJ, Rice WC, et al. Critical analysis of the chiari malformation type I found in children with lipomyelomeningocele. J Neurosurg. 2007;106(3 Suppl):196-200. 15. Xie D, Qiu Y, Sha S, et al. Syrinx resolution is correlated with the upward shifting of cerebellar tonsil following posterior fossa decompression in pediatric patients with chiari malformation type I. Eur Spine J. 2014. 16. Albert GW, Menezes AH, Hansen DR, Greenlee JD, Weinstein SL. Chiari malformation type I in children younger than age 6 years: Presentation and surgical outcome. J Neurosurg Pediatr. 2010;5(6):554-561. 17. Guo F, Wang M, Long J, et al. Surgical management of chiari malformation: Analysis of 128 cases. Pediatr Neurosurg. 2007;43(5):375-381. 18. Attenello FJ, McGirt MJ, Gathinji M, et al. Outcome of chiari-associated syringomyelia after hindbrain decompression in children: Analysis of 49 consecutive cases. Neurosurgery. 2008;62(6):1307-13; discussion 1313. 19. Sindou M, Chavez-Machuca J, Hashish H. 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 (Wien). 2002;144(10):1005-1019. 20. Attenello FJ, McGirt MJ, Garces-Ambrossi GL, Chaichana KL, Carson B, Jallo GI. Suboccipital decompression for chiari I malformation: Outcome comparison of duraplasty with expanded polytetrafluoroethylene dural substitute versus pericranial autograft. Childs Nerv Syst. 2009;25(2):183-190. 21. Bowers CA, Brimley C, Cole C, Gluf W, Schmidt RH. AlloDerm for duraplasty in chiari malformation: Superior outcomes. Acta Neurochir (Wien). 2014. 22. Sindou M, Gimbert E. 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. 2009;34:85-110. 23 Greenberg JK, Milner E, Yarbrough CK, et al. Outcome methods used in clinical studies of chiari malformation type I: A systematic review. J Neurosurg. 2014:1-11. 24. Parker SL, Godil SS, Zuckerman SL, Mendenhall SK, Wells JA, Shau DN et al.: Comprehensive Assessment of 1-Year Outcomes and Determination of Minimum Clinically Important Difference in Pain, Disability, and Quality of Life After Suboccipital Decompression for Chiari Malformation I in Adults. Neurosurgery 73(4), p 569–581, October 2013 25. Chotai S, Kshettry V, Lamki T, Ammirati M: Surgical outcomes using wide suboccipital decompression for adult Chiari I malformation with and without syringomyelia. Clin Neurol Neurosurg. 120:129-35, May 2014 26. Sakushima K, Hida K, Yabe I, Tsuboi S, Uehara R, Sasaki H: Different surgical treatment techniques used by neurosurgeons and orthopedists for syringomyelia caused by Chiari I malformation in Japan. J Neurosurg: Spine: Vol 18(6), 588-592, Jun 2013

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy