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  • Comparison of Minimally Invasive Occipito-Cervical Decompression with Standard Open Surgery For Type I Chiari Malformation: Surgical Technique and Early Clinical Results

    Final Number:

    Juan P Sardi MD; Roberto C. Diaz MD; Jorge MD Camacho; David Gomez MD; Miguel E. Berbeo

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Chiari-I Malformation (CM-I) is characterized by a shallow posterior fossa and hindbrain herniation through the foramen magnum. Posterior fossa decompressive craniectomy (PFDC) is the standard treatment for symptomatic patients. However, there are many variations to this approach, definitive treatment remains unresolved and there is no consensus on the optimal surgical technique. The authors report their experience with a minimally invasive occipitocervical decompression (MIOCD) for patients with CM-I and compare this novel technique with the traditional open approach.

    Methods: We conducted a retrospective review of 23 consecutive patients who underwent surgical treatment for symptomatic CM-I. Patient records were appraised and statistical analyses were performed on clinical status, intraoperative factors, length of hospitalization and postoperative results. Findings were used to compare the outcomes after minimally invasive and standard open approaches.

    Results: Ten patients underwent MIOCD, and thirteen standard open PFDC. All 23 procedures included duraplasty and resection of the posterior arch of C1. Patient age ranged from 9 to 60 years (mean 32.4) and follow-up duration varied from 1 to 57 months (Mean 14.7 months). There were no statistically significant differences between the 2 groups in terms of neurological recovery, pain scores, length of stay, diameter of the craniectomy and complications. Nevertheless, the MIOCD group showed a tendency to present better results when compared to the PFDC in terms of blood loss (Mean 320ml Vs. 400ml), operation time (Mean 134.9min Vs. 164.5min) and immediate POP pain scores (1.9 Vs. 2.9 in the VAS).

    Conclusions: We present a novel technique for minimally invasive decompression of the posterior fossa that provides similar outcomes as the standard PFDC in the surgical treatment of CM-I. Preservation of the posterior tension band and musculature could result in better postoperative pain control, lower incidence of craniocervical instability and better cosmetic results. However, further prospective studies are needed to confirm these hypotheses.

    Patient Care: Minimally invasive occipito-cervical decompression can represent an effective treatment for symptoms associated with CM-I with similar outcomes as the standard open technique. It is a feasible and simple surgical alternative that takes advantage of an anatomical corridor to avoid excessive exposure, muscle disinsertion and preserves the posterior tension band; hence it could result in better postoperative pain control, cosmetic results and lower incidence of craniocervical instability. We open a window for further studies that could eventually validate the importance of a less invasive approach to the patient with CM-I, hence improving surgical outcomes and lowering surgery-related morbidity.

    Learning Objectives: By the conclusion of this session, participants should be able to identify the minimally invasive occipito-cervical decompression approach as an effective treatment alternative for patients with Chiari Type I malformation. Furthermore, they should understand the anatomical and biomechanical implications of preserving the posterior tension band and neck musculature. Finally, we seek to open a window for further studies that aim to validate the advantages of an MIS approach and improve postoperative results in patients with Chiari Type I malformation

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