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Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications.
J Neurosurg Pediatr. 2020 Oct 30; 27(1):1-8.JN

Abstract

OBJECTIVE

While a select population of pediatric patients with Chiari malformation type I (CM-I) remain asymptomatic, some patients present with tussive headaches, neurological deficits, progressive scoliosis, and other debilitating symptoms that necessitate surgical intervention. Surgery entails a variety of strategies to restore normal CSF flow, including increasing the posterior fossa volume via bone decompression only, or bone decompression with duraplasty, with or without obex exploration. The indications for duraplasty and obex exploration following bone decompression remain controversial. The objective of this study was to describe an institutional series of pediatric patients undergoing surgery for CM-I, performed by a single neurosurgeon. For patients presenting with a syrinx, the authors compared outcomes following bone-only decompression with duraplasty only and with duraplasty including obex exploration. Clinical outcomes evaluated included resolution of syrinx, scoliosis, presenting symptoms, and surgical complications.

METHODS

A retrospective review was conducted of the medical records of 276 consecutive pediatric patients with CM-I operated on at a single institution between 2001 and 2015 by the senior author. Imaging findings of tonsillar descent, associated syrinx (syringomyelia or syringobulbia), basilar invagination, and clinical assessment of CM-I-attributable symptoms and scoliosis were recorded. In patients presenting with a syrinx, clinical outcomes, including syrinx resolution, symptom resolution, and impact on scoliosis progression, were compared for three surgical groups: bone-only/posterior fossa decompression (PFD), PFD with duraplasty (PFDwD), and PFD with duraplasty and obex exploration (PFDwDO).

RESULTS

PFD was performed in 25% of patients (69/276), PFDwD in 18% of patients (50/276), and PFDwDO in 57% of patients (157/276). The mean follow-up was 35 ± 35 months. Nearly half of the patients (132/276, 48%) had a syrinx. In patients presenting with a syrinx, PFDwDO was associated with a significantly higher likelihood of syrinx resolution relative to PFD only (HR 2.65, p = 0.028) and a significant difference in time to symptom resolution (HR 2.68, p = 0.033). Scoliosis outcomes did not differ among treatment groups (p = 0.275). Complications were not significantly higher when any duraplasty (PFDwD or PFDwDO) was performed following bone decompression (p > 0.99).

CONCLUSIONS

In this series of pediatric patients with CM-I, patients presenting with a syrinx who underwent expansile duraplasty with obex exploration had a significantly greater likelihood of syrinx and symptom resolution, without increased risk of CSF-related complications, compared to those who underwent bone-only decompression.

Authors+Show Affiliations

1Department of Neurological Surgery and.2Department of Neurosurgery, University of California, Los Angeles, California; and.3UPMC Children's Hospital of Pittsburgh, Pennsylvania.1Department of Neurological Surgery and. 4Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington.1Department of Neurological Surgery and.1Department of Neurological Surgery and.1Department of Neurological Surgery and.1Department of Neurological Surgery and.

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

33126216

Citation

Ene, Chibawanye I., et al. "Expansile Duraplasty and Obex Exploration Compared With Bone-only Decompression for Chiari Malformation Type I in Children: Retrospective Review of Outcomes and Complications." Journal of Neurosurgery. Pediatrics, vol. 27, no. 1, 2020, pp. 1-8.
Ene CI, Wang AC, Collins KL, et al. Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications. J Neurosurg Pediatr. 2020;27(1):1-8.
Ene, C. I., Wang, A. C., Collins, K. L., Bonow, R. H., McGrath, L. B., Durfy, S. J., Barber, J. K., & Ellenbogen, R. G. (2020). Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications. Journal of Neurosurgery. Pediatrics, 27(1), 1-8. https://doi.org/10.3171/2020.6.PEDS20376
Ene CI, et al. Expansile Duraplasty and Obex Exploration Compared With Bone-only Decompression for Chiari Malformation Type I in Children: Retrospective Review of Outcomes and Complications. J Neurosurg Pediatr. 2020 Oct 30;27(1):1-8. PubMed PMID: 33126216.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Expansile duraplasty and obex exploration compared with bone-only decompression for Chiari malformation type I in children: retrospective review of outcomes and complications. AU - Ene,Chibawanye I, AU - Wang,Anthony C, AU - Collins,Kelly L, AU - Bonow,Robert H, AU - McGrath,Lynn B, AU - Durfy,Sharon J, AU - Barber,Jason K, AU - Ellenbogen,Richard G, Y1 - 2020/10/30/ PY - 2020/05/07/received PY - 2020/06/29/accepted PY - 2020/10/31/pubmed PY - 2022/2/16/medline PY - 2020/10/30/entrez KW - Chiari I malformation KW - duraplasty KW - obex KW - scoliosis KW - syringomyelia SP - 1 EP - 8 JF - Journal of neurosurgery. Pediatrics JO - J Neurosurg Pediatr VL - 27 IS - 1 N2 - OBJECTIVE: While a select population of pediatric patients with Chiari malformation type I (CM-I) remain asymptomatic, some patients present with tussive headaches, neurological deficits, progressive scoliosis, and other debilitating symptoms that necessitate surgical intervention. Surgery entails a variety of strategies to restore normal CSF flow, including increasing the posterior fossa volume via bone decompression only, or bone decompression with duraplasty, with or without obex exploration. The indications for duraplasty and obex exploration following bone decompression remain controversial. The objective of this study was to describe an institutional series of pediatric patients undergoing surgery for CM-I, performed by a single neurosurgeon. For patients presenting with a syrinx, the authors compared outcomes following bone-only decompression with duraplasty only and with duraplasty including obex exploration. Clinical outcomes evaluated included resolution of syrinx, scoliosis, presenting symptoms, and surgical complications. METHODS: A retrospective review was conducted of the medical records of 276 consecutive pediatric patients with CM-I operated on at a single institution between 2001 and 2015 by the senior author. Imaging findings of tonsillar descent, associated syrinx (syringomyelia or syringobulbia), basilar invagination, and clinical assessment of CM-I-attributable symptoms and scoliosis were recorded. In patients presenting with a syrinx, clinical outcomes, including syrinx resolution, symptom resolution, and impact on scoliosis progression, were compared for three surgical groups: bone-only/posterior fossa decompression (PFD), PFD with duraplasty (PFDwD), and PFD with duraplasty and obex exploration (PFDwDO). RESULTS: PFD was performed in 25% of patients (69/276), PFDwD in 18% of patients (50/276), and PFDwDO in 57% of patients (157/276). The mean follow-up was 35 ± 35 months. Nearly half of the patients (132/276, 48%) had a syrinx. In patients presenting with a syrinx, PFDwDO was associated with a significantly higher likelihood of syrinx resolution relative to PFD only (HR 2.65, p = 0.028) and a significant difference in time to symptom resolution (HR 2.68, p = 0.033). Scoliosis outcomes did not differ among treatment groups (p = 0.275). Complications were not significantly higher when any duraplasty (PFDwD or PFDwDO) was performed following bone decompression (p > 0.99). CONCLUSIONS: In this series of pediatric patients with CM-I, patients presenting with a syrinx who underwent expansile duraplasty with obex exploration had a significantly greater likelihood of syrinx and symptom resolution, without increased risk of CSF-related complications, compared to those who underwent bone-only decompression. SN - 1933-0715 UR - https://www.unboundmedicine.com/medline/citation/33126216/Expansile_duraplasty_and_obex_exploration_compared_with_bone_only_decompression_for_Chiari_malformation_type_I_in_children:_retrospective_review_of_outcomes_and_complications_ DB - PRIME DP - Unbound Medicine ER -