The effects of posterior fossa decompressive surgery in adult patients with Chiari malformation and sleep apnea

Clinical article

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Object

One of the feared consequences of craniovertebral junction diseases is apnea. Although several cases of patients with central apnea have been described, obstructive sleep apnea has been identified as the most frequent manifestation of sleep respiratory disorder. Neuronal involvement may be responsible for both central and obstructive apneas. The objective of this work was to study the effect of posterior fossa decompressive surgery on respiratory parameters during sleep in patients with craniovertebral junction malformations and breathing-related sleep disorders.

Methods

In this study, prospectively enrolled consecutive symptomatic adult patients were monitored with full-night polysomnography before and after surgical decompression of the cranial posterior fossa.

Results

Of the 25 patients who were evaluated, 68% received a diagnosis of sleep apnea. After surgery, the mean number of respiratory events decreased from 180.70 to 69.29 (p = 0.005); the mean number of obstructive events decreased from 107.37 to 60.58 (p = 0.01); and the mean number of central events decreased from 38.45 to 8.05 (p = 0.01). The mean preoperative apnea/hypopnea index decreased from 26.68 to 12.98 (p = 0.06), and the mean central apnea index decreased from 13.81 to 1.68 (p = 0.01).

Conclusions

Decompressive surgery in patients with craniovertebral junction malformations resulted in decreased respiratory events during sleep, lowered sleep fragmentation, and enhanced the sleep apnea index in a significant number of patients. The effect was more pronounced in patients with central apnea.

Abbreviations used in this paper: AHI = apnea/hypopnea index; BI = basilar invagination; BMI = body mass index; CAI = central apnea index; CM = Chiari malformation; CVJM = craniovertebral junction malformation; EEG = electroencephalogram; EMG = electromyogram; EOG = electrooculogram.

Article Information

Address correspondence to: Ricardo Vieira Botelho, M.D., Ph.D., Department of Neurosurgery, Hospital do Servidor Publico de Estado, Haberbeck Brandão 68-92, Indianópolis-São Paulo, Brazil 04026040. email: bitbot@uol.com.br.

Please include this information when citing this paper: published online August 7, 2009; DOI: 10.3171/2009.7.JNS09174.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Intraoperative photograph showing extraarachnoidal decompression according to the modified Sahuquillo technique but without anchoring the dura mater.

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    Preoperative (left) and postoperative (right) MR images demonstrating the reappearance of the cisterna magna, narrowing of syringomyelia cavity, and the presence of CSF in the craniocervical junction.

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    Preoperative (A, C, E, and G) and postoperative (B, D, F, and H) pairs of MR images obtained in 4 patients. In these cases, the new cisterna magna formation and narrowing of the syringomyelia cavity may be seen. The patients whose MR images are displayed in the upper left (A and B) and lower left (E and F) pairs of panels were treated with cranial traction and craniocervical fixation to reduce the BI.

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    Boxplot graphs showing preoperative (Pre) and postoperative (Post) findings in patients with CMs. Left: Sleep respiratory events. CE = central events; OE = obstructive events; RE = respiratory events. Right: The AHI and CAI scores. The p values represent the Wilcoxon estimated Type I error. Numbers on the y axis represent the number of events (left) and the index score (right).

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    Diagnostic MR imaging studies of the patients with central apnea.

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