Dura-splitting decompression of the craniocervical junction: reduced operative time, hospital stay, and cost with equivalent early outcome

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  • 1 Division of Pediatric Neurosurgery, Doernbecher Children's Hospital and Oregon Health & Science University, Portland, Oregon
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Object. The choice of surgical technique for decompressive surgery in patients with Chiari I malformation is controversial. Good preliminary postoperative outcomes have been achieved in patients with Chiari I malformation (without syringomyelia) after using a dura-splitting technique. The authors evaluated safety, resource use, and early outcome after this surgery in patients without syringomyelia and compared the findings associated with duraplasty in patients with syringomyelia.

Methods. A prospective series of 24 patients with Chiari I malformation (12 with a syrinx) underwent decompression of the craniocervical junction (CCJ). An allograft-augmented duraplasty was performed in patients with syringomyelia. Intraoperative ultrasonography confirmed adequate tonsillar decompression after lysis of the periosteal bands at the foramen magnum and C-1 arch as well as partial resection of the outer leaf of the dura in patients without syringomyelia. Patients in each group were of similar mean age (syringomyelia 10.8 years and no syringomyelia 7.6 years old; p = 0.07) and functional status. The mean follow-up period was 15.3 months (range 3–30 months). Dura-splitting decompression required significantly less mean operative time (99 minutes compared with 169 minutes, respectively; p < 0.001), total operating room time (166 minutes compared with 249 minutes, respectively; p < 0.001), duration of hospitalization (3 days compared with 3.75 days, respectively; p < 0.05), perioperative charges ($3615 compared with $5538, respectively; p < 0.001), and overall hospital charges ($7705 compared with $9759, respectively; p < 0.001) than the duraplasty. Mean clinical outcome scores were similar (syringomyelia 1.53 of 2; no syringomyelia 1.67 of 2; not statistically significant).

Conclusions. Dura-splitting CCJ decompression in pediatric patients with Chiari I malformation and without syringomyelia is safe, provides good early clinical results, and significantly reduces resource use. A randomized controlled trial of dura-splitting decompression in a uniform population of patients with Chiari I malformation is indicated.

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Contributor Notes

Address reprint requests to: Nathan R. Selden, M.D., Ph.D., Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon 97239. email: seldenn@ohsu.edu.
  • 1.

    Arnett B: Arnold-Chiari malformation. Arch Neurol 60:898900, 2003 Arnett B: Arnold-Chiari malformation. Arch Neurol 60:898–900, 2003

    • Search Google Scholar
    • Export Citation
  • 2.

    Dyste GN, , Menezes AH, & VanGilder JC: Symptomatic Chiari malformations. An analysis of presentation, management, and long-term outcome. J Neurosurg 71:159168, 1989 Dyste GN, Menezes AH, VanGilder JC: Symptomatic Chiari malformations. An analysis of presentation, management, and long-term outcome. J Neurosurg 71:159–168, 1989

    • Search Google Scholar
    • Export Citation
  • 3.

    Gardner WJ: Hydrodynamic mechanism of syringomyelia: its relationship to myelocele. J Neurol Neurosurg Psychiatry 28:247259, 1965 Gardner WJ: Hydrodynamic mechanism of syringomyelia: its relationship to myelocele. J Neurol Neurosurg Psychiatry 28:247–259, 1965

    • Search Google Scholar
    • Export Citation
  • 4.

    Gardner WJ, & Angel J: The mechanism of syringomyelia and its surgical correction. Clin Neurosurg 6:131140, 1959 Gardner WJ, Angel J: The mechanism of syringomyelia and its surgical correction. Clin Neurosurg 6:131–140, 1959

    • Search Google Scholar
    • Export Citation
  • 5.

    Gardner WJ, & Goodall RJ: The surgical treatment of Arnold-Chiari malformation in adults. An explanation of its mechanisms and importance of encephalography in diagnosis. J Neurosurg 7:199206, 1950 Gardner WJ, Goodall RJ: The surgical treatment of Arnold-Chiari malformation in adults. An explanation of its mechanisms and importance of encephalography in diagnosis. J Neurosurg 7:199–206, 1950

    • Search Google Scholar
    • Export Citation
  • 6.

    Isu T, , Iwasaki Y, & Akino M, et al: Hydrosyringomyelia associated with a Chiari I malformation in children and adolescents. Neurosurgery 26:591597, 1990 Isu T, Iwasaki Y, Akino M, et al: Hydrosyringomyelia associated with a Chiari I malformation in children and adolescents. Neurosurgery 26:591–597, 1990

    • Search Google Scholar
    • Export Citation
  • 7.

    James HE, & Brant A: Treatment of the Chiari malformation with bone decompression without durotomy in children and young adults. Childs Nerv Syst 18:202206, 2002 James HE, Brant A: Treatment of the Chiari malformation with bone decompression without durotomy in children and young adults. Childs Nerv Syst 18:202–206, 2002

    • Search Google Scholar
    • Export Citation
  • 8.

    Klekamp J, , Batzdorf U, & Samii M, et al: The surgical treatment of Chiari I malformation. Acta Neurochir (Wien) 138:788801, 1996 Klekamp J, Batzdorf U, Samii M, et al: The surgical treatment of Chiari I malformation. Acta Neurochir (Wien) 138:788–801, 1996

    • Search Google Scholar
    • Export Citation
  • 9.

    Krieger MD, , McComb JG, & Levy ML: Toward a simpler surgical management of Chiari I malformation in a pediatric population. Pediatr Neurosurg 30:113121, 1999 Krieger MD, McComb JG, Levy ML: Toward a simpler surgical management of Chiari I malformation in a pediatric population. Pediatr Neurosurg 30:113–121, 1999

    • Search Google Scholar
    • Export Citation
  • 10.

    Oldfield EH, , Muraszko K, & Shawker TH, et al: Pathophysiology of syringomyelia associated with Chiari I malformation of the cerebellar tonsils. Implications for diagnosis and treatment. J Neurosurg 80:315, 1994 Oldfield EH, Muraszko K, Shawker TH, et al: Pathophysiology of syringomyelia associated with Chiari I malformation of the cerebellar tonsils. Implications for diagnosis and treatment. J Neurosurg 80:3–15, 1994

    • Search Google Scholar
    • Export Citation
  • 11.

    Park JK, , Gleason PL, & Madsen JR, et al: Presentation and management of Chiari I malformation in children. Pediatr Neurosurg 26:190196, 1997 Park JK, Gleason PL, Madsen JR, et al: Presentation and management of Chiari I malformation in children. Pediatr Neurosurg 26:190–196, 1997

    • Search Google Scholar
    • Export Citation
  • 12.

    Williams B: Syringomyelia. Neurosurg Clin N Am 1:653685, 1990 Williams B: Syringomyelia. Neurosurg Clin N Am 1:653–685, 1990

  • 13.

    Wisoff JH, & Epstein F: Management of hydromyelia. Neurosurgery 25:562571, 1989 Wisoff JH, Epstein F: Management of hydromyelia. Neurosurgery 25:562–571, 1989

    • Search Google Scholar
    • Export Citation
  • 14.

    Yundt KD, , Park TS, & Tantuwaya VS, et al: Posterior fossa decompression without duraplasty in infants and young children for treatment of Chiari malformation and achondroplasia. Pediatr Neurosurg 25:221226, 1996 Yundt KD, Park TS, Tantuwaya VS, et al: Posterior fossa decompression without duraplasty in infants and young children for treatment of Chiari malformation and achondroplasia. Pediatr Neurosurg 25:221–226, 1996

    • Search Google Scholar
    • Export Citation

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