Dural augmentation approaches and complication rates after posterior fossa decompression for Chiari I malformation and syringomyelia: a Park-Reeves Syringomyelia Research Consortium study

Alexander T. Yahanda MS 1 , P. David Adelson MD 2 , S. Hassan A. Akbari MD 3 , Gregory W. Albert MD, MPH 4 , Philipp R. Aldana MD 5 , Tord D. Alden MD 6 , Richard C. E. Anderson MD 7 , David F. Bauer MD 8 , Tammy Bethel-Anderson 1 , Douglas L. Brockmeyer MD 9 , Joshua J. Chern MD, PhD 10 , Daniel E. Couture MD 11 , David J. Daniels MD, PhD 12 , Brian J. Dlouhy MD 13 , Susan R. Durham MD 14 , Richard G. Ellenbogen MD 15 , Ramin Eskandari MD, MS 16 , Timothy M. George MD 17 , Gerald A. Grant MD 18 , Patrick C. Graupman MD 19 , Stephanie Greene MD 20 , Jeffrey P. Greenfield MD, PhD 21 , Naina L. Gross MD 22 , Daniel J. Guillaume MD 23 , Todd C. Hankinson MD 24 , Gregory G. Heuer MD, PhD 25 , Mark Iantosca MD 26 , Bermans J. Iskandar MD 27 , Eric M. Jackson MD 28 , James M. Johnston MD 3 , Robert F. Keating MD 29 , Mark D. Krieger MD 30 , Jeffrey R. Leonard MD 31 , Cormac O. Maher MD 32 , Francesco T. Mangano DO 33 , J. Gordon McComb MD 30 , Sean D. McEvoy MD 1 , Thanda Meehan RN 1 , Arnold H. Menezes MD 13 , Brent R. O’Neill MD 24 , Greg Olavarria MD 34 , John Ragheb MD 35 , Nathan R. Selden MD, PhD 36 , Manish N. Shah MD 37 , Chevis N. Shannon DrPH 38 , Joshua S. Shimony MD, PhD 39 , Matthew D. Smyth MD 1 , Scellig S. D. Stone MD, PhD 40 , Jennifer M. Strahle MD 1 , James C. Torner PhD 13 , Gerald F. Tuite MD 41 , Scott D. Wait MD 42 , John C. Wellons III MD 38 , William E. Whitehead MD 43 , Tae Sung Park MD 1 , and David D. Limbrick Jr. MD, PhD 1
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  • 1 Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO;
  • 2 Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ;
  • 3 Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL;
  • 4 Division of Neurosurgery, Arkansas Children’s Hospital, Little Rock, AR;
  • 5 Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL;
  • 6 Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, IL;
  • 7 Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children’s Hospital of New York, Columbia-Presbyterian, New York, NY;
  • 8 Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH;
  • 9 Division of Pediatric Neurosurgery, Primary Children’s Hospital, Salt Lake City, UT;
  • 10 Division of Pediatric Neurosurgery, Children’s Healthcare of Atlanta, GA;
  • 11 Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC;
  • 12 Department of Neurosurgery, Mayo Clinic, Rochester, MN;
  • 13 Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA;
  • 14 Department of Neurosurgery, University of Vermont, Burlington, VT;
  • 15 Division of Pediatric Neurosurgery, Seattle Children’s Hospital, Seattle, WA;
  • 16 Department of Neurosurgery, Medical University of South Carolina, Charleston, SC;
  • 17 Division of Pediatric Neurosurgery, Dell Children’s Medical Center, Austin, TX;
  • 18 Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA;
  • 19 Division of Pediatric Neurosurgery, Gillette Children’s Hospital, St. Paul, MN;
  • 20 Division of Pediatric Neurosurgery, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA;
  • 21 Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY;
  • 22 Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK;
  • 23 Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN;
  • 24 Department of Neurosurgery, Children’s Hospital Colorado, Aurora, CO;
  • 25 Division of Pediatric Neurosurgery, Children’s Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;
  • 26 Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA;
  • 27 Department of Neurological Surgery, University of Wisconsin at Madison, WI;
  • 28 Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD;
  • 29 Department of Neurosurgery, Children’s National Medical Center, Washington, DC;
  • 30 Division of Pediatric Neurosurgery, Children’s Hospital of Los Angeles, CA;
  • 31 Division of Pediatric Neurosurgery, Nationwide Children’s Hospital, Columbus, OH;
  • 32 Department of Neurosurgery, University of Michigan, Ann Arbor, MI;
  • 33 Division of Pediatric Neurosurgery, Cincinnati Children’s Medical Center, Cincinnati, OH;
  • 34 Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL;
  • 35 Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL;
  • 36 Department of Neurological Surgery and Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR;
  • 37 Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX;
  • 38 Division of Pediatric Neurosurgery, Monroe Carell Jr. Children’s Hospital of Vanderbilt University, Nashville, TN;
  • 39 Department of Radiology, Washington University School of Medicine, St. Louis, MO;
  • 40 Division of Pediatric Neurosurgery, Boston Children’s Hospital, Boston, MA;
  • 41 Department of Neurosurgery, Neuroscience Institute, All Children’s Hospital, St. Petersburg, FL;
  • 42 Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
  • 43 Division of Pediatric Neurosurgery, Texas Children’s Hospital, Houston, TX
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OBJECTIVE

Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM.

METHODS

The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft.

RESULTS

A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain.

CONCLUSIONS

In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.

ABBREVIATIONS AP = anteroposterior; CM-I = Chiari I malformation; PFD = posterior fossa decompression without duraplasty; PFDD = posterior fossa decompression with duraplasty; PRSRC = Park-Reeves Syringomyelia Research Consortium; SM = syringomyelia.

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Contributor Notes

Correspondence Alexander T. Yahanda: Washington University School of Medicine, St. Louis, MO. ayahanda@wustl.edu.

INCLUDE WHEN CITING Published online February 12, 2021; DOI: 10.3171/2020.8.PEDS2087.

Disclosures Dr. Limbrick has received research funds and/or research equipment for unrelated projects from Medtronic, Inc., Karl Storz, Inc., and Microbot Medical, Inc. He has also received philanthropic equipment contributions for humanitarian relief work from Karl Storz, Inc., and Aesculap, Inc.

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