Timing of syrinx reduction and stabilization after posterior fossa decompression for pediatric Chiari malformation type I

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  • 1 Department of Neurosurgery, Vanderbilt University Medical Center;
  • 2 Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center, Nashville, Tennessee;
  • 3 Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
  • 4 Division of Pediatric Neurosurgery, Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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OBJECTIVE

The aim of this study was to determine the timeline of syrinx regression and to identify factors mitigating syrinx resolution in pediatric patients with Chiari malformation type I (CM-I) undergoing posterior fossa decompression (PFD).

METHODS

The authors conducted a retrospective review of records from pediatric patients (< 18 years old) undergoing PFD for the treatment of CM-I/syringomyelia (SM) between 1998 and 2015. Patient demographic, clinical, radiological, and surgical variables were collected and analyzed. Radiological information was reviewed at 4 time points: 1) pre-PFD, 2) within 6 months post-PFD, 3) within 12 months post-PFD, and 4) at maximum available follow-up. Syrinx regression was defined as ≥ 50% decrease in the maximal anteroposterior syrinx diameter (MSD). The time to syrinx regression was determined using Kaplan-Meier analysis. Multivariate analysis was conducted using a Cox proportional hazards model to determine the association between preoperative, clinical, and surgery-related factors and syrinx regression.

RESULTS

The authors identified 85 patients with CM-I/SM who underwent PFD. Within 3 months post-PFD, the mean MSD regressed from 8.1 ± 3.4 mm (preoperatively) to 5.6 ± 2.9 mm within 3 months post-PFD. Seventy patients (82.4%) achieved ≥ 50% regression in MSD. The median time to ≥ 50% regression in MSD was 8 months (95% CI 4.2–11.8 months). Using a risk-adjusted multivariable Cox proportional hazards model, the patients who underwent tonsil coagulation (n = 20) had a higher likelihood of achieving ≥ 50% syrinx regression in a shorter time (HR 2.86, 95% CI 1.2–6.9; p = 0.02). Thirty-six (75%) of 45 patients had improvement in headache at 2.9 months (IQR 1.5–4.4 months).

CONCLUSIONS

The maximum reduction in syrinx size can be expected within 3 months after PFD for patients with CM-I and a syrinx; however, the syringes continue to regress over time. Tonsil coagulation was associated with early syrinx regression in this cohort. However, the role of surgical maneuvers such as tonsil coagulation and arachnoid veil identification and sectioning in the overall role of CM-I surgery remains unclear.

ABBREVIATIONS CM-I = Chiari malformation type I; MSD = maximal anteroposterior syrinx diameter; PFD = posterior fossa decompression; SM = syringomyelia.

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Contributor Notes

Correspondence Silky Chotai: Vanderbilt University Medical Center, Nashville, TN. silky.chotai@vumc.org.

INCLUDE WHEN CITING Published online April 24, 2020; DOI: 10.3171/2020.2.PEDS19366.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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