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

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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.

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.

In Brief

The authors conducted this study to better clarify complication rates and symptom improvements for different kinds of dural graft materials used for posterior fossa decompression with duraplasty in patients with Chiari I malformation and syringomyelia. This study is important because complication rates for these different graft types are not well established and determining what may be the best graft types could be very beneficial to these patients.

Advocates of posterior fossa decompression without duraplasty (PFD) for Chiari I malformation (CM-I) posit that this technique provides effective decompression while minimizing postoperative complications that are more commonly associated with posterior fossa decompression with duraplasty (PFDD).1 Nevertheless, despite potentially higher postoperative complication rates and lengths of hospital stay after PFDD, some literature suggests superior long-term symptomatic relief and lower reoperation rates for PFDD versus PFD, particularly for patients with CM-I and syringomyelia (SM).2–4 Therefore, understanding the complication profile for commonly used dural augmentation materials is of great importance for mitigating short-term postoperative morbidity for PFDD.

There is a broad range of possible dural augmentation materials for PFDD, including autograft, allograft, xenograft (e.g., bovine), or synthetic dural substitutes. Because the rates of complications associated with each type of dural graft are not well established, comparing graft types is difficult. The ideal type of graft is not widely agreed upon and prior studies have been inconsistent in their findings.5,6 Previous studies examining autograft and different kinds of nonautologous grafts have also been limited by single-center experiences or by small patient cohorts.7–15 Such studies have found that bovine collagen or cadaveric graft material may yield higher rates of complications compared to other kinds of grafts, or that synthetic grafts may be superior to biologically derived grafts.7–9,10 It is difficult to generalize the results of retrospective studies examining individual kinds of dural substitutes—for instance, autograft,11 bovine pericardium,12,13 bovine collagen,14 or synthetic grafts.15

The goal of this study was to better clarify complication rates within 6 months of surgery among autograft and various types of allograft, xenograft, or synthetic dural substitutes, using the largest multicenter cohort of pediatric patients who underwent PFDD for CM-I/SM at medical centers across the United States. We also examined changes in syrinx size and clinical symptoms of headache and neck pain after PFDD in which different graft types were used.

Methods

This study used both retrospectively acquired (from July 2011 until October 2014) and prospectively acquired (since October 2014) data from the Park-Reeves Syringomyelia Research Consortium (PRSRC). Use of the PRSRC database received institutional review board approval at the host institution (Washington University in St. Louis) and at all individual participating centers. No individual patient consent was required because all data were de-identified and retrospectively analyzed. All patients were < 21 years of age. The database was queried for patients who had undergone PFDD for CM-I with SM. Data included patients who had received surgery between November 2001 and April 2019. Based on study enrollment criteria, patients had tonsillar positions ≥ 5 mm below the foramen magnum, syrinx diameters ≥ 3 mm, and ≥ 6 months of postoperative follow-up from their PFDD procedure (Fig. 1). All patients received PFDD with a single type of dural graft material. Patients whose PFDD used more than one type of dural graft were excluded. Thirty-five different sites contributed data to this study.

FIG. 1.
FIG. 1.

Flowchart of the patient selection process.

Demographic data, radiological measurements, and clinical symptoms at the time of both initial treatment and follow-up encounters were collected and recorded in the PRSRC database. Radiological measurements included syrinx diameter in the anteroposterior (AP) direction (measured in mm) and syrinx length in vertebral segments. Clinical symptoms included location and severity of headaches, severity of neck pain, and changes to headaches and neck pain after surgery. The type of dural augmentation material (autograft or nonautologous graft) and complications that arose within 6 months after surgery were recorded. Autograft types included pericranium, cervical fascia, or nuchal ligament harvested using the same incision as the PFDD; pericranium harvested from a separate incision located rostral to the PFDD incision; or autologous fascia lata. Nonautologous graft types included bovine pericardium, bovine collagen, synthetic graft, and cadaveric acellular dermal graft (this cadaveric dermal graft will be referred to herein as allograft).

Complications recorded included pseudomeningocele, CSF leak, need for external CSF drainage, wound revision (including simple over-sewing or wound revision in the operating room), meningitis (chemical or infectious), hydrocephalus, craniovertebral instability (and any subsequent fusion procedures), and postoperative nausea/vomiting. Clinical symptoms (e.g., headache and neck pain) were recorded preoperatively in a yes/no fashion. Postoperatively, these symptoms were classified on an ordinal scale as being resolved, improved, stable, or worse compared to preoperative levels. The diagnosis of pseudomeningocele required both clinical signs and symptoms and positive imaging. Infectious meningitis was determined from clinical signs and symptoms with a culture-positive lumbar puncture and treatment with antibiotics. Chemical meningitis was determined from clinical signs and symptoms, nonantibiotic medical treatment (e.g., steroids), and a lumbar puncture that ruled out infectious meningitis.

Complication rates were compared for autograft versus nonautologous graft as well as for the different types of nonautologous grafts. Postoperative changes in syrinx size, syrinx length, headaches, and neck pain were also assessed for autograft versus nonautologous graft. All statistical analyses were performed using SAS version 9.4 (SAS Institute Inc.). Chi-square and Fisher’s exact tests were used to compare categorical variables. The Student t-test was used to compare continuous variables. A 2-sided p value < 0.05 for all statistical tests was considered statistically significant.

Results

In total, 781 PFDD cases in which a single type of dural graft material was used were identified in the Park-Reeves registry (Table 1). Ten patients were excluded for receiving PFDD with multiple graft types. Of the eligible PFDD patients, 327 (41.9%) were male and 454 (58.1%) were female. The mean age at PFDD was 10.16 ± 4.7 years and the mean tonsil position was 12.95 ± 5.2 mm below the foramen magnum. The mean clinical follow-up time was 2.67 ± 1.2 years. Three hundred fifty-nine (46.0%) PFDD procedures used dural autograft and 422 (54.0%) used nonautologous graft material (Table 2).

TABLE 1.

Demographic and clinical characteristics of all 781 patients who underwent surgery for CM-I with SM

VariableAutograft, n = 359Nonautologous Graft, n = 422
Mean age in yrs, ± SD10.3 ± 4.610.2 ± 4.7
Median age in yrs10.610.4
Age range in yrs1–201–19
Mean follow-up in yrs, ± SD2.7 ± 1.22.5 ± 1.2
Median follow-up in yrs2.62.5
Sex, n (%)
 Male152 (42.3)175 (41.5)
 Female207 (57.7)247 (58.5)
Tonsillar herniation in mm, n (%)
 5–10149 (41.5)150 (35.5)
 11–15120 (33.4)143 (33.9)
 16–2065 (18.1)75 (17.8)
 >2025 (7.0)54 (12.8)
Preop comorbidities, n (%)
 Hydrocephalus12 (3.3)15 (3.5)
 Craniosynostosis3 (0.8)7 (1.7)
 Platybasia9 (2.5)7 (1.7)
 Other skull abnormality9 (2.5)11 (2.6)
 Scoliosis118 (32.9)122 (28.9)
 Basilar invagination8 (2.2)4 (0.9)
Preop symptoms, n (%)
 Headache212 (59.0)225 (53.3)
 Neck pain128 (35.6)121 (28.7)
 Sensory deficits97 (27.0)122 (28.9)
 Weakness52 (14.5)72 (17.1)
 Swallowing or speaking difficulties58 (16.2)70 (16.6)
 Apnea15 (4.2)22 (5.2)
TABLE 2.

Study subjects undergoing PFDD, categorized by type of dural graft

VariableNo. of Patients (%)
No. of posterior fossa decompressions using dural augmentation781
 Autograft only359 (46.0)
  Pericranium253 (70.5)
  Cervical fascia40 (11.1)
  Nuchal ligament23 (6.4)
  Unknown43 (12.0)
 Nonautologous graft only422 (54.0)
  Bovine pericardium63 (14.9)
  Bovine collagen225 (53.3)
  Synthetic99 (23.5)
  Allograft35 (8.3)
PFDD cases w/ subsequent revision PFDD
 Nonautologous graft, n = 42226 (6.2)
  Bovine pericardium, n = 632 (3.2)
  Bovine collagen, n = 22513 (5.8)
  Synthetic, n = 998 (8.1)
  Allograft, n = 353 (8.6)
 Autograft, n = 35918 (5.01)

Information on autograft type was available for 316/359 (88.0%) patients, of whom 253 (80.1%) received pericranium, 40 (12.6%) received cervical fascia, and 23 (7.3%) received nuchal ligament. For the types of nonautologous grafts used, 63/422 (14.9%) PFDD procedures used bovine pericardium, 225/422 (53.3%) used bovine collagen, 99/422 (23.5%) used synthetic, and 35/422 (8.3%) used allograft. Seven hundred twenty-one (92.3%) PFDD cases were primary PFDD. The other 60 (7.7%) PFDD cases were revisions—41 after a prior PFDD and 19 after a prior PFD. There were no significant differences between autograft and nonautologous graft (p = 0.49) or among nonautologous graft types (p = 0.57) with respect to the need for revision decompression after PFDD.

Within 6 months postoperatively, in 103/359 (28.7%) autograft cases, patients experienced complications compared to 143/422 (33.9%) in nonautologous graft cases (p = 0.12) (Table 3). Significantly higher incidences of pseudomeningocele (p = 0.04) and meningitis (p = 0.0003) were seen for nonautologous graft compared to autograft. The significantly higher rate of meningitis in the nonautologous cohort was due primarily to the higher rate of chemical meningitis (p = 0.002) in these patients. By contrast, there was not a significant difference in the rate of infectious meningitis (p = 0.13). No significant differences were observed for CSF leak or patients requiring surgical treatment for CSF leak, need for external CSF drainage, postoperative hydrocephalus, craniovertebral instability, postoperative nausea/vomiting, or complications requiring surgical wound revision. Of the patients with postoperative hydrocephalus (n = 19), only 1 had a preoperative diagnosis of hydrocephalus and 5 also developed postoperative CSF leaks. Multivariate logistic regression was performed to assess the impact of age, sex, and preoperative comorbidities (e.g., hydrocephalus, basilar invagination, obex position below the foramen magnum, clivoaxial angle < 125°, and known skull malformations) on the odds that a patient would experience a postoperative complication within 6 months. Ultimately, no variables were found to be significant predictors.

TABLE 3.

Overall complication rates within 6 months for dural autograft versus nonautologous graft

VariableAutograft, n = 359Nonautologous Graft, n = 422p Value
No. of cases w/ complications103 (28.7%)143 (33.9%)0.12
Types of postop complications
 Pseudomeningocele20 (5.6%)40 (9.5%)0.04
 CSF leak*15 (4.2%)12 (2.8%)
  Received surgical treatment; wound over-sewing or surgical wound revision12 (3.3%)6 (1.4%)0.09
  Received no surgical treatment3 (0.84%)6 (1.4%)0.52
 External CSF drainage required16 (4.5%)18 (4.3%)0.90
 Meningitis6 (1.7%)30 (7.1%)<0.001
  Chemical meningitis5 (1.4%)24 (5.7%)0.002
  Infectious meningitis1 (0.28%)6 (1.4%)0.13
 Postop hydrocephalus9 (2.5%)10 (2.4%)0.90
 Cervical instability2 (0.56%)1 (0.24%)0.60
 Postop nausea/vomiting24 (6.7%)20 (4.7%)0.24

Boldface type indicates statistical significance.

Five of these patients also developed postoperative hydrocephalus.

One patient had a preoperative diagnosis of hydrocephalus.

Among the 4 nonautologous graft types, there was a significant difference in complication rates (p = 0.02) (Table 4), with synthetic graft demonstrating the highest overall complication rate (42.4%), followed by bovine collagen (34.7%), bovine pericardium (28.6%), and allograft (14.3%). Significant differences were seen among all 4 nonautologous graft types for the rate of meningitis (p = 0.01), which was driven primarily by significant differences in the rate of chemical (p = 0.01) but not infectious (p = 0.46) meningitis—probably due to the relatively higher rate of meningitis for synthetic graft (14/99, 14.1%). There were significant differences as well for postoperative nausea/vomiting among nonautologous grafts (p = 0.03). No other significant differences in complications were noted among these grafts.

TABLE 4.

Postoperative complications within 6 months for nonautologous graft materials

VariableBovine Pericardium, n = 63Bovine Collagen, n = 225Synthetic, n = 99Allograft, n = 35p Value
No. of cases w/ complications18 (28.6%)78 (34.7%)42 (42.4%)5 (14.3%)0.02
Types of postop complications
 Pseudomeningocele8191120.59
 CSF leak24600.13
  Received surgical treatment, including wound over-sewing or surgical wound revision12300.42
  Received no surgical treatment12300.42
 External drainage required27810.20
 Meningitis4121400.01
  Chemical meningitis2101200.01
  Infectious meningitis22200.46
 Hydrocephalus23410.49
 Cervical instability0010
 Postop nausea/vomiting011900.03

Boldface type indicates statistical significance.

Comparisons between specific types of nonautologous grafts and autograft showed that allograft demonstrated significantly lower overall complication rates compared to bovine collagen (p = 0.02) and synthetic dura mater (p = 0.003) (Table 5). Synthetic dura had a significantly higher complication rate versus autograft (p = 0.01). The rate of complications for allograft was close but not significantly lower compared to autograft (p = 0.07). No differences were found between bovine pericardium and bovine collagen (p = 0.36), bovine pericardium and synthetic (p = 0.07), bovine pericardium and allograft (p = 0.11), or bovine collagen and synthetic (p = 0.18) grafts.

TABLE 5.

Pairwise comparisons of overall complication rates between individual types of nonautologous graft and between autograft and individual types of nonautologous graft

Dural Graft Comparison (no. of complications)*p ValueGraft w/ Lower Complication Rate
Bovine pericardium (n = 18) vs bovine collagen (n = 78)0.36No difference
Bovine pericardium (n = 18) vs synthetic (n = 42)0.07No difference
Bovine pericardium (n = 18) vs allograft (n = 5)0.11No difference
Bovine collagen (n = 78) vs synthetic (n = 42)0.18No difference
Bovine collagen (n = 78) vs allograft (n = 5)0.02Allograft
Synthetic (n = 42) vs allograft (n = 5)0.003Allograft
Autograft (n = 103) vs bovine pericardium (n = 18)0.98No difference
Autograft (n = 103) vs bovine collagen (n = 78)0.13No difference
Autograft (n = 103) vs synthetic (n = 42)0.01Autograft
Autograft (n = 103) vs allograft (n = 5)0.07No difference

Boldface type indicates statistical significance.

Total number of patients: autograft = 359; bovine pericardium = 63; bovine collagen = 225; synthetic = 99; allograft = 35.

The overall mean preoperative AP syrinx diameter was 7.76 ± 3.14 mm (n = 781). There was no difference in preoperative syrinx diameter between autograft and nonautologous graft cases (p = 0.54). PFDD performed using either autograft or nonautologous graft resulted in a significant decrease in syrinx size, from 7.84 ± 3.13 mm to 4.31 ± 3.38 mm (a 45% reduction; p < 0.0001) and from 7.70 ± 3.16 mm to 4.71 ± 3.40 mm (a 39% reduction; p < 0.0001), respectively (Table 6). There was not a significant difference in postoperative syrinx size between autograft and nonautologous graft (p = 0.21). The average preoperative syrinx length spanned 9.48 ± 4.80 vertebral segments for autograft cases and 8.65 ± 4.43 segments for nonautologous graft cases, which was significantly different (p = 0.01) (Table 6). However, postoperatively, significantly shorter syrinx lengths were noted for both autograft (7.44 ± 4.47 segments, a 21.5% reduction; p < 0.0001) and nonautologous graft (7.30 ± 4.02 segments, a 15.6% reduction; p = 0.0002), and there was no significant difference in postoperative syrinx lengths between autograft and nonautologous graft (p = 0.53).

TABLE 6.

Postoperative changes in syrinx size and length by type of dural graft

VariableAutograft (SD)Nonautologous Graft (SD)p Value (auto- vs allograft)
Avg preop AP syrinx diam in mm7.84 (3.13)7.70 (3.16)0.54
Avg postop AP syrinx diam in mm4.31 (3.38)4.71 (3.40)0.21
 p value: preop vs postop<0.0001<0.0001
Avg preop syrinx length in vertebral segments9.48 (4.80)8.65 (4.43)0.01
Avg postop syrinx length in vertebral segments7.44 (4.47)7.30 (4.02)0.53
 p value: preop vs postop<0.00010.0002

Avg = average; diam = diameter.

Boldface type indicates statistical significance.

Follow-up data on headache symptoms after PFDD were available for 437 patients (212 autograft, 225 nonautologous graft) who had reported preoperative headaches (Table 7). The most common headache location was occipital/suboccipital (n = 199, 45.5%), followed by holocranial (n = 126, 28.9%), frontal (n = 87, 19.9%), temporal (n = 15, 3.4%), and parietal (n = 10, 2.3%). Between autograft and nonautologous graft, there were no differences in the proportions of headaches that resolved (p = 0.87), improved (p = 0.12), remained stable (p = 0.23), or became worse (p = 0.20) after PFDD. After stratifying headaches by occipital/suboccipital location (n = 199), there were still no significant differences between autograft (n = 100) and nonautologous graft (n = 99) for changes in headache symptoms. There similarly were no significant differences in outcomes for nonoccipital/suboccipital headaches (n = 238) between autograft (n = 112) and nonautologous graft (n = 126).

TABLE 7.

Postoperative changes in headaches and neck pain by type of dural graft

VariableNo. w/ Autograft (%)No. w/ Nonautologous Graft (%)p Value
Preop headaches, n = 437212225
 Occipital/suboccipital100 (47.2)99 (44.1)
 Holocranial49 (23.1)77 (34.2)
 Frontal48 (22.6)39 (17.3)
 Temporal8 (3.8)7 (3.1)
 Parietal7 (3.3)3 (1.3)
Headache changes after PFDD, n = 437212225
 Resolved, n = 291142 (67.0)149 (66.2)0.87
 Improved, n = 7643 (20.3)33 (14.7)0.12
 Stable, n = 4518 (8.5)27 (12.0)0.23
 Worse, n = 259 (4.2)16 (7.1)0.20
Occipital/suboccipital headaches after PFDD, n = 19910099
 Resolved, n = 14174 (74.0)67 (67.7)0.33
 Improved, n = 3317 (17.0)16 (16.2)0.87
 Stable, n = 154 (4.0)11 (11.1)0.06
 Worse, n = 105 (5.0)5 (5.0)0.99
Nonoccipital/suboccipital headaches after PFDD, n = 238112126
 Resolved, n = 15068 (60.7)82 (65.1)0.49
 Improved, n = 4326 (23.2)17 (13.5)0.052
 Stable, n = 3014 (12.5)16 (12.7)0.96
 Worse, n = 154 (3.6)11 (8.7)0.10
Neck pain changes after PFDD, n = 249*128121
 Resolved, n = 190100 (78.1)90 (74.4)0.49
 Improved, n = 3217 (13.3)15 (12.4)0.83
 Stable, n = 178 (6.3)9 (7.4)0.71
 Worse, n = 103 (2.3)7 (5.8)0.21

A total of 249 patients had pre- and postoperative information on neck pain.

Follow-up data were available for 249 patients who had reported preoperative neck pain (Table 7). After PFDD (128 autograft, 121 nonautologous graft), 190/249 (76.3%) patients reported resolution of neck pain, 32/249 (12.9%) reported improved neck pain, 17/249 (6.8%) reported stable neck pain, and 10/249 (4.0%) reported worse neck pain. For autograft, 100/128 (78.1%) patients had resolved pain, 17/128 (13.3%) had improved pain, 8/128 (6.3%) had stable pain, and 3/128 (2.3%) had worse pain. For nonautologous graft, 90/121 (74.4%) patients had resolved pain, 15/121 (12.4%) had improved pain, 9/121 (7.4%) had stable pain, and 7/121 (5.8%) had worse pain. No significant differences were seen between autograft and nonautologous graft for resolved (p = 0.49), improved (p = 0.83), stable (p = 0.71), or worse (p = 0.21) neck pain.

Discussion

To our knowledge, this is the largest study examining complication rates between dural graft materials coupled with changes in syrinx size and clinical symptoms after PFDD. We found that there was no significant difference in overall complication rates between autograft and nonautologous graft, but that there was a significantly higher rate of pseudomeningocele and meningitis (primarily chemical meningitis) in the nonautologous graft cohort. There was no difference in CSF leak frequency between autograft and nonautologous graft. Importantly, there was a significant difference in the overall rate of complications among the 4 kinds of nonautologous grafts examined. Allograft was associated with the lowest rate of complications and had significantly lower complication rates compared to bovine pericardium and synthetic dura, whereas there was no difference in complication rates detected between the other pairwise comparisons. Both autograft and nonautologous graft were associated with equally significant decreases in syrinx size and syrinx length. Autograft and nonautologous graft were equivalent with respect to postoperative changes in headaches and neck pain.

Prior studies have compared complications for multiple graft types after PFDD, with varying conclusions. Moskowitz et al.7 analyzed several graft types for posterior fossa surgeries and concluded that only suturable bovine collagen was significantly associated with increased complications (p = 0.0014) compared to acellular dermis, autograft, nonsuturable bovine collagen, and no dural graft at all. Bowers et al.8 found that acellular human dermis allograft led to significantly lower rates of pseudomeningocele (p = 0.01) and graft failure (p ≤ 0.001) when compared to 3 different kinds of collagen matrix grafts. Attenello et al.9 found that patients with CM-I and SM receiving duraplasty with expanded polytetrafluoroethylene (ePTFE; a synthetic dural substitute) experienced no CSF leaks, surgical site infections, or pseudomeningocele. Radiographic syrinx improvement was seen in 80% of patients with ePTFE versus 52% of patients with autograft (p < 0.05). Contrary to our findings, Vanaclocha and Saiz-Sapena10 determined that cadaveric allograft was associated with CSF leak and pseudomeningocele in 15.3% and 46.3% of PFDD cases, respectively, compared to a 0% complication rate with autologous pericranium. That said, the sample size in each arm of their study was limited to 13 patients, and no tests were performed to assess statistical significance.

Studies that examine complication rates for single types of dural grafts12,16–22 have produced findings that may be difficult to compare to our results. Some of these use types of grafts that were not found in the PRSRC database—for instance, porcine small intestine17—and most do not use cohorts of patients who all have SM in addition to CM-I. A few studies have reported near-zero complication rates for autograft,11 bovine pericardium,12,13 bovine collagen,14 or synthetic grafts,15 but these conclusions are often hindered by small patient cohorts and therefore may not represent true complication rates for all patients who undergo PFDD. In general, reviews of PFDD have placed the range for graft complication rates somewhere between 18% and 40%.23–27 The complication rates in our study for autograft, bovine collagen, and bovine pericardium were within this range, whereas the rate for synthetic graft was higher and the rate for allograft was lower. However, in a single-institution analysis of 500 decompressions (499 of which were PFDD) for patients with CM-I (285 of whom had SM), Tubbs et al.28 found an overall complication rate of 2.4%, which is markedly lower than our findings.

Ideally, the material used for dural augmentation is able to achieve a watertight seal, yields minimal scarring, does not produce an inflammatory or immune reaction, is easily handled, and potentially provides a platform for the growth of the patient’s own dura.10,17,18,20,29,30 Allograft offers several of these advantages,31,32 but as a foreign material, theoretically it may incite an inflammatory reaction.32 In addition, the use of cadaveric acellular dermal matrix as a dural substitute remains an off-label application of this material, according to the FDA, as opposed to other nonautologous graft types such as xenografts or synthetic graft. Another reason may be that allograft has been identified in the past as a possible vector for Creutzfeldt-Jakob disease, primarily in Japan.33–36 Its overall use has fallen in the past decades and some institutions have called for its outright ban as a dural substitute.31 These factors may account, at least in part, for our modest numbers of allograft cases, and accruing more such cases would be necessary to discern actual complication rates for this graft versus others.

Regarding changes in syrinx size after surgery, Wetjen et al.37 reported a series of 29 adult and pediatric patients who underwent PFDD for CM-I/SM. In this cohort, the mean syrinx diameter decreased from 6.9 ± 2.1 mm to < 1.5 mm (p < 0.0001), after which 94% of patients reported improvement in preoperative symptoms. Kumar et al.38 studied syrinx changes for 22 patients who underwent either PFD or PFDD for CM-I/SM and found a significant decrease in syrinx size for patients who underwent PFDD (from 8.51 to 5.61 mm, p = 0.002) but not for those who underwent PFD (from 7.91 to 6.04 mm, p = 0.06). Neither of these studies compared autograft to nonautologous graft. Our findings affirmed these 2 studies in that PFDD led to significant decreases in syrinx size and length. Moreover, to complement these and similar studies, our data support the idea that a significant decrease may be equally obtained with either autograft or nonautologous graft. Very little, if anything, has been published specifically looking at autograft versus nonautologous graft for the alleviation of preoperative neck pain in patients with CM-I/SM.

Our study is the first to compare both autograft and nonautologous graft as well as 4 different kinds of nonautologous grafts for children with CM-I/SM. The PRSRC is a large, multiinstitutional consortium; consequently, our findings are more generalizable to the general population of these patients. The data presented in this current study support the idea that human-derived graft materials (e.g., autograft and allograft) are associated with fewer postoperative complications and similar clinical outcomes compared with bovine-derived or synthetic grafts. Pseudomeningocele and chemical meningitis were more likely to occur with nonautologous grafts, but allograft had no instances of meningitis noted. Moreover, as compared to 2 other kinds of nonautologous grafts, allograft yielded significantly fewer complications. Synthetic graft, by multiple metrics, was the least advantageous graft material in our cohort, with the highest rates of meningitis (14.1%), CSF leak (6.1%), need for external drainage (8.1%), and postoperative nausea/vomiting (9.1%) (Table 4). To complement our study, additional studies investigating complication rates across multiple kinds of dural graft materials and using large sample sizes of patients with both CM-I and SM are warranted.

Study Limitations

This study has limitations. Analyses of these PRSRC data were retrospective. As such, only associations, not definite causation, can be drawn from these data. All patients had CM-I with SM, and these results may not translate in the exact same way to patients with only CM-I. The number of patients who received allograft was modest, which may have influenced the analysis of the data. Information on the surgical technique of autograft harvest, dural opening, suture type, and dural sealants, all of which may impact the risk of wound complications, was limited in this data set. Although retrospective information on complications was extracted after thorough reviews of operative notes, inpatient records, postoperative imaging studies, and follow-up encounter records at each institution, it is possible that some data regarding postoperative complications were missed during this retrospective collection phase of our database. Moreover, variability in electronic medical records in the early days of the Park-Reeves database led to inconsistencies in retrospective medication reporting at a number of sites. Thus, for this study we were unable to determine for all cases if surgeons used steroids in the postoperative period. Moreover, other variations in practice (e.g., bedside over-sewing or surgical revision for CSF leakage, intraoperative/postoperative steroids) may have influenced complication rates. These factors and others have been tracked in our ongoing randomized clinical trial comparing PFD and PFDD and will be evaluated in detail using this rigorous platform. Finally, our database was not constructed to assess hospital readmissions after surgery.

Conclusions

Analyses of a large, multicenter pediatric database demonstrated that overall complication rates for dural autograft and nonautologous grafts were similar up to 6 months after PFDD for CM-I with SM. Pseudomeningocele and meningitis were more common with nonautologous graft. There were significantly different rates of complications among types of nonautologous grafts, with allograft yielding superior outcomes compared to bovine collagen and synthetic grafts. Autograft and nonautologous grafts were equivalent for reducing postoperative syrinx size, headaches, and neck pain. Importantly, these data support the idea that autograft and allograft (i.e., human-derived grafts) may be associated with fewer complications compared to nonhuman grafts (i.e., bovine-derived and synthetic grafts).

Acknowledgments

This publication was made possible through the support of Sam and Betsy Reeves, the Spears and O’Keefe families, and the many other contributors to the PRSRC. Support was also provided by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the NIH under award number U54 HD087011 to the Intellectual and Developmental Disabilities Research Center at Washington University.

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.

Author Contributions

Conception and design: Yahanda, Limbrick. Acquisition of data: all authors. Analysis and interpretation of data: Yahanda, Limbrick. Drafting the article: Yahanda, Krieger, Meehan, Smyth, Stone, Strahle, Limbrick. Critically revising the article: Yahanda, Adelson, Akbari, Albert, Aldana, Alden, Anderson, Bauer, Bethel-Anderson, Brockmeyer, Chern, Couture, Daniels, Dlouhy, Durham, Ellenbogen, Eskandari, George, Grant, Graupman, Greene, Greenfield, Gross, Guillaume, Hankinson, Heuer, Iantosca, Iskandar, Jackson, Johnston, Keating, Krieger, Leonard, Maher, Mangano, McComb, McEvoy, Menezes, O’Neill, Olavarria, Ragheb, Selden, Shah, Shannon, Shimony, Smyth, Stone, Strahle, Torner, Tuite, Wait, Wellons, Whitehead, Park, Limbrick. Reviewed submitted version of manuscript: Yahanda, Adelson, Akbari, Albert, Aldana, Alden, Anderson, Bauer, Bethel-Anderson, Brockmeyer, Chern, Couture, Daniels, Dlouhy, Durham, Ellenbogen, Eskandari, George, Grant, Graupman, Greene, Greenfield, Gross, Guillaume, Hankinson, Heuer, Iantosca, Iskandar, Jackson, Johnston, Keating, Leonard, Maher, Mangano, McComb, McEvoy, Menezes, O’Neill, Olavarria, Ragheb, Selden, Shah, Shannon, Shimony, Smyth, Strahle, Tuite, Wait, Wellons, Whitehead, Park, Limbrick. Approved the final version of the manuscript on behalf of all authors: Yahanda. Statistical analysis: Yahanda, Torner. Administrative/technical/material support: Meehan, Torner, Limbrick. Study supervision: Limbrick.

Supplemental Information

Previous Presentations

Some of the results from this study were presented at the 48th Annual Meeting of the AANS/CNS Section on Pediatric Neurosurgery held in Scottsdale, AZ, on December 6, 2019.

References

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    • PubMed
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    • PubMed
    • Search Google Scholar
    • Export Citation
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    • PubMed
    • Search Google Scholar
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    Stevens EA, Powers AK, Sweasey TA, et al. Simplified harvest of autologous pericranium for duraplasty in Chiari malformation Type I. Technical note. J Neurosurg Spine. 2009;11(1):8083.

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    • PubMed
    • Search Google Scholar
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    • Export Citation
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    • Search Google Scholar
    • Export Citation
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Images from LoPresti et al. (pp 406–410).

  • 1

    James HE, Brant A. Treatment of the Chiari malformation with bone decompression without durotomy in children and young adults. Childs Nerv Syst. 2002;18(5):202206.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Lin W, Duan G, Xie J, et al. Comparison of results between posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation type I: a systematic review and meta-analysis. World Neurosurg. 2018;110:460474.e5.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Xu H, Chu L, He R, et al. Posterior fossa decompression with and without duraplasty for the treatment of Chiari malformation type I—a systematic review and meta-analysis. Neurosurg Rev. 2017;40(2):213221.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Lu VM, Phan K, Crowley SP, Daniels DJ. The addition of duraplasty to posterior fossa decompression in the surgical treatment of pediatric Chiari malformation Type I: a systematic review and meta-analysis of surgical and performance outcomes. J Neurosurg Pediatr. 2017;20(5):439449.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Raghavan A, Wright JM, Huang Wright C, et al. Effect of dural substitute and technique on cranioplasty operative metrics: a systematic literature review. World Neurosurg. 2018;119:282289.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Haroun RI, Guarnieri M, Meadow JJ, et al. Current opinions for the treatment of syringomyelia and Chiari malformations: survey of the Pediatric Section of the American Association of Neurological Surgeons. Pediatr Neurosurg. 2000;33(6):311317.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Moskowitz SI, Liu J, Krishnaney AA. Postoperative complications associated with dural substitutes in suboccipital craniotomies. Neurosurgery. 2009;64(3 Suppl):ons28ons34.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Bowers CA, Brimley C, Cole C, et al. AlloDerm for duraplasty in Chiari malformation: superior outcomes. Acta Neurochir (Wien). 2015;157(3):507511.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Attenello FJ, McGirt MJ, Garcés-Ambrossi GL, et al. Suboccipital decompression for Chiari I malformation: outcome comparison of duraplasty with expanded polytetrafluoroethylene dural substitute versus pericranial autograft. Childs Nerv Syst. 2009;25(2):183190.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Vanaclocha V, Saiz-Sapena N. Duraplasty with freeze-dried cadaveric dura versus occipital pericranium for Chiari type I malformation: comparative study. Acta Neurochir (Wien). 1997;139(2):112119.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Lam FC, Kasper E. Augmented autologous pericranium duraplasty in 100 posterior fossa surgeries—a retrospective case series. Oper Neurosurg. 2012;71(suppl_2):302307.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Rosen CL, Steinberg GK, DeMonte F, et al. Results of the prospective, randomized, multicenter clinical trial evaluating a biosynthesized cellulose graft for repair of dural defects. Neurosurgery. 2011;69(5):10931104.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Filippi R, Schwarz M, Voth D, et al. Bovine pericardium for duraplasty: clinical results in 32 patients. Neurosurg Rev. 2001;24(2-3):103107.

  • 14

    Costa BS, Cavalcanti-Mendes G de A, de Abreu MS, de Sousa AA. Clinical experience with a novel bovine collagen dura mater substitute. Asian J Neurosurg. 2010;5(2):3134.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Messing-Jünger AM, Ibáñez J, Calbucci F, et al. Effectiveness and handling characteristics of a three-layer polymer dura substitute: a prospective multicenter clinical study. J Neurosurg. 2006;105(6):853858.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Abuzayed B, Kafadar AM, Oğuzoğlu SA, et al. Duraplasty using autologous fascia lata reenforced by on-site pedicled muscle flap: technical note. J Craniofac Surg. 2009;20(2):435438.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Bejjani GK, Zabramski J. Safety and efficacy of the porcine small intestinal submucosa dural substitute: results of a prospective multicenter study and literature review. J Neurosurg. 2007;106(6):10281033.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Dlouhy BJ, Menezes AH. Autologous cervical fascia duraplasty in 123 children and adults with Chiari malformation type I: surgical technique and complications. J Neurosurg Pediatr. 2018;22(3):297305.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Stevens EA, Powers AK, Sweasey TA, et al. Simplified harvest of autologous pericranium for duraplasty in Chiari malformation Type I. Technical note. J Neurosurg Spine. 2009;11(1):8083.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    San-Galli F, Darrouzet V, Rivel J, et al. Experimental evaluation of a collagen-coated vicryl mesh as a dural substitute. Neurosurgery. 1992;30(3):396401.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Tubbs RS, Wellons JC III, Blount JP, Oakes WJ. Posterior atlantooccipital membrane for duraplasty. Technical note. J Neurosurg. 2002;97(2 Suppl):266268.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Costantino PD, Wolpoe ME, Govindaraj S, et al. Human dural replacement with acellular dermis: clinical results and a review of the literature. Head Neck. 2000;22(8):765771.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Azzam D, Romiyo P, Nguyen T, et al. Dural repair in cranial surgery is associated with moderate rates of complications with both autologous and nonautologous dural substitutes. World Neurosurg. 2018;113:244248.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Parker SR, Harris P, Cummings TJ, et al. Complications following decompression of Chiari malformation Type I in children: dural graft or sealant? J Neurosurg Pediatr. 2011;8(2):177183.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

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