surgical results from chiari decompression: comparing duroplasty versus dural splitting techinques

Surgical Results from Chiari Decompression: Comparing Duroplasty versus Dural Splitting Techinques

John A. Jane, Jr., M.D.Associate Professor of Neurosurgery and

PediatricsDirector of Pediatric Neurosurgery

University of Virginia Health System

Disclosures

• None

Surgical Technique• Bone removal:

– Posterior fossa decompression aka suboccipital craniectomy aka foramen magnum decompression

– C1 laminectomy, sometimes C2 and/or C3

Dural splitting• The spinal dura only

has one layer• “Dural splitting”

over the spine is not really splitting two layers

Surgical Technique

• Decompression (bone removal) alone

• Dural splitting– Use of intraoperative

ultrasound– Type of splitting

• Creation and removal of an outer layer

Surgical Series

• 2006-2009, Age<18• N=16

– Posterior fossa decompression and duraplasty=8• 6 syringomyelia

– Posterior fossa decompression alone=8• 6 syringomyelia

– Both groups similar in terms of age, symptoms, degree of tonsillar herniation, and syringomyelia

Outcomes

• Syringes – Significantly decreased or resolved in 5 of 6 patients in

each group

• Tonsillar regression– PFD alone: 6 of 7– PFD plus duraplasty: 5 of 7

PFD with dural splitting

PFD with dural splitting

Complications

• Postoperative nausea– PFD alone: 0/8– PFD with duraplasty: 5/8

• Higher rate of complications associated with PFD with duraplasty– Meningitis, Reoperation for CSF leak, Symptomatic

pseudomeningocele

Complications• Original

surgery: PFD with division of adhesions and continuous sutured duraplasty

Complications• Chemical meningitis: repeat PFD

with removal of dural graft and placement of pericranial graft

• Pseudomeningocele with CSF leak requiring repeat closure of incision

• Continued pseudomeningocele treated with a ventriculoperitoneal shunt

Recent reports

• Decompression alone procedures were shorter, had shorter hospital stays, and less pain and nausea

• However, PFD alone was associated with a higher incidence of symptomatic recurrence and need for dural opening (12.5% versus 3.1%)

Conclusions

• Posterior fossa decompression with dural splitting is better tolerated and associated with fewer complications than PFD with duraplasty

• Posterior fossa decompression with dural splitting can provide effective treatment of syringomyelia in most patients

Thank you!

Questions?