Surgical Results from Chiari Decompression Comparing Duroplasty versus

Surgical Results from Chiari Decompression: Comparing Duroplasty versus Dural Splitting Techinques John A. Jane, Jr. , M. D. Associate Professor of Neurosurgery and Pediatrics Director of Pediatric Neurosurgery University of Virginia Health System

Disclosures • None

Surgical Technique • Bone removal: – Posterior fossa decompression aka suboccipital craniectomy aka foramen magnum decompression – C 1 laminectomy, sometimes C 2 and/or C 3

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?