Petter Förander1, Kristin Sjåvik2, Ole Solheim3, Ingrid Riphagen4, Sasha Gulati5, Øyvind Salvesen6, Asgeir Store Jakola7. 1. Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden. Electronic address: petter.forander@karolinska.se. 2. Department of Ophthalmology and Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway. Electronic address: Kristin.Sjavik@unn.no. 3. Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway; National Centre for Ultrasound and Image Guided Therapy, Trondheim, Norway. Electronic address: ole.solheim@ntnu.no. 4. Unit for Applied Clinical Research, Norwegian University of Science and Technology, Trondheim, Norway. Electronic address: ingrid.i.riphagen@ntnu.no. 5. Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway; Norwegian Centre of Competence in Deep Brain Stimulation for Movement Disorders, Trondheim, Norway. Electronic address: sashagulati@hotmail.com. 6. Unit for Applied Clinical Research, Norwegian University of Science and Technology, Trondheim, Norway. Electronic address: oyvind.salvesen@ntnu.no. 7. Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway; National Centre for Ultrasound and Image Guided Therapy, Trondheim, Norway; MI Lab, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway. Electronic address: asgeir.s.jakola@ntnu.no.
Abstract
BACKGROUND: Posterior fossa decompression is carried out to improve passage of cerebrospinal fluid (CSF) in patients with symptomatic Chiari 1 malformations (CM1), but the extent and means of decompression remains controversial. Dural opening with subsequent duraplasty may contribute to clinical outcome, but may also increase complication risk. The aim of this systematic review and meta-analysis is to assess the effects of durotomy with subsequent duraplasty on clinical outcome in surgical treatment of adults with CM1. DATA SOURCES AND STUDY ELIGIBILITY CRITERIA: We systematically searched MEDLINE, Embase and CENTRAL, and screened references in relevant articles and in UpToDate. Publications with previously untreated adults (>15 years) with CM1 with or without associated syringomyelia, treated in the period 1990-2013 were eligible. INTERVENTIONS: Posterior fossa decompression with duraplasty (PFDD group) was compared to posterior fossa decompression with bony decompression alone (PFD group). RESULTS: The search retrieved 233 articles. After the review we included 12 articles, but only 4 articles included posterior fossa decompression with both techniques. Only 2 out of 12 studies were prospective. The odds ratio (OR) for reoperation was 0.15 (95% CI 0.05-0.49) in the PFDD group compared to PFD (p=0.002). The OR of clinical failure at follow-up was 1.06 (95% CI 0.52-2.14) for PFDD compared to PFD (p=0.88). There was also no difference in syringomyelia improvement between techniques (p=0.60). The OR for CSF-related complications were 6.12 (95% CI 0.37-101.83) for PFDD compared to PFD (p=0.21). CONCLUSION: This systematic review of observational studies reveals higher reoperation rates after bony decompression alone, but clinical improvement was not higher after primary decompression with duraplasty. There are so far no high-quality studies that offer guidance in the choice of decompressive technique in adult CM1 patients. We think that a randomized controlled trial on this topic is both needed and feasible.
BACKGROUND: Posterior fossa decompression is carried out to improve passage of cerebrospinal fluid (CSF) in patients with symptomatic Chiari 1 malformations (CM1), but the extent and means of decompression remains controversial. Dural opening with subsequent duraplasty may contribute to clinical outcome, but may also increase complication risk. The aim of this systematic review and meta-analysis is to assess the effects of durotomy with subsequent duraplasty on clinical outcome in surgical treatment of adults with CM1. DATA SOURCES AND STUDY ELIGIBILITY CRITERIA: We systematically searched MEDLINE, Embase and CENTRAL, and screened references in relevant articles and in UpToDate. Publications with previously untreated adults (>15 years) with CM1 with or without associated syringomyelia, treated in the period 1990-2013 were eligible. INTERVENTIONS: Posterior fossa decompression with duraplasty (PFDD group) was compared to posterior fossa decompression with bony decompression alone (PFD group). RESULTS: The search retrieved 233 articles. After the review we included 12 articles, but only 4 articles included posterior fossa decompression with both techniques. Only 2 out of 12 studies were prospective. The odds ratio (OR) for reoperation was 0.15 (95% CI 0.05-0.49) in the PFDD group compared to PFD (p=0.002). The OR of clinical failure at follow-up was 1.06 (95% CI 0.52-2.14) for PFDD compared to PFD (p=0.88). There was also no difference in syringomyelia improvement between techniques (p=0.60). The OR for CSF-related complications were 6.12 (95% CI 0.37-101.83) for PFDD compared to PFD (p=0.21). CONCLUSION: This systematic review of observational studies reveals higher reoperation rates after bony decompression alone, but clinical improvement was not higher after primary decompression with duraplasty. There are so far no high-quality studies that offer guidance in the choice of decompressive technique in adult CM1 patients. We think that a randomized controlled trial on this topic is both needed and feasible.
Authors: Maria Caffo; Salvatore M Cardali; Gerardo Caruso; Elena Fazzari; Rosaria V Abbritti; Valeria Barresi; Antonino Germanò Journal: Surg Neurol Int Date: 2019-05-10