title: Intraoperative ultrasonography as a guide to patient selection for duraplasty after suboccipital decompression in children with Chiari malformation Type I.
abstract: OBJECTIVE
  Indications for duraplasty in treatment of Chiari malformation Type I (CM-I) remain unclear. In the present study, the authors evaluate their surgical experience to determine whether intraoperative ultrasonography is effective in the selection of patients with CM-I who can be adequately treated with craniectomy alone without duraplasty.
  
  
  METHODS
  The authors reviewed the records of 256 children who underwent first-time hindbrain decompression for CM-I. Craniectomy alone (without duraplasty) was performed when intraoperative ultrasonography suggested adequate decompression of the subarachnoid spaces ventral and dorsal to the tonsils after suboccipital craniectomy alone. Duraplasty was performed if intraoperative ultrasonography demonstrated persistent dural compression of the tonsils following craniectomy. Symptom recurrence as a function of time was compared between cases of duraplasty versus suboccipital decompression alone stratified by extent of tonsillar herniation.
  
  
  RESULTS
  Duraplasty was performed in 140 patients (55%), and suboccipital decompression alone was performed in 116 patients (45%). Patients underwent follow-up for 29 +/- 15 months. Symptoms included headache in 192 patients (75%) and lower cranial nerve and brainstem dysfunction in 68 (27%). In 38 patients (15%) there was tonsillar herniation rostral to the C-1 lamina, in 195 (76%) it extended between the C-1 and C-2 lamina, and in 23 patients (9%) there was herniation caudal to the lower border of the C-2 lamina. In children with tonsillar herniation caudal to C-1, ultrasonography-guided suboccipital decompression alone was associated with a 2-fold increase in the risk of symptom recurrence compared with those who also underwent duraplasty (p = 0.01). In children with tonsillar herniation rostral to C-1, outcome was equivalent between suboccipital decompression alone and duraplasty (p = 0.41).
  
  
  CONCLUSIONS
  In the setting of moderate-to-severe tonsillar CM-I, intraoperative ultrasonography demonstrating decompression of the subarachnoid spaces ventral and dorsal to the tonsils may not effectively select patients in whom bone decompression alone is sufficient. Duraplasty may be warranted in cases of tonsillar herniation that extends below the C-1 lamina regardless of intraoperative ultrasonography findings. More objective cerebrospinal fluid flow or volumetric measures may be needed intraoperatively to guide duraplasty in patients with more pronounced tonsillar herniation.
authors.affiliation: Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA. mmcgirt1@jhmi.edu
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: McGirt
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Attenello
authors.forename: Ghazala
authors.initials: G
authors.lastname: Datoo
authors.forename: Muraya
authors.initials: M
authors.lastname: Gathinji
authors.forename: April
authors.initials: A
authors.lastname: Atiba
authors.forename: Jon D
authors.initials: JD
authors.lastname: Weingart
authors.forename: Benjamin
authors.initials: B
authors.lastname: Carson
authors.forename: George I
authors.initials: GI
authors.lastname: Jallo
mesh_terms: D001139:Arnold-Chiari Malformation / Q000000981:diagnostic imaging* / Q000601:surgery*; D002648:Child; D003399:Craniotomy; D019299:Decompression, Surgical; D004388:Dura Mater / Q000601:surgery*; D004677:Encephalocele / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D018579:Patient Selection; D012008:Recurrence; D012249:Rhombencephalon / Q000601:surgery*; D013346:Subarachnoid Space; D014463:Ultrasonography