Classification of symptomatic Chiari I malformation to guide surgical strategy.
BACKGROUND
Treatment options for Chiari I malformations include posterior fossa decompression (PFD) with additional techniques including laminectomy, intradural exploration, and duraplasty. Neuroimaging findings of cisterna magna volume, syringomyelia, and intraoperative ultrasonography may tailor surgical intervention.


METHODS
We developed an algorithm classifying symptomatic Chiari I patients into three groups to define minimum operation. Without syringomyelia, the presence of cisterna magna defined Group A and the absence defined Group B. Patients with syrinx formed Group C. Mild structural pathology (Group A) or adequate space following PFD (Group B, normal intraoperative ultrasound (IOUS)) should be treated by PFD alone. Conversely, presence of syringomyelia (Group C) or inadequate space following PFD (Group B, abnormal IOUS) should additionally have duraplasty. We applied this algorithm to patients treated at a single institution over 16 years.


RESULTS
Twenty-four symptomatic Chiari I malformation patients were divided into three groups that did not differ by age, gender, or extent of tonsillar ectopia. All patients treated by this algorithm experienced clinical and radiographic improvement. This included eight Group B patients who underwent PFD only (n=6) or additional duraplasty (n=2) decided by IOUS.


CONCLUSIONS
Treatment of symptomatic Chiari I malformation may have inadequate outcome with conservative strategy or complications with aggressive strategy. This algorithm utilizes preoperative neuroimaging and intraoperative ultrasound to tailor intervention, with excellent clinical outcome and radiographic syrinx resolution on application to 24 patients. Further validation requires prospective multicenter evaluation with larger patient population.
Shamji
Mohammed F
MF
Division of Neurosurgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
Ventureyra
Enrique C G
EC
Baronia
Benedicto
B
Nzau
Munyao
M
Vassilyadi
Michael
M
D000293:Adolescent; D001139:Arnold-Chiari Malformation / Q000145:classification* / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D002946:Cisterna Magna / Q000601:surgery; D019299:Decompression, Surgical / Q000379:methods*; D004388:Dura Mater / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007432:Intraoperative Period; D007796:Laminectomy / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D013595:Syringomyelia / Q000209:etiology / Q000601:surgery; D016896:Treatment Outcome; D014463:Ultrasonography