title: Surgical outcomes after posterior fossa decompression with and without duraplasty in Chiari malformation-I.
abstract: BACKGROUND
  Chiari malformation-I (CM) is one of the most controversial entities in the contemporary neurosurgical literature. Posterior fossa decompression (PFD) is the preferred treatment for CM with and without syringomyelia. A variety of surgical techniques for PFD have been advocated in the literature. The aim of this study was to evaluate our results of surgically treated patients for CM-I with and without syringomyelia; using extradural dura-splitting and intradural intraarachnoid techniques.
  
  
  METHODS
  A retrospective review of the medical records of all the patients undergoing PFD was conducted. Symptomatic patients with tonsillar herniation≥3-mm below the foramen magnum on neuroimaging, and CSF flow void study demonstrating restricted or no CSF flow at the craniocervical junction, were offered surgical treatment. In patients without syringomyelia, extradural decompression with thinning of the sclerotic tissue at the cervicomedullary junction and splitting of outer dural layer was performed. In patients with syringomyelia, the dura was opened and an expansile duraplasty was performed.
  
  
  RESULTS
  The mean age of 8 males and 34 females was 33.8 years (range, 16-58 years). Headache (39/41; 95%), and/or tingling and numbness (17/41; 42%) were the most common presenting symptoms. The syrinx was associated with CM-I in 5/41 (12%) patients. PFD without durotomy was performed in 29/41 (73%) patients. The mean duration of preoperative symptoms was significantly longer in duraplasty group (4.6 versus 1.7 years, P=0.005, OR=0.48, CI=0.29-0.8). The use of duraplasty was significantly associated with presence of complications (P=0.004, OR=0.5, CI=0.3-0.8) and longer duration of hospital stay (P=0.03, OR=2.7, CI=1.1-6.8). The overall complication rate was 6/41(15%) patients. The overall improvement rate was evident in 84% (36/41); 12% (5/41) were stable; and 5% (2/41) had worsening of symptoms. The history of prior CM decompression was associated with unfavorable outcomes (P=0.04, OR=14, CI=1.06-184). One patient experienced recurrence one year after the PFD with duraplasty.
  
  
  CONCLUSIONS
  The present study reports favorable surgical outcomes with extra-dural decompression of the posterior fossa in patients CM-I without syringomyelia. For patients with syringomyelia and history of prior PFD, intradural intra-arachnoid decompression is required. The prior history of decompression was associated with unfavorable outcomes. The use of duraplasty was associated with longer duration of hospital stay and higher complication rate. Further large cohort prospective study is needed to provide any recommendation on the indication of intra or extradural decompression for a given CM-I patient.
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, USA.
authors.forename: Silky
authors.initials: S
authors.lastname: Chotai
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, USA. Electronic address: azedine.medhkour@utoledo.edu.
authors.forename: Azedine
authors.initials: A
authors.lastname: Medhkour
mesh_terms: D000293:Adolescent; D000328:Adult; D001139:Arnold-Chiari Malformation / Q000601:surgery*; D019299:Decompression, Surgical / Q000009:adverse effects / Q000379:methods; D004388:Dura Mater / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D013595:Syringomyelia / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Chiari malformation; Dura-splitting; Extra-dural; Intradural; Syringomyelia