Posterior Fossa Decompression With or Without Duraplasty in the Treatment of Paediatric Chiari Malformation Type I: A Literature Review and Meta-Analysis

Abstract

Abstract INTRODUCTION Chiari malformation I (CM-1) is a posterior fossa structural abnormality, characterized by caudal displacement of cerebellar tonsils, through the foramen magnum. Posterior fossa decompression (PFD), involving a suboccipital craniectomy and C1 laminectomy, remains the definitive treatment. Both PFD alone (PFDO) and PFD with additional duraplasty (PFDD) are used in surgical practices. This review evaluates the current literature comparing outcomes of CM-1 treatment using PFDO and PFDD. METHODS A literature search of EMBASE and MEDLINE was conducted. References from January 1980 to January 2018 were retrieved. Only papers containing original data, comparing the use of PFDD and PFDO in paediatric CM-1 patients, were included. RESULTS Eighteen relevant papers were identified, with a resulting cohort of 4030 patients, 46.1% underwent PFDD and 53.9% PFDO. PFDD was associated with 60 min longer mean operation duration, and longer mean hospital stays by 0.7 d. PFDD provided greater symptomatic improvement (OR: 2.13; 95% CI: 1.31-3.45; P = .002). However, PFDD was also associated with increased postoperative complications (OR: 1.71, 95% CI: 1.41-2.08; P = .0001), in particular CSF leak and meningitis. PFDD was not significantly associated with incidence of syrinx improvement or revision surgery, relative to PFDO. CONCLUSION From the current literature, PFDD is associated with greater clinical improvement but higher risk of postsurgical complications, in comparison to PFDO for the treatment of paediatric CM-1. The requirement for a large cohort prospective study, adjusting for case-mix, which evaluates the relative efficacy of these 2 techniques have been identified. Current evidence is low quality, with limited statistical power.