Selection of the volume of suboccipital decompression in surgery for Chiari I malformation, according to intraoperative ultrasound data

• Levin R.S.
• Vasilyev S.A.
• Aslanukov M.N.
• Oshepkov S.K.

Abstract

Chiari I malformation is a developmental pathology of the craniocervical junction and hindbrain. The symptomatic course of the disease in the form of a headache in the occipital region when straining, as well as in cases of the presence of myelopathy symptoms associated with syringomyelia, significantly reduces the quality of life of patients and over time can lead to their disability. Suboccipital decompression can significantly improve the quality of life of patients. To determine the rational volume of surgical intervention, sufficient enough to achieve adequate decompression, but allowing to reduce surgical trauma and the risk of complications, is an urgent goal.

Aim. Analyze different options for suboccipital decompression in patients with Chiari I malformation and determine the role of intraoperative ultrasound as a method for selecting the volume of decompression and assessing its adequacy.

Material and methods. There are literature data describing various options for suboccipital decompression in patients with Chiari I malformation and 2 clinical observations demonstrating the capabilities of intraoperative ultrasound for choosing the volume of suboccipital decompression.

Conclusion. The represented literature data and clinical observations clearly demonstrate the possibility of using intraoperative ultrasound to select a rational volume of suboccipital decompression, determine the need for duraplasty, and monitor the adequacy of decompression of the craniocervical structures in the surgical treatment of patients with Chiari I malformation, which allows achieving good clinical results and reducing risks surgical complications.

Keywords: chiari I malformation; syringomyelia; duraplasty; craniocervical decompression

References

1.     Shane Tubbs R.S., Oakes W.J. The Chiari Malformations. New York: Springer-Verlag, 2013: 83.

2.     Greenberg M.S. Handbook of Neurosurgery. New York: Thieme, 2020: 294.

3.     Guinto G., Zamorano C., Domínguez F., Sandoval B., Villasana O., Ortiz A. Chiari I malformation. Contemp Neurosurg. 2004; 26: 1–7. DOI: https://doi.org/10.1097/00029679-200412310-00001

4.     Oldfield E.H., Muraszko K., Shawker T. H., Patronas N.J. Pathophysiology of syringomyelia associated with Chiari I malformation of the cerebellar tonsils. J Neurosurg. 1994; 80 (1): 3–15. DOI: https://doi.org/10.3171/jns.1994.80.1.0003

5.     Williams H. A unifying hypothesis for hydrocephalus, Chiari malformation, Syringomyelia, anencephaly and spina bifida. Cerebrospinal Fluid Res. 2008; 5: 7. DOI: https://doi.org/10.1186/1743-8454-5-7

6.     Mazzola C.A., Fried A.H. Revision surgery for Chiari malformation decompression. Neurosurg Focus. 2003; 15 (3): 1–8. DOI: https://doi.org/10.3171/foc.2003.15.3.3

7.     Korshunov A.E., Kushel’ Yu.V. Posterior decompression of the craniovertebral junction in children with Chiari malformation: a surgery extent issue. Voprosy neyrokhirurgii imeni N.N. Burdenko [Problems of Neurosurgery named after N.N. Burdenko]. 2016; 80 (4): 13–20. DOI: https://doi.org/10.17116/neiro201680413-20 (in Russian, in English)

8.     Brock R.S., Taricco M.A., de Oliveira M.F., de Lima Oliveira M., Teixeira M.J., Bor-Seng-Shu E. Intraoperative ultrasonography for definition of less invasive surgical technique in patients with Chiari type I malformation. World Neurosurg. 2017; 101: 466–75. DOI: https://doi.org/10.1016/j.wneu.2017.02.003

9.     Cui L.G., Jiang L., Zhang H.B., Liu B., Wang J.R., Jia J.W., Chen W. Monitoring of cerebrospinal fluid flow by intraoperative ultrasound in patients with Chiari I malformation. Clin Neurol Neurosurg. 2011; 113 (3): 173–6. DOI: https://doi.org/10.1016/j.clineuro.2010.10.011

10. Kennedy B.C., Kelly K.M., Phan M.Q., Bruce S.S., McDowell M.M., Anderson R.C., et al. Outcomes after suboccipital decompression without dural opening in children with Chiari malformation type I. J Neurosurg Pediatr. 2015; 16 (2): 150–8. DOI: https://doi.org/10.3171/2014.12.peds14487

11. Mc Girt M.J., Attenello F.J., Datoo G., Gathinji M., Atiba  A., Weingart J.D., et al. Intraoperative ultrasonography as a guide to patient selection for Duraplasty after suboccipital decompression in children with Chiari malformation type I. J Neurosurg Pediatr. 2008; 2 (1): 52–7. DOI: https://doi.org/10.3171/ped/2008/2/7/052

12. Tubbs R.S., Webb D.B., Oakes W.J. Persistent syringomyelia following pediatric Chiari I decompression: radiological and surgical findings. J Neurosurg. 2004; 100 (5): 460–4. DOI: https://doi.org/10.3171/ped.2004.100.5.0460

13. Litvack Z.N., Lindsay R.A., Selden N.R. Dura splitting decompression for Chiari I malformation in pediatric patients. Neurosurgery. 2013; 72 (6): 922–9. DOI: https://doi.org/10.1227/neu.0b013e31828ca1ed

14. Yeh D.D., Koch B., Crone K.R. Intraoperative ultrasonography used to determine the extent of surgery necessary during posterior fossa decompression in children with Chiari malformation type I. J Neurosurg. 2006; 105 (1): 26–32. DOI: https://doi.org/10.3171/ped.2006.105.1.26

15. Milhorat T.H., Bolognese P.A. Tailored operative technique for Chiari type I malformation using intraoperative color Doppler ultrasonography. Neurosurgery. 2003; 53 (4): 899–906. DOI: https://doi.org/10.1227/01.neu.0000083591.22113.cb

16. Beecher J.S., Liu Y., Qi X., Bolognese P.A. Minimally invasive subpial tonsillectomy for Chiari I decompression. Acta Neurochir. 2016; 158 (9): 1807–11. DOI: https://doi.org/10.1007/s00701-016-287 7-2

All articles in our journal are distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0 license)