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More Evidence that Riskiest Part of Chiari Surgery May Not be Necessary

Surgeons* at the Pediatric Neurosurgery Center treat a number of children with a neurological birth defect called Chiari Malformation (CM). Increasingly, they are finding that the most risky part of their surgical treatment, that is, opening the dura, may not always be necessary. They recently completed a research project that looked at children with Chiari Malformation that caused Scoliosis. They wanted to see if dural opening made a difference on how the scoliosis responded to the surgical treatment. They presented their research at the recent Pediatric Neurosurgery Section Meeting.

CM is a boney malformation at the opening of skull that can cause increased pressure on the lower part of the brain and the spine. In some cases, this causes the spinal column to curve and create a Scoliosis.

The surgical treatment for this problem aims to remove this pressure. Bone is taken from the back of the skull and neck. It is also standard for surgeons to open up the dura to relieve pressure. Dura, short for dura mater, is a thick lining that surrounds the brain and spinal cord creating a closed system. Coursing through this system is spinal fluid that regulates pressure and cushions these vital structures.

Though it is patched afterward, opening the dura is risky because it makes this protected system vulnerable to contamination such as meningitis or leaks that can create a dangerous disruption of the pressure system. Their research indicates that this part of the procedure may not always be worth the risk.

They looked at patients with Scoliosis and CM who had surgery at this institution since 1995. The patients treated until 2003 had their dura opened and after that year the dura was not opened unless the scoliosis progression was unusually rapid.

The degree of scoliosis and neurological symptoms like limb weakness, hyperactive reflexes, and difficulty swallowing were assessed before and after surgery and compared between these two groups. Their results showed that improvements following surgery were more or less the same with or without dural opening.

There was a slightly higher chance that a second surgery would be needed in the non-dural-opening group but this group also had significantly fewer complications.

This was the first study of it’s kind and the authors encourage other neurosurgeons to compare their results with and without dural opening.  It may be that this part of the surgery isn’t always necessary and they can expose fewer children to these risks.

*Doctors from the Pediatric Neurosurgery Center involved in this study were: TC Hankinson, J Wade, C Shannon, S Ghatan, RCE Anderson, and NA Feldstein

The Annual Pediatric Neurosurgery Section Meeting is a joint venture of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. (See the full agenda from the December 2009 meeting).

See a related blog about Chiari 1 Malformations: Pediatrics Added to this Year’s IML at the Congress of Neurosurgery Meeting

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