- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Division of Neurosurgery, University of California San Diego Medical Center, San Diego, California, USA
Correspondence Address:
Ekkehard M. Kasper
Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
DOI:10.4103/2152-7806.106262
Copyright: © 2013 Lam FC This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Lam FC, Penumaka A, Chen CC, Fischer EG, Kasper EM. Fibrin sealant augmentation with autologous pericranium for duraplasty after suboccipital decompression in Chiari 1 patients: A case series. Surg Neurol Int 18-Jan-2013;4:6
How to cite this URL: Lam FC, Penumaka A, Chen CC, Fischer EG, Kasper EM. Fibrin sealant augmentation with autologous pericranium for duraplasty after suboccipital decompression in Chiari 1 patients: A case series. Surg Neurol Int 18-Jan-2013;4:6. Available from: http://sni.wpengine.com/surgicalint_articles/fibrin-sealant-augmentation-with-autologous-pericranium-for-duraplasty-after-suboccipital-decompression-in-chiari-1-patients-a-case-series/
Abstract
Background:The Chiari 1 malformation (CM1) involves decent of the tonsils of the cerebellum through the foramen magnum. Symptomatic disease requires a posterior fossa decompression with or without an expansile duraplasty. To date, the optimal surgical treatment for CM1 has not been delineated. The extent of bony removal, size of the dural opening, necessity for expansion of the dural space, choice of materials for the duraplasty, and possible need for augmentation with dural sealant are all factors that continue to be debated amongst neurological surgeons worldwide. We herein evaluate the use of fibrin sealant augmentation in combination with locally harvested autologous pericranium for duraplasty in adult CM1 decompression.
Methods:Retrospective data collected from January 2006 to December 2011. Data were reviewed for surgical site infection or meningitis, cerebrospinal fluid leak, symptomatic pseudomeningocele, radiographic improvement of hindbrain compression, and postoperative recurrence of symptoms at a minimum of 1 year of follow-up. Outcomes were studied clinically, radiographically, as well as by using a patient-specific questionnaire.
Results:Twenty-two consecutive patients were included. One patient required a revision for a delayed graft dehiscence in the setting of a rare form of aseptic meningitis with cerebrospinal fluid (CSF) pleocytosis due to a nonsteroidal anti-inflammatory drug (NSAID) allergy. All remaining patients had successful decompressions with full resolution of their symptoms except for one patient who had persistent headaches.
Conclusion:Autologous pericranium with dural sealant augmentation is an effective technique for expansile duraplasty in CM1 decompressions.
Keywords: Autologous pericranium, chiari malformation, duraplasty, dural sealant
INTRODUCTION
The Chiari 1 malformation (CM1) is defined as protrusion of the cerebellar tonsils below the foramen magnum of greater than 5 mm [
Figure 1
Intraoperative images outlining the technique used for decompressing a symptomatic Chiari 1 malformation. (a) Representative sagittal T2-weighted MRI of a patient with a symptomatic CM1. (b) Midline incision from one inch above the inion extending inferiorly to the mid-cervical spine. Extension of the incision above the inion allows for harvesting of the occipital pericranium using Bovie cautery. (c) Harvested pericranium kept moist in saline. (d) Suboccipital craniectomy showing initial preservation of the midline bony keel, which is later removed using Kerrison upbiters. (e) Release of dural bands exposing the cervicomedullary junction. (f) Y-shaped dural opening revealing contents of the hindbrain. (g) Expansile duraplasty with autologous pericranium. (h) Application of dural sealant over the dural graft and suture line. (i) Postoperative MRI showing full resolution of tonsillar herniation and a patent foramen magnum
Surgical treatment of CM1 remains one of the most debated issues in neurosurgery today. CM1 with or without syringomyelia is managed with a suboccipital craniectomy with or without removal of at least the posterior arch of the C1-vertebra, depending on the extent of tonsillar descent[
Expansion of the dura with graft material following bony decompression is intended to create a capacious p-fossa to prevent recurrence of symptoms.[
Meticulous closure of the dura is required following bony decompression for preventing CSF-related complications including meningitis, encephalitis, low-pressure headaches, arachnoiditis, and wound dehiscence.[
MATERIALS AND METHODS
Study design
An institutional review board approved retrospective analysis was performed of clinical, and radiographic data collected in adult cases of symptomatic CM1. All patients underwent a standardized bilateral subcoccipital decompression including at least a C1 laminectomy and a dural repair using locally harvested autologous pericranium augmented with dural sealant.
Operative procedure
Patients are positioned prone on the operative table with their head secured in Mayfield pins. Following clipping of the posterior hairline using an electric razor, a midline incision is fashioned one inch above the inion extending inferiorly to the level of the mid cervical spine [
Postoperative follow-up
Patients were discharged from hospital and were seen in our clinic at 10-14 days, 3 months, and at 1 year following surgery for evidence of surgical site infection or meningitis, CSF leak, pseudomeningocele, and radiographic improvement of hindbrain compression as detected with a MRI scan [
RESULTS
Twenty-two CM1 patients were identified. Twenty-one had tussive headaches, five had vertigo, three had visual changes, four had neck pain, three had gait disturbances, and four had dissociated sensory deficits, prior to surgery [
One patient presented with a delayed CSF leak at 8 weeks due to a dehiscence of the dural graft requiring surgical revision and also subsequently developed aseptic meningitis and CSF pleocytosis due to an allergy to NSAID medications. None of the other patients had any CSF-related complications or surgical morbidities at the time of follow-up.
DISCUSSION
Symptomatic progression of CM1 is secondary to crowding of the cerebellar tonsils as they sit in a shallow p-fossa and smaller than normal foramen magnum.[
We believe that, when available, autologous grafts should be used to prevent known adverse reactions to nonautologous materials including graft dissolution, encapsulation, immunoallergic reactions, and adhesions.[
A watertight dural closure is often difficult to achieve when using dural grafts because of holes produced by surgical needles.[
We attempted to further quantify the outcomes of our surgical technique in suitable CM1 patients using a questionnaire survey asking for the absence or presence of tussive headaches, vertigo, visual disturbance, tinnitus, drop attacks, neck pain, gait and balance disturbances, dysmetria, bladder or bowel symptoms, dysphagia, and sensory deficits in the extremities, before and after the decompression. Our survey is similar to the Chicago Chiari Outcome Scale (CCOS) published recently by Aliaga and colleagues in which they used four categories: pain-related symptoms (tussive headaches, neck. and shoulder pain, dyesthesias in the upper extremities), nonpain-related symptoms (dysphagia, ataxia, vertigo, muscle weakness, sensory loss, tinnitus, paresthesias, and drop attacks), functionality, and surgical complications to assess their Chiari outcomes.[
In summary, locally harvested autologous pericranium with dural sealant augmentation is a safe and effective surgical technique for CM1 decompression. Further validation with a larger patient pool, inclusion of a comparison arm, and longer follow-up period are required to establish superiority compared to other techniques.
References
1. Abla AA, Link T, Fusco D, Wilson DA, Sonntag VK. Comparison of dural grafts in Chiari decompression surgery: Review of the literature. J Craniovertebr Junction Spine. 2010. 1: 29-37
2. Adams CB. “I’ve torn it: How to repair it”. Br J Neurosurg. 1995. 9: 201-4
3. .editors. Administration USFaD. Summary of Safety and Effectiveness Data: Dura Seal Dural Sealant System. Silver Spring: U.S. Food and Drug Administration; 2005. p.
4. Aitken LA, Lindan CE, Sidney S, Gupta N, Barkovich AJ, Sorel M. Chiari type I malformation in a pediatric population. Pediatr Neurol. 2009. 40: 449-54
5. Aliaga L, Hekman KE, Yassari R, Straus D, Luther G, Chen J. A novel scoring system for assessing Chiari malformation type I treatment outcomes. Neurosurgery. 2012. 70: 656-64
6. Anderson RC, Emerson RG, Dowling KC, Feldstein NA. Improvement in brainstem auditory evoked potentials after suboccipital decompression in patients with chiari I malformations. J Neurosurg. 2003. 98: 459-64
7. Armonda RA, Citrin CM, Foley KT, Ellenbogen RG. Quantitative cine-mode magnetic resonance imaging of Chiari I malformations: An analysis of cerebrospinal fluid dynamics. Neurosurgery. 1994. 35: 214-23
8. Attenello FJ, McGirt MJ, Garces-Ambrossi GL, Chaichana KL, Carson B, Jallo GI. Suboccipital decompression for Chiari I malformation: Outcome comparison of duraplasty with expanded polytetrafluoroethylene dural substitute versus pericranial autograft. Childs Nerv Syst. 2009. 25: 183-90
9. Bejjani GK, Zabramski J. Safety and efficacy of the porcine small intestinal submucosa dural substitute: Results of a prospective multicenter study and literature review. J Neurosurg. 2007. 106: 1028-33
10. Black P. Cerebrospinal fluid leaks following spinal or posterior fossa surgery: Use of fat grafts for prevention and repair. Neurosurg Focus. 2000. 9: e4-
11. Blackburn SL, Smyth MD. Hydrogel-induced cervicomedullary compression after posterior fossa decompression for Chiari malformation. Case report. J Neurosurg. 2007. 106: S302-4
12. Boogaarts JD, Grotenhuis JA, Bartels RH, Beems T. Use of a novel absorbable hydrogel for augmentation of dural repair: Results of a preliminary clinical study. Neurosurgery. 2005. 57: S146-151
13. Chiari H. Uber Veranderungen des Kleinhirns infolge von Hydrocephalie des Grosshirns. Deutsche Medizinische Wochenshrift. 1891. 17: 1172-5
14. Cosgrove GR, Delashaw JB, Grotenhuis JA, Tew JM, Van Loveren H, Spetzler RF. Safety and efficacy of a novel polyethylene glycol hydrogel sealant for watertight dural repair. J Neurosurg. 2007. 106: 52-8
15. Dickerman RD, Reynolds AS. Duraplasty is required for Chiari decompression. Br J Neurosurg. 2008. 22: 450-
16. Durham SR, Fjeld-Olenec K. Comparison of posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation Type I in pediatric patients: A meta-analysis. J Neurosurg Pediatr. 2008. 2: 42-9
17. Hadley MN, Martin NA, Spetzler RF, Sonntag VK, Johnson PC. Comparative transoral dural closure techniques: A canine model. Neurosurgery. 1988. 22: 392-7
18. Haroun RI, Guarnieri M, Meadow JJ, Kraut M, Carson BS. Current opinions for the treatment of syringomyelia and chiari malformations: Survey of the Pediatric Section of the American Association of Neurological Surgeons. Pediatr Neurosurg. 2000. 33: 311-7
19. Kosnik EJ. Use of ligamentum nuchae graft for dural closure in posterior fossa surgery. Technical note. J Neurosurg. 1998. 89: 155-6
20. Lam FC, Kasper E. Augmented autologous pericranium duraplasty in 100 posterior fossa surgeries-a retrospective case series. Neurosurgery. 2012. 71: ons302-7
21. Litvack ZN, West GA, Delashaw JB, Burchiel KJ, Anderson VC. Dural augmentation: Part I-evaluation of collagen matrix allografts for dural defect after craniotomy. Neurosurgery. 2009. 65: 890-7
22. Malliti M, Page P, Gury C, Chomette E, Nataf F, Roux FX. Comparison of deep wound infection rates using a synthetic dural substitute (neuro-patch) or pericranium graft for dural closure: A clinical review of 1 year. Neurosurgery. 2004. 54: 599-603
23. Manley GT, Dillon W. Acute posterior fossa syndrome following lumbar drainage for treatment of suboccipital pseudomeningocele. Report of three cases. J Neurosurg. 2000. 92: 469-74
24. Martinez-Lage JF, Perez-Espejo MA, Palazon JH, Lopez Hernandez F, Puerta P. Autologous tissues for dural grafting in children: A report of 56 cases. Childs Nerv Syst. 2006. 22: 139-44
25. Martinez-Lage JF, Poza M, Sola J, Tortosa JG, Brown P, Cervenakova L. Accidental transmission of Creutzfeldt-Jakob disease by dural cadaveric grafts. J Neurol Neurosurg Psychiatry. 1994. 57: 1091-4
26. Matsumoto T, Symon L. Surgical management of syringomyelia--current results. Surg Neurol. 1989. 32: 258-65
27. McGirt MJ, Attenello FJ, Datoo G, Gathinji M, Atiba A, Weingart JD. 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: 52-7
28. Milhorat TH, Chou MW, Trinidad EM, Kula RW, Mandell M, Wolpert C. Chiari I malformation redefined: Clinical and radiographic findings for 364 symptomatic patients. Neurosurgery. 1999. 44: 1005-17
29. Munshi I, Frim D, Stine-Reyes R, Weir BK, Hekmatpanah J, Brown F. Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery. 2000. 46: 1384-9
30. Nohria V, Oakes WJ. Chiari I malformation: A review of 43 patients. Pediatr Neurosurg. 1990. 16: 222-7
31. Oldfield EH, Muraszko K, Shawker TH, Patronas NJ. Pathophysiology of syringomyelia associated with Chiari I malformation of the cerebellar tonsils. Implications for diagnosis and treatment. J Neurosurg. 1994. 80: 3-15
32. Pirouzmand F, Tucker WS. A modification of the classic technique for expansion duroplasty of the posterior fossa. Neurosurgery. 2007. 60: ONS60-2
33. Pritz MB. Surgical treatment of chiari i malformation: Simplified technique and clinical results. Skull base. 2003. 13: 173-7
34. Rengachary SS. Surgical repair of cerebrospinal fluid fistula: A modified technique. Am Surg. 1981. 47: 268-71
35. Robertson SC, Menezes AH. Hemorrhagic complications in association with silastic dural substitute: Pediatric and adult case reports with a review of the literature. Neurosurgery. 1997. 40: 201-5
36. Rosen DS, Wollman R, Frim DM. Recurrence of symptoms after Chiari decompression and duraplasty with nonautologous graft material. Pediatr Neurosurg. 2003. 38: 186-90
37. Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery. 1998. 42: 1044-55
38. Schijman E. History, anatomic forms, and pathogenesis of Chiari I malformations. Childs Nerv Syst. 2004. 20: 323-8
39. Schijman E, Steinbok P. International survey on the management of Chiari I malformation and syringomyelia. Childs Nerv Syst. 2004. 20: 341-8
40. Sciubba DM, Kretzer RM, Wang PP. Acute intracranial subdural hematoma following a lumbar CSF leak caused by spine surgery. Spine (Phila Pa 1976). 2005. 30: E730-2
41. Stevens EA, Powers AK, Sweasey TA, Tatter SB, Ojemann RG. Simplified harvest of autologous pericranium for duraplasty in Chiari malformation Type I. Technical note. J Neurosurg Spine. 2009. 11: 80-3
42. Stovner LJ, Bergan U, Nilsen G, Sjaastad O. Posterior cranial fossa dimensions in the Chiari I malformation: Relation to pathogenesis and clinical presentation. Neuroradiology. 1993. 35: 113-8
43. Tubbs RS, Lyerly MJ, Loukas M, Shoja MM, Oakes WJ. The pediatric Chiari I malformation: A review. Childs Nerv Syst. 2007. 23: 1239-50
44. Tubbs RS, Wellons JC, Blount JP, Oakes WJ. Posterior atlantooccipital membrane for duraplasty. Technical note. J Neurosurg. 2002. 97: S266-8
45. Vanaclocha V, Saiz-Sapena N. Duraplasty with freeze-dried cadaveric dura versus occipital pericranium for Chiari type I malformation: Comparative study. Acta Neurochir (Wien). 1997. 139: 112-9
46. Vernooij MW, Ikram MA, Tanghe HL, Vincent AJ, Hofman A, Krestin GP. Incidental findings on brain MRI in the general population. N Engl J Med. 2007. 357: 1821-8
47. Weinstein JS, Liu KC, Delashaw JB, Burchiel KJ, van Loveren HR, Vale FL. The safety and effectiveness of a dural sealant system for use with nonautologous duraplasty materials. J Neurosurg. 2010. 112: 428-33
48. Yilmaz A, Kanat A, Musluman AM, Colak I, Terzi Y, Kayaci S. When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale?. World Neurosurg. 2011. 75: 307-13
49. Zamel K, Galloway G, Kosnik EJ, Raslan M, Adeli A. Intraoperative neurophysiologic monitoring in 80 patients with Chiari I malformation: Role of duraplasty. J Clin Neurophysiol. 2009. 26: 70-5