RESUMEN
Background/Objectives: The management of Chiari malformations (CMs) remains a clinical challenge and a topic of great controversy. Results may vary between children and adults. The purpose of the current single-center study is to critically assess the one-year surgical outcomes of a cohort of 110 children with CM-1 or CM-1.5 who were treated using "posterior fossa reconstruction" (PFR), a surgical technique described in 1994 that has since been used in both adults and children. We also review the literature and discuss the possible causes of the drawbacks and pitfalls in children in whom PFR was ineffective in controlling the disease. Methods: The present cohort was selected from a prospective registry of adults and children with CMs collected since 2006. Patients included in this study were selected from a group of children with CMs who were operated on in our Pediatric Neurosurgical Unit between 1 January 2007 and 31 November 2023. Surgical outcome was defined based on clinical and neuroradiological results as very good, good, or bad. Results: The mean age of our child cohort was 9.9 ± 4.7 years, with 54 girls (49%) and 56 boys (51%). Sixty-six children had CM-1 (60%) while forty-four had CM-1.5 (40%). Following surgery, there was no neurological worsening or death among the children. Most children (70%) had an uneventful recovery and were discharged home on average one week after surgery. However, in 33 children (30%), we recorded at least one postoperative adverse event. Aseptic meningitis syndrome was the most frequent adverse event (n = 25, 22.7%). The final surgical outcome was evaluated one year after PFR by using both clinical and neuroradiological results. The one-year surgical outcome was excellent in 101 children (91.9%), good in 5 (4.5%), and bad in 4 (3.6%). Conclusions: PFR significantly enlarges the volume of the posterior fossa and recreates a CSF environment that generates buoyancy of the cerebellum, with a high percentage of excellent and good clinical results evaluated one year post-surgery.
RESUMEN
We present an effective and easily applied technique for cisterna magna reconstruction with arachnoid suturing in brainstem surgery. Suturing with 10-0 monofilament was done in a patient with a medulla oblongata hemangioblastoma (diagnosed von Hippel-Lindau disease). Seven years later, follow-up imaging revealed a new lesion close to the previous one and the patient underwent reoperation. The craniotomy and dural incision were repeated, and the intact arachnoid was visualized with no meningocerebral adhesions. This technique preserves normal anatomic landmarks and facilitates and shortens dissection in reoperations, almost like a virgin case. We propose this technique for every lower brainstem and fourth ventricle procedure. The video can be found here: https://youtu.be/RKMcSoK6ycY.
RESUMEN
Objective To explore a modified method of cerebellar tonsillectomy combined with posterior fossa decompression via small-size craniotomy for Chiari- malformation associated with syringomyelia and to evaluate its clinical efficacy. Methods The clinical data of 29 Chiari- malformation patients associated with syringomyelia, who underwent modified cerebellar tonsillectomy combined with posterior fossa decompression via small-size craniotomy from January 2012 to January 2014, were analyzed retrospectively.Patients were prone with head and neck in the coaxial position and received surgical intervention including posterior fossa decompression via small-size craniotomy, opening the rear atlas arch, resection of the inner part of cervical canal of the cerebellar tonsil herniation while keeping the integrity of soft meninges, adhesiolysis of median aperture of the fourth ventricle, dissection of the suture of arachnoid and dural edge to avoid latrogenic dead space, and suture of the dura with autologous fascia. The cerebrospinal fluid release rate of the whole process was controlled. Results A total of 24 patients were followed up after operation while 5 patients were lost in follow-up. The clinical symptom of 23 patients was improved within one year after operation. The repression of medulla oblongata and posterior upper part of cervical cord was removed in MRI examination 6 months after operation. The lower edge of cerebellar tonsillar was up to the plane above the foramen magnum and the herniation was resolved. The syringomyelia was shortened or disappeared. Conclusion Modified cerebellar tonsillectomy combined with posterior fossa decompression via small-size craniotomy, as a microscopy neurosurgery, is an effective method for the treatment of Chiari- malformation associated with syringomyelia.