Comparison of posterior fossa decompression with or without duraplasty in children with Type I Chiari malformation

Purpose: Chiari malformation type I (CM1) is a common and often debilitating neurosurgical disease. Whether to treat CM1 patients with a traditional posterior fossa decompression with duraplasty (PFDD) or a less invasive extradural decompression (PFDO) is controversial. The purpose of this study was to compare clinical outcome and syrinx resolution between the two procedures. Methods: We retrospectively reviewed the records of 36 patients treated with PFDD and 29 patients with PFDO between 2003 and 2011. We compared baseline demographic, clinical, and radiographic characteristics. The primary clinical outcome was the Chicago Chiari Outcome Scale (CCOS). The primary radiographic outcome was qualitative syrinx improvement or resolution. Results: At baseline, age and sex distributions, radiographic characteristics, and presenting symptoms were similar in patients undergoing PFDD and PFDO. Patients undergoing PFDO had shorter surgical time (1.5 vs. 2.8 h; p<0.001) and length of hospital stay (2.1 days compared to 3.3 days; p<0.001). Cerebrospinal fluid-related complications were more common in patients receiving PFDD (7/36) than PFDO (0/29) (p=0.014). Clinical improvement, defined by the mean CCOS score, was comparable in patients receiving PFDO (14.7) and PFDD (14.6) (p=0.70). Among patients with postoperative syrinx imaging, 10/13 in the PFDD group improved or resolved, compared to 8/8 in the PFDO group (p=0.26). Conclusions: Extradural decompression for CM1 produces comparable rates of clinical and radiographic improvement as the more invasive decompression with duraplasty. Given the increased morbidity and resource utilization associated with PFDD, PFDO should be considered an attractive first-line option for most CM1 patients.