1. Surgical Results from Chiari Decompression: Comparing Duroplasty versus Dural Splitting Techinques John A. Jane, Jr., M.D. Associate Professor of Neurosurgery and Pediatrics Director of Pediatric Neurosurgery University of Virginia Health System

2. Disclosures None

3. Surgical Technique Bone removal: –Posterior fossa decompression aka suboccipital craniectomy aka foramen magnum decompression –C1 laminectomy, sometimes C2 and/or C3

5. Dural splitting The spinal dura only has one layer “Dural splitting” over the spine is not really splitting two layers

6. Surgical Technique Decompression (bone removal) alone Dural splitting –Use of intraoperative ultrasound –Type of splitting Creation and removal of an outer layer

7. Surgical Series 2006-2009, Age<18 N=16 –Posterior fossa decompression and duraplasty=8 6 syringomyelia –Posterior fossa decompression alone=8 6 syringomyelia –Both groups similar in terms of age, symptoms, degree of tonsillar herniation, and syringomyelia

8. Outcomes Syringes –Significantly decreased or resolved in 5 of 6 patients in each group Tonsillar regression –PFD alone: 6 of 7 –PFD plus duraplasty: 5 of 7

9. PFD with dural splitting

11. Complications Postoperative nausea –PFD alone: 0/8 –PFD with duraplasty: 5/8 Higher rate of complications associated with PFD with duraplasty –Meningitis, Reoperation for CSF leak, Symptomatic pseudomeningocele

12. Complications Original surgery: PFD with division of adhesions and continuous sutured duraplasty

13. Complications Chemical meningitis: repeat PFD with removal of dural graft and placement of pericranial graft Pseudomeningocele with CSF leak requiring repeat closure of incision Continued pseudomeningocele treated with a ventriculoperitoneal shunt

14. Recent reports Decompression alone procedures were shorter, had shorter hospital stays, and less pain and nausea However, PFD alone was associated with a higher incidence of symptomatic recurrence and need for dural opening (12.5% versus 3.1%)

15. Conclusions Posterior fossa decompression with dural splitting is better tolerated and associated with fewer complications than PFD with duraplasty Posterior fossa decompression with dural splitting can provide effective treatment of syringomyelia in most patients

16. Thank you! Questions?