Skip to main content
SpringerLink
Log in

Radiological outcome after surgical treatment of syringomyelia-Chiari I complex in adults: a systematic review and meta-analysis

  • Review
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

Foramen magnum decompression (FMD) is widely accepted as the standard treatment for syringomyelia associated with Chiari type I malformation (CMI). Despite extensive clinical investigations, relevant surgical details are still matter of debate. The authors performed a systematic review and meta-analysis of the literature examining the radiological outcome of syringomyelia in adult patients with CMI after different surgical strategies. PRISMA guidelines were followed. A systematic search of three databases was performed for studies published between 1990 and 2018. Our systematic review included 13 studies with a total of 276 patients with CMI associated with syringomyelia. Overall, the rate of post-operative radiological improvement at last follow-up was 81.1% (95% CI 73.3–88.9%; p < 0.001; I2 = 71.4%). The rate of post-operative syrinx shrinkage did not differ significantly among both groups of decompression with the extra-arachnoidal technique and arachnoid dissection (90%, 95% CI 85.1–94.8%, I2 = 0% vs 79.8%, 95% CI 61.7–98%, I2 = 85.5%). A lower rate of post-operative radiological syrinx shrinkage was observed after decompression with splitting of the outer layer of the dura (55.6% 95% CI 40.5–70.8%, I2 = 0%). CSF-related complications and infections were similar among the different groups. Our meta-analysis found that FMD with the extra-arachnoidal technique and arachnoid dissection provides similar results in terms of post-operative shrinkage of syringomyelia. Patients undergoing decompression with splitting of the dura presented the lower rate of syrinx reduction. These data should be considered when choosing the surgical approach in adult patients with CMI associated with syringomyelia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Alfieri A, Pinna G (2012) Long-term results after posterior fossa decompression in syringomyelia with adult Chiari type I malformation. J Neurosurg Spine 17:381–387. https://doi.org/10.3171/2012.7.SPINE12272

    Article  PubMed  Google Scholar 

  2. Baker WL, White CM, Cappelleri JC, Kluger J, Coleman CI (2009) Understanding heterogeneity in meta-analysis: the role of meta-regression. Int J Clin Pract 63:1426–1434. https://doi.org/10.1111/j.1742-1241.2009.02168.x

    Article  CAS  PubMed  Google Scholar 

  3. Ball MJ, Dayan AD (1972) Pathogenesis of syringomyelia. Lancet. https://doi.org/10.1016/S0140-6736(72)92152-6

  4. Barr ML (1948) Observations on the foramen of magendie in a series of human brains. Brain. https://doi.org/10.1093/brain/71.3.281

  5. Batzdorf U, Mcarthur DL, Bentson JR (2013) Surgical treatment of Chiari malformation with and without syringomyelia: experience with 177 adult patients ; Clinical article J Neurosurg

  6. Chai Z, Xue X, Fan H, Sun L, Cai H, Ma Y, Ma C, Zhou R (2018) Efficacy of posterior fossa decompression with duraplasty for patients with Chiari malformation type I: a systematic review and meta-analysis. World Neurosurg

  7. Chauvet D, Carpentier A, George B (2009) Dura splitting decompression in Chiari type 1 malformation: clinical experience and radiological findings. Neurosurg Rev 32:465–470. https://doi.org/10.1007/s10143-009-0214-4

    Article  PubMed  Google Scholar 

  8. DerSimonian R, Laird N (2015) Meta-analysis in clinical trials revisited. Contemp Clin Trials. https://doi.org/10.1016/j.cct.2015.09.002

  9. Dlouhy B, Dawson J, Menezes A (2017) Intradural pathology and pathophysiology associated with Chiari I malformation with and without syringomyelia. Childs Nerv Syst 33:1785–1853. https://doi.org/10.1007/s00381-017-3557-0

    Article  Google Scholar 

  10. Easterbrook PJ, Gopalan R, Berlin JA, Matthews DR (1991) Publication bias in clinical research. Lancet 337:867–872

    Article  CAS  Google Scholar 

  11. Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Bmj 315:629–634

    Article  CAS  Google Scholar 

  12. Fischer EG (1995) Posterior fossa decompression for Chiari I deformity, including resection of the cerebellar tonsils. Childs Nerv Syst. https://doi.org/10.1007/BF00300718

  13. Gardner WJ (1965) Hydrodynamic mechanism of syringomyelia: its relationship to myelocele. J Neurol Neurosurg Psychiatry. https://doi.org/10.1136/jnnp.28.3.247

  14. Heiss JD, Patronas N, DeVroom HL, Shawker T, Ennis R, Kammerer W, Eidsath A, Talbot T, Morris J, Eskioglu E, Oldfield EH (1999) Elucidating the pathophysiology of syringomyelia. J Neurosurg. https://doi.org/10.3171/jns.1999.91.4.0553

  15. Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ Br Med J 327:557–560. https://doi.org/10.1136/bmj.327.7414.557

    Article  Google Scholar 

  16. Isu T, Sasaki H, Takamura H, Kobayashi N (1993) Foramen magnum decompression with removal of the outer layer of the dura as treatment for syringomyelia occurring with Chiari I malformation. Neurosurgery. https://doi.org/10.1227/00006123-199311000-00009

  17. Klekamp J (2012) Surgical treatment of Chiari I malformation-analysis of intraoperative findings, complications, and outcome for 371 foramen magnum decompressions. Neurosurgery. https://doi.org/10.1227/NEU.0b013e31825c3426

  18. Kotil K, Ton T, Tari R, Savas Y (2009) Delamination technique together with longitudinal incisions for treatment of Chiari I/syringomyelia complex: a prospective clinical study. Cerebrospinal Fluid Res 6:1–7. https://doi.org/10.1186/1743-8454-6-7

    Article  Google Scholar 

  19. Koyanagi I, Houkin K (2010) Pathogenesis of syringomyelia associated with Chiari type 1 malformation: review of evidences and proposal of a new hypothesis. Neurosurg Rev

  20. Liber AF, Lisa JR (1937) Rosenthal fibers in non-neoplastic syringomyelia: a note on the pathogenesis of syringomyelia. J Nerv Ment Dis 86:549–558

    Article  Google Scholar 

  21. Lin W, Duan G, Xie J, Shao J, Wang Z, Jiao B (2018) Comparison of results between posterior fossa decompression with and without duraplasty for the surgical treatment of Chiari malformation type I: a systematic review and meta-analysis. World Neurosurg

  22. Milhorat TH, Miller JI, Johnson WD, Adler DE, Heger IM (1993) Anatomical basis of syringomyelia occurring with hindbrain lesions. Neurosurgery. https://doi.org/10.1227/00006123-199305000-00008

  23. Moher D, Liberati A, Tetzlaff J, Altman DG, Grp P (2009) Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement (reprinted from Annals of Internal Medicine). Phys Ther 89:873–880. https://doi.org/10.1371/journal.pmed.1000097

    Article  PubMed  Google Scholar 

  24. Nagoshi N, Iwanami A, Toyama Y, Nakamura M (2014) Factors contributing to improvement of syringomyelia after foramen magnum decompression for Chiari type I malformation. J Orthop Sci 19:418–423. https://doi.org/10.1007/s00776-014-0555-x

    Article  PubMed  Google Scholar 

  25. Oldfield EH, Muraszko K, Shawker TH, Patronas NJ (1994) Pathophysiology of syringomyelia associated with Chiari I malformation of the cerebellar tonsils. Implications for diagnosis and treatment. J Neurosurg : https://doi.org/10.3171/jns.1994.80.1.0003

  26. Ono A, Numasawa T, Wada K, Yokoyama T, Takeuchi K, Suetsuna F, Ueyama K, Toh S (2010) Surgical outcomes of foramen magnum decompression for syringomyelia associated with Chiari i malformation: relation between the location of the syrinx and body pain. J Orthop Sci 15:299–304. https://doi.org/10.1007/s00776-010-1462-4

    Article  PubMed  Google Scholar 

  27. Perrini P, Benedetto N, Tenenbaum R, Di Lorenzo N (2007) Extra-arachnoidal cranio-cervical decompression for syringomyelia associated with Chiari I malformation in adults: technique assessment. Acta Neurochir 149:1015–1022. https://doi.org/10.1007/s00701-007-1276-0

    Article  CAS  PubMed  Google Scholar 

  28. Pillay PK, Awad IA, Little JR, Hahn JF (1991) Symptomatic Chiari malformation in adults: a new classification based on magnetic resonance imaging with clinical and prognostic significance. Neurosurgery. https://doi.org/10.1227/00006123-199105000-00001

  29. Prat R, Galeano I (2009) Pain improvement in patients with syringomyelia and Chiari I malformation treated with suboccipital decompression and tonsillar coagulation. J Clin Neurosci. https://doi.org/10.1016/j.jocn.2008.06.012

  30. Rahman A, Rana MS, Bhandari PB, Asif DS, Uddin ANW, Obaida ASMA, Rahman MA, Alam MS (2017) “Stealth cranioplasty:” a novel endeavor for symptomatic adult Chiari i patients with syringomyelia: technical note, appraisal, and philosophical considerations. J Craniovertebr Junction Spine. https://doi.org/10.4103/jcvjs.JCVJS_76_17

  31. Rehman L, Akbar H, Bokhari I, Babar AK, Hashim ASM, Arain SH (2015) Posterior fossa decompression with duraplasty in Chiari-1 malformations. J Coll Physicians Surg Pakistan

  32. Romero FR, Pereira CA de B (2010) Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation? Arq Neuropsiquiatr https://doi.org/10.1590/s0004-282x2010000400027

  33. Spena G, Bernucci C, Garbossa D, Valfrè W, Versari P (2010) Clinical and radiological outcome of craniocervical osteo-dural decompression for Chiari I-associated syringomyelia. Neurosurg Rev 33:297–304. https://doi.org/10.1007/s10143-010-0260-y

    Article  PubMed  Google Scholar 

  34. Tannenberg J (1924) Über die Pathogenese der Syringomyelie, zugleich em Beitrag zum Vorkommen von Capillarhämangiomen im Rückenmark. Zeitschrift für die gesamte Neurol und Psychiatr 92:119–174

    Article  Google Scholar 

  35. Thakar S, Sivaraju L, Jacob KS, Arun AA, Aryan S, Mohan D, Kiran NAS, Hegde AS (2018) A points-based algorithm for prognosticating clinical outcome of Chiari malformation type i with syringomyelia: results from a predictive model analysis of 82 surgically managed adult patients. J Neurosurg Spine. https://doi.org/10.3171/2017.5.SPINE17264

  36. Tubbs RS, Smyth MD, Wellons JC, Oakes WJ (2004) Arachnoid veils and the Chiari I malformation. J Neurosurg

  37. Vanaclocha V, Saiz-Sapena N, Garcia-Casasola MC (1997) Surgical technique for cranio-cervical decompression in syringomyelia associated with Chiari type I malformation. Acta Neurochir 139:529–540. https://doi.org/10.1007/BF02750996

    Article  CAS  PubMed  Google Scholar 

  38. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P (2013) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa Hosp Res Inst 1–4. https://doi.org/10.2307/632432

  39. Wetjen NM, Heiss JD, Oldfield EH (2008) Time course of syringomyelia resolution following decompression of Chiari malformation type I. J Neurosurg Pediatr 1:118–123. https://doi.org/10.3171/PED/2008/1/2/118

    Article  PubMed  PubMed Central  Google Scholar 

  40. Williams B (1969) The distending force in the production of communicating syringomyelia. Lancet. https://doi.org/10.1016/s0140-6736(69)91427-5

  41. Williams B (1978) A critical appraisal of posterior fossa surgery for communicating syringomyelia. Brain. https://doi.org/10.1093/brain/101.2.223

  42. Willis BH, Riley RD (2017) Measuring the statistical validity of summary meta-analysis and meta-regression results for use in clinical practice. Stat Med 36:3283–3301. https://doi.org/10.1002/sim.7372

    Article  PubMed  PubMed Central  Google Scholar 

  43. Yilmaz A, Kanat A, Musluman AM, Çolak I, Terzi Y, Kayaci S, Aydin Y (2011) When is duraplasty required in the surgical treatment of Chiari malformation type I based on tonsillar descending grading scale? World Neurosurg

Download references

Acknowledgements

We thanks Professor Beth De Felici for English revision.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56100, Pisa, Italy

    Paolo Perrini, Yury Anania, Nicola Benedetto & Davide Tiziano Di Carlo

  2. Neuroradiology Department, Gui de Chauliac Hospital, CHU Montpellier, Montpellier, France

    Federico Cagnazzo

  3. Department of Clinical and Experimental Medicine, Section of Statistics, University of Pisa, Pisa, Italy

    Riccardo Morganti

Authors
  1. Paolo Perrini
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yury Anania
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Federico Cagnazzo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nicola Benedetto
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Riccardo Morganti
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Davide Tiziano Di Carlo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paolo Perrini.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

For this type of study, formal consent is not required.

Informed consent

The nature of this article did not require informed consent.

Research involving human participants and/or animals

This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(PDF 43 kb)

ESM 2

(PDF 2086 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Perrini, P., Anania, Y., Cagnazzo, F. et al. Radiological outcome after surgical treatment of syringomyelia-Chiari I complex in adults: a systematic review and meta-analysis. Neurosurg Rev 44, 177–187 (2021). https://doi.org/10.1007/s10143-020-01239-w

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-020-01239-w

Keywords

Search

Navigation