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Decompression with or without Duraplasty for Chiari I and Syringomyelia
Journal article   Peer reviewed

Decompression with or without Duraplasty for Chiari I and Syringomyelia

David D Limbrick Jr, Chevis N Shannon, Emine O Bayman, Thanda Meehan, Marisa Kallem, Laurie L Ackerman, P David Adelson, Raheel Ahmed, Gregory Albert, Philipp R Aldana, …
The New England journal of medicine, Vol.394(20), pp.2015-2025
05/28/2026
DOI: 10.1056/NEJMoa2402821
PMID: 42202320

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Abstract

In children with Chiari type I malformation and syringomyelia, neurosurgical posterior fossa decompression (PFD) provides clinical improvement, but whether duraplasty (incising the dura and placing a dural graft) improves outcomes is unclear. We conducted a multicenter, cluster-randomized, controlled trial of PFD with duraplasty (PFD-D) as compared with PFD alone. Persons 21 years of age or younger with cerebellar tonsillar ectopia of at least 5 mm and a maximum syrinx diameter of 3.0 to 9.9 mm were enrolled at 38 centers. Centers were cluster-randomized: all the participants within each center underwent the same intervention. The primary outcome was surgical complications within 6 months. Secondary outcomes were clinical improvement, syrinx reduction, and repeat decompression at 10 to 24 months and the change in overall health-related quality of life at 6 to 24 months. A total of 162 participants were included in the trial, of whom 78 were assigned to undergo PFD-D and 84 to undergo PFD alone. The percentage of participants with complications within 6 months was 14% with PFD-D and 6% with PFD (adjusted odds ratio, 2.59; 95% confidence interval [CI], 0.86 to 7.84; P = 0.11). At 24 months, the percentage of participants with clinical improvement was 58% with PFD-D and 46% with PFD; the mean (±SD) syrinx reduction was 3.08±2.33 mm and 1.22±1.79 mm, respectively; and the percentage of participants with repeat decompression was 3% and 14%. Changes in health-related quality of life were similar in the two groups. The percentage of participants with surgical complications did not differ significantly between those who underwent PFD-D and and those who underwent PFD alone. Larger trials are needed to determine the relative benefits and risks of these two procedures. (Funded by the Patient-Centered Outcomes Research Institute and others; ClinicalTrials.gov number, NCT02669836.).
 Magnetic Resonance Imaging Quality of Life Adolescent Arnold-Chiari Malformation - complications Arnold-Chiari Malformation - diagnostic imaging Arnold-Chiari Malformation - psychology Arnold-Chiari Malformation - surgery Cervical Vertebrae Child Child, Preschool Cranial Fossa, Posterior - surgery Decompression, Surgical - adverse effects Decompression, Surgical - methods Dura Mater - surgery Dura Mater - transplantation Female Follow-Up Studies Humans Male Postoperative Complications - epidemiology Reoperation Spinal Cord - diagnostic imaging Spinal Cord - surgery Syringomyelia - complications Syringomyelia - diagnostic imaging Syringomyelia - psychology Syringomyelia - surgery Treatment Outcome

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