Journal of neurosurgery. Pediatrics · 2025
Subpial cerebellar tonsillectomy for decompression of the cervicomedullary junction in children and young adults.
СтатьяНазвание и аннотация: Перевод в очереди
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Laird David G, Troy Christopher, Lesha Emal, Saleh Mallory, Snyder Kendall, Wait Scott D, Van Poppel Mark D, Shears Danielle, Vaughn Brandy N, Klimo Paul
Аннотация
OBJECTIVE: The choice of surgical technique for decompression of the cervicomedullary junction remains controversial. The authors report their experience with using subpial tonsillectomy for Chiari malformation with and without associated syringohydromyelia.
METHODS: Children from two institutions who underwent the subpial tonsillar resection technique for decompression of the craniocervical junction from 2014 to 2024 were included. Demographic information, relevant presurgical symptoms, surgical history, perioperative radiographic characteristics, postoperative outcomes, complications, reoperations, and 90-day readmissions were collected. Two outcomes were assessed at last follow-up: 1) status of presenting symptom(s); and 2) radiographic status of syringohydromyelia or isolated presyrinx edema, if present preoperatively.
RESULTS: A total of 109 patients were identified with a mean age of 10.8 years. Seventy-eight (71.6%) of these patients presented with headaches, and 23 (21.1%) had medullary or lower cranial nerve dysfunction. Radiographically, 86 (78.9%) patients had Chiari type 1 and 23 (21.1%) had Chiari type 1.5. The mean (range) preoperative cerebellar tonsillar herniation was 14.0 (4.5-40) mm, and 49 (45%) patients had syringohydromyelia or presyrinx edema. The mean operative time was 152 minutes, and the mean length of stay was 3.49 days. Fourteen patients were readmitted within 90 days of surgery, 9 within the first 30 days, and 5 after 30 days. Of these 14 readmissions, 8 (57%) were for reasons attributable to the index operation. Over a mean follow-up of 3.70 years, headaches resolved or improved in 68 of 78 (87.2%) patients, and 18 of 23 (78.3%) patients with brainstem or lower cranial nerve dysfunction demonstrated improvement. Of the patients with syringohydromyelia who had follow-up (n = 45), 39 (86.7%) had complete resolution of their syringohydromyelia (n = 16) or > 50% reduction in diameter of the syrinx (n = 23). One patient was deemed a treatment failure, eventually needing a syringopleural shunt.
CONCLUSIONS: Subpial tonsillar resection for Chiari malformations is a safe and effective method to maximally decompress the craniocervical junction and immediately reestablish pulsatile cerebrospinal fluid flow out of the fourth ventricle. Most patients will experience improvement or resolution of their associated symptoms and significant reduction (> 50% diameter reduction) or resolution of their syringohydromyelia.
METHODS: Children from two institutions who underwent the subpial tonsillar resection technique for decompression of the craniocervical junction from 2014 to 2024 were included. Demographic information, relevant presurgical symptoms, surgical history, perioperative radiographic characteristics, postoperative outcomes, complications, reoperations, and 90-day readmissions were collected. Two outcomes were assessed at last follow-up: 1) status of presenting symptom(s); and 2) radiographic status of syringohydromyelia or isolated presyrinx edema, if present preoperatively.
RESULTS: A total of 109 patients were identified with a mean age of 10.8 years. Seventy-eight (71.6%) of these patients presented with headaches, and 23 (21.1%) had medullary or lower cranial nerve dysfunction. Radiographically, 86 (78.9%) patients had Chiari type 1 and 23 (21.1%) had Chiari type 1.5. The mean (range) preoperative cerebellar tonsillar herniation was 14.0 (4.5-40) mm, and 49 (45%) patients had syringohydromyelia or presyrinx edema. The mean operative time was 152 minutes, and the mean length of stay was 3.49 days. Fourteen patients were readmitted within 90 days of surgery, 9 within the first 30 days, and 5 after 30 days. Of these 14 readmissions, 8 (57%) were for reasons attributable to the index operation. Over a mean follow-up of 3.70 years, headaches resolved or improved in 68 of 78 (87.2%) patients, and 18 of 23 (78.3%) patients with brainstem or lower cranial nerve dysfunction demonstrated improvement. Of the patients with syringohydromyelia who had follow-up (n = 45), 39 (86.7%) had complete resolution of their syringohydromyelia (n = 16) or > 50% reduction in diameter of the syrinx (n = 23). One patient was deemed a treatment failure, eventually needing a syringopleural shunt.
CONCLUSIONS: Subpial tonsillar resection for Chiari malformations is a safe and effective method to maximally decompress the craniocervical junction and immediately reestablish pulsatile cerebrospinal fluid flow out of the fourth ventricle. Most patients will experience improvement or resolution of their associated symptoms and significant reduction (> 50% diameter reduction) or resolution of their syringohydromyelia.