Attenello Frank J, McGirt Matthew J, Garcés-Ambrossi Giannina L, Chaichana Kaisorn L, Carson Benjamin, Jallo George I
Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
Childs Nerv Syst. 2009 Feb;25(2):183-90. doi: 10.1007/s00381-008-0700-y. Epub 2008 Sep 4.
Treatment failure for Chiari decompression is frequently associated with scarring, intradural adhesions, and recurrent loss of hindbrain space. While autograft has been our standard for hindbrain duraplasty, we investigated whether introducing anti-adhesive synthetic GORE PRECLUDE MVP Dura Substitute (expanded polytetrafluoroethylene [ePTFE] graft) was associated with improved patient outcomes.
We retrospectively reviewed records of patients undergoing first-time suboccipital decompression/duraplasty for Chiari-I malformation utilizing ePTFE graft or pericranial autograft. Magnetic resonance imaging (MRI) at last follow-up was assessed for: (1) recurrent loss of dorsal hindbrain cerebrospinal fluid (CSF) space/CSF flow(cine-MR) at duraplasty site, (2) pseudomeningocele, or (3) syringomyelia improvement. Symptom recurrence warranting revision surgery was compared between cohorts.
Sixty-seven patients (age 11 +/- 5 years) underwent duraplasty with pericranial autograft (n = 40) or ePTFE graft (n = 27). Perioperative morbidity did not differ between cohorts. No patients receiving ePTFE graft experienced incisional CSF leak, surgical site infection, or symptomatic pseudomeningocele. At median 8 months postoperatively, all (100%) patients with ePTFE graft maintained physiological CSF flow/decompressed hindbrain CSF space on cine-MRI versus 32 (79%) patients receiving pericranial autograft (p < 0.05). Radiographic syrinx improvement occurred in 80% of patients with ePTFE graft and 52% of patients with pericranial autograft (median time to improvement: 5 vs 12 months, respectively, p < 0.05). At median 16 months postoperatively, four (10%) patients with pericranial autograft required revision decompression versus 0 (0%) patients with ePTFE graft (p = 0.090).
Duraplasty utilizing ePTFE graft was associated with improved maintenance of hindbrain space, accelerated syringomyelia improvement, and a trend toward decreased treatment failure versus pericranial autograft. Future studies of long-term outcome are warranted to confirm observed effects. Synthetic ePTFE graft is a safe alternative for duraplasty in the setting of Chiari malformation.
Chiari减压术治疗失败常与瘢痕形成、硬膜内粘连及后脑间隙反复丧失有关。虽然自体移植一直是我们后脑硬脑膜成形术的标准方法，但我们研究了引入抗粘连合成材料GORE PRECLUDE MVP硬脑膜替代物（膨体聚四氟乙烯[ePTFE]移植物）是否能改善患者预后。
我们回顾性分析了首次接受枕下减压/硬脑膜成形术治疗Chiari-I畸形患者的记录，这些患者使用了ePTFE移植物或颅骨膜自体移植。在最后一次随访时，对磁共振成像（MRI）进行评估，内容包括：（1）硬脑膜成形术部位后脑背侧脑脊液（CSF）间隙/CSF流动（电影MRI）的反复丧失情况，（2）假性脑脊膜膨出，或（3）脊髓空洞症的改善情况。比较两组患者因症状复发需要翻修手术的情况。
67例患者（年龄11±5岁）接受了颅骨膜自体移植（n = 40）或ePTFE移植物（n = 27）的硬脑膜成形术。两组患者围手术期发病率无差异。接受ePTFE移植物的患者均未发生切口脑脊液漏、手术部位感染或有症状的假性脑脊膜膨出。术后中位8个月时，所有（100%）接受ePTFE移植物的患者在电影MRI上维持了生理性CSF流动/减压后脑CSF间隙，而接受颅骨膜自体移植的患者有32例（79%）维持了该状态（p < 0.05）。80%接受ePTFE移植物的患者和52%接受颅骨膜自体移植的患者出现了影像学上脊髓空洞症的改善（改善的中位时间分别为5个月和12个月，p < 0.05）。术后中位16个月时，4例（10%）接受颅骨膜自体移植的患者需要进行翻修减压，而接受ePTFE移植物的患者为0例（0%）（p = 0.090）。
与颅骨膜自体移植相比，使用ePTFE移植物进行硬脑膜成形术可改善后脑间隙的维持情况，加速脊髓空洞症的改善，并降低治疗失败的趋势。有必要进行长期预后的进一步研究以证实观察到的效果。合成ePTFE移植物是Chiari畸形情况下硬脑膜成形术的一种安全替代方法。
