Parker Stephen R, Harris Peggy, Cummings Thomas J, George Timothy, Fuchs Herbert, Grant Gerald
Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
J Neurosurg Pediatr. 2011 Aug;8(2):177-83. doi: 10.3171/2011.5.PEDS10362.
Posterior fossa decompression with duraplasty for Chiari malformation Type I (CM-I) is a common pediatric neurosurgery procedure. Published series report a complication rate ranging from 3% to 40% for this procedure. Historically, many dural substitutes have been used, including bovine grafts, human cadaveric pericardium, synthetic dura, and autologous pericranium. The authors hypothesized that a recently observed increase in complications was dependent on the graft used.
Between January 2004 and January 2008, 114 consecutive patients ≤ 18 years old underwent primary CM-I decompression using duraplasty. Records were retrospectively reviewed for short- and intermediate-term complications and operative technique, focusing on the choice of duraplasty graft with or without application of a tissue sealant.
The average age of the patients was 8.6 years. The dural graft used was variable: 15 were treated with cadaveric pericardium, 12 with Durepair, and 87 with EnDura. Tisseel was used in 75 patients, DuraSeal in 12, and no tissue sealant was used in 27 patients. The overall complication rate was 21.1%. The most common complications included aseptic meningitis, symptomatic pseudomeningocele, or a CSF leak requiring reoperation. The overall complication rates were as follows: cadaveric pericardium 26.7%, Durepair 41.7%, and EnDura 17.2%; reoperation rates were 13%, 25%, and 8.1%, respectively. Prior to adopting a different graft product, the overall complication rate was 18.1%; following the change the rate increased to 35%. Complication rates for tissue sealants were 14.8% for no sealant, 18.7% for Tisseel, and 50% for DuraSeal. Nine patients were treated with the combination of Durepair and DuraSeal and this subgroup had a 56% complication rate.
Complication rates after CM-I decompression may be dependent on the dural graft with or without the addition of tissue sealant. The complication rate at the authors' institution approximately doubled following the adoption of a different graft product. Tissue sealants used in combination with a dural substitute to augment a duraplasty may increase the risk of aseptic meningitis and/or CSF leak. The mechanism of the apparent increased inflammation with this combination remains under investigation.
I型Chiari畸形（CM-I）的后颅窝减压及硬脑膜成形术是一种常见的小儿神经外科手术。已发表的系列报道称该手术的并发症发生率在3%至40%之间。从历史上看，许多硬脑膜替代物都曾被使用，包括牛移植物、人尸体心包、合成硬脑膜和自体颅骨膜。作者推测，最近观察到的并发症增加与所使用的移植物有关。
在2004年1月至2008年1月期间，114例年龄≤18岁的连续患者接受了使用硬脑膜成形术的原发性CM-I减压手术。回顾性查阅记录，以了解短期和中期并发症及手术技术，重点关注硬脑膜成形术移植物的选择以及是否应用组织密封剂。
患者的平均年龄为8.6岁。所使用的硬脑膜移植物各不相同：15例使用尸体心包，12例使用Durepair，87例使用EnDura。75例患者使用了Tisseel，12例使用了DuraSeal，27例患者未使用组织密封剂。总体并发症发生率为21.1%。最常见的并发症包括无菌性脑膜炎、有症状的假性脑膜膨出或需要再次手术的脑脊液漏。总体并发症发生率如下：尸体心包为26.7%，Durepair为41.7%，EnDura为17.2%；再次手术率分别为13%、25%和8.1%。在采用不同的移植物产品之前，总体并发症发生率为18.1%；改变之后，该发生率增至35%。未使用密封剂时组织密封剂的并发症发生率为14.8%，Tisseel为18.7%，DuraSeal为50%。9例患者接受了Durepair和DuraSeal联合治疗，该亚组的并发症发生率为56%。
CM-I减压术后的并发症发生率可能取决于硬脑膜移植物以及是否添加组织密封剂。在采用不同的移植物产品后，作者所在机构的并发症发生率大约翻了一番。与硬脑膜替代物联合使用以增强硬脑膜成形术的组织密封剂可能会增加无菌性脑膜炎和/或脑脊液漏的风险。这种联合使用时明显炎症增加的机制仍在研究中。
