Massimi Luca, Frassanito P, Bianchi F, Tamburrini G, Caldarelli M
Neurochirurgia Infantile, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.
Università Cattolica del Sacro Cuore, Istituto Neurochirurgia, Rome, Italy.
Childs Nerv Syst. 2019 Oct;35(10):1827-1838. doi: 10.1007/s00381-019-04218-9. Epub 2019 Jun 18.
The management of Chiari I malformation (CIM) still raises the problem of the optimal surgical treatment, with special regard to the "eternal dilemma" of the posterior fossa bony decompression alone (PFBD) or with duraplasty (PFBDD). The goal of the present review is to update the results (outcome and complications) of both techniques to better understand the correct indication for each of them.
A review of the literature has been performed, focusing on the articles and the meta-analyses specifically addressing the problem of PFBD vs PFBDD. Also, the personal authors' experience is briefly discussed.
PFBD (usually with C1 laminectomy, often with delamination of the external dural layer) is the most commonly used technique in children, especially if syringomyelia is absent. It ensures a high success rate, with > 80% clinical improvement and about 75% reduction of the syringomyelia, and a very low risk of complications, hospital stay, and costs. A certain risk of recurrence is present (2-12%). PFBDD (with autologous tissues or dural substitutes), on the other hand, is mostly used not only in adults but also in children with large syringomyelia. It is burdened by a higher risk of complications (namely, the CSF-related ones), longer hospital stay, and higher costs; however, it warrants a better clinical improvement (> 85%) and a lower risk of reoperation (2-3.5%). Eight meta-analyses of the literature (three on pediatric series and five in adult series) and one prospective study in children, published in the last decade, largely confirm these findings.
PFBD and PFBDD are different techniques that are indicated for different types of patients. In children, PFBD has been demonstrated to represent the best choice, although some patients may require a more aggressive treatment. Therefore, the success in the management of CIM, with or without syringomyelia, depends on the correct indication to surgery and on a patient-tailored choice rather than on the surgical technique.
Chiari I 畸形（CIM）的治疗仍然存在最佳手术治疗的问题，特别是关于单纯后颅窝骨性减压（PFBD）或联合硬脑膜成形术（PFBDD）这一“永恒难题”。本综述的目的是更新这两种技术的结果（疗效和并发症），以便更好地理解它们各自的正确适应证。
进行了文献综述，重点关注专门探讨 PFBD 与 PFBDD 问题的文章和荟萃分析。此外，还简要讨论了作者个人的经验。
PFBD（通常行 C1 椎板切除术，常伴有硬脑膜外层分层）是儿童中最常用的技术，尤其是在无脊髓空洞症的情况下。它确保了较高的成功率，临床改善率>80%，脊髓空洞症缩小约 75%，且并发症、住院时间和费用风险极低。存在一定的复发风险（2 - 12%）。另一方面，PFBDD（使用自体组织或硬脑膜替代物）不仅大多用于成人，也用于患有大脊髓空洞症的儿童。它的并发症风险（即与脑脊液相关的并发症）更高，住院时间更长，费用更高；然而，它保证了更好的临床改善（>85%）和更低的再次手术风险（2 - 3.5%）。过去十年发表的八项文献荟萃分析（三项针对儿科系列，五项针对成人系列）和一项儿童前瞻性研究在很大程度上证实了这些发现。
PFBD 和 PFBDD 是适用于不同类型患者的不同技术。在儿童中，PFBD 已被证明是最佳选择，尽管有些患者可能需要更积极的治疗。因此，无论有无脊髓空洞症，CIM 治疗的成功取决于正确的手术适应证和根据患者量身定制的选择，而非手术技术。
