Naessig Sara, Kapadia Bhaveen H, Para Ashok, Ahmad Waleed, Pierce Katherine, Janjua Burhan, Vira Shaleen, Diebo Bassel, Sciubba Daniel, Passias Peter Gust
Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, USA.
Department of Orthopedics, SUNY Downstate Medical Center, Brooklyn, NY, USA.
J Craniovertebr Junction Spine. 2020 Jul-Sep;11(3):232-236. doi: 10.4103/jcvjs.JCVJS_67_20. Epub 2020 Aug 14.
Chiari malformations (CM) are congenital defects due to hypoplasia of the posterior fossa with cerebellar herniation into the foramen magnum and upper spinal canal. Despite the vast research done on this neurological and structural syndrome, clinical features and management options have not yet conclusively evolved. Quantification of proper treatment planning, can lead to potential perioperative benefits based on diagnoses and days to procedure. This study aims to identify if early operation produces better perioperative outcomes or if there are benefits to delaying CM surgery.
Assess outcomes for Chiari type I.
The KID database was queried for diagnoses of Chiari Malformation from 2003-2012 by icd9 codes (348.4, 741.0, 742.0, 742.2). Included patients: had complete time to procedure (TTP) data. Patients were stratified into 7 groups by TTP: Same-day as admission (SD), 1-day delay (1D), 2-day delay (2D), 3-day delay (3D), 4-7 days delay (4-7D), 8-14 days delay (8-14D), >14 days delay (>14D). Differences in pre-operative demographics (age/BMI) and perioperative complication rates between patient cohorts were assessed using Pearson's chi-squared tests and T-tests. Surgical details, perioperative complications, length of stay (LOS), total charges, and discharge disposition was compared. Binary logistic regressions determined independent predictors of varying complications (reference: same-day).
13,812 Chiari type I patients were isolated from KID (10.12 ± 6.3, 49.2F%, .063 ± 1.3CCI). CM-1 pts were older (10.12 yrs vs 3.62 yrs) and had a higher Charlson Comorbidity Score (0.62 vs 0.53; all < 0.05). Procedure rates: 27.8% laminectomy, 28.3% decompression, and 2.2% spinal fusion. CM-1 experienced more complications (61.2% vs 37.9%) with the most common being related to the nervous system (2.8%), anemia (2.4%), acute respiratory distress disorder (2.1%), and dysphagia (1.2%). SD was associated with the low length of stay (5.3 days vs 9.5-25.2 days, < 0.001), total hospital charges ($70,265.44 vs $90, 945.33-$269, 193.26, < 0.001) when compared to other TTP groups. Relative to SD, all delay groups had significantly increased odds of developing postoperative complications (1D-OR: 1.29 [1.1- 1.6] → 8-14D-OR: 4.77[3.4-6.6]; all < 0.05), more specifically, nervous system (1D-OR: 1.8 [1.2-2.5] → 8-14D-OR: 3.3 [1.8-6.2]; all < 0.05).Sepsis complications were associated with a delay of at least 3D(2.5[1.4-4.6]) while respiratory complications (6.2 [3.1-12.3]) and anemia (2 [1.1-3.5]) were associated with a delay of at least 8-14D (all < 0.05).
Chiari 畸形（CM）是由于后颅窝发育不全导致小脑疝入枕骨大孔和上椎管的先天性缺陷。尽管对这种神经和结构综合征进行了大量研究，但临床特征和治疗选择尚未最终明确。基于诊断和手术天数进行适当的治疗计划量化，可带来潜在的围手术期益处。本研究旨在确定早期手术是否能产生更好的围手术期结果，或者延迟 Chiari 畸形手术是否有益。
评估 I 型 Chiari 畸形的治疗结果。
通过国际疾病分类第九版（ICD9）编码（348.4、741.0、742.0、742.2）在 KID 数据库中查询 2003 年至 2012 年期间 Chiari 畸形的诊断病例。纳入患者：有完整的手术时间（TTP）数据。患者按 TTP 分为 7 组：入院当天（SD）、延迟 1 天（1D）、延迟 2 天（2D）、延迟 3 天（3D）、延迟 4 - 7 天（4 - 7D）、延迟 8 - 14 天（8 - 14D）、延迟超过 14 天（>14D）。使用 Pearson 卡方检验和 T 检验评估患者队列术前人口统计学特征（年龄/体重指数）和围手术期并发症发生率的差异。比较手术细节、围手术期并发症、住院时间（LOS）、总费用和出院处置情况。二元逻辑回归确定不同并发症的独立预测因素（参考：入院当天）。
从 KID 数据库中筛选出 13812 例 I 型 Chiari 畸形患者（10.12 ± 6.3 岁，49.2%为女性，0.063 ± 1.3 合并症指数）。CM - 1 型患者年龄较大（10.12 岁 vs 3.62 岁），Charlson 合并症评分较高（0.62 vs 0.53；均 P < 0.05）。手术率：椎板切除术 27.8%，减压术 28.3%，脊柱融合术 2.2%。CM - 1 型患者并发症更多（61.2% vs 37.9%），最常见的与神经系统相关（2.8%）、贫血（2.4%）、急性呼吸窘迫障碍（2.1%）和吞咽困难（1.2%）。与其他 TTP 组相比，SD 组住院时间较短（5.3 天 vs 9.5 - 25.2 天，P < 0.001），总住院费用较低（70265.44 美元 vs 90945.33 - 269193.26 美元，P < 0.001）。相对于 SD 组，所有延迟组术后发生并发症的几率均显著增加（1D - 比值比：1.29 [1.1 - 1.6] → 8 - 14D - 比值比：4.77 [3.4 - 6.6]；均 P < 0.05），更具体地说，神经系统并发症（1D - 比值比：1.8 [1.2 - 2.5] → 8 - 14D - 比值比：3.3 [1.8 - 6.2]；均 P < 0.05）。脓毒症并发症与至少延迟 3 天相关（2.5 [1.4 - 4.6]），而呼吸系统并发症（6.2 [3.1 - 12.3]）和贫血（2 [1.1 - 3.5]）与至少延迟 8 - 14 天相关（均 P < 0.05）。
