1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and.
2Department of Neurosurgery, Duke University, Durham, North Carolina.
J Neurosurg Pediatr. 2024 Sep 20;34(6):619-627. doi: 10.3171/2024.7.PEDS247. Print 2024 Dec 1.
Chiari malformation type I (CM-I) is defined by the herniation of the cerebellar tonsils into the spinal canal. When symptomatic, surgical decompression is recommended. Reported CM-I reoperation rates have ranged from 3% to 30%. However, the relationship between patient age at first surgical intervention and the likelihood of reoperation and postoperative complications remains poorly characterized. Therefore, this study aimed to determine whether patient age was associated with reoperation and complication rates.
Patients 0-21 years old with a diagnosis of CM-I and surgical decompression were queried from the 2007-2021 MarketScan databases. Patient sex, age at time of first procedure, comorbidities, 90-day postoperative complications, and reoperations were identified. Bootstrap-augmented binary classifiers were constructed to determine the optimal timing of first surgical decompression with respect to all-cause 90-day postoperative complications and reoperation. Multivariate logistic regression models were built to assess the relationship between age, sex, and comorbidities and the likelihood of reoperation and complications following surgical decompression.
A total of 2675 patients were included for analysis of 90-day postoperative complications, and 1157 were included in the reoperation analysis cohort. A total of 524 patients (19.6%) experienced a complication within 90 days of surgical decompression, and 84 patients (7.3%) had reoperations. On multivariate regression, increased age was an independent predictor of a reduced likelihood of both reoperations (OR 0.94, 95% CI 0.90-0.98; p < 0.01) and 90-day postoperative complications (OR 0.96, 95% CI 0.94-0.98; p < 0.01). The optimal age cutoff to predict both complications and reoperations was 4 years. For patients ages 4 years and older, both the reoperation rate (5.5% vs 13.2%, p < 0.01) and 90-day postoperative complication rates (18.4% vs 27.7%; p < 0.01) were significantly less than those for children 3 years and younger.
In a national cohort of pediatric patients undergoing surgically managed CM-I, there was a significantly increased likelihood of reoperation and complications in patients ages 3 years and younger. Although CM-I decompression should not be postponed in the face of progressive neurological deficits, the authors' findings suggest that delaying surgery until after the age of 3 years, when medically feasible, may help mitigate adverse events.
Chiari 畸形 I 型（CM-I）的定义是小脑扁桃体疝入椎管。出现症状时，建议进行手术减压。报告的 CM-I 再次手术率范围为 3%至 30%。然而，患者首次手术干预时的年龄与再次手术和术后并发症的可能性之间的关系仍未得到很好的描述。因此，本研究旨在确定患者年龄是否与再次手术和并发症发生率有关。
从 2007 年至 2021 年的 MarketScan 数据库中查询了诊断为 CM-I 并接受手术减压的 0-21 岁患者。确定了患者的性别、首次手术时的年龄、合并症、90 天术后并发症和再次手术情况。构建了自举增强二元分类器，以确定首次手术减压的最佳时机，以降低所有原因 90 天术后并发症和再次手术的风险。建立多变量逻辑回归模型，以评估年龄、性别和合并症与手术减压后再次手术和并发症发生的可能性之间的关系。
共有 2675 名患者纳入 90 天术后并发症分析，1157 名患者纳入再次手术分析队列。共有 524 名患者（19.6%）在手术减压后 90 天内出现并发症，84 名患者（7.3%）接受了再次手术。多变量回归分析显示，年龄增加是降低再次手术（OR 0.94，95%CI 0.90-0.98；p<0.01）和 90 天术后并发症（OR 0.96，95%CI 0.94-0.98；p<0.01）可能性的独立预测因素。预测并发症和再次手术的最佳年龄截点为 4 岁。对于 4 岁及以上的患者，再次手术率（5.5% vs 13.2%，p<0.01）和 90 天术后并发症发生率（18.4% vs 27.7%；p<0.01）均显著低于 3 岁及以下的患儿。
在接受手术治疗的小儿 CM-I 患者的全国性队列中，3 岁及以下患者再次手术和并发症的可能性显著增加。尽管在出现进行性神经功能缺损的情况下不应推迟 CM-I 减压，但作者的研究结果表明，在医学上可行的情况下，延迟手术至 3 岁以后可能有助于减轻不良事件。
