Decompression with or without Duraplasty for Chiari I and Syringomyelia

BACKGROUND: In children with Chiari type I malformation and syringomyelia, neurosurgical posterior fossa decompression (PFD) provides clinical improvement, but whether duraplasty (incising the dura and placing a dural graft) improves outcomes is unclear. METHODS: We conducted a multicenter, cluster-randomized, controlled trial of PFD with duraplasty (PFD-D) as compared with PFD alone. Persons 21 years of age or younger with cerebellar tonsillar ectopia of at least 5 mm and a maximum syrinx diameter of 3.0 to 9.9 mm were enrolled at 38 centers. Centers were cluster-randomized: all the participants within each center underwent the same intervention. The primary outcome was surgical complications within 6 months. Secondary outcomes were clinical improvement, syrinx reduction, and repeat decompression at 10 to 24 months and the change in overall health-related quality of life at 6 to 24 months. RESULTS: A total of 162 participants were included in the trial, of whom 78 were assigned to undergo PFD-D and 84 to undergo PFD alone. The percentage of participants with complications within 6 months was 14% with PFD-D and 6% with PFD (adjusted odds ratio, 2.59; 95% confidence interval [CI], 0.86 to 7.84; P = 0.11). At 24 months, the percentage of participants with clinical improvement was 58% with PFD-D and 46% with PFD; the mean (±SD) syrinx reduction was 3.08±2.33 mm and 1.22±1.79 mm, respectively; and the percentage of participants with repeat decompression was 3% and 14%. Changes in health-related quality of life were similar in the two groups. CONCLUSIONS: The percentage of participants with surgical complications did not differ significantly between those who underwent PFD-D and and those who underwent PFD alone. Larger trials are needed to determine the relative benefits and risks of these two procedures. (Funded by the Patient-Centered Outcomes Research Institute and others; ClinicalTrials.gov number, NCT02669836.).

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Journal
New England Journal of Medicine
Published
2026-05-27
DOI
https://doi.org/10.1056/nejmoa2402821
Primary Topic
Spinal Dysraphism and Malformations
Type
article
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article

Decompression with or without Duraplasty for Chiari I and Syringomyelia

Thanda Meehan, Gregory Heuer, Rick Labuda, Francesco T. Mangano et al.
New England Journal of Medicine
Spinal Dysraphism and Malformations
article

Decompression with or without Duraplasty for Chiari I and Syringomyelia

Thanda Meehan, Gregory Heuer, Rick Labuda, Francesco T. Mangano, Sean D. McEvoy, Jacob K. Greenberg, Jeffrey P. Greenfield, Laurie L. Ackerman, Toba N. Niazi, Cormac O. Maher, George I. Jallo, Tammy Bethel-Anderson, Gerald F. Tuite, Scellig S. D. Stone, Joshua J. Chern, Patrick Graupman, Mark D. Krieger, Naina L. Gross, Scott D. Wait, Robert C. McKinstry, Haley Vance, Joshua S. Shimony, James M. Johnston, Ralph G. Dacey, Arnold H. Menezes, Douglas L. Brockmeyer, Richard C. E. Anderson, Jerry Oakes, Elizabeth C. Tyler‐Kabara, Bermans J. Iskandar, Tord D. Alden, Brian J. Dlouhy, Raheel Ahmed, M Tamber, John C. Wellons, Philipp R. Aldana, Greg Olavarria, Marisa Kallem, Sandy Spears, Gina Tramelli, Samuel Reeves, Brent R. O’Neill, WE Whitehead, Robert C. Dauser, Stephen R. Gannon, Susan Durham, P. David Adelson, Ramin Eskandari, Daniel Couture, T. Hankinson, Jeffrey R. Leonard, David Bauer, Chevis N. Shannon, Alexander T. Yahanda, Abhaya V. Kulkarni, Daniel J. (Daniel James) Guillaume, David J. Daniels, Michael P. Kelly, J. Gordon McComb, Yan Yan, Lissa C. Baird, James C. Torner, John Ragheb, Mark Iantosca, Gregory Albert, David D. Limbrick, Eric M. Jackson, Richard G. Ellenbogen, Jennifer M. Strahle, Emine O. Bayman, Stephanie Greene, Nathan R. Selden, Robert F. Keating, Matthew D. Smyth, Elaine Kennedy, Tae Sung Park, Lisa Reynolds, Gerald A. Grant, Karin Bierbrauer, Dorothy Poppe, Manish N. Shah
article en

Abstract

BACKGROUND: In children with Chiari type I malformation and syringomyelia, neurosurgical posterior fossa decompression (PFD) provides clinical improvement, but whether duraplasty (incising the dura and placing a dural graft) improves outcomes is unclear. METHODS: We conducted a multicenter, cluster-randomized, controlled trial of PFD with duraplasty (PFD-D) as compared with PFD alone. Persons 21 years of age or younger with cerebellar tonsillar ectopia of at least 5 mm and a maximum syrinx diameter of 3.0 to 9.9 mm were enrolled at 38 centers. Centers were cluster-randomized: all the participants within each center underwent the same intervention. The primary outcome was surgical complications within 6 months. Secondary outcomes were clinical improvement, syrinx reduction, and repeat decompression at 10 to 24 months and the change in overall health-related quality of life at 6 to 24 months. RESULTS: A total of 162 participants were included in the trial, of whom 78 were assigned to undergo PFD-D and 84 to undergo PFD alone. The percentage of participants with complications within 6 months was 14% with PFD-D and 6% with PFD (adjusted odds ratio, 2.59; 95% confidence interval [CI], 0.86 to 7.84; P = 0.11). At 24 months, the percentage of participants with clinical improvement was 58% with PFD-D and 46% with PFD; the mean (±SD) syrinx reduction was 3.08±2.33 mm and 1.22±1.79 mm, respectively; and the percentage of participants with repeat decompression was 3% and 14%. Changes in health-related quality of life were similar in the two groups. CONCLUSIONS: The percentage of participants with surgical complications did not differ significantly between those who underwent PFD-D and and those who underwent PFD alone. Larger trials are needed to determine the relative benefits and risks of these two procedures. (Funded by the Patient-Centered Outcomes Research Institute and others; ClinicalTrials.gov number, NCT02669836.).

New England Journal of MedicineVol. 394(20)
University of Arkansas at Little Rock (US), West Virginia University (US), University of Iowa (US), Atrium Health Wake Forest Baptist (US), Cincinnati Children's Hospital Medical Center (US), Primary Children's Hospital (US), Children's Hospital of Philadelphia (US), Children's National (US), Children's Hospital of Los Angeles (US), NewYork–Presbyterian Hospital (US), University of Wisconsin–Madison (US), Harvard University (US), Johns Hopkins University (US), Medical University of South Carolina (US), Oregon Health & Science University (US), Duke University (US), Baylor College of Medicine (US), Virginia Commonwealth University (US), University of Washington (US), Washington University in St. Louis (US), Cornell University (US), Johns Hopkins Medicine (US), Arnold Palmer Hospital for Children (US), New York Hospital Queens (US), Hospital for Sick Children (CA), University of Iowa Hospitals and Clinics (US), University of Alabama at Birmingham (US), Jacksonville University (US), Rady Children's Hospital-San Diego (US), Carolina Neurosurgery and Spine Associates (US), Children's Hospital Colorado (US), Johns Hopkins All Children's Hospital (US), Gillette Children's Specialty Healthcare (US), Mallinckrodt (United States) (US), Hope Center for Neurological Disorders (US), Mayo Clinic in Arizona (US), Lurie Children's Hospital (US), University of Minnesota Medical Center (US), Stanford Medicine (US), Saint Francis Health System (US), Chiari & Syringomyelia Foundation (US), Miami Children's Hospital (US), Children's Healthcare of Atlanta (US), BC Children's Hospital (CA), Instituto de Fomento Pesquero (CL), Neurological Surgery (US), The University of Texas Health Science Center (US), Virginia Mason Bainbridge Island Medical Center (US), The Ohio State University (US), Indiana University – Purdue University Indianapolis (US), New York University (US), Penn State Milton S. Hershey Medical Center (US), The University of Texas at Austin (US), Vanderbilt University Medical Center (US), University of Colorado Denver (US), Florida College (US)
Patient-Centered Outcomes Research Institute
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Spinal Dysraphism and Malformations
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