Decompression with or without Duraplasty for Chiari I and Syringomyelia

Clinical Snapshot

Key Findings

• P Value: P = 0.11

• Effect Size: Adjusted odds ratio 2.59 for complications with duraplasty

• Primary Outcome: Surgical complications within 6 months: 14% (PFD-D) vs 6% (PFD alone)

• Nnt Or Sensitivity: Number needed to harm: 13 patients (95% CI: harm in 6 to benefit in 50)

• Confidence Interval: 95% CI 0.86 to 7.84

Clinical Application

Both procedures are standard neurosurgical techniques available in tertiary paediatric centres with appropriate expertise Relevant to Australian paediatric neurosurgical practice. Both procedures covered under public health system. Results may inform clinical guidelines and shared decision-making discussions Children and adolescents with symptomatic Chiari I malformation and moderate syringomyelia presenting to paediatric neurosurgical services

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.).

References

1. 1.Limbrick, D. D., Shannon, C. N., Bayman, E. O., Meehan, T., Kallem, M., Ackerman, L. L., Adelson, P. D., Ahmed, R., Albert, G., Aldana, P. R., Alden, T. D., Anderson, R. C. E., Baird, L. C., Bauer, D., Bethel-Anderson, T., Bierbrauer, K., Brockmeyer, D. L., Chern, J. J., Couture, D. E., ... Park, T. S., & Torner, J. C. (2026). Decompression with or without duraplasty for Chiari I and syringomyelia. *New England Journal of Medicine*. https://doi.org/10.1056/NEJMoa2402821