Elsevier

World Neurosurgery

Volume 140, August 2020, Pages e14-e22
World Neurosurgery

Original Article
Professional Profiles, Technical Preferences, Surgical Opinions, and Management of Clinical Scenarios from a Panel of 63 International Experts in the Field of Chiari I Malformation

https://doi.org/10.1016/j.wneu.2020.03.119Get rights and content

Background

Chiari I Malformation (CMI) and the topics concerning it have been the subject of numerous discussions and polarizing controversies over the course of the past 20 years.

Methods

The opinions of 63 recognized international Neurosurgical CMI experts from 4 continents, with a collective surgical experience of more than 15,000 CMI cases, were gathered through a detailed questionnaire, divided in two parts: diagnostic and therapeutic.

The therapeutic part was organized into four sections: Professional Profile, Technical Preferences, Surgical Opinions, and Clinical Scenarios.

Results

The data reflected a wide spectrum of opinions, approaches, and expertise.

The second part of the questionnaire dealt with the surgical aspects of CMI care and painted a more complex picture:

• 81% of the surgeons preferred the Intradural technique.

• 88% of the experts agreed that CMI surgery is not indicated for minimal non-debilitating symptoms alone, or as prophylaxis.

• In the face of given clinical scenarios, a wide spectrum of therapeutic approaches was chosen by the whole group, but the 4 Surgeons with the largest case series expressed the same opinion.

• Eight out of 63 Surgeons had a surgical experience above 600 cases, were responsible for more than half of the total 15,000 declared CMI cases, and shared a similar profile in terms of technical surgical choices, therapeutic opinions, and low complication rate, with a marked preference for Intradural techniques and tonsillar manipulation.

• Once large individual case series were accumulated, we did not see any differences in the opinions and preferences between Adult and Pediatric Neurosurgeons.

Conclusion

Surgeons who have focused on CMI have been able to accumulate large surgical series, have chosen in their practices the more aggressive (and intrinsically more effective) CMI surgical techniques, and have achieved a low complication rate which compares favorably with that one of the extradural techniques.

Introduction

Chiari I malformation (CMI) and the topics concerning it have been the subject of numerous discussions and polarizing controversies over the course of the last 20 years.1, 2, 3, 4

To get a clearer idea of current opinions among clinicians focused on CMI management, we decided to poll a number of experts in that field, to gather information relative to their opinions and their experience.

Section snippets

Materials and Methods

We contacted 100 clinicians with a recognized interest in CMI from 4 continents to answer an ad hoc questionnaire, as a preface to the XXIX Conference of the American Chiari and Syringomyelia Alliance Project, which took place in Long Island, New York, on July 19–23, 2017. These clinicians were identified from a PubMed search of authors of Chiari-related publications over the last 20 years. We received replies from a total of 63 CMI experts, with a collective surgical experience of more than

Results

The list of the questions is presented in Table 2, Table 3, Table 4, Table 5. Each question was identified by its progressive number in the questionnaire. The questions are arranged in numerical order and grouped by topic, along with the polling results, as a percentage of the responders: professional profiles (Table 2), technical preferences (Table 3), surgical opinions (Table 4), and clinical scenarios (Table 5).

Fourteen questions scored agreements at 75% or above and have been marked within

Surgical Opinions Regarding the Management and Treatment of Patients with SM

A series of axioms about aspects of the surgical management of SM were submitted to the pollers (Table 4). The axioms agreed on by most of the polled experts are as follows:

  • 1.

    Aspiration of an SM cavity19 is an obsolete procedure, fraught with risks and ultimately leading to the spontaneous reinflation of the SM (95%).

  • 2.

    Whenever an SM needs surgical attention, you treat the cause, then you treat the cause again, and you shunt the SM only as a last resort (93%).

  • 3.

    Lysis of adhesions complemented by an

Discussion

The results of a questionnaire focused on CMI surgical practices among pediatric neurosurgeons were published in 2004 by Schijman and Steinbok.24 There were 76 responders, out of 246 pediatric neurosurgeons reached worldwide. A consensus was reached about not operating on asymptomatic patients with CMI, unless SM or scoliosis was present. Most of the responders favored intradural techniques, with pericranial or synthetic patches. SM shunting was recommended by most of the pollers, in case of

Conclusions

Surgeons who have focused on CMI have been able to accumulate large surgical series, have chosen in their practices the more aggressive (and intrinsically more effective) CMI surgical techniques, and have achieved a low complication rate which compares favorably with that of the extradural techniques.

Acknowledgments

The authors thank Matthew Bloom for proofreading, Robert Keating, M.D., for sound advice, Ms. Patrice Schaublin for logistical support, Thomas H. Milhorat, M.D., for unforgettable mentoring, and Allison Bloom, M.D., for unwavering support.

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    • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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