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Complications and Resource Use Associated With Surgery for Chiari Malformation Type 1 in Adults: A Population Perspective.

ABSTRACT: Outcomes research on Chiari malformation type 1 (CM-1) is impeded by a reliance on small, single-center cohorts.To study the complications and resource use associated with adult CM-1 surgery using administrative data.We used a recently validated International Classification of Diseases, Ninth Revision, Clinical Modification code algorithm to retrospectively study adult CM-1 surgeries from 2004 to 2010 in California, Florida, and New York using State Inpatient Databases. Outcomes included complications and resource use within 30 and 90 days of treatment. We used multivariable logistic regression to identify risk factors for morbidity and negative binomial models to determine risk-adjusted costs.We identified 1947 CM-1 operations. Surgical complications were more common than medical complications at both 30 days (14.3% vs 4.4%) and 90 days (18.7% vs 5.0%) postoperatively. Certain comorbidities were associated with increased morbidity; for example, hydrocephalus increased the risk for surgical (odds ratio [OR] = 4.51) and medical (OR = 3.98) complications. Medical but not surgical complications were also more common in older patients (OR = 5.57 for oldest vs youngest age category) and male patients (OR = 3.19). Risk-adjusted hospital costs were $22530 at 30 days and $24852 at 90 days postoperatively. Risk-adjusted 90-day costs were more than twice as high for patients experiencing surgical ($46264) or medical ($65679) complications than for patients without complications ($18880).Complications after CM-1 surgery are common, and surgical complications are more frequent than medical complications. Certain comorbidities and demographic characteristics are associated with increased risk for complications. Beyond harming patients, complications are also associated with substantially higher hospital costs. These results may help guide patient management and inform decision making for patients considering surgery.

SUBMITTER: Greenberg JK

PROVIDER: S-EPMC4506249 | biostudies-literature | 2015 Aug

REPOSITORIES: biostudies-literature

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Complications and Resource Use Associated With Surgery for Chiari Malformation Type 1 in Adults: A Population Perspective.

Greenberg Jacob K JK Ladner Travis R TR Olsen Margaret A MA Shannon Chevis N CN Liu Jingxia J Yarbrough Chester K CK Piccirillo Jay F JF Wellons John C JC Smyth Matthew D MD Park Tae Sung TS Limbrick David D DD

Neurosurgery 20150801 2

<h4>Background</h4>Outcomes research on Chiari malformation type 1 (CM-1) is impeded by a reliance on small, single-center cohorts.<h4>Objective</h4>To study the complications and resource use associated with adult CM-1 surgery using administrative data.<h4>Methods</h4>We used a recently validated International Classification of Diseases, Ninth Revision, Clinical Modification code algorithm to retrospectively study adult CM-1 surgeries from 2004 to 2010 in California, Florida, and New York using ...[more]

PMID: 25910086

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Project description:OBJECTIVE Chiari malformation Type I (CM-I) is a common and often debilitating pediatric neurological disease. However, efforts to guide preoperative counseling and improve outcomes research are impeded by reliance on small, single-center studies. Consequently, the objective of this study was to investigate CM-I surgical outcomes using population-level administrative billing data. METHODS The authors used Healthcare Cost and Utilization Project State Inpatient Databases (SID) to study pediatric patients undergoing surgical decompression for CM-I from 2004 to 2010 in California, Florida, and New York. They assessed the prevalence and influence of preoperative complex chronic conditions (CCC) among included patients. Outcomes included medical and surgical complications within 90 days of treatment. Multivariate logistic regression was used to identify risk factors for surgical complications. RESULTS A total of 936 pediatric CM-I surgeries were identified for the study period. Overall, 29.2% of patients were diagnosed with syringomyelia and 13.7% were diagnosed with scoliosis. Aside from syringomyelia and scoliosis, 30.3% of patients had at least 1 CCC, most commonly neuromuscular (15.2%) or congenital or genetic (8.4%) disease. Medical complications were uncommon, occurring in 2.6% of patients. By comparison, surgical complications were diagnosed in 12.7% of patients and typically included shunt-related complications (4.0%), meningitis (3.7%), and other neurosurgery-specific complications (7.4%). Major complications (e.g., stroke or myocardial infarction) occurred in 1.4% of patients. Among children with CCCs, only comorbid hydrocephalus was associated with a significantly increased risk of surgical complications (OR 4.5, 95% CI 2.5-8.1). CONCLUSIONS Approximately 1 in 8 pediatric CM-I patients experienced a surgical complication, whereas medical complications were rare. Although CCCs were common in pediatric CM-I patients, only hydrocephalus was independently associated with increased risk of surgical events. These results may inform patient counseling and guide future research efforts.

Project description:BackgroundPseudomeningoceles (PMCs) as abnormal collections of cerebrospinal fluid are quite common findings on follow-up MRI after Chiari decompression surgery (CDS). However, the importance of their identification has not been truly determined, especially when PMCs are described occasionally in the process of radiological follow-up. We retrospectively analyzed surgical outcomes and imaging findings after CDS depending upon the occurrence and thickness of PMCs.MethodsA total of 76 adult patients who underwent CDS were analyzed. The clinical and radiological outcomes of patients with a pseudomeningocele (wPMC) were evaluated and compared to those of patients without a pseudomeningocele (w/oPMC). Radiological morphometric measurements were performed and compared between groups. Comparisons of the maximal PMC thickness were made within the wPMC group.ResultsPMCs were recognized in 27 (35.5%) patients, of whom 3 (11.1%) required reoperation. Differences in satisfactory result rates regarding gestalt assessment and Chicago Chiari Outcome Scale were statistically insignificant between the w/oPMC and wPMC groups (p = 1 and p = 0.56, respectively). The postoperative syringomyelia decrease and cerebellar tonsil elevation were similar between the groups (p = 1 and p = 0.74, respectively) in the long-term follow-up. Additionally, the clinical or radiological outcomes with radiological details were not related to PMC thickness in the long-term follow-up. However, radiological details showed the cooccurrence of PMCs with a postsurgical of cerebello-tentorial distance increase (p < 0.05), basion-pontomedullary sulcus distance decrease (p < 0.05) and tonsillo-graft distance decrease (p < 0.05).ConclusionsWe found no significant relationships between PMC presence or thickness and clinical or radiological outcomes. However, postoperative changes within the posterior fossa associated with PMCs resemble brain sagging, which occurs in intracranial hypotension. Therefore, extradural cerebrospinal fluid escape may also be responsible for symptoms in some patients with PMCs after CDS.

Project description:OBJECT:Chiari malformation Type I (CM-I) is characterized by hindbrain deformity. We investigated the effects of craniocervical decompression surgery on the anatomical features of hindbrain deformity with a prospective MRI study of patients with CM-I. METHODS:A prospective longitudinal study was conducted in 48 patients with CM-I (39 with syringomyelia) treated with craniocervical decompression. Clinical examinations and cervical MRI were performed before surgery and 1 week, 3-6 months, and annually after surgery. Hindbrain deformity was defined by tonsillar ectopia, pointed cerebellar tonsils, and/or cervicomedullary protuberance. The length of the clivus, basiocciput (sphenooccipital synchondrosis to basion), supraocciput (internal occipital protuberance to opisthion), and anteroposterior (AP) width of CSF pathways at the foramen magnum were measured and compared with those from 18 healthy volunteers (control group). RESULTS:Before surgery, the patients' posterior fossa bones were short and their CSF pathways were narrow. All patients had tonsillar ectopia (mean [± SD] 12.3 ± 5.1 mm; normal 0.3 ± 1.0). The majority of patients had pointed tonsils and more than two-thirds exhibited a cervicomedullary protuberance. Clivus and basiocciput lengths were significantly shorter than the values obtained in the control group. However, the supraocciput length did not differ significantly from control measurements. The mean bulbopontine sulcus distance superior to the basion was 9.5 ± 2.6 mm (vs 13.6 ± 2.8 mm in controls; p < 0.0001). The AP widths of the CSF pathways at the level of the foramen magnum were significantly narrowed. After surgery, CSF pathways significantly expanded both ventrally and dorsally. By 3-6 months after surgery, pointed tonsils became round, cervicomedullary protuberance disappeared, and tonsillar ectopia diminished by 51% (to 6.0 ± 3.3 mm; p < 0.0001). CONCLUSIONS:The cerebellar tonsils and brainstem assumed a normal appearance within 6 months after craniocervical decompression. These findings support the concept that the CM-I is not a congenital malformation of the neural elements but rather an acquired malformation that arises from pulsatile impaction of the cerebellar tonsils into the foramen magnum. Clinical trial registration no.: NCT00001327.

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Complications and Resource Use Associated With Surgery for Chiari Malformation Type 1 in Adults: A Population Perspective.

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Complications and Resource Use Associated With Surgery for Chiari Malformation Type 1 in Adults: A Population Perspective.

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