Chiari I malformation management in patients with heritable connective tissue disorders

Jamie E Clarke; Joshua M Reyes; Evan Luther; Vaidya Govindarajan; Jessica D Leuchter; Toba Niazi; John Ragheb; Shelly Wang

doi:10.1016/j.wnsx.2023.100173

Chiari I malformation management in patients with heritable connective tissue disorders

World Neurosurg X. 2023 Mar 5:18:100173. doi: 10.1016/j.wnsx.2023.100173. eCollection 2023 Apr.

Authors

Jamie E Clarke¹, Joshua M Reyes¹, Evan Luther^{1

2}, Vaidya Govindarajan¹, Jessica D Leuchter¹, Toba Niazi^{2

3}, John Ragheb^{2

3}, Shelly Wang^{2

3}

Affiliations

¹ Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.
² Department of Neurosurgery, University of Miami, Miami, FL, USA.
³ Division of Neurosurgery, Brain Institute, Nicklaus Children's Hospital, Miami, FL, USA.

Abstract

Background: Chiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges.

Objective: This study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD.

Methods: Patients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26).

Results: 38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001).

Conclusions: Patients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.

Keywords: Chiari I Malformation; Connective tissue disease; Ehlers-danlos syndrome; Marfan syndrome; Neurosurgery; Osteogenesis imperfecta; Syringomyelia.