Similar Surgical Complication Rates Seen With PFD-D and PFD Alone in kids with Chiari type I malformation and syringomyelia: NEJM

A new study published in The New England Journal of Medicine found no significant difference in surgical complication rates between patients undergoing posterior fossa decompression with duraplasty (PFD-D) and those receiving posterior fossa decompression (PFD) alone among children with Chiari type I malformation and syringomyelia.

The findings suggest that both surgical approaches may have comparable short-term safety profiles. However, investigators emphasized that larger clinical trials are needed to better define the relative benefits, risks, and long-term outcomes associated with each procedure.

Across 38 medical centers, this study examined whether PFD-D provided better outcomes than decompression alone. Chiari type I malformation is a neurological condition in which brain tissue extends into the spinal canal, often leading to the development of syringomyelia, that can cause pain, weakness, and neurological deficits.

This research enrolled 162 patients aged 21 years or younger who had cerebellar tonsillar ectopia of at least 5 millimeters and a syrinx measuring between 3.0 and 9.9 millimeters in diameter. Participants were assigned by treatment center to undergo either PFD-D or PFD alone. The goal was to compare surgical complications within six months of treatment, while secondary outcomes included symptom improvement, syrinx reduction, need for repeat surgery, and health-related quality of life over a period of up to 24 months.

Surgical complications occurred in 14% of patients who underwent PFD-D, when compared to 6% of those who received PFD alone. Although the complication rate was numerically higher in the duraplasty group, the difference did not reach statistical significance.

By 24 months after surgery, 58% of patients in the PFD-D group experienced clinical improvement, when compared to 46% in the PFD-only group. Patients receiving duraplasty also demonstrated substantially greater reduction in syrinx size, with an average decrease of 3.08mm versus 1.22mm among those treated with decompression alone.

Only 3% of patients who underwent PFD-D required another operation, when compared to 14% of patients treated with PFD alone. This finding suggests that duraplasty may provide a more durable surgical result for some patients. Despite these differences, overall health-related quality of life improved similarly in both group.

While duraplasty did not significantly increase or decrease complication rates, it may offer advantages in reducing syrinx size and lowering the likelihood of repeat surgery. Further larger studies will be necessary to fully clarify the balance of benefits and risks between the two surgical approaches.

Source:

Limbrick, D. D., Jr, 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-Reeves Syringomyelia Research Consortium Investigators. (2026). Decompression with or without duraplasty for Chiari I and syringomyelia. The New England Journal of Medicine, 394(20), 2015–2025. https://doi.org/10.1056/NEJMoa2402821