Toward a simpler surgical management of Chiari I malformation in a pediatric population

A wide variety of surgical adjuvants to the standard bony decompression hav e been advocated in the treatment of the Chiari I malformation, especially when the tonsillar herniation is associated with hydrosyringomyelia. These include various shunting procedures, duroplasty, obex plugging, and resecti on of the cerebellar tonsils. Our practice has been to avoid these adjuvant s and to perform a simple limited occipital craniectomy, C-1 laminectomy, a nd dural opening. The dura mater is left open and overlain with oxidized ce llulose. To evaluate the efficacy of this more limited procedure, a retrosp ective review was performed of the medical records of 31 consecutive patien ts treated over a 6-year period. Twenty-six (84%) of these patients had an associated spinal cord syrinx; all underwent the same procedure. The follow -up period ranged from 15 to 93 months, with all patients having at least o ne postoperative magnetic resonance imaging at 6 months. Twenty-three of th e 26 patients (88%) who presented with a syrinx had significant resolution of the syrinx on follow-up scans with concomitant improvement of presenting signs and symptoms. Of the remaining 3 patients, 1 had progressive hydroce phalus and received a ventriculoperitoneal shunt, with symptom resolution. In the other 2 patients the syrinx did not diminish; both received syringop leural shunts. Postoperative morbidity includes a 26% incidence of headache s, of which half resolved within 5 days, and only 1 persisted beyond 2 week s. Nausea and vomiting occurred in 16%. Neither of these figures significan tly exceeds those of other large surgical series in which the dura mater wa s closed with a patch graft. Three patients (10%) did have a postoperative cerebrospinal fluid leak; all responded to bedside suturing without further sequelae. This study indicates that a simple bone removal and open dural d ecompression of the cervicomedullary junction is a safe, effective operativ e treatment for Chiari I malformation in children. Shunts, duroplasty, obex plugging, and tonsillar resection offer no benefit regarding the outcome w hen our series is compared to others in which such adjuvants were used.