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Cervical Conundrum

Diagnosis and Treatment

Diagnosis

Based on the history, clinical examination, and MRI findings, the diagnosis of Chiari I malformation was made.

Objectives

• Describe the operative procedure for Chiari I malformation
• Describe the possible operative risks
• Describe the post-operative course

Operative Procedure: Posterior Fossa Decompression

The patient is taken to the operating room, where general anesthesia is induced. The patient is then positioned prone with the head supported in a three-pin head holder. The occipital area is shaved and prepped in a sterile fashion. A midline incision is created from the inion to C2. Dissection continues until the suboccipital area is exposed. A craniectomy of the suboccipital area is performed to visualize the dura and C1 area. A straight or Y-shaped incision is made into the dura over the cerebellar hemisphere. Drainage from the Foramen of Magendi is evaluated. Fine electrocautery may be needed to shrink the cerebellar tonsils in effort to restore normal CSF pathway. A patch graft of either bovine pericardium, synthetic material, or periosteum is then created to enlarge the posterior fossa at the foramen magnum and upper cervical spine. The incision is then closed with subcutaneous suture and external staples. The patient is generally extubated in the operating room and transferred to post anesthesia recovery room during the immediate post-operative period.

Possible Operative Risks

The operative risks include (but are not limited to) bleeding from the operative site, infection, spinal fluid leak and neurologic damage. The specific risks are discussed with each patient prior to surgery.

Post Operative Course

The patient is generally observed in the neurosurgical stepdown unit for approximately 24 hours after surgery. Pain control is achieved with patient controlled analgesia (usually morphine) and an antiinflammatory (such as Toradol®). Most patients state the neck is "sore;" however, pain is manageable with medications. Nausea is a common complaint after surgery, and is generally controlled with antiemetics. The patient is encouraged to sit in a chair on post-operative day 1, and is allowed to ambulate by post-operative day 2. Most patients will be discharged by day 3 or 4, depending on pain control and ability to maintain adequate caloric intake. The patient is then evaluated in clinic at 1 month intervals until discharge from the clinic.