Surgical Treatment of Chiari I Malformation

Neurosurgery 71:365–380, 2012 DOI: 10.1227/NEU.0b013e31825c3426

Foramen magnum decompression is widely accepted as the treatment of choice for Chiari I malformation. However, important surgical details of the procedure are controversial.

OBJECTIVE: This study analyzes 371 decompressions focusing on intraoperative findings, analysis of complications, and long-term outcomes.

METHODS: Among 644 patients between 1985 and 2010, 359 patients underwent 371 decompressions. Surgery for symptomatic patients consisted of suboccipital craniectomy, C1 laminectomy, arachnoid dissection, and duraplasty. Short-term results were determined after 3 months; long-term outcomes were evaluated with Kaplan-Meier statistics.

RESULTS: The mean age was 40 ± 16 years; mean follow-up was 49 ± 56 months; 75.8% demonstrated syringomyelia. The complication rate was 21.8% with permanent surgical morbidity of 3.2% and surgical mortality of 1.3%. Of the patients, 73.6% reported improvement after 3 months; 21% were unchanged. Overall, 14.3% demonstrated a neurological deterioration within 5 years and 15.4% within 10 years. The severity of neurological symptoms correlated with the grade of arachnoid pathology. Outcome data correlated with the number of previous decompressions, severity of arachnoid pathology, handling of the arachnoid, type of duraplasty, and surgical experience. Firsttime decompressions with arachnoid dissection and an alloplastic duraplasty resulted in surgical morbidity for 2.0%, a 0.9% mortality rate, postoperative improvement after 3 months for 82%, and neurological recurrence rates of 7% after 5 years and 8.7% after 10 years.

CONCLUSION: Arachnoid pathology in Chiari I malformation has an impact on clinical symptoms and postoperative results. Decompressions with arachnoid dissection and an alloplastic duraplasty performed by surgeons experienced with this pathology offer a favorable long-term prognosis.