Persons with the Chiari malformation, syringomyelia, or the tethered cord often seek Consultation for a number of symptoms. Evaluation begins with the completion of a questionnaire to help determine the symptoms a person is experiencing and to obtain other important medical information such as the presence of other medical conditions, previous surgeries, medications you are taking, and any allergies to medications latex or tape.

Once completed, a nurse practitioner will review the questionnaire with you and ask additional questions. This information is then reviewed by Dr. Oró who will visit with you, clarify any areas to make sure your symptoms are well understood, and assess how they are affecting your life.

Neurological Examination

A neurological examination is then performed and includes testing eye movements, facial movement and sensation, hearing, shoulder shrug, and other cranial nerves. Strength and sensation in the arms and legs is assesses, as is coordination. Walking, heel-to-toe walking and other functions are tested. Depending on the problem evaluated and the symptoms present, other neurological examination tests are performed.

Imaging Studies

Previous imaging studies, such as MRI scans, pertinent to your condition are reviewed. Additional studies may be recommended are usually done in one of the radiology facilities on The Medical Center of Aurora campus, one of the most comprehensive in the state.

Persons living in Colorado will usually schedule a second visit a week or two later to review their studies with Dr. Oró. Persons from out-of-state will usually meet with Dr. Oró either later that day or a couple of days later.

Dr. Oró will meet with you and family or friends, to review the imaging studies. The area of a Chiari malformation, syringomyelia, or tethered cord is explained. If one or more of these conditions are present, and if the quality of your life is significantly affected, surgical treatment may be an option. If surgery is an option, the decision to have surgery is made by you. Minors, of course, make the decision with their parents. Dr. Oró’s goal is to explain the condition, its relation (or lack of relation) to the symptoms, and the nature of the surgery, the possible benefits, and the associated risks.

This review of the imaging studies is an open discussion where all present have an opportunity to ask questions. Scans, models, illustrations are often used to discuss the issues involved. If surgery is an option, you are encouraged to have all your questions answered, make your decision carefully, and take time in making that decision.

Medical Treatment

Some persons will have symptoms that do not significantly impact the quality of their life and are tolerable, or, they want to hold off on any surgical treatment. Therapy and the judicious use of medications may be helpful. Participation by the family physician, therapists, or pain specialists may be needed.

Surgical Treatment

If surgical treatment is an option and you wish to proceed with surgery, Dr. Oró will provide several dates to choose from. Once a decision is made, you will be scheduled to meet with Dr. Oró again prior to the surgery to review the procedure, the benefits and risks involved, and sign a permission (consent) form. (Always remember, you can change your mind at any point before anesthesia.)

The goal of surgery for the Chiari malformation is to create more space at the region of the foramen magnum, to allow the spinal flow to return toward normal, and to reduce compression on the neurological tissues. The procedure is called a posterior fossa decompression. In addition, at The Chiari Care Center, we perform a reconstruction that will be described below.

There are two general types of posterior fossa decompression procedures available: one with opening of the dura membrane, and the other without opening the dura. The open decompression (opening of the dura) is much more common and is the procedure of choice for most patients. Both are described below.

Posterior Fossa Decompression & Reconstruction

A posterior fossa decompression and reconstruction with opening of the dura and sewing in a graft is the procedure performed in most cases with the Chiari I malformation. The surgery is customized depending on an analysis of the morphology (shape and form) of the skull and neurological tissues, and the findings at surgery.

The surgery is performed with the person asleep under general anesthesia. An area of hair about 2 inches wide is shaved at the back of the head. An incision is created from the occipital area at the back of the head to upper neck. Bone is removed at the base of the back of the skull and from the back part of the cervical one (C1) vertebrae. In rare case, the lamina (roof bone) of C2 is also removed.

Once the bone in this area is removed, a tough membrane, called the dura matter, is seen. Ultrasound is then performed. Called color doppler-ultrasonography, it allows visualization of the tonsils, the degree of crowding, and most importantly, the locations of the blood vessels in the area. This helps guide the opening of the dura membrane.

Once the dura membrane is opened, the position of the tonsils and the degree of crowding is assessed. In persons with a syrinx, it is important to look between the tonsils and make sure that a drainage path for spinal fluid, the foramen of Magendie, is open. Sometimes a thin veil is found over the foramen which must be opened to allow freer spinal fluid flow.

In some cases, marked crowding is present despite opening of the dura. In these cases the tips of the cerebellar tonsils are shrunk with electrocautery applied with a fine pincer forceps. No specific deficit has been described from this shrinking the tips of the tonsils. The important point is to create more room in the area, remove the crowding, and allow more normal flow of spinal fluid.

A patch of tissue is then sewn to the edges of the open dura to enlarge the dural sac. The patch material used, called pericranium, is your own tissue that is obtained from underneath the scalp in the area just above the bony removal. Once the patch is sewn in, a customized titanium plate designed by Dr. Oró and produced by the Biomet Microfixation company is attached to the edges of the bony resection using very small titanium screws. The plate is designed to cover but not compress the area of decompression. The muscles previously attached to the bone in this area can now be stiched to the plate. This gives a more natural reconstruction and helps avoid the sunken defect that some persons develop after posterior fossa decompression surgery. The tissues are then closed with stitches and staples are used to close the skin.

MIS Decompression

The MIS Decompression procedure (MIS: minimally invasive surgery) performed without opening of the dura membrane is possible in persons in appropriate morphology: when there is a milder amount of herniation and crowding. As a newer surgical option, there is less information on the results of this technique. Dr. Oró will discuss with you if this procedure is an option in your case.

Risks of Surgery

In deciding whether or not to consider surgical treatment, you should weigh the intensity of your symptoms and quality of your life versus what you understand about the possible benefits and risks of surgery. It is important to ask questions until you are comfortable with your understanding of the procedure, the possible benefits, and the associated risks.

The risks to surgery include leakage of spinal fluid through the membrane repair creating a fluid pocket in the muscle (pseudomeningocele), infection, either in the wound or in the spinal fluid (meningitis), occipital pain (occipital neuralgia), and neurological injury such as hemorrhage, or stroke. There are also the risks of any major surgery such as pneumonia, or cardiac problems. Fortunately, for many people the risks are low. Dr. Oro’ will discuss the risks with you.

Post-op Care

After surgery, you will stay, at least overnight, in the ICU for close observation. During this time, the ICU nurses monitor your vital signs and neurological status. The area of the neck incision is generally stiff and sore after surgery. Pain medication is usually given with a patient-controlled infusion machine, and is tailored to meet your individual needs.

Often, patients complain of nausea or upset stomach after surgery. A medication is given if this occurs. The head of the bed is generally elevated to allow normal flow of the cerebral spinal fluid (CSF), but you can lie on their back or side (whatever is most comfortable). Generally, you may sit in a chair by the following day and walk with assistance. The hospital stay is generally 2 to 3 days. The staples are removed 7 to 10 days after surgery. If you live far away, your family doctor can often remove the staples.

Recovery

Activities
After discharge from the hospital you may be up and walking about the house for the first week. This is a time of healing - so remember - do not overdo the activity. The body needs time to rest, therefore some patients take a nap in the afternoon. Activities such as washing dishes, fixing light meals and dusting are fine. Avoid activities such as vacuuming, lifting, carrying, or anything that requires stretching of the neck muscles. Do not lift anything heavier than a gallon of milk (about 10 pounds) during the first month after surgery. If you are recovering well, the second month you can increase your lifting be 5 more pounds per week to your normal.

Hygiene
Do your best to keep the incision clean and dry at all times. Though sponge bathing is recommended until the staples are removed, you may shower but should try to keep the incision dry and be sure to not rub or soak the incision. You will be allowed to shower 48 hours (two days) after surgery – provided there is no scrubbing on the incision.

It is best to use very light shampoos such as baby shampoo for the first three weeks after surgery.

Be sure to not use any dye, hair coloring or other hair treatments like perm solutions until your follow up appointment.

Driving
Driving should be avoided for the first few weeks after surgery – and especially if any pain medications are being used. Because movement of the neck may feel tight, it is difficult to see in all directions when driving. DO NOT DRIVE if taking narcotic pain medications.

Nutrition
Good nutrition is an essential part of healing. Eating a balanced diet each day, including fruits and vegetables, dairy products and protein will aid in the healing process. A multivitamin is not necessary, unless one is taken normally. Remember to drink plenty of water.

Medications
The neck incision may be tender and stiff for several days. This is normal. Avoid rubbing or scrubbing the area until the staples are removed. If any redness, swelling, heat or drainage is noticed around the incision, the neurosurgeon needs to know immediately.

Most people resume their normal medications after surgery and will also receive a prescription for pain medication after discharge. The pain medication works best if taken every 6-8 hours before the pain worsens. To reduce upset stomach, take the medication with food such as crackers or bread. The pain medication should not be necessary after about the second week. If a refill is needed on pain medication, do not wait until the bottle is empty – call the neurosurgery office at least 2 days before the prescription runs out. DO NOT DRIVE if you are taking narcotic pain medications.

When to notify your neurosurgeon or family doctor if:

1. •your pain is severe unrelieved by medications
   

2. •there is marked swelling at the incision site
   

3. •there is redness, heat or drainage from the incision site
   

4. •you have a fever
   

The Healing Process
Healing after surgery is a gradual process. There are some good days and some days when things seem achy or sore - this is normal. Slowly increasing activity, eating healthy, avoiding strenuous lifting, adhering to your doctor’s advice/instructions and maintaining a positive attitude is the best way to allow the body to recover. Concentrate and focus on the symptoms that have improved, instead of what symptoms remain. The goal is not to recover fully in the first 2 weeks, but to generally progress over the months following surgery.