Surgical treatment of the Chiari malformation involves creating more space at the region of the foramen magnum to allow the spinal flow in this area to return toward normal. This is done by a procedure called a Posterior Fossa decompression. The surgery is performed by creating an incision at the back of the head into the upper part of the neck. The muscles are spread to either side and the occipital bone and the back of the C1 vertebrae are visualized. Skull bone and often the arch of C1 (in some cases C2) are removed.

Under the bone is a tough membrane called the dura. The surgeon then opens the dura. Here, the surgical technique varies depending on the practice of the surgeon. Some surgeons open the next layer called the Arachnoid and may shrink the tips of the Tonsils with Electrocautery. Others do not open the arachnoid. Studies to date do not tell us which is the best procedure as there is no documented negative effect from shrinking the tonsils. The important point is to create more room and thus remove the crowding.

Most surgeons will then sew a patch of material into the dura to enlarge the foramen magnum. The wound is then closed with stitches to bring the muscles together and stitches or staples are used to close the skin.

The risks to surgery include leak 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 neuralgia, and neurological deficit such as an injury, 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. Your neurosurgeon will discuss the risks with you.

Recovery

Usually, the patient will stay in the ICU overnight for close observation. During this time, the ICU nurses will monitor the 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 the needs of the individual patient.

Often, patients complain of nausea or upset stomach after the 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 the patient can lie on their back or side (whatever is most comfortable). Generally, the patient may sit in a chair by the following day and may walk with assistance. The hospital stay is generally 2 to 3 days. The staples are removed 7 to 10 days after surgery.

Activities

After discharge from the hospital the patient 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. Avoid reaching forward to lift anything. Do not lift anything heavier than a gallon of milk (about 10 pounds).

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. After the staples are removed in 7 to 10 days, taking a normal shower is fine – provided there is no scrubbing on the incision. Also, be sure to not use any die, hair coloring or other hair treatments like perm solutions until your follow up appointment. It is best to use very light shampoos such as baby shampoo for the first three weeks after surgery.

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 health care provider . . .

– the neurosurgeon should be notified if:

• · patient has severe pain unrelieved by medications
• · patient has swelling at the incision site
• · patient has redness, heat or drainage from the incision site
• · patient has 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.