title: Treatment of Chiari I malformation in patients with and without syringomyelia: a consecutive series of 66 cases.
abstract: OBJECTIVE
  The authors describe the results of performing a standard posterior craniovertebral decompression and placement, if indicated, of a syringosubarachnoid shunt for the treatment of patients with Chiari I malformation with and without syringomyelia.
  
  
  METHODS
  This is a retrospectively analyzed consecutive series of 66 patients (mean patient age 15 years, range 1-53 years). The uniform posterior craniovertebral decompression consisted of a small suboccipital craniectomy, a C-1 laminectomy, microsurgical reduction of the cerebellar tonsils, and dural closure with a synthetic dural graft to increase the cerebrospinal fluid space at the craniocervical junction. The presence of a large syrinx, with significant thinning of the spinal cord tissue and obliteration of the spinal subarachnoid space, particularly when combined with syrinx-related symptoms, was an indication for the placement of a syringosubarachnoid shunt. In 32 patients Chiari I malformation alone was present, and 34 in patients it was present in combination with syringomyelia. Clinical findings included pain, neurological deficits, and spinal deformity. The presence of syringomyelia was significantly associated with the presence of scoliosis (odds ratio 74.4 [95% confidence interval 8.894-622.4]). All patients underwent a posterior craniovertebral decompression procedure. In 22 of the 34 patients with syringomyelia a syringosubarachnoid shunt was also placed. The mean follow-up period was 24 months (range 3-95 months). Excellent outcome was achieved in 54 patients (82%) and good outcome in 12 (18%). In no patient were symptoms unchanged or worse at follow-up examination, including four patients who initially required a second operation for persistent syringomyelia. Pain was more likely to resolve than sensory and motor deficits after decompressive surgery. Radiological examination revealed normalization of tonsillar position in all patients. The syrinx had disappeared in 15 cases, was decreased in size in 17, and remained unchanged in two.
  
  
  CONCLUSIONS
  Posterior craniovertebral decompression and selective placement of a syringosubarachnoid shunt in patients with Chiari I malformation and syringomyelia is an effective and safe treatment. Primary placement of a shunt in the presence of a sufficiently large syrinx appears to be beneficial. The question of if and when to place a shunt, however, requires further, preferably prospective, investigation.
authors.affiliation: Institute for Neurology and Neurosurgery, Singer Division, Department of Pediatric Neurosurgery, Beth Israel Medical Center, New York, New York 10128, USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Alzate
authors.forename: K F
authors.initials: KF
authors.lastname: Kothbauer
authors.forename: G I
authors.initials: GI
authors.lastname: Jallo
authors.forename: F J
authors.initials: FJ
authors.lastname: Epstein
mesh_terms: D000293:Adolescent; D000328:Adult; D001139:Arnold-Chiari Malformation / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D002531:Cerebellum / Q000473:pathology / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007796:Laminectomy / Q000379:methods*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D014066:Palatine Tonsil / Q000473:pathology / Q000601:surgery; D011184:Postoperative Period; D011859:Radiography; D012189:Retrospective Studies; D013595:Syringomyelia / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*