Why is this surgery done?
You may need this surgery if you have been diagnosed with a Chiari malformation: a brain abnormality that occurs when the back part of the brain (cerebellar tonsils) extends through the opening at the base of the skull (the foramen magnum) and into the spinal canal. This causes crowding in that area that can interrupt the flow of cerebrospinal fluid (CSF).
CSF usually flows freely around the brain and up and down the spinal canal. When the CSF flow is interrupted, it can cause neurological symptoms such as:
- Neck pain
- Numbness and tingling of the hands and feet
- Vision and speech problems
- Difficulty swallowing and/or increased gagging
- Buildup of fluid in the spinal cord (called a syringomyelia or syrinx) or in the brain (called hydrocephalus)
The goal of a Chiari decompression is to reduce the crowding and improve the flow of CSF.
How is Chiari decompression done?
A Chiari decompression involves the pediatric neurosurgeon making a small incision on the back of the child’s head. The surgeon will remove a small section of skull and part of the first bone of the neck. This is done to widen the area and create space for the brain. The dura, a layer of tissue that covers the brain, is opened to expose the part of the brain that is protruding into the spinal canal. Sometimes this part of the brain is shrunk or surgically removed to allow the CSF to flow. Following this, the dura is put back together using a patch graft of synthetic tissue that is sewn in to help provide more room for the flow of spinal fluid. The incision is closed with multiple layers of sutures underneath the skin. The skin is protected with a special skin glue. This operation is carried out using general anesthesia and is normally well tolerated.
What are my risks? What are common complications?
Common postoperative complications include problems with wound healing, especially if a child picks at their incision; and swelling under the incision site caused by a collection of CSF, called a pseudomeningocele. Most pseudomeningoceles after a Chiari decompression are small and resolve on their own.
Less common risks of the procedure include but are not limited to:
- Neurological deficits
- Complications from anesthesia
If your child’s symptoms prior to surgery were caused by the Chiari malformation, they should get better following the decompression surgery. If the symptoms were not related to the Chiari malformation, they will still be there after surgery.
What do I need to know before surgery?
If your child is diagnosed with a Chiari malformation, the pediatrician will refer them to a pediatric neurosurgeon for consultation. You will then meet with the neurosurgeon to discuss their symptoms. If your child is having symptoms felt to be related to the Chiari malformation and the symptoms are affecting the child’s quality of life, surgery will likely be recommended. Questions and concerns will also be addressed at that appointment.
You will receive communication before coming to the hospital with specifics about where to go the day of surgery and instructions for the day before and day of surgery. This information will include details about home medications and when to stop eating and drinking.
Typically, the morning of surgery your child will get a full spine MRI (if they haven’t already had one) with a special technique used to look at CSF flow and to look for a buildup of CSF in the spinal cord (syrinx). Surgery typically takes 3 – 4 hours and your child will spend 2 – 3 nights in the hospital. The first night will be in the pediatric intensive care unit (PICU) for close monitoring. Your child will come out of surgery very sleepy and their medical team will likely give them medicine that makes them extra sleepy for the first 12 hours after surgery to help with pain control.
Your child will have a rubber tube in their bladder (Foley catheter) to drain their urine while sedated and also additional monitoring devices to closely watch their blood pressure and heart rate.
Your child will be allowed to drink and eat slowly as soon as they are able, and they will be allowed to get up out of bed as soon as they are awake and the extra monitoring devices and bladder catheter have been removed.
Your child will be discharged from the hospital once their pain is well controlled with oral pain medications and they are able to eat and drink, go to the bathroom and walk around the room.
The pediatric neurosurgery providers at Goodman Campbell Brain and Spine are specially trained on this diagnosis and are experts in the care of Chiari malformations. We know it can be a scary time, and we have a team of medical professionals who are available to answer any questions or discuss any concerns you might have.
General discharge instructions
Your child will likely be sent home with the following medications: valium (diazepam), hydrocodone/oxycodone (lortab/percocet), zofran (ondansetron) and MiraLax.
If skin glue (also called Dermabond) was used, this will fall off in about 2 – 3 weeks. Do not apply oils, lotions or creams to the glue or the area surrounding the incision. Do not allow your child to peel or pick at the glue. The glue may curl at the edges and peel as it falls off naturally. If the edges curl, you may carefully trim the curled edges with nail clippers. Make sure the clippers are clean before use.
If the incision is covered with a bandage, it may be removed five days after surgery (usually 2 – 3 days after going home). The bandage may be left off if the incision is dry. If your child is touching the incision a lot or picking at it, keep it covered. Change the dressing as soon as possible if it becomes wet or dirty. Your child must keep the incision completely dry the first five days after surgery.
Your child may bathe five days after surgery. Allow soap and water to gently run over the incision, then pat dry with a clean towel or cloth. Be sure to rinse with clean water, fresh from the faucet. Do not submerge the incision in bath water until the incision looks like a scar and is scab free.
We recommend no school for two weeks. Your child should be off all narcotics before attending school.
No lifting greater than 10 pounds until cleared to do so at your follow-up visit.
Activity restrictions 4 – 6 weeks following surgery include: no recess/gym/sports, no climbing or riding anything with wheels and both feet must stay on the ground.
Continue doing neck exercises given by physical therapy at home until your child is able to touch their chin to their shoulder.
No swimming in lakes or oceans, hot tubs or soaking in baths until the incision is healed completely and looks like a scar (about two months). Your child may swim in a clean (not public) chlorinated pool four weeks after surgery.
When to contact our office:
- If your child has signs or symptoms of infection: redness or drainage at incision, pain not relieved by medications or fevers over 100.5°F
- Difficulty with bowel or bladder function despite stool softeners and laxatives
- Worsening headache, nausea or vomiting one week after surgery
Your child will likely have two post-op appointments with the neurosurgery office. This first will be about 2 – 3 weeks after surgery to make sure that the incision is healing properly and the second appointment will be about three months following surgery with the neurosurgeon. If a syrinx was found on the spinal MRI prior to surgery, another spinal MRI will be performed about 7 – 8 months after surgery to see if the syrinx is getting smaller.
What should I expect while recovering?
The neck is often sore and stiff right after surgery. This should gradually improve and be relieved by the muscle relaxer and pain medications prescribed for your child. Continue to have your child do the range-of-motion neck exercises you were shown by the physical therapist while at the hospital.
Nausea and headaches are also common after a Chiari decompression. You should give your child the prescribed anti-nausea and pain medications as needed. Headaches may be present daily to some degree and may persist for several weeks. They will change in their location, character and severity as the bone heals and the scalp nerves grow back.
Tiredness and fatigue are also very common and will gradually improve with time. It is common for it to take up to three months before your child feels back to normal. Ensure they have plenty of rest during the day and eat healthy foods. (Avoid candy, soda and fast food.) Set a regular bedtime and wake-up time to ensure they get plenty of sleep.
Also, it’s important to remember that if your child’s symptoms prior to surgery were caused by the Chiari malformation, they will likely get better following the decompression surgery. If the symptoms were not related to the Chiari malformation, they will likely persist after the decompression surgery.
Possible physical therapy exercises
A physical therapy evaluation will be ordered the day after surgery to help with walking. This evaluation may not take place until after they have been able to sit up without complaining of a headache.
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