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Treating Chiari Malformation

Chiari treatment is mainly based on symptoms. There is no cure for Chiari yet, but symptoms can be managed in most cases. 

  Conservative Options 
These treatments are based on controlling symptoms in hopes to avoid surgery. 
  - Yearly observation
  - Pain Management
  - Physiotherapy
  - Medication for symptoms. 
  - Headache Neurologists/Clinics

  Surgical Options 
Surgery is considered the last option if symptoms can not be controlled in other ways. Or some cases surgery is mandatory to avoid issues like syringomyelia and for "red flag symptoms". This surgery is commonly called "the chiari decompression" and can encompass several surgical techniques to cater to the individual differences. The aim of the surgery is to make space in the foreman magnum to take the pressure off the cerebellum and allow room for the CSF to flow back and forth between the brain and spinal cord [1]. The headache is the most likely symptom that can be helped, that is why most surgeons focus on the headache severity/impact on whether to perform surgery or not. Other symptoms have been seen to improve but there is no research to help support/guarantee there will be any impact from surgery. 

Components of a Chiari Decompression can include some or all of the following surgical techniques:
This is the "standard" surgery, but research is always trying to find new and less invasive measures to improve the surgery. 

Posterior Fossa/Occipital Decompression
An incision is made at the back of the back near the base of the skull. This is opened and muscle is moved to expose the base of the skull and first couple of vertebrae. A small bit of bone around the foramen magnum (hole at the base of the skull) using a high-speed drill. This creates a larger hole for the herniated tonsils to sit without being compressed and allow CSF fluid to move freely. 

Sometimes the cerebellar tonsils extend further down into the spinal canal. if this is the case the back part of the vertebrae called the lamina/posterior arch is removed. This is usually reserved only for the first vertebrae (C1), multi-level laminectomies are generally avoided and suggested against in 2021 consensus

Your brain and cord are surrounded by a membrane called the Dura mater (like a bag around the brain). Some surgeries will include a surgical procedure where this dura is split and a patch is put on to create more space (a larger bag). There are a few different types of patches used and different doctors can prefer different ones. Some dura patches are created by your own tissue (autologous) or synthetic/from a donor (analogous). 

Autologous dura grafts are the most common and are now usually takes from the peri-cranium and are harvested from the tissue around the area of your scar.  Other are include fascia lata, which is taken from the tendon in your thigh, which creates a second scar. 

Synthetic patches are the second most commonly used and are made to match the dura. Older versions of dura patches used to include cadaver or bovine tissue. These are rarely used nowadays thanks to improved surgical techniques and artificial choices. 

Cauterization/Resection of the Cerebellar Tonsils
This procedure is fairly uncommon these days. Electrocauterization is used to shrink the cerebellar tonsils. 

Adhesion removal
Sometimes there can be a build-up to scar tissue found. Surgeons will remove these to allow for more space for the CSF to flow.  

Spinal Stabilisation
Sometimes reserved for patients with complex chiari who show signs of instability. The surgical fusion of vertebrae in the craniocervical junction which may include the skull as well. 

Potential Complications of Surgery [1]
 Risks are usually minimal for this type of surgery, but all surgeries carry risks that should be discussed with your surgeon. 
- Infection
- CSF Leak
- Stroke
- Meningitis
- Elevated CSF pressure (Intracranial Hypertension)
- Cerebellar Ptosis
- Spinal Instability
- Occipital Neuralgia 
- Numbness around Scar
- Cosmetic issues with scar
- Seizures
- Death

What happens After Surgery?
Most cases will spend 24-48hrs in the Intensive Care Unit (ICU) for observation and pain management. Afterwards, most people spend 3-5 days on a normal hospital ward. They will usually be visited by the surgeon or someone from their team during this time. A visit from the physiotherapist is common and will check your walking and give some gentle exercises. You should be given a discharge summary to give to your GP with information to help your healing. Getting moving soon is very important to help avoid complications and improve pain. 

Once you are discharged it is recommended to see your GP to check your would and have them removed your staples or stitches around 12-14 days post-op. It is also advised you should avoid driving until your surgeon gives you permission (different states will have different liscence requirements). Return to work is usually based on the type of work you perform and healing. Weight restrictions for lifting are usually set around 3-5 kilos. Also to avoid straining (including in the bathroom) and do gentle exercise such as walking. If at any time your wound becomes hot, weeps or looks infected, see your GP ASAP. Sometimes a build-up of CSF from a leak can occur. If there is any bulging around the wound see your doctor ASAP. Many times early intervention can mean conservative treatments will help complications. So if in doubt see a doctor. 

You will follow up with your surgeon around 6 weeks post-op where further imaging may be done to check your scars healing. If everything is going well follow-ups with the surgeon commonly occur at 6months, then yearly until discharged. If issues occur between these times contact your GP or surgeon for an earlier review or imaging. 
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