Surgical technique for cranio-cervical decompression in syringomyelia associated with Chiari type I malformation

Our purpose is to present our results with the surgical treatment of syringomyelia associated with Chiari type I malformation. Between October 1989 and October 1995, twenty-eight patients underwent a sub-occipital craniotomy and a C1 laminectomy. After dura mater opening the cerebellar tonsils were mobilised. Neither catheter, nor plugging of the obex, nor tonsillar tissue removal was performed. The dura mater was enlarged by means of a wide graft to create a new cisterna magna of adequate size. Postoperative MRI scans showed an ascent of the cerebellum of 4.3 +/- 4.8 mm (measured by the fastigium to basal line), as well as of the brainstem (mean migration of the mesencephalon-pons junction of 4.3 +/- 3.3 mm). The tonsils emigrated cranially 6.5 +/- 4.8 mm. While preoperative mean syringo-cord ratio was 66.3% +/- 13.3, post-operatively was 12.1% +/- 12.7 (p < 0.0001). A complete collapse of the syrinx was observed in 39% of the patients. Long-term improvements were obtained in 73% of the cases and 27% were unchanged. No patient got worse. We conclude that in the treatment of syringomyelia associated with Chiari I malformation an artificial cisterna magna of sufficient size must be created. This is achieved by means of an extensive sub-occipital craniotomy and C1 laminectomy, followed by dural opening. Small bone removal with limited enlargement of the posterior fossa often results in failures of treatment and recurrences. Tonsillar removal is not necessary to obtain a good reconstruction of the cisterna magna.