Concurrent Chiari decompression and spinal cord untethering in children: feasibility in a small case series

Background and purpose We describe the rationale and safety of concurrent decompression of Chiari type 1 malformation (CM1) and untethering of the spinal cord. Spinal cord traction is considered one of the pathogenic mechanisms involved in the development of CM, and 14% of patients with CM1 have tethered cord syndrome (Milhorat et al., Surg Neurol 7:20–35, 2009; Roth, Neuroradiology 21:133–138, 1981; Royo-Salvador, Rev Neurol 24:937–959, 1996; Royo- Salvador et al., Acta Neurochir 147:515–523, 2005). Therefore, intraspinal anomalies that require intervention are commonly treated before surgical decompression of Chiari malformation (Cheng et al., Neurologist 8:357–362, 2002; Menezes, Pediatr Neurosurg 23:260–269, 1995; Milhorat et al., Surg Neurol 7:20–35, 2009; Royo-Salvador et al., Acta Neurochir 147:515–523, 2005; Schijman and Steinbok, Childs Nerv Syst 20:341–348, 2004; Yamada et al., Neurol Res 26:719–721, 2004). However, in the interval between the spinal cord untethering and the decompression surgery, patients may continue to suffer from the untreated symptoms of CM. In a series of four patients with concurrent severe and progressive symptoms referable to both conditions, we performed both surgeries simultaneously. Methods Charts of four patients who underwent concurrent Chiari decompression and spinal cord untethering were reviewed. Results All patients tolerated the procedures well without complication. They reported significant or complete early postsurgical resolution of headaches and ambulating difficulties. On average, patients started to walk on postoperative day 3 (3±1 days) and were discharged on hospital day 6 (6± 1 days). No patient experienced a persistent subcutaneous or transcutaneous cerebrospinal fluid leak. Subsequent postoperative courses were uneventful. Conclusion Concurrent Chiari decompression and untethering of the spinal cord is a feasible option and in some patients may be preferred in lieu of staged procedures.