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.