Minimally Invasive Craniocervical Decompression for Chiari 1 Malformation: An Operative Technique

Abstract

Chiari malformation type 1 (CM-1) is an ectopia of the cerebellar tonsils below the foramen magnum that causes severe disability due to its neurologic symptoms. The treatment of choice for CM-1 is decompression of the craniovertebral junction (CVJ). In some patients only an extradural decompression by removing the atlanto-occipital ligament may be sufficient. In other patients, duraplasty is necessary. In this case, we report the operative technique used to treat a CM-1 in a 16-year-old male patient who presented with severe headache and gait instability. A micro-decompression of the suboccipital bone and posterior arch osteotomy of C1 through a 2-cm midline incision was performed under surgical microscope magnification. A duraplasty was performed through the same approach. The patient was discharged home after 2 days in the hospital and returned to regular activities at school 3 weeks after surgery. The minimally invasive technique presented here is a viable option for the posterior decompression of the CVJ in patients with CM-1 using a low-cost self-retaining retractor.

Interlayer dural split technique for Chiari I malformation treatment in adult—Technical note

“…Certain authors support a minimally invasive surgical (MIS) decompression of the foramen magnum, in which an MIS tube is inserted after performing a midline incision no larger than 3 cm. [67][68][69] After performing a midline incision of 2 or 3 cm centered over the atlantooccipital junction, an MIS tube or a Gelpi self-retaining retractor is inserted. The MIS tube limits the extent of the subperiosteal dissection, bone resection, dural peeling or delamination and, if required, durotomy.…”

Letter to the Editor. Perioperative complications in patients older than 80 years of age

“…The authors are correct in stating that minimally invasive spine surgery (MISS) techniques have been used since 2016 to achieve extradural bony decompression of the craniocervical junction (CCJ). [2][3][4][5][6] However, in 2019 Quillo-Olvera et al 7 described in detail how to perform a microscopic technique very similar to that reported by Mandel et al, through a 2-cm skin incision by using a Gelpi retractor to address the bony decompression of CCJ in a patient with Chiari malformation type I. The MISS procedure described by Quillo-Olvera et al 7 allowed intradural exploration, and the authors at that time pointed out some of the procedure-related advantages also reported by Mandel et al 1 Due to the novelty and similarities of the approaches presented by Mandel et al 1 and Quillo-Olvera et al, 7 we consider some points to be worth clarifying.…”

“…[1][2][3][4][5] Instead, our focus was on prospectively evaluating the pathophysiology of CSF flow dynamics and syrinx cavity expansion using MRI in CCJS. We read with great interest the case report published by Quillo-Olvera et al 6 of a 16-year-old patient with Chiari malformation, but we did not cite this article as the report was not associated with CCJS and also in part because we cited other authors' reports of larger series using a similar surgical technique. [1][2][3][4][5] We emphasize that the novelty of the procedure reported in our paper lies in the combination of an MIS decompression with a durectomy and obexostomy targeting the pathophysiology of CCJS in adult patients.…”

Letter to the Editor. Innovative procedure to decompress the craniocervical junction

“…[1][2][3][4][5] Instead, our focus was on prospectively evaluating the pathophysiology of CSF flow dynamics and syrinx cavity expansion using MRI in CCJS. We read with great interest the case report published by Quillo-Olvera et al 6 of a 16-year-old patient with Chiari malformation, but we did not cite this article as the report was not associated with CCJS and also in part because we cited other authors' reports of larger series using a similar surgical technique. [1][2][3][4][5] We emphasize that the novelty of the procedure reported in our paper lies in the combination of an MIS decompression with a durectomy and obexostomy targeting the pathophysiology of CCJS in adult patients.…”

“…The authors are correct in stating that minimally invasive spine surgery (MISS) techniques have been used since 2016 to achieve extradural bony decompression of the craniocervical junction (CCJ). [2][3][4][5][6] However, in 2019 Quillo-Olvera et al 7 described in detail how to perform a microscopic technique very similar to that reported by Mandel et al, through a 2-cm skin incision by using a Gelpi retractor to address the bony decompression of CCJ in a patient with Chiari malformation type I. The MISS procedure described by Quillo-Olvera et al 7 allowed intradural exploration, and the authors at that time pointed out some of the procedure-related advantages also reported by Mandel et al 1 Due to the novelty and similarities of the approaches presented by Mandel et al 1 and Quillo-Olvera et al, 7 we consider some points to be worth clarifying.…”