A member presented a medical case:
Chiari Malformation symptoms came back
Chiari I malformation dx 2001. Surgery a week later. Dura patch and c1 c2 laminectomy. Recently developed sudden recurrence of symptoms.
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Patient demographics
Gender
male
Age
37
Ethnicity
White or Caucasian
Occupation
Self employed
Chief complaint or problem to solve
Can a second decompression be done for relief of symptoms
Case history
After surgical correction of a Chiari type 1 malformation 14 years ago, a 37 year-old man has sudden recurrence of symptoms. Can a second surgery be done? What is the usual evaluation and treatment of a recurrence of Chiari symptoms? Allergies to amoxicillin and avelox. Recent history includes vertigo and severe basilar migraine temporarily affecting speech and motor function
Purpose of case discussion
Treatment decision: "What's the best treatment?"
Supplemental Materials

Dr. Csaba Magassy
Surgery - Plastics
8 doctors agree

In brief: Neurosurgeon

That type of surgery that was performed, will dictate the present clinical condition.
.You should consult either your previous Neurosurgeon , if he is still in practice, or his successor that has access to your records...That will be very valuable clinical data

In brief: Neurosurgeon

That type of surgery that was performed, will dictate the present clinical condition.
.You should consult either your previous Neurosurgeon , if he is still in practice, or his successor that has access to your records...That will be very valuable clinical data
Dr. Csaba Magassy
Dr. Csaba Magassy
Thank
2 comments
Dr. Paul Garrett
Totally agree with Dr. M. Some may find interesting : www.researchgate.net/profile/Lisa_Merck/publication/7411794_The_Chiari_Pseudotumor_cerebri_syndrome_Symptom_recurrence_after_decompressive_surgery_for_Chiari_malformation_type_I/links/550b2b3f0cf265693cef6bd6.pdf Also further diagnosis via MRI CSF fluid dynamic study may be helpful, see: http://www.ncbi.nlm.nih.gov/pubmed/11496092
Dr. Zeyad Morcos
I agree 100%. I am a neurologist, and many times, I prefer and advise to refer surgical patient to same surgeon, or who has the old records, it make sense and a lot of difference.
Dr. Daniel Clayton
Neurosurgery
7 doctors agree

In brief: I would get an MRI with CSF flow study to evaluate

Simple answer, yes, a second surgery can be done if it is determined that there is still compression at the foramen magnum. More nuanced answer, it really depends upon what is causing the symptoms at this time.
Recurrent compression does happen that can require a second surgery. Other things can also happen over time, such as "slumping" of the cerebellum into the bony defect from the initial surgery, worsening of a tethered cord that could be coexisting or development of hydrocephalus (new or coexisting).

In brief: I would get an MRI with CSF flow study to evaluate

Simple answer, yes, a second surgery can be done if it is determined that there is still compression at the foramen magnum. More nuanced answer, it really depends upon what is causing the symptoms at this time.
Recurrent compression does happen that can require a second surgery. Other things can also happen over time, such as "slumping" of the cerebellum into the bony defect from the initial surgery, worsening of a tethered cord that could be coexisting or development of hydrocephalus (new or coexisting).
Dr. Daniel Clayton
Dr. Daniel Clayton
Thank
2 comments
Dr. Vikram Patel
Blockage to CSF flow is one of the most common complications that can happen after a stunt placement and should be checked.
Dr. Peter Ihle
Also an MRI of the brain as well as the C spine. A 2'nd process may be active to cause the same symptoms, such as space occupying lesion, or high C-spine lesion. The old studies R a must 2 have 4 comparison .
Dr. Romanth Waghmarae
Pain Management
7 doctors agree

In brief: Chiari

Yes a second surgery can be done provided it is determined to be due to the same cause.

In brief: Chiari

Yes a second surgery can be done provided it is determined to be due to the same cause.
Dr. Romanth Waghmarae
Dr. Romanth Waghmarae
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Dr. Edward Hellman
Orthopedic Surgery
6 doctors agree

In brief: Depends

It really depends on the specific cause.
Not the symptoms, but the specific cause of the symptoms. But yes, if there is a structural abnormality between the brainstorm and upper cervical spine that had recurred it can be fixed.

In brief: Depends

It really depends on the specific cause.
Not the symptoms, but the specific cause of the symptoms. But yes, if there is a structural abnormality between the brainstorm and upper cervical spine that had recurred it can be fixed.
Dr. Edward Hellman
Dr. Edward Hellman
Thank
4 doctors agree

In brief: This is a complicated question and has a complicated answer (details).

Patient has recurrence of chiari symptoms 14 years after decompression.
This is unlikley to be from the downward descent of the brain again unless there are factors that cause intracranial hypertension as well as altered CSF hydro-dynamics. The ddx of this is to look for scar tissue at site of prior surgery to see if release of adhesions is required (especially if no prior mesh placement). One can also perform a lumbar puncture if no obvious descent and beaking of the cerebelar tonsils to evaluate for presence of high pressure with drainage to see if improvement of symptoms. If high pressure documented, then patient will need an MRVenogram to evaluate for venous drainage obstruction intracranial as well as extra-cranial in the craniocervical junction. The short answer is yes, repeat surgery may be required, but the long answer is that it is unlikely that further decompression of the cranium will address anything. It is more likely to be a cranioplasty revision to address dural adhesion

In brief: This is a complicated question and has a complicated answer (details).

Patient has recurrence of chiari symptoms 14 years after decompression.
This is unlikley to be from the downward descent of the brain again unless there are factors that cause intracranial hypertension as well as altered CSF hydro-dynamics. The ddx of this is to look for scar tissue at site of prior surgery to see if release of adhesions is required (especially if no prior mesh placement). One can also perform a lumbar puncture if no obvious descent and beaking of the cerebelar tonsils to evaluate for presence of high pressure with drainage to see if improvement of symptoms. If high pressure documented, then patient will need an MRVenogram to evaluate for venous drainage obstruction intracranial as well as extra-cranial in the craniocervical junction. The short answer is yes, repeat surgery may be required, but the long answer is that it is unlikely that further decompression of the cranium will address anything. It is more likely to be a cranioplasty revision to address dural adhesion
Dr. Mahan Chehrenama
Dr. Mahan Chehrenama
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Dr. James Macon
Neurosurgery
3 doctors agree

In brief: Yes. recurrence rate is 25% bone removal only and 7.5% + dural graft

Hayhurst C, Richards O, Zaki H, Findlay G, Pigott TJ.
Hindbrain decompression for Chiari - syringomyelia complex: an outcome analysis comparing surgical techniques. Br J Neurosurg. 2008 Feb;22(1):86-91

In brief: Yes. recurrence rate is 25% bone removal only and 7.5% + dural graft

Hayhurst C, Richards O, Zaki H, Findlay G, Pigott TJ.
Hindbrain decompression for Chiari - syringomyelia complex: an outcome analysis comparing surgical techniques. Br J Neurosurg. 2008 Feb;22(1):86-91
Dr. James Macon
Dr. James Macon
Thank
Dr. Diane Stein
Pediatrics - Neurology
2 doctors agree

In brief: Chiari redo vs other treatments

Yes, Chiari redo's are done and, unfortunately they are sometimes done 3 or 4 times.
Clearly there are times when nothing short of surgery is appropriate - typically this is when brainstem signs or an exterme deterioation in quality of life is present. One also needs to evaluate if the symptoms are from chiari or were present but not do to Chiari previously AND if surgical intervention will help. I have a patient who had slow cresendo of chiari symptoms with cognitive slowing, vertigo, ataxia, hoarse voice, shortness of breath. CINE flow MRI did not show any change from pre or post surgery studies. Neck flexion brought on symptoms. What helped? Treatment of systemic inflammation - she has developed Celiac Disease. Symptoms lessened with removal of wheat / gluten from her diet, stress management, adequate sleep, watching posture. No surgery needed. Eval should be done at Chiari center of excellence. www.conquerchiari.org

In brief: Chiari redo vs other treatments

Yes, Chiari redo's are done and, unfortunately they are sometimes done 3 or 4 times.
Clearly there are times when nothing short of surgery is appropriate - typically this is when brainstem signs or an exterme deterioation in quality of life is present. One also needs to evaluate if the symptoms are from chiari or were present but not do to Chiari previously AND if surgical intervention will help. I have a patient who had slow cresendo of chiari symptoms with cognitive slowing, vertigo, ataxia, hoarse voice, shortness of breath. CINE flow MRI did not show any change from pre or post surgery studies. Neck flexion brought on symptoms. What helped? Treatment of systemic inflammation - she has developed Celiac Disease. Symptoms lessened with removal of wheat / gluten from her diet, stress management, adequate sleep, watching posture. No surgery needed. Eval should be done at Chiari center of excellence. www.conquerchiari.org
Dr. Diane Stein
Dr. Diane Stein
Thank
Dr. Joseph Watson
Neurosurgery
1 doctor agrees

In brief: Recurrent Chiari

A second surgery for a Chiari malformation is not unheard of, but the sudden onset is unusual.
I find a Cervical spine MRI to be the most useful study since it shows the Chiari and rules out a Chiari-related complication called a syrinx.

In brief: Recurrent Chiari

A second surgery for a Chiari malformation is not unheard of, but the sudden onset is unusual.
I find a Cervical spine MRI to be the most useful study since it shows the Chiari and rules out a Chiari-related complication called a syrinx.
Dr. Joseph Watson
Dr. Joseph Watson
Thank
1 comment
Dr. Peter Ihle
How about MRI of the brain to look for a secondary cause as an expansile lesion?

In brief: Need more info

need to rule out other causes that could cause this kind of pain like degenerative spine disease that could cause cervical radiculopathy which can cause occipital and neck pain.
you need mri c-spine

In brief: Need more info

need to rule out other causes that could cause this kind of pain like degenerative spine disease that could cause cervical radiculopathy which can cause occipital and neck pain.
you need mri c-spine
Dr. Galina Nikolskaya
Dr. Galina Nikolskaya
Thank
Dr. Peter Ihle
Orthopedic Surgery

In brief: It can B done again-

-but a work up is needed 2 determine if this is due 2 Ur congenital lesion or is caused by another problem, as this is late 4a recurrence .
Get back 2 Ur initial surgeon if able, otherwise C a neurosurgeon .

In brief: It can B done again-

-but a work up is needed 2 determine if this is due 2 Ur congenital lesion or is caused by another problem, as this is late 4a recurrence .
Get back 2 Ur initial surgeon if able, otherwise C a neurosurgeon .
Dr. Peter Ihle
Dr. Peter Ihle
Thank
1 comment
Dr. Peter Ihle
MTI brain & C-spine R needed as well as the original imaging both pre & post- op 4 comparison .
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Dr. William Forsythe
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