You know better than anyone just how unique your child is, so you can appreciate that his or her Chiari malformation is not going to be the same as another child’s. Each case of Chiari malformation is different, and certain cases will necessitate surgery, while others will require observation. There is no one-size-fits-all approach when it comes to treating Chiari malformation in children.
Your child’s doctor will make treatment recommendations based on several factors, including the specifics of your child’s malformation and the symptoms that he or she is experiencing. By learning a little about which treatment options are appropriate in which cases, you can have a better understanding about why your child’s doctor may recommend one treatment over another.
Observation and Monitoring vs. Surgery
Some children with Chiari malformation will require surgical intervention while those without true chiari symptoms and incidental findings will benefit more from observation and monitoring. Pediatric neurosurgeons with expertise in Chiari malformations use their experience and evidence based medicine to treat your child appropriately.
Children with minor Chiari malformations who are not asymptomatic (or children with frontal headaches or symptoms not typically related to Chiari malformations) are referred to non-surgical management by neurologists. In this case, your child will intermittently follow-up with the pediatric neurosurgeon to track his or her progress.
If your child has true Chiari symptoms, such as but not limited to occipital headaches and/or pressure, upper extremity paresthesias (burning or prickling feeling), swallowing difficulty or has a significant syrinx in the spinal cord, surgery will be required. A syrinx is fluid accumulation within the spinal cord that causes compression and pressure on the nerves in the spine. This can lead to significant neurological issues and requires definitive surgery by a pediatric neurosurgeon with specific expertise in dealing with a complex chiari malformation.
Even if your child does not have a syrinx, if he or she is experiencing occipital headaches due to Chiari malformation, surgery will be required at some point. Because there is no syrinx, your child’s doctor may not feel it is an emergency situation and may recommend a period of monitoring, but your child will ultimately need surgery to correct the problem and alleviate symptoms.
Surgical Treatments for Pediatric Chiari Malformation
If your child’s symptoms are such that pediatric Chiari specialists have recommended surgical treatment, the procedure chosen will to be based on your child’s individual Chiari malformation.
In a Chiari malformation, there is not enough room for the back-most portion of the brain (the cerebellum), and it cannot fit within the skull and is being displaced downward, along the spine. Exactly how far it extends into the cervical spine is going to be the major determining factor in which surgery your child’s doctor recommends.
Based on clinical research performed by our chiari specialists, our group determines the type of surgery recommend for each individual child based on what the chiari malformation looks like on radiographic imaging (brain/cervical spine MRI). Our surgeons determine whether to offer a dural opening versus non-dural opening procedure based on how low the tonsils extend into the cervical spinal cord.
In both cases, the goal of surgery is to create space for the cerebellum by removing a small portion of the skull in a procedure known as suboccipital craniectomy and C1 laminectomy for Chiari decompression.
Non-Dural Opening Chiari Decompression
If your child’s cerebellar tonsils are above the C2 level, his or her surgeon will likely use a non-dural opening approach. This is considered a more minimally invasive procedure and has shown to be highly effective in children. Our pediatric neurosurgeons specializing in Chiari malformations prefer to use a non-dural opening approach when it is an option because of the reduced surgical risks, decreased operative time, shorter hospital stays and improved healing time.
Dural Opening Chiari Decompression
Some children are not candidates for the minimally invasive approach and will instead require the traditional dural opening procedure. If your child’s cerebellar tonsils extend below the level of C2, then his or her surgeon will likely recommend this approach.
The difference in dural opening Chiari decompression surgery is that the incision is slightly larger, and your child’s surgeon will open the layer of tissue covering the brain, the dura. This is performed to create more space in the region and to allow for coagulation (shrinkage) of the tonsils. After this, a synthetic graft will be sewn onto the dura thus further helping to increase the space for the brain and alleviating the pressure.
A Better Understanding
Because you are educating yourself to better understand your child’s condition and potential treatment options, you are already ahead of the game. Whether a pediatric neurosurgeon has already seen your child and recommended treatment or your child was just diagnosed, self-education is a great way to help you have confidence throughout the process.
If at any time you find that you have questions or concerns, be sure to bring them up to your child’s physician or pediatric neurosurgeon. They understand that, as a parent, it can be incredibly difficult to watch your child deal with an illness, and they are here to support both you and your child on your path to healing.