Tuesday, March 13, 2012

What is a Chiari?

What is a Chiari Malformation?
Chiari Malformation Type I (CM) is a neurological disorder where part of the brain, the cerebellum (or more specifically the cerebellar tonsils), descends out of the skull into the spinal area. This results in compression of parts of the brain and spinal cord, and disrupts the normal flow of cerebrospinal fluid (a clear fluid which bathes the brain and spinal cord).

Does the size of the malformation matter?
Traditionally, Chiari Malformation has been defined as the cerebellar tonsils descending more than 3-5mm out of the skull. However, research has shown there is no real correlation between the amount of descent (or herniation) and clinical symptoms. Some people with herniations of less than 3mm are extremely symptomatic and some people with quite large herniations are symptom free. Because of this, doctors are now focusing on whether the cerebellar tonsils block the normal flow of cerebrospinal fluid (CSF). The current theory is that disruption of CSF flow is a more important measure than the size of the herniation.

How did I get this condition?
Chiari was originally thought to be a congenital condition - meaning you are born with it. While this may be true for many people, published case studies have also demonstrated that Chiari can be acquired and even reverse itself if the source of the problem is removed. It is not known how many cases are congenital and how many are acquired. Complicating the situation is that for reasons that aren't clear, some people develop symptoms as children, and some people develop symptoms as adults. What triggers symptoms is not fully understood.

How is Chiari treated?
If the symptoms aren't severe, doctors may recommend just monitoring the situation with regular MRI's and treating the symptoms individually. However, if symptoms are interfering with quality of life, are getting worse, or if the nervous system is being impaired, doctors may recommend surgery. The most common surgical treatment, performed by a neurosurgeon, is known as decompression surgery. An alternative surgery involves placing a shunt (a tube like device) to channel the flow of CSF and relieve pressure.

How do I know whether to have surgery?
The decision whether to have surgery is up to each individual and their doctor. Some of the factors that are considered are the severity of symptoms, whether the symptoms are getting worse, whether the nervous system is being compromised, whether there are any complicating issues, and the surgeon's own experience and judgment. Unfortunately, there is no single, objective measure to say whether someone should have surgery and many patients will find that different doctors may have different opinions.

What is the surgery like?
Decompression surgery is a general term used to refer to any of a number of variations on the same basic procedure. The goal of the surgery is to create more space around the cerebellar tonsils and restore the normal flow of CSF. The procedure involves removing a piece of the skull in the back of the head near the bottom (craniectomy). Often part of the top one or two vertebra are also removed (laminectomy). At this point, depending on the individual case and doctor, some doctors will also open the covering of the brain, the dura, and sew a patch in to make it larger (duraplasty). There are many variations in how the surgery is performed, including (but not limited to) how much bone to remove, whether to open the dura, what type of material to use for a dural patch, whether to shrink or remove the cerebellar tonsils, and whether to replace the missing piece of skull with anything. Unfortunately, there is no consensus, and no strong evidence, on which technique(s) is the best. Because of this, it is important for patients to understand specifically what their surgeon will be doing and why. The procedure itself lasts several hours and most people will spend a night in the ICU and an additional couple of days in the hospital.

Is the surgery always successful?
Unfortunately, there is not a lot of strong surgical outcome research, but there are enough reports to get a general idea of the overall success rates. For patients with just Chiari (no syringomyelia), up to 50% become symptom free after surgery, with another 10%-30% improving significantly. On the flip side, for 10%-20%, the surgery will be a failure and they will likely require additional surgeries. Keep in mind these are not scientific numbers and each patient should discuss their own chance of success with their doctor.

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