Chiari I malformation headaches are triggered by alterations in intracranial hydrodynamics and compliance. Three types of CMI headaches have been described: suboccipital-headaches induced by Valsalva maneuvers (the most common), non-Valsalva related suboccipital-headaches, and non-suboccipital non-Valsalva induced headaches. The overarching goal in the surgical treatment of CMI is reduction of altered intracranial hydrodynamics and compliance by obtaining adequate expansion of the posterior craniocervical junction. Adequate relief of the anatomic obstruction generally results in good relief of Chiari headaches.
Our approach to posterior craniocervical expansion is focused on the malformation’s “choke point.” In our patient population (14 years of age and older), expansion of the posterior craniocervical junction at the choke point usually includes seven surgical steps, each critical to achieving a successful, complication-free outcome. The seven steps, or decision points, are: the extent of bony decompression, management of the dura, management of the arachnoid, management of the neural tissue, cranial reconstruction, closure of the wound, and infection prevention. Failure at any one of these steps can result in persistent or worsening symptoms that may lead to surgical revision. This presentation will review each surgical step in our posterior craniocervical expansion and reconstruction procedure.