Redo Posterior Fossa Decompression with Duraplasty for the Treatment of Chiari Type I Malformation

Chiari decompression is a common neurosurgical procedure.  Chiari malformations present with a number of symptoms including Valsalva-induced headaches, swallowing dysfunction, and sleep apnea.  Chiari malformations can also cause syringomyelia and syringobulbia.  Surgical procedures used for the treatment of Chiari malformation include bone-only decompression (posterior fossa craniectomy +/- cervical laminectomy), craniectomy/laminectomy with duraplasty, and craniectomy/laminectomy/duraplasty with shrinkage or resection of the cerebellar tonsils.  The procedure used depends on the specifics of the patient’s condition and the preference of the surgeon.

The patient presented here had undergone a prior Chiari decompression at the age of 20 months.  This was bone-only with posterior fossa craniectomy and C1-2 laminectomy.  The dura was not opened due to the presence of a venous lake.  He initially had improvement in his symptoms.  However, his headaches and snoring recurred, balance worsened, and dysphagia never improved.  Therefore, a repeat Chiari decompression at the age of 28 months was performed as presented here.

Endoscopic Third Ventriculostomy for Non-communicating, Obstructive Hydrocephalus

An endoscopic third ventriculostomy (ETV) can be a sufficient alternative to a cerebral shunt in the treatment of noncommunicating forms of hydrocephalus. Hydrocephalus can present with numerous signs and symptoms, including headache, vomiting, neck pain, macrocephaly, and vision impairment. Surgical procedure includes entrance of the lateral ventricles through a bur hole, and blunt/cautery fenestration of the third ventricular floor, which lies between the mamillary bodies and tuber cinereum. Choroid plexus cautery has been noted in the literature as being a viable addition to the procedure, in which a reduction in CSF production is achieved. Though, exact surgical procedure is left to the discretion of the surgeon.

The patient presented is a 30-month-old boy with non-communicating obstructive hydrocephalus secondary to congenital aqueductal stenosis. The patient has a history of progressive developmental delays, balance issues, and increased seizure frequency from a known seizure disorder. Therefore, an endoscopic third ventriculostomy via right frontal approach was elected.

Authors: William Fuell, Marcus Stephens M.D., Eylem Ocal M.D.
Institutions: Arkansas Children’s Hospital, University of Arkansas for Medical Sciences

Fully Endoscopic Uniportal Interlaminar Microdiscectomy

The conventional approach to the lumbar discectomy requires significant tissue dissection to obtain a sufficient working space and is known to cause possible complications and injuries. The minimally invasive, fully endoscopic uniportal interlaminar discectomy provides numerous advantages to the typical open procedure. Some advantages include: good visualization of anatomical structures utilizing continuous lavage; lower rates of operative complications such as dural injury, bleeding, and infection; and shorter hospitalization, with increased post-operative rehabilitation. Surgical procedure utilizes guided fluoroscopy to gain access to the interlaminar window, with subsequent placement of the working channel endoscope. Microscopic debridement of herniated lumbar disc and decompression of nerve roots is conducted.

This case highlights a patient with significant disc herniation at the L5-S1 level with concurrent mild to moderate cervicothoracic scoliosis. The patient elected for the minimally invasive, fully endoscopic interlaminar microdiscectomy.

Authors: William Fuell, Eylem Ocal M.D., Salih Aydin M.D.

Institutions: Emsey Hospital-Istanbul, Arkansas Children’s Hospital

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