DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chiari I malformation with cervical syrinx.
POSTOPERATIVE DIAGNOSIS: Chiari I malformation with cervical syrinx.
OPERATION PERFORMED:
1. Suboccipital craniectomy.
2. C1 laminectomy.
3. Duraplasty.
SURGEON: John Doe, MD
ANESTHESIA: General
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old woman who presents with neck pain, progressive early signs of myelopathy, on imaging demonstrates cervical syrinx from C1 through T1, Chiari I malformation, cerebellar tonsils descending to the superior arch of C2 level. Indication, risks, and details for craniectomy with duraplasty has been explained to the patient. The patient requested to proceed with surgery.
OPERATIVE FINDINGS: Cerebellar tonsillar compression at the C1 ring level associated with fibrosis and thickening of the dura and dilation of the upper cervical cord consistent with the underlying syrinx.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and underwent general anesthetic. She was given a gram of Ancef preoperatively, placed in the Mayfield headrest, rolled prone on chest rolls where her neck was kept in a neutral position. Posterior occipital cervical region was shaved, prepped, and draped out sterilely.
A midline incision was made reflecting the tissue away from the suboccipital bone, exposing C1 and C2. The occipital bone appeared to be somewhat flattened consistent with the underlying Chiari malformation. The bone was thinned out with a high-speed drill and decompressed completing a craniectomy in the suboccipital bone in an oval fashion, up to but not including the region of the transverse sinus. C1 arch was removed posteriorly as well. The midline dura was quite thickened at the level of the craniocervical junction. This tissue was sharply excised and then a midline opening in the dura made, extending from the superior portion of C2 up just to the right of the midline and then across the midline decompressing the cerebellar tonsils. They were noted to be somewhat scarred and very adherent to the underlying cervical cord at the C1 level. There was dilation of the cervical cord consistent with the underlying syrinx and significant flattening of the cerebellar tonsils. Using microdissection, the tonsils were freed up from the underlying cervical cord. A small amount of cautery used to shrink up the fibrotic portion of the tonsils and to allow for opening up of the entrance into the fourth ventricle.
Following wide decompression, duraplasty was performed using a piece of ligamentum nuchae harvested during exposure. This was reapproximated in a watertight fashion with 4-0 Prolene in a running fashion. DuraGen and Gelfoam were placed over the exposure. The wound was closed in layers with Vicryl suture, 3-0 nylon for skin, and a dry dressing applied. The patient was rolled supine, extubated, and taken to the recovery room in stable condition. Sponge and needle counts were correct. Estimated blood loss was approximately 100 mL.
