Archives of Neurosurgery

Corresponding Author

Prof. Atul Goel,

Head of Department,

Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai-400012, India

Telephone no: 22-24129884 Fax no: 22-24143435 E-mail:atulgoel62@hotmail.com

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Commentaries to published articles - Invited


The authors have reviewed Chiari formation treatment and have put-forth their personal experience with minimally invasive techniques to perform foramen magnum decompression surgery. Based on the historical review of the subject, the authors have discussed the historical validity of only bone decompression, extra-arachnoidal decompression, and tonsillectomy. The article falls in line with the current minimally invasive surgery wave, a slightly larger cousin of the buttonhole surgery trend. It may be pertinent that I review my understanding of the subject based on the ongoing experience of nearly four decades. In the year 1998, we identified that the posterior fossa volume in cases with basilar invagination associated with Chiari formation is reduced. Accordingly, we suggested that foramen magnum decompression was the treatment. For the first time in literature, we suggested that only bone decompression is necessary and dural opening or decompression is unnecessary. As our understanding of the subject progressed, it was realized that the atlantoaxial joint, which is the most mobile joint of the body, is also most susceptible to developing instability. Chronic atlantoaxial instability is associated with a range of natural protective secondary maneuvers. Musculoskeletal alterations include short neck, torticollis, Klippel-Feil bone fusions, assimilation of atlas and platybasia, and neural alterations include Chiari formation and syringomyelia. Consequently, we preferred to label Chiari ‘malformation’ as Chiari ‘formation.’ More importantly, it was identified that all musculoskeletal and neural alterations could return to normalcy after the surgery, which involves only atlantoaxial fixation. We recently reported gratifying surgical results of 388 consecutively treated cases of Chiari formation by atlantoaxial stabilization. The successful conduct of surgery can lead to a cure from the disease. The validity of foramen magnum decompression as a format of treatment will have to be re-evaluated.

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