A minimally invasive, posterior fossa bony decompression in the management of symptomatic Chiari type 1 anomalies in children was evaluated at the Children’s Hospital, Turin, Italy. Of 53 patients observed, 27 were asymptomatic and treated conservatively, and 26 had symptoms, associated with brain stem compression in 16 and syringomyelia in 10. Of the group with brain stem compression, 44% had neck pain, 31% vertigo, and 31% headache. In those with syringomyelia, the commonest symptoms were numbness (50%), sensory loss (40%), neck pain (40%), and vertigo (40%). With an average follow-up after surgery of 22 months (6-60 months), symptoms improved or resolved in all but 3 patients, with no serious complications. A simple extradural surgical approach appears to have comparable results with more aggressive procedures and less complications. [1]

COMMENT. Surgery for Chiari type 1 is controversial. The American Association of Neurological Surgeons Pediatric Section suggested in 1988 that decompression may be indicated for brain stem or cranial nerve dysfunction associated with the anomaly [2]. In symptomatic cases the aim of posterior fossa decompression and cervical laminectomy is to restore a normal CSF circulation at the foramen magnum. The authors find that the simple extradural surgical approach can provide symptomatic relief in most cases, and is superior to more aggressive techniques described in the literature. The following case report of complete and spontaneous resolution of childhood Chiari 1 malformation and associated syringomyelia is noteworthy.

Spontaneous resolution of Chiari I anomaly. A 7-year-old boy with a one month history of severe headaches and vomiting and a family history of migraine was found to have on MRI a Chiari I malformation and cervical syringomyelia. Treated conservatively as migraine with an incidental anomaly, headaches improved following dietary modification and omission of chocolate. At age 13, headaches recurred with greater severity, despite medication. A repeat MRI was normal, showing no evidence of either anomaly. At 16 years, he continues to have headaches every 3 months despite prophylactic Inderal. His neurologic examination is normal [3]. The authors advocate less prophylactic decompression and more frequent conservative management, with serial imaging and neurologic monitoring, in asymptomatic childhood Chiari 1 malformation with associated small or moderate sized syringomyelia. In this case the anomaly was apparently not the cause of the headaches.