What is a Chiari Malformation?

A Chiari malformation is a condition in which a portion of the brain called the cerebellar tonsils extends downward into the upper spinal canal.

This is typically identified on MRI and is considered a structural (anatomical) finding at the junction between the brain and spine.

 

How is it Diagnosed?

Chiari malformation is primarily diagnosed on MRI of the brain and cervical spine.

Radiographically, it is defined by:

• Downward displacement of the cerebellar tonsils below the base of the skull
• Crowding at the foramen magnum (the opening at the base of the skull)

In addition, we often obtain specialized imaging such as CINE MRI, which evaluates the flow of cerebrospinal fluid (CSF) around the brain and spinal cord. This helps determine whether normal fluid circulation is being obstructed.

 

Do All Chiari Malformations Require Treatment?

No. Many Chiari malformations are found incidentally and may never cause symptoms.

If a patient is asymptomatic, observation with periodic imaging is often the most appropriate approach.

Treatment is only considered when symptoms or associated findings are present.

 

Symptoms of Chiari Malformation

When symptoms occur, they are often related to disruption of normal CSF flow or pressure at the base of the brain.

Common symptoms may include:

• Headaches (often worse with coughing, straining, or Valsalva)
• Neck pain
• Dizziness or balance difficulties
• Numbness or tingling in the arms or hands
• Difficulty swallowing
• In some cases, associated conditions such as syringomyelia (fluid within the spinal cord)

 

Why Do Symptoms Occur?

Symptoms are often caused by blockage of normal cerebrospinal fluid (CSF) pathways at the base of the skull.

When CSF flow is disrupted:

• Pressure dynamics around the brain and spinal cord change
• This can lead to headaches and neurological symptoms
• Over time, it may contribute to conditions like syrinx formation

This is why evaluating CSF flow with CINE MRI is an important part of the workup.

 

Treatment Options

Observation

For patients without symptoms or with minimal findings, monitoring with periodic imaging is often appropriate.

Conservative Management

Mild symptoms may be managed with:

• Activity modification
• Pain management
• Close clinical follow-up

 

Surgery

When symptoms are significant or progressive, surgery may be recommended.

The goal of surgery is to restore normal CSF flow and relieve pressure at the base of the brain.

Surgical options include:

• Bony Decompression: Removal of a small portion of bone at the back of the skull to create more space
• Duraplasty: Opening the protective covering of the brain (dura) and expanding it with a patch to further improve CSF flow

The decision to perform decompression alone versus adding a duraplasty is individualized based on imaging findings and patient-specific factors.

 

Our Approach

We focus on precise diagnosis and individualized treatment, ensuring that surgery is only recommended when clearly beneficial.

When surgery is indicated, we utilize minimally invasive techniques to significantly reduce the size of the incision and limit disruption to surrounding tissues.

It is common for patients to encounter images online showing large incisions for Chiari surgery. These can be alarming, but they do not reflect all modern surgical techniques. Our approach emphasizes:

• Smaller, targeted incisions
• Less muscle dissection
• Reduced postoperative pain
• Lower risk of complications
• Faster recovery

In many cases, the incision is significantly smaller than what is commonly depicted online, while still allowing for safe and effective decompression.

Our goal is to achieve the necessary surgical outcome while minimizing the overall impact on the patient.

View the approach