Two weeks, my friends. Boy how time flies. I’ve always dealt with challenges better when I know exactly what I’m going to face, so I was quite lucky to find an Australian website that outlined the details of Chiari Decompression Surgery. The first time I read this, I felt considerably ill and didn’t open the site again for a few weeks, but upon reading it again I’m actually feeling a lot more confident about my ability to handle this.
If you happen to be a Chiari sufferer reading this and do not wish to know the occasionally frightening technical details of what will happen during and after decompression surgery, please skip reading this post. For those of you who do read it and are afraid, I’m right there with you… but I can promise the fear will diminish as you give yourself a while to adjust to the idea of it. Take a deep breath, we can get through this.
You can read the whole article here, but for now I’ll just copy and paste the most important parts:
What is a Chiari decompression?
A Chiari decompression is a specific type of craniotomy designed to make more room for the herniated cerebellum, and to relieve pressure on the brain. It also may permit restoration of the normal flow of cerebrospinal fluid (CSF) round the brain and sometimes results in an improvement in any associated hydrocephalus, hydromyelia, or syringmyelia.
What are the Specific Risks of a Chiari Decompression?
As with all types of surgery, there is a risk of complications, and the likelihood of these will depend upon a number of individual factors. You should discuss your specific circumstances with your neurosurgeon.
Whilst the majority of patients will not have any complications, there is a small risk of problems. In general the risks of surgery include, but are not limited to:
- Stroke or haemorrhage
- Quadriplegia (paralysis of the arms and legs)
- Meningitis (this may be due to infection, but is more commonly a chemical or ‘aseptic’ meningitis which settles with time and steroid medication)
- Impaired speech (dysarthria)
- Memory loss
- Cognitive impairment (problems with your thinking)
- Swallowing impairment
- Balance problems
- Hydrocephalus (fluid build-up within the head necessitating a shunt)
- Numbness of the skin around the scalp incision
- Headaches (these usually settle after a couple of weeks following surgery, but may last longer)
- Cosmetic issues (your scar will extend a few cm below your hairline)
How is a Chiari decompression performed?
Prior to your surgery you may have undergone a chlorhexidine (antiseptic) shampoo as well as a steretactic MRI scan. You will not eat or drink anything for 6-8 hours before your operation.
Anaesthetic and Preparation
A general anesthetic is given and a breathing (‘endotracheal’) tube is inserted. Intravenous antibiotics and dexamethasone (steroids which reduce some types of brain swelling and protect the brain and spinal cord from injury) are administered.
You will be positioned face-down on the operating table. The frameless stereotactic navigation system is set up. Antibiotics are given, and compression devices are used on your calves to reduce the risk of blood clot formation in your legs (deep venous thrombosis).
Some hair at the back of your head is shaved, and the skin is cleaned with antiseptic solution. Local anaesthetic and adrenaline are then injected into the proposed incision site.
A midline incision is made at the back of your head, and extends down to the upper part of your neck. The incision is typically 5 or 6cm in length. The muscles attaching to the back of your skull and spinal bones are elevated. A small window of bone ( measuring around 2.5cm diameter is then removed from the base of your skull using a fine high-speed drill. This is part of the occipital bone and adjoining foramen magnum. This gives the cerebellum more room, and decompresses the brainstem.
Because the tonsillar herniation frequently extends through the spinal canal formed by the first neck bone (cervical vertebra, C1), the posterior arch of the C1 bone is also removed.
In many cases the above maneuvers are enough and nothing further is required. In some situations, however, such as when there is a tight band of tissue constricting the lining of the brain (dura), or where it is thought that there is scarring (adhesions) around the cerebellum and brain stem, the dura is opened and a patulous graft of tissue is sewn in place to create more room. If adhesions are found, they may be divided. (Note: I am getting the dura patch in my surgery)The incision is then closed with staples.
What happens next?
- You will be transferred to the recovery room immediately after surgery, where you will wake up. The recovery room nurses will monitor you closely, particularly in relation to your level of consciousness, arm and leg strength, as well as breathing, blood pressure and heart rate.
Once you are more awake and stable, you will be moved to the neurosurgical high dependency unit or a closely monitored bed on the neurosurgery ward, where your condition can be closely monitored for around 24hrs. These highly specialised areas provide ongoing close observation with highly-trained nursing care.
The first 24 hours after surgery represents the period of highest risk for post-operative bleeding. Your blood pressure will be kept under control and your level of consciousness will be watched closely. When fully conscious and completely stable, you will be returned to your regular room.
- Postoperative Pain and Nausea
A dull headache is common, and most patients experience significant neck pain and stiffness after a Chiari decompression. The neck pain is due to the surgical elevation of the muscles from the back of the spine, and may take a number of weeks (or even longer) to settle. Pain medication will be ordered. Nausea and vomiting may also occur, and these will be treated with medications.
- Incision care
The incision will be covered with a dressing, and sometimes a crepe bandage. The wound is usually checked, cleaned and redressed 3 or 4 days after surgery. The staples are usually removed 7 or 8 days after surgery. The wound must be kept dry for the first 2 weeks following your operation.
- Fluid Replacement and Nutrition
Intravenous fluids will be ordered during the early recovery period and continued until you are fully awake and tolerating a reasonable amount of liquid by mouth.
- Emotional changes
Brain surgery is generally fairly stressful, both physically and psychologically. It is common to feel discouraged and tired for several days after surgery. This emotional let-down must not be permitted to obstruct the positive attitude essential to recovery and a return to fairly normal activity.
The amount of time spent in the hospital may be different for each patient, but is usually 3-5 days. (Note: This is not recommended by my own neurosurgeon. I am booked in for a minimum of 8 days in hospital).
You are encouraged to set a flexible plan for your recovery, and should work slowly and steadily to increase your physical and mental tolerance.
During the first week at home, you should relax and just move around at will. Lifting anything over 2-3kg is discouraged for the first two or three months.
Your dressing will be changed a few days after surgery, and can be removed a week or so later. Once the dressing is no longer required, you can wear a clean hat or scarf until your hair has re-grown. The staples are generally removed at 7-8 days post-op.
You can shower and gently wash your hair with shampoo, but you should keep your wound dry for the first 2 weeks after surgery. The best way to do this is to wear a shower cap. Avoid hair products such as mousse or gels, as well as hair colourants and perms for at least 2 months after surgery.
Walking is the best exercise to undertake after brain surgery. Commence a walking program your second week home and increase the time and distance as each week passes. Aim for 1-2 hours per day on flat ground after two months.
You should avoid riding bicycles or running for at least two months. Other activities should be discussed with your neurosurgeon or the Precision Neurosurgery Registered Nurse.
You can resume sexual activity when you feel comfortable, but this should not be too vigorous for the first month or so after surgery.
Driving should be discussed with your neurosurgeon, as these guidelines vary from State to State, as well as from patient to patient.
What is “normal” after a Chiari decompression?
The following are common problems encountered by many patients, and usually do not mean anything serious is wrong:
- Headaches: these are usually present daily to some degree, and may persist for a number of weeks. They will change in their location, character and severity as the bone heals and the scalp nerves regenerate.
- Neck pain: this is the most common and bothersome symptom after a Chiari decompression. It usually responds to anti-inflammatory medications and small doses of muscle relaxants, and tends to settle with time. Some gentle physiotherapy commencing 4-6 weeks after surgery may be beneficial.
- Numbness: this is common, and arises because the skin nerves have been cut. The area of numbness usually decreases over weeks to months, but sometimes does not disappear completely.
- Concentration: this is usually impaired for weeks to months after craniotomy. It is common to find difficulty focusing on tasks, you may need to re-read information in order to retain it. These symptoms tend to get better with time.
- Emotional instability (lability): you may experience irritability, depression, crying spells, anxiety, and sensitivity to noise or people in crowded places. Try to relax and take it easy. Spend more quiet time. If you have major problems with these symptoms and cannot relax, call us and we will arrange for you to see a Clinical Psychologist to receive some strategies to do so.
- Tiredness and fatigue: these are very common, and gradually improve. Once you commence a regular walking program, you will start to feel more energy.
It is common for it to take up to 3 months before you feel “well” again. Have plenty of rest during the day and eat healthy foods. Do not drink more than a small amount of alcohol during this time. Get up at your regular time and get plenty of sleep. Your internal clock would have been severely deranged during your hospitalisation, and it takes some time to return to normal.
What should you notify your neurosurgeon or the Precision Neurosurgery Registered Nurse of after surgery?
- Increasing headache which is unrelieved by pain medication
- Fever (high temperature) or chills
- Swelling or infection of the wound (redness, increasing pain or tenderness)
- Leakage of fluid from the wound, or any opening in the wound after the staples have been removed
- Fitting (seizures) or fainting spells
- Abnormal sensations or movements in your face, arms or legs
- Weakness or numbness
- Problems with balance or walking
- Nausea or vomiting
- Pain in the calf muscles or chest
- Shortness of breath
- Any other concerns