Cerebrospinal fluid hydrocephalus shunting: cisterna magna, ventricular frontal, ventricular occipital.

Despite advances in cerebrospinal fluid shunting technology, complications remain a significant concern. There are some contradictions about the effectiveness of proximal catheter entry sites that decrease shunt failures. We aim to compare efficiency of shunts with ventricular frontal, ventricular occipital, and cisterna magna entry sites. The systemic search was conducted in the database from conception to February 16, 2022 following guidelines of PRISMA. Between 2860 identified articles, 24 articles including 6094 patients were used for data synthesis. The aggregated results of all patients showed that "overall shunt failure rate per year" in mixed hydrocephalus with ventricular frontal and occipital shunts, and cisterna magna shunt (CMS) were 9.0%, 12.6%, and 30.7%, respectively. The corresponding values for "shunt failure rate" due to obstruction were 15.3%, 31.5%, and 10.2%, respectively. The similar results for "shunt failure rate" due to infection were 11.3%, 9.1%, and 27.2%, respectively. The related values for "shunt failure rate" due to overdrainage were 2.9%, 3.9%, and 13.6%, respectively. CMS was successful in the immediate resolution of clinical symptoms. Shunting through an occipital entry site had a greater likelihood of inaccurate catheter placement and location. Contrary to possible shunt failure due to overdrainage, the failure likelihood due to obstruction and infection in pediatric patients was higher than that of mixed hydrocephalus patients. In both mixed and pediatric hydrocephalus, obstruction and overdrainage were the most and least common complications of ventricular frontal and occipital shunts, respectively. The most and least common complications of mixed CMS were infection and obstruction, respectively.

The role of operating variables in improving the performance of skull base grinding.

Control of the thermal and physical damage during skull base grinding is of great importance. We assess the effects of bur material (3 materials), angle of the bur (10 angles), bur diameter (10 diameters), gas coolant (4 coolants), and grinding time (10 times) to evaluate the role of operating variables in thermal and physical damage during skull bone grinding. After validation of finite element analysis (FEA) results with experimental data, the temperature in the grinding site and axial force are calculated using FEA. The use of a diamond bur leads to at least 24.48 and 12.9% reduction in thermal and physical damage, respectively. A change in angle of the bur from 0º to 90º leads to a 19.76-31.62 times increment in axial force. An increase in bur diameter from 1 to 5.5 mm led to 10.78-14.36% and 23.43-43.90% increase in maximum temperature and axial force, respectively. However, a bur diameter between 2.5 and 4 mm could provide enough grinding force with less thermal damage. Skull base grinding with dry (D) and normal saline (NS) coolants was always accompanied with thermal damage. The results of maximum and duration of temperature, axial force, and surface defect evaluation show CO2 coolants (especially internal CO2 coolant) are the best options to decrease thermal damage. The equations of temperature and axial force were estimated by regression analysis. This may be used as a guideline for neurosurgeons to control damage during skull base grinding and can also be helpful for the programming of robot-assisted skull grinding during surgery.

Clivus length distinguishes between asymptomatic healthy controls and symptomatic adult women with Chiari malformation type I.

PURPOSE: While the presence of cerebellar tonsillar descent in radiological images has been used as evidence of Chiari malformation type I (CMI), tonsillar ectopia alone is insufficient to identify individuals with symptomatic CMI. This study sought to identify differences in brain morphology between symptomatic CMI and healthy controls in adult females. METHODS: Two hundred and ten adult females with symptomatic CMI and 90 age- and body mass index-matched asymptomatic female controls were compared using seven brain morphometric measures visible on magnetic resonance images. The CMI and control groups were divided into four subgroups based on the tonsillar position (TP) relative to the foramen magnum: group 1 was made up of healthy controls with normal TP (TP < 0 mm); group 2 was comprised of control individuals with low-lying TP (1-5 mm); group 3 was comprised of symptomatic CMI patients with low-lying TP (1-5 mm); group 4 contained symptomatic CMI patients with severe tonsillar descent (6-13 mm). RESULTS: All morphometrics for symptomatic CMI with severe tonsillar descent were significantly different than those for both control groups. The CMI group with low-lying TP was significantly different for four measures when compared to controls with normal TP. However, only clivus length was statistically different between the CMI and healthy control groups with low-lying TP. CONCLUSION: This study demonstrates that clivus length distinguishes adult female healthy individuals with low-lying tonsils from those with symptomatic CMI. Further investigation is required to understand the importance of a shorter clivus length on CMI symptomatology and pathophysiology.

Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS).

PURPOSE: The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis. METHODS: We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex. RESULTS: Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up. CONCLUSION: ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Quantification of changes in brain morphology following posterior fossa decompression surgery in women treated for Chiari malformation type 1.

PURPOSE: While 84% of patients surgically treated for Chiari malformation type 1 (CM1) demonstrate improved quality of life after posterior fossa decompression surgery, there are many risks associated with this surgery. Surgical planning to identify candidates likely to improve postoperatively may benefit from an improved understanding of morphological changes after decompression surgery. To evaluate these changes, we quantified 59 morphological parameters on 42 CM1 adult female patients before and after CM1 decompression surgery. METHODS: Fifty-nine morphological parameters in the posterior cranial fossa, cranio-cervical, and intracranial regions in the midsagittal plane were evaluated using 42 T1-weighted magnetic resonance images of female CM1 patients before and after surgery, and 42 healthy female controls. Morphological differences before and after surgery were compared through the development of a technique to establish the opisthion location, a key reference point not present after surgery. RESULTS: In addition to the expected reduction of the cranio-caudal dimension of the cerebellum, objective analyses showed a significant increase in the area of the cerebrospinal fluid spaces, posterior (6×) and inferior (2.6×) to the cerebellum (+ 112 ± 102 and + 140 ± 127 mm2, respectively). This increased area was primarily impacted by an average reduction in the occipital bone length of 24.5 ± 7.3 mm following surgery. Based on multiple angles, results demonstrated a 2°-4° anterior rotation of the cerebellum after surgery. CONCLUSION: Our results show that decompression surgery results in significant changes in the cerebellum and cerebrospinal fluid spaces. Further investigation should determine how these morphological changes impact clinical outcomes.

Prevalence of Psychiatric Diagnoses in Pediatric Chiari Malformation Type 1.

This cross-sectional study investigates the prevalence and risks for psychiatric diagnoses in a large cohort of children with Chiari malformation type 1 (CM1) presenting for neurosurgical evaluation. Children between the ages of 6 and 17 years who were evaluated and diagnosed with CM1 at a neurosurgery clinic were identified. Eighty-six participants were recruited for this study with an average age of 11 years. Parents of participants completed a pediatric medical history questionnaire and a semistructured interview regarding the child's psychiatric, developmental, medical, and family history. A review of medical records was completed to complement interview data. Elevated rates of psychiatric diagnoses, including attention deficit hyperactivity disorder (ADHD) (22.1%), anxiety (12.8%), and depression (10.5%), were identified in the study population when compared to published norms in the general population documented by the American Psychiatric Association in 2013. In addition, elevated rates of psychiatric diagnoses in first-degree relatives of study participants were also identified. A 2-step binary logistic regression analysis revealed that maternal complications during pregnancy (Wald = 6.52, p = 0.01) increased the risk of a psychiatric diagnosis 9-fold. Premature birth (Wald = 6.79, p = 0.01) also significantly predicted a psychiatric diagnosis amongst participants. The current findings suggest a high prevalence of psychiatric illness in children with CM1. Pregnancy complications were associated with a high risk of a psychiatric diagnosis. Early CNS developmental disturbance may explain this relationship. Prematurity only slightly improved the prediction model. Limitations and future directions are discussed, including the cross-sectional nature of the present study, possible self-selection bias, and the importance of future investigation of other causative and/or associative factors of CM1, such as cognitive, psychiatric, and medical influences on health status.

Transcardiac migration of ventriculoperitoneal shunt requiring open cardiac surgery: case report and review of the literature.

INTRODUCTION: Cardiac migration of ventriculoperitoneal (VP) shunts has been reported, with most easily removed or shortened via a cervical incision. We present a review of the literature, highlighting our unique case with significant scarring requiring open, on-pump, cardiac surgery for removal of migrated distal tubing. CASE PRESENTATION: A 7-year-old boy underwent VP shunt insertion for hydrocephalus secondary to intracranial astrocytoma. He presented at age 17 with evidence of right heart strain, associated with the distal shunt catheter proximally migrated into his heart and pulmonary arteries. Due to his delayed presentation, the catheter was knotted and partially immobilized by scar formation, finally requiring open-heart surgery to remove the catheter. CONCLUSIONS: A multi-disciplinary evaluation with endovascular, neurosurgery, and cardiothoracic surgery may be the safest approach, especially in those patients with knotting on preoperative imaging.

Parent-Reported Executive Dysfunction in Children and Adolescents with Chiari Malformation Type 1.

BACKGROUND: Children with Chiari malformation type 1 (CM1) have increasingly presented to neurosurgery clinics. Limited research relating to the cognitive dysfunction experienced by this population has been completed. In adults, inhibition problems and executive dysfunction have been documented. METHODS: Seventy-seven parental reports of children with CM1 were included in the study. Parents completed questions on a scale rating daily executive functioning as well as reporting on common neurological symptoms. RESULTS: The sample consisted of 41 males and 36 females with a mean age of 133.57 ± 42.18 months. Thirty-eight subjects had had decompression surgery. The most common neurological symptoms included: headache (69%), a history of pain (31%) and gait disturbance (20%). One third of the sample demonstrated overall executive functioning impairment, with working memory elevations being most prevalent (44%). Depression, gender, age and decompression surgery were not related to executive dysfunction. CONCLUSIONS: The parental report of executive dysfunction in children with CM1 was higher than the standardized healthy sample. Metacognitive problems, especially working memory and initiation problems were most prevalent. A quick parental rating scale identifying children with executive dysfunction may be beneficial for neurosurgeons and assist with referrals for a more comprehensive neuropsychological assessment.

Patterns of Hydrocephalus Caused by Congenital Toxoplasma gondii Infection Associate With Parasite Genetics.

Four anatomical patterns of hydrocephalus secondary to congenital Toxoplasma gondii infection were identified and characterized for infants enrolled in the National Collaborative Chicago-based Congenital Toxoplasmosis Study. Analysis of parasite serotype revealed that different anatomical patterns associate with Type-II vs Not-Exclusively Type-II strains (NE-II) (P = .035).

MRI Findings After Surgery for Chiari Malformation Type I.

OBJECTIVE: Surgery plays an important role in the management of Chiari I malformation. The purpose of this article is to review expected and unexpected MRI findings after the various types of surgery performed during the treatment of Chiari I malformation and associated abnormalities. CONCLUSION: Familiarity with optimal MRI techniques and findings is important when evaluating postoperative changes after treatment of Chiari I malformation.

Urodynamic studies in spinal cord tethering.

INTRODUCTION: Tethered cord syndrome (TCS) is of particular interest to urologists through its effects on the function of the lower urinary tract. Tethering of the spinal cord can result in bladder dysfunction with multiple manifestations, clinically raging from urinary retention and detrusor under-activity to urinary incontinence, over-activity of the detrusor, and sphincter dysfunction. Goals of management include protecting renal function and preserving patient quality of life. METHODS: Evaluation of a TCS patient with urinary complaints begins with a thorough history and physical examination. Further characterization of urinary symptoms with a voiding diary provides vital information that helps to direct treatment while engaging the patient and family in the treatment plan. Urodynamic studies then provide key diagnostic data regarding bladder function, bladder outlet resistance, and urinary sphincter function. In the pediatric population, particular care must be paid to counseling patients and their families prior to the procedure to alleviate the often-considerable anxiety associated with an invasive procedure. CONCLUSION: The armamentarium for management of neurogenic bladder associated with TCS includes behavioral training, biofeedback therapy, medications, patient-performed procedures, and surgical intervention. The choice of intervention depends on the patient's symptoms, urodynamic findings, and patient and family preferences. The primary problem of TCS should be addressed first through detethering, and then the urological team can use progressively more aggressive therapies as necessary. Interpretation and treatment by a dedicated, specialized, multidisciplinary team that includes the pediatric urologist, pediatric neurosurgeon and dedicated nurse practitioner, is critical for successful treatment.

Parent ratings of executive functioning in children with shunted hydrocephalus.

OBJECTIVES: The present study examined the executive functioning of a group of children with a history of communicating hydrocephalus and how their level of functioning was correlated with parent ratings of executive functioning. METHODS: The study examined the executive functioning of 39 shunted children with a history of hydrocephalus and 20 healthy peers. Additionally, parents of both groups of children completed the Behavior Rating Inventory of Executive Function (BRIEF) to assess the parents' perceptions of their children's executive functioning. Finally, the study investigated the relationship between the shunted hydrocephalus children's executive functioning and the parent ratings of their executive functioning. RESULTS: Overall, the children with a history of shunted hydrocephalus displayed more executive dysfunction than their healthy peers. These children were rated by their parents as having more executive dysfunction than their healthy peers and displaying working memory, initiation, mental flexibility and self-monitoring difficulties, which appear to increase with age among the shunted hydrocephalus group. While parent ratings as measured by the BRIEF indices did not correlate with all executive tasks within the shunted hydrocephalus group, the cognitive tests assessing mental flexibility may be sensitive to the problems noted by parents at home. CONCLUSIONS: The children with a history of shunted hydrocephalus displayed executive functioning deficits on formal examination. The parents of children with a history of shunted hydrocephalus report ongoing executive difficulties which may increase with age.

Is repeat head computed tomography necessary in children admitted with mild head injury and normal neurological exam?

BACKGROUND: Children admitted following mild head injury (MHI) often undergo repeat head computed tomography (HCT) to identify progression of injury, although there is little evidence to support this practice. METHODS: From January 2007 to December 2009, we retrospectively reviewed the medical records of patients aged 2 months to 18 years admitted with a diagnosis of MHI to a Level I Pediatric Trauma Center. Data including Glasgow Coma Scale, loss of consciousness, length of stay (LOS), and number and results of HCTs were analyzed. RESULTS: A total of 507 patients were admitted with MHI and normal neurological exam; 389 had a normal and 118 had an abnormal initial HCT. The median LOS in the normal HCT group was 17.68 h (5.47-109.68) and in the abnormal HCT group 36.63 h (10.15-192.40). The median number of HCTs in the normal HCT group was 1 (1-2) and in the abnormal HCT group 2 (1-5). CONCLUSIONS: Children admitted with MHI, abnormal initial HCT and normal neurological exam had longer LOS and more HCTs compared with children with normal initial HCTs. No patient in either group had any change in their management based on HCT. Therefore, repeat HCT may be unnecessary for patients with MHI and normal neurological exam.

Intrapleural migration of a spinal catheter in a patient with arachnoiditis and extensive epidural scarring after tethered cord release: a case report and review of literature.

OBJECTIVE: The objective of this study was to report a case of new onset refractory pain from intrapleural migration of a spinal catheter five months after the implantation of an intrathecal drug delivery system (IDDS). MATERIALS AND METHODS: A 57-year-old man had intractable pain because of multiple intradural spinal explorations for tethered cord release. His pain was effectively treated with intrathecal morphine via an IDDS. Five months after the implantation, the patient developed return of the original pain more than two weeks after intrapleural migration of the intrathecal catheter. RESULTS: The migration was documented by computed tomography, and repositioning of the catheter rendered the patient comfortable. The gradual onset of pain may have been due to decreasing delivery of drug to the cerebrospinal fluid as the catheter tip migrated further away from the dura. To our knowledge, this complication has not been reported in the literature. CONCLUSION: Physicians and nursing staff that place and manage an IDDS should be aware of this complication.

Long-term recovery behavior of brain tissue in hydrocephalus patients after shunting.

The unpredictable complexities in hydrocephalus shunt outcomes may be related to the recovery behavior of brain tissue after shunting. The simulated cerebrospinal fluid (CSF) velocity and intracranial pressure (ICP) over 15 months after shunting were validated by experimental data. The mean strain and creep of the brain had notable changes after shunting and their trends were monotonic. The highest stiffness of the hydrocephalic brain was in the first consolidation phase (between pre-shunting to 1 month after shunting). The viscous component overcame and damped the input load in the third consolidation phase (after the fifteenth month) and changes in brain volume were stopped. The long-intracranial elastance (long-IE) changed oscillatory after shunting and there was not a linear relationship between long-IE and ICP. We showed the long-term effect of the viscous component on brain recovery behavior of hydrocephalic brain. The results shed light on the brain recovery mechanism after shunting and the mechanisms for shunt failure.

A New Definition for Intracranial Compliance to Evaluate Adult Hydrocephalus After Shunting.

The clinical application of intracranial compliance (ICC), ∆V/∆P, as one of the most critical indexes for hydrocephalus evaluation was demonstrated previously. We suggest a new definition for the concept of ICC (long-term ICC) where there is a longer amount of elapsed time (up to 18 months after shunting) between the measurement of two values (V1 and V2 or P1 and P2). The head images of 15 adult patients with communicating hydrocephalus were provided with nine sets of imaging in nine stages: prior to shunting, and 1, 2, 3, 6, 9, 12, 15, and 18 months after shunting. In addition to measuring CSF volume (CSFV) in each stage, intracranial pressure (ICP) was also calculated using fluid-structure interaction simulation for the noninvasive calculation of ICC. Despite small increases in the brain volume (16.9%), there were considerable decreases in the ICP (70.4%) and CSFV (80.0%) of hydrocephalus patients after 18 months of shunting. The changes in CSFV, brain volume, and ICP values reached a stable condition 12, 15, and 6 months after shunting, respectively. The results showed that the brain tissue needs approximately two months to adapt itself to the fast and significant ICP reduction due to shunting. This may be related to the effect of the "viscous" component of brain tissue. The ICC trend between pre-shunting and the first month of shunting was descending for all patients with a "mean value" of 14.75 ± 0.6 ml/cm H2O. ICC changes in the other stages were oscillatory (nonuniform). Our noninvasive long-term ICC calculations showed a nonmonotonic trend in the CSFV-ICP graph, the lack of a linear relationship between ICC and ICP, and an oscillatory increase in ICC values during shunt treatment. The oscillatory changes in long-term ICC may reflect the clinical variations in hydrocephalus patients after shunting.

Olig1 is expressed in human oligodendrocytes during maturation and regeneration.

Myelin repair is inhibited in multiple sclerosis (MS), ultimately leading to axonal damage and disability. We aimed to understand the transcriptional mechanisms of regeneration in primary human oligodendrocyte cultures isolated from white matter of medically intractable epilepsy patients. Cultures at isolation contained 84% mature oligodendrocytes and 16% oligodendrocyte progenitor cells (OPC). The two populations showed a protracted regeneration of membranes expressing myelin proteins after 2-3 weeks in culture, and were kept long-term to study membranes maintenance. We profiled by quantitative PCR (qPCR) the sequential mRNA expression of transcription factors Olig1, Olig2, Nkx2.2, Sox10, PPARδ, PPARγ, cyclic nucleotide phosphodiesterase (CNP), myelin basic protein (MBP), myelin-associated glycoprotein (MAG) and myelin oligodendrocyte glycoprotein (MOG). In summary, Olig1 was not expressed in freshly isolated oligodendrocytes, but was expressed from the beginning of process extension until membranes maintenance. In contrast, Olig2 expression was restricted to isolation and during membranes production. We show for the first time PPARδ expression and absence of PPARγ in human oligodendrocytes. Nkx2.2, Sox10, PPARδ, CNP, MBP and MOG messengers were expressed at any time, while MAG messenger was expressed at mature stage only. Myelin proteins CNP, MBP, MAG, and MOG were confirmed by immunocytochemistry. Our findings point to different roles of Olig1 and Olig2 in regeneration of cultured adult human oligodendrocytes. Noticeably, the transcriptional profiles found in cultured neonatal rodent OPC are different. More studies are necessary to elucidate myelin repair in the adult human brain.

Interictal regional delta slowing is an EEG marker of epileptic network in temporal lobe epilepsy.

PURPOSE: Several studies have suggested that interictal regional delta slowing (IRDS) carries a lateralizing and localizing value similar to interictal spikes and is associated with favorable surgical outcomes in patients with temporal lobe epilepsy (TLE). However, whether IRDS reflects structural dysfunction or underlying epileptic activity remains controversial. The objective of this study is to determine the cortical electroencephalography (EEG) correlates of scalp-recorded IRDS, in so doing, to further understand its clinical and biologic significances. METHODS: We examined the cortical EEG substrates of IRDS with electrocorticography (ECoG-IRDS) and delineated the spatiotemporal relationship between ECoG-IRDS and both interictal and ictal discharges by recording simultaneously scalp and intracranial EEG in 18 presurgical candidates with TLE. KEY FINDINGS: Our results demonstrated that ECoG-IRDS is typically a mixture of delta/theta slowing and spike-wave potentials. ECoG-IRDS was predominantly recorded from basal and anterolateral temporal cortex, occasionally in mesial, posterior temporal, and extratemporal regions. Abundant IRDS was most commonly observed in patients with neocortical temporal lobe epilepsy (NTLE), whereas infrequent to moderate IRDS was usually observed in patients with mesial temporal lobe epilepsy (MTLE). The anatomic distribution of ECoG-IRDS was highly correlated with the irritative and seizure-onset zones in 10 patients with NTLE. However, it was poorly correlated with the irritative and seizure-onset zones in the 8 patients with MTLE. SIGNIFICANCE: These findings demonstrate that IRDS is an EEG marker of epileptic network in patients with TLE. Although IRDS and interictal/ictal discharges likely arise from the same neocortical generator in patients with NTLE, IRDS in patients with MTLE may reflect a network disease that involves temporal neocortex.

Concurrent Chiari decompression and spinal cord untethering in children: feasibility in a small case series.

BACKGROUND AND PURPOSE: We describe the rationale and safety of concurrent decompression of Chiari type 1 malformation (CM1) and untethering of the spinal cord. Spinal cord traction is considered one of the pathogenic mechanisms involved in the development of CM, and 14% of patients with CM1 have tethered cord syndrome (Milhorat et al., Surg Neurol 7:20-35, 2009; Roth, Neuroradiology 21:133-138, 1981; Royo-Salvador, Rev Neurol 24:937-959, 1996; Royo-Salvador et al., Acta Neurochir 147:515-523, 2005). Therefore, intraspinal anomalies that require intervention are commonly treated before surgical decompression of Chiari malformation (Cheng et al., Neurologist 8:357-362, 2002; Menezes, Pediatr Neurosurg 23:260-269, 1995; Milhorat et al., Surg Neurol 7:20-35, 2009; Royo-Salvador et al., Acta Neurochir 147:515-523, 2005; Schijman and Steinbok, Childs Nerv Syst 20:341-348, 2004; Yamada et al., Neurol Res 26:719-721, 2004). However, in the interval between the spinal cord untethering and the decompression surgery, patients may continue to suffer from the untreated symptoms of CM. In a series of four patients with concurrent severe and progressive symptoms referable to both conditions, we performed both surgeries simultaneously. METHODS: Charts of four patients who underwent concurrent Chiari decompression and spinal cord untethering were reviewed. RESULTS: All patients tolerated the procedures well without complication. They reported significant or complete early postsurgical resolution of headaches and ambulating difficulties. On average, patients started to walk on postoperative day 3 (3 ± 1 days) and were discharged on hospital day 6 (6 ± 1 days). No patient experienced a persistent subcutaneous or transcutaneous cerebrospinal fluid leak. Subsequent postoperative courses were uneventful. CONCLUSION: Concurrent Chiari decompression and untethering of the spinal cord is a feasible option and in some patients may be preferred in lieu of staged procedures.