The Hospital Experience:

Undergoing surgery

In this section, we’ll cover undergoing a craniovertebral decompression. People who have decided to take up an offer for surgical intervention, for their syringomyelia or Chair malformation, may well ask one or more of the questions we propose in this section. These are questions that can also be very reasonably put to their neurosurgeon or a Clinical Nurse Specialist. We have, nevertheless, tried to provide some idea as to what the answers might be.

Common questions & answers

This varies from one individual to another. The total length of time somebody spends in hospital depends upon several factors, including an individual’s age, what facilities they have at home when they are discharged and whether any complications develop after the surgery. Most people stay in hospital for about a week after the operation, sometimes longer, perhaps as long as two weeks on occasions. This assumes there are no complications. Obviously, the spell in hospital may be a good deal longer if complications develop.

Craniovertebral decompression is a major operation for anybody to undergo. The body needs time to recover. It will take at least a month for an individual to feel anywhere near normal again. It is advisable for anybody to assume they will be off work for at least six weeks, perhaps as much as three months. To some extent the period off work is determined by how essential it is for somebody to get back to their employment. Professional people, self-employed and highly motivated individuals tend to get back to work sooner but unless there is a pressing need it is best for somebody to recover adequately. It would not look good for someone appearing not to cope after brain surgery.

The operating time would be about two hours on average, but the period will vary according to the state of anatomy of an individual case. There is, however, a good deal of preparation to be made, both before and after someone is anaesthetised, before the operation as such begins. After the procedure, when the anaesthetic is reversed, there is a period to be spent in the recovery bay, before a patient returns to the ward. All in all it is likely that you will be in the theatre suite for the best part of a half day.

The wound is about 4″ long, in the midline at the back of the head/upper part of the neck. Quite a few stitches need to be placed deep to the skin, in the muscles and other layers. These will absorb over time. The skin is usually closed with non-absorbable stitches or metallic clips, which need to be removed, usually after about ten days.

Some surgeons choose not to remove hair but most neurosurgeons will take a generous strip of hair in the midline, at the back of the head. Most surgeons feel more comfortable doing this, feeling that the skin can be cleansed and the risk of infection is reduced, although this is not something that can be proven. The head shave also allows for an adequate wound dressing to be applied.

In most cases an outpatient review appointment will be arranged in due course. Ideally this will be six to eight weeks after the surgery but it may be longer, depending upon the pressures on local clinic appointments. Most surgeons would provide emergency access to patients if any problems arose in the meantime.

Craniovertebral decompression aims to correct an internal anatomical abnormality. Many of the symptoms that arise as a result of this condition may improve after surgery. Headache, the most common symptom, is the one that usually responds well. Even if headaches do not resolve completely, they usually improve significantly. Indeed, craniovertebral decompression can be a life transforming operation. Sometimes headaches may return after an interval but they are not usually as severe as they were prior to the surgery. There are a variety of possible causes of recurrent headaches. You would need to discuss matters with your surgeon.

This is a commonly asked question, following intracranial surgery of any type, not just craniovertebral decompression. The only restriction is when there is air in the head, which occurs after any intracranial surgery, particularly craniovertebral decompression. Theoretically problems could arise if somebody was carried on a high altitude, long haul flight within a short time after such an operation. By a month after surgery any air in the head will be well absorbed. It is unlikely that anybody would choose to take a flight within such a short time after a major brain operation.

In the UK the Driver and Vehicle Licensing Authority place restrictions upon driving following some types of intracranial surgery. The so-called posterior fossa surgery – craniovertebral decompression falls into this category – does not generally require a set period off driving, beyond the requirement for the individual to have recovered in general terms from the surgery. You should not, therefore, plan to drive yourself home from hospital a week after the procedure! It is probably best that you find a “chauffeur” for the first month or so after the operation.

A. There are no strict rules here. Most surgical departments will try to avoid hair washes until the sutures are removed. Even when the stitches do come out the wound is not fully healed by any degree so you should take care when washing your hair. Gentle rinsing rather than vigorous rubbing would be appropriate.

You should consult your General Practitioner. They will almost certainly refer you back to your neurosurgeon who will see you in the clinic and take matters from there.

Even though skin stitches are removed early on, there is a long way to go, both in terms of wound healing and recovery from the surgical trauma. Nature’s healing processes cannot be rushed. It will be at least a month before you feel human again. By three months after the surgery you should have resumed most normal activities. It will be six months, however, before you can push yourself to any degree, e.g. vigorous sporting activity. As regards recovery of lost neurological function this varies. There may be no recovery – the principle aim of the surgery may have been defined as preventing further deterioration, particularly if it is for syringomyelia associated with hind brain hernia. As a general rule of thumb it may take up to two years for recovery of lost neurological function. Beyond that period it is unlikely that further improvement will occur.

A Chiari malformation is a true hernia in the sense that one body part, in this case the tonsils of the cerebellum, protrude through an opening, in this case the foramen magnum at the base of the skull. A much more common hernia, of course, is one in the abdominal wall or the groin. These can certainly recur if a surgical repair fails. Craniovertebral decompression is somewhat different from repair of the abdominal wall. At the craniovertebral junction we are trying to create room for the herniated cerebellar tonsils and to allow CSF to flow across the craniovertebral junction. We are not trying to repair a weak container. All surgeons will, therefore, try to open up the CSF channels at the craniovertebral junction. Most will open the membranes that enclose the CSF. Some will apply heat to the cerebellar tonsils, to shrink them in volume. Some surgeons will apply a patch to the membranes that they have opened but others will not. Problems may arise later on if scar tissue forms at the operation site and causes the surgically created artificial cisterna magna to close down once more, obstructing CSF movement again. This is not a recurrence of the hind brain hernia as such but it can certainly lead to a recurrence of symptoms. Furthermore, it can be very difficult to treat. Revisional surgery at the craniovertebral junction to post-operative scar tissue, is hazardous, the anatomy is distorted. Verging as against revisional surgery can be likened to the difference between driving on a sunny day and driving through thick fog.

Craniovertebral decompression constitutes major brain surgery. It needs to be carried out in Specialist Neurosurgical Units. These exist in many major cities in the UK but not in all district general hospitals. There are 35 units in the UK, including children’s units.

In-patient experience