Craniocervical decompression

Craniocervical decompression

Anesthesia type	General
Airway	ETT
Lines and access	Arterial line Large bore IV
Monitors	Standard ABP
Primary anesthetic considerations
Preoperative	Neuro exam to characterize deficits
Intraoperative	Risk of venous air embolus
Postoperative	PONV Airway protection reflexes Respiratory depression ICU for neuro checks
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A craniocervical decompression is a neurosurgical procedure performed to decompress the craniocervical junction, most commonly to treat a Chiari malformation.

Overview

Indications

• Chiari malformation (type I or II)
• Syringomyelia

Surgical procedure

A suboccipital craniotomy is performed an the posterior arch of C1 is removed. The dura is opened and the cerebellar tonsils are dissected and reduced. A shunt may be placed to allow CSF to flow from the fourth ventricle to the subarachnoid space. A dural patch may be used to expand the dural space at the foramen magnum. The dura is then closed and bone flap replaced.

Preoperative management

Patient evaluation

System	Considerations
Airway	Evaluate airway protection reflexes
Neurologic	Focused neuro exam to characterize preexisting deficits
Pulmonary	If dysphagia is present, may have recurrent aspirations

Labs and studies

• MRI to characterize extent of herniation and any other intracranial abnormalities
• BMP
• CBC
• Type and screen

Patient preparation and premedication

• Increased risk of PONV from posterior fossa craniotomy
  • Consider additional prophylaxis such as aprepitant

Intraoperative management

Monitoring and access

• Arterial line
• Large bore IV
• Monitor for venous air embolism (EtCO2 and/or precordial doppler)

Induction and airway management

• Avoid hypoventilation (→hypercarbia→cerebral vasodilation→increased ICP)

Positioning

• Prone or sitting
• Mayfield pin fixation

Maintenance and surgical considerations

• Avoid increased ICP
• Monitor for venous air embolism due to proximity of transverse sinuses
• Hemodynamic instability from brainstem manipulation
  • Atropine for severe bradycardia
• Massive blood loss due to proximity to vertebral artery and transverse sinuses

Emergence

• Verify intact airway protective reflexes prior to extubation

Postoperative management

Disposition

• ICU for neuro checks

Pain management

• Acetaminophen IV prior to emergence

Potential complications

• Respiratory depression
• CSF leak