The patient was operated 1991 for arachnoid cyst left sylvian and VPS was performed. & months ago after delivery, got headache with ataxia for 3 months and falling to the left. The last 3 days swallowing difficulty.

On examination: the patient is neurologically free but in Romberg sway to the left.

The patient was sent for thorough investigations and MRI of the brain revealed Arnold-Chiari malformation III degrees with compression of the medulla by the bony elements.

In the setting position, posterior occipital approach with drilling of the posterior ring of C1 and and the occipital bone. The band running posterior to the junction between the occipital dura and spinal cord was bisected without opening the dura. Fenestration of the external layer of the dural to regain more ample also was performed. Routine closure of the wound.

The patient came several times with mild improvement of her condition, but still complaining. MRI brain done 17-December-2003 showing the tonsilar herniation without medullary compression.

The patient then came to me urging to be operated after performed surgery elsewhere  22-February-2004 with CSF leak coming out of the surgical wound.

It seems that decompressing the bones with releasing the fibrous bands and mesh the external layer of the dura is not sufficient to resolve the problem of Arnold-Chiari, even if in the MRI the compression of the medulla disappeared, but not to a sufficient degree to radically resolve the problem, for what the patient continued to complain and went to other neurosurgeon, who also made a mistake, leaving the neural structures open with CSF coming freely out. I was under the influence of one of crazy article in the Journal of American Association, telling that this technique is effective, which turned to be untrue. I usually open the dura over the cerebellar hemispheres and the spinal cord and put a rhomboid artificial dura. This scenario was performed for years. Do not trust all what is written in the most prestigious journals, even from AANS.