The posterior atlanto-occipital membrane (PAO) contributes little to craniocervical stability and is generally underappreciated and incised with most suboccipital craniectomies. We report a case of a child who underwent posterior fossa decompression for Chiari I malformation with syringomyelia whose symptoms had not resolved months after surgery. A secondary exploratory operation revealed a healed constricting PAO which had been incised linearly at the initial operation. This patient's symptoms improved soon after the second surgery. We propose that attention be given to this membrane, and if it is incised with underlying dura mater as in a standard posterior fossa decompression, it should be removed or cauterized separately and laterally to inhibit its reformation. Copyright © 2003 S. Karger AG, Basel.