Introduction: Chiari I malformation (CIM) is a congenital abnormality defined as downward herniation of the cerebellar tonsils through the foramen magnum. Syringomyelia is present in 30–85% of cases. Magnetic resonance (MR) imaging has increased the frequency of diagnosis of this complex disorder. Great variety exists in the indications and techniques recommended for the surgical management of this complex. Methods: In a group of 23 prospectively selected patients (15 males and 8 females) having (CIM) with and without syringomyelia (11 patients and 12 patients respectively) during a five years period from January, 2005 to January, 2010. Cranio-cervical bony decompression alone was done in 8 patients, Cranio-cervical bony decompression with duroplasty was done in 12 patients, and Cranio-cervical bony decompression with syringo-subarachnoid shunt was done in three patients. Outcome was defined as good, fair, or bad. Results: During a mean follow-up period of 32 months, the overall outcome was good in 19 patients (83%), fair in 3 patients (13%), and bad in one patient (4%). No operative mortality or permanent post operative morbidity was encountered. Transient post operative morbidity was encountered in 6 patients (26%) namely mild temporary neurological deterioration, CSF leak, and mild wound sepsis. There were no statistically significant differences between the various decompressive approaches. Conclusion: Decompression of the cranio-cervical junction through suboccipital craniectomy (SOC) with cervical laminectomy, duroplasty, or syringo-subarachnoid shunt is the recommended surgical management option for CIM±S. Further studies utilizing larger patient volumes are necessary to confirm our recommendation.