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Chiari Malformation, Cervical Spinal Stenosis and Fibromyalgia

Many of our readers have asked for my opinion about the recent reports of Chiari malformation, cervical spinal stenosis and fibromyalgia and fatigue syndromes.

It is estimated that there are ten million or more people in North America suffering from a pain condition commonly named fibromyalgia and/or chronic fatigue syndrome. For years, the condition has been labeled a psychiatric disorder as many with the condition have a higher association of depression and anxiety than the general population. It has also been labeled a blood-borne condition or autoimmune or even infection-related disease.

ABC News

Recently, on ABC News, Dr. Tim Johnson reported that a neurosurgical procedure being performed on sufferers of fibromyalgia and chronic fatigue had improved their pain and fatigue.

To review and paraphrase from the ABC web release, Dr. Banner of Dotham, Alabama was himself disabled with a fatigue and pain syndrome. So much so that he had to change his style of practice. He changed to a form of disability practice.

He found many of his patients with chronic pain syndromes had cervical spinal pathology. It was often referred to as cervical spinal stenosis or stenosis of the cervical nerve roots from bone and disk compression. Some had compression of the spinal cord at the exit from the skull or foramen magnum- also known as Chiari malformation. All had neurological evidence of some kind demonstrating nerve or spinal cord compression. Many of these patients had surgery at the University of Alabama by a Dr. Michael Rosner and Dr. Dan Heffez. Many had good results with respect to reduction in pain and fatigue after having the surgery. The surgery was different for every patient but generally consisted of surgical decompression of the spinal cord or nerve roots from the removal of excess bone or disk around the compressed area.

The patients chosen for surgery had significant evidence of nerve root or spinal cord compression on X-ray, CT, MRI, physical examination or EMG scans. Some argument surrounds the selection process of the patients.

Dr. Banner noted that his symptoms were much like his patients and wondered if he too had a neck disorder. He had an MRI demonstrating abnormal cervical changes (the exact abnormalities were not disclosed). He had surgical decompression with improvement in pain and fatigue and he continues to feel better.

The Charlotte Observer

Again paraphrased, from Karen Garloch, the Charlotte Observer, February 26,2000.

An interview with Dr. Hipp, a former partner of Dr. Rosner, feels that many pain sufferers have been mislabeled as suffering from fibromyalgia and that he is not operating to cure fibromyalgia. Dr. Tony Asher of Charlotte feels that there will be "something to this approach" but " the controversy seems to revolve around whether nor not all the patients receiving this therapy are appropriate candidates."

Dr. Charles Lapp, a Charlotte physician who specializes in treating patients with CFS and Fibromyalgia, agreed there is "great potential" but claims he has seen patients relapse later after surgery.

Dr. Rosner states that, " the degree of disability you see in some people is way in excess of what you see (on the scans). Unless you’re looking for this or you have a high degree of suspicion, you say there is nothing wrong with the patient. Some doctors rely too much on scans and don’t do adequate physical exams. I don’t operate on somebody who doesn’t have an abnormal exam."

Dr. Lamb’s Opinion

My first thoughts are of great excitement. Finally there is some medical recognition of this problem called fibromyalgia. It is my hope that sufferers of fibromyalgia and other chronic pain disorders will get some recognition from the medical and insurance communities, that their pain has a neurological basis. 

I suspect there will be an increase in diagnostic scanning techniques to demonstrate the neurological changes that I have seen in patients suffering from fibromyalgia, having specialized in this area for the past seven years.

Compression Neuropathy

It has always been my opinion that the major abnormality of most fibromyalgics is a compression neuropathy, typically involving the cervical spine and other parts of the spine. This then causes  other symptoms, such as irritable bowel and leg pains.

I suspect that the Chiari Malformation is present at birth but that symptoms probably occur in people after cervical spinal compression from injury, repetitive work or progressive spinal degeneration. Perhaps the bone of the foramen magnum enlarges with cervical spine traction contributing to the Chiari syndrome. 

It has been similarly suspected that deep paraspinal muscle scarring causes enlargement and arthritis of the facet joints causing spinal stenosis. Dr. Rosner emphasizes much upon cervical spinal stenosis and less upon the actual Chiari malformation. This may not be much different from that of lumbar spinal stenosis and the surgical decompression involved at the lower lumbar levels.

I believe that the deep paraspinal muscles contribute to persistent spinal compression leading to facet joint inflammation, swelling and arthritis. I believe it may also lead to disk compression, wearing, degeneration and herniation of the disks. Spinal muscle scarring may cause minor spinal malrotation that is deemed insignificant on scanning or may be missed, as all scans are performed in the laying position- a position that allows for decompression of the spine. These malrotations and subluxations may cause nerve root irritation or compression.

The Thoracolumbar Spine

In the low back, the result may be disk injury or herniation, spinal stenosis and sciatica. The hip, knee and foot joints may pain, swell or stiffen, signifying the onset of compression arthritis or osteoarthritis. When the thoracic spine is similarly affected, chest, abdominal and upper limb pain may result. I have seen hip pain originate as high as the low thoracic spine, despite normal pain referral patterns being much lower in the lower lumbar spine. I have seen rotator cuff originate as low as T2 to T6 or the upper thoracic spine.

The Cervical Spine

I find the cervical spine a little more complicated. I have seen high cervical lesions (C1 to C4) contribute to sleep disruption, fatigue, headache, TMJ, sinus congestion, vertigo and decreased hearing. I have seen middle to low neck lesions (C4 to T1) contribute to carpal tunnel syndrome, ulnar neuritis, thoracic outlet syndrome, tennis elbow, golfer’s elbow, headache and sleep disruption. Of course, there will be tremendous overlapping.

Some of the explanation is directly obvious- that is a C5 to C6 nerve root compression will cause pain and numbness radiating down into the neck, shoulder, arm and forearm. Some of the explanation is a little more perplexing- that is, how does a T6 nerve root disruption or compression cause shoulder or arm pain when classical neurology tells us that the upper limb derives most of it’s nerve supply from C5 to T1, far above the level of T6?

Similarly, in the neck, cranial nerve abnormalities may partly originate from the cervical spine. It seems that some of the cranial nerves in the brainstem may derive part of their nerve supply from the cervical spine. Hence cervical spondylosis may "refer" pain or dysfunction into a cranial nerve area causing referred headache or even dysfunction such as vertigo. 

Much of this is part of the crux of a group known as the North American Cervicogenic Headache Society, of which I am a member. It is then possible that the upper limb may derive some of its nerve supply from the upper thoracic spine, thereby contributing to conditions such as RSI, rotator cuff and more.

Beyond Simple Spinal segments

It is also important to understand that spinal muscles are five layers deep with the deepest layers running fairly locally. However, the top three layers may traverse large areas of the thorax and spine. This may partly explain lower spinal segments affecting higher spinal segments and vice versa. For example, it is not uncommon to see patients with low back problems acquire neck and upper back problems within months or a few years of the low back problem. Conversely, it is not unusual for those with neck pain and dysfunction to develop lower lumbar spine pain. 

It is also important to remember my comments throughout the website on "injury factors." There may be other factors at play in a chronic pain patient. Factors such as rheumatoid arthritis, long spines, radiation injury, chemical exposure, drug side effects, aging factors, body-positional factors and structural irregularities of the spine and limbs need to be considered.

Post Surgical Effect

I am excited, yet watchful of the surgical cervical decompression procedure for fibromyalgia and like conditions. Historically, in the sixties, we began operating on lower backs for back pain. Many individuals have had back surgery and some had successes but many have had terrible post-operative back pain. So much so that Doctors have coined the term "post-operative back syndrome." As a result, since the sixties, most surgeons have greatly reduced their lower spinal surgeries and require strict abnormalities on MRI before operating on the lower back.

Surgery represents only a few percent of recurring or chronic back pain patients. The rest must make do with other therapy and many do very well with stretching, medications, yoga, chiropractic and new and old injection therapies. 

Interestingly, both my parents had back surgeries with some success but some degree of failure. They have managed quite well with stretching, medication and needling procedures. I was able to avoid surgery on my own spine and made a full recovery.

I suspect cervical decompression surgery will develop similar rules eventually. There will be many that will acquire relief from the decompression surgery but I suspect many will relapse much like the lower back procedures. Nevertheless, This new, yet old, procedure may likely help many of those who have demonstrable cervical spinal disease. The rest may gain benefit from a combination of treatments. I recommend maintaining interest in new injection technologies, including BOTOX™.

Prevention

My final points are not on the treatment but on the prevention of fibromyalgia and other pain syndromes. Assuming muscle and spinal pathology is the origin of many sufferers pain, then prevention technologies such as regular spinal and limb stretching, resting at repetitive work stations, spine and muscle awareness and education may help many of us avoid the diagnosis of fibromyalgia and like syndromes.

Early recognition of neuropathic symptoms such as sleep disruption, restless limbs, joint crepitus and stiffness, minor limb numbness and tingling and itchy body parts, especially at rest or bed-time is important. I have incorporated early recognition and treatment into my practice and seminars and this has helped many from progressing into a chronic pain syndrome.

Consult your doctor and keep long and strong.

G. Blair Lamb MD, C.C.F.P.

Pain and Rehabilitation Consultant

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