Chiari Malformation Diagnosis and Treatment
Patients living with a Chiari malformation face tough choices because we know so little about the condition. We know so little about it because until the advent of MRI, especially upright MRI, we were under the impression that it was rare. Apparently it is not, which is what I suspected many years ago and recently describe in my book "The Downside of Upright Posture." Humans are predisposed by design, to the descent of the brainstem and cerebellum into the foramen magnum due to upright posture.
But that's only part of the dilemma. The other part is that Chiari isn't always a problem. Some people have large malformations (deep descent) and little or no symptoms and some people have mimimal descent, referred to as Chiari 1 or Chiari 0, with major problems. The issue with all Chiari type malformations, though, is that they have the potential to compress the components of the brainstem and upper cervical cord in the foramen magnum and upper cervical spinal canal, and because of this, blocking the flow of CSF.
Wait, See, Surgery and Shunts
For good reason, physicians, families and patients face fairly rigorous criteria before surgical options can be acted on. These options cannot and should not be taken lightly. That may explain why the success rate is high in light of risk versus rewards. Even with strict criteria, however, there is still a significant failure rate of ten to twenty percent.
Neurosurgeons will consider the severity of symptoms the patient is experiencing before invasive therapies are considered. They also take into consideration age and whether or not the symptoms are progressing. The surgical choices for Chiari malformations are decompression, duraplasty and shunting.
The picture on the left showing decompression surgery comes from the late neurosurgeon Dr. Emil Popovic. Decompression surgery entails removing a piece of the occipital bone in the rear of the skull and shaving down the posterior arch of the first cervical vertebra called atlas. This creates more room for the compressed parts of the brain and cord that have descended.
Decompression surgery, however, weakens the bones of the skull and the upper cervical spine. Consequently, surgeons attach the skull and first cervical vertebra together with a plate screwed into both bones. They must be especially careful in the placement and size of the screws due to their close location to the vertebral arteries. The anchored plate strengthens the bones, limits motion and increases stability. Lastly shunts are also used to drain and reroute CSF flow around the Chiari malformation and syrinx, also known as syringomyelia, in the cord that develop along with the malformation.
Duraplasty is sometimes used to further enlarge the space by expanding the protective covering around the brain (see picture below.) In this procedure the dura (outer covering of the brain) is cut open and a dural patch of graft tissue is added (sewn over the opening) to create more space for the cerebellar tonsils (lower middle portion of the cerebellum) to allow for more normal CSF flow. Some surgeons have shown similar success with fewer complications from leaks in the patches by scoring lines in the dura instead of using a patch. The surgical slits weaken the strength of the dura slightly and allow it to expand. As an aside, as I suggest in my book, I believe the indigenous people of Peru and Bolivia may have used surgical holes in the skull, called trephinations, to similarly relieve pressure and allow the brain to expand.
In addition to the surgical options for Chiari malformation, there are particular types of chiropractic corrective care of the spine that may be beneficial for borderline cases such as Chiari 0 and Chiari 1. It may even be beneficial for more extreme cases with minimal signs and symptoms. These would be the wait and see cases that can continue to be monitored according to current protocols during corrective care of the spine. Corrective care of the spine may even obviate the need for surgery in certain cases. In other cases it may aid in the co-management of the wait and see type cases.
Two chiropractic methods, in particular, that should be considered and researched further are low force and the Cox method of spinal decompression. Follow-up neurological exams and brain scans can be used to determine the effectiveness of both methods.
Living with Chiari
On a regular basis I receive emails asking about Chiari treatments and results. There are no better people to inform others than those who have dealt with it personally.
Help others by sharing your Chiari experience. You can include, for example, the level of Chiari, the probable cause, symptoms, treatment, how you responded to the treatment, would you recommend it to others and even how the condition has affected your life!
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