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  • The Ryan & Zona McGee Story – A Chiari Angel’s Fight

    The Ryan & Zona McGee Story – A Chiari Angel’s Fight

    Zona McGee was blessed with a vibrant and beautiful little boy on July 2nd, 1993. She named him Ryan Andrew and fell in love with his sweet face the second she first held him. He looked just like her! Her husband, Kevin, and daughter Crystal, eight-years old at the time, were over the moon as well.

    Zona had been battling a genetic kidney disorder her entire life, causing both of her pregnancies to be considered high-risk, so when her second delivery and birth went well, she was elated. She counted her blessings and relaxed into the day-to-day tasks of being a young mother. Her life was happy, and she adored her children very much.

    By her beaming account, Ryan was a gregarious and charming little boy. “If there was something to explore, he would be all in it,” she told me. He had more energy than she knew what to do with and she kept him busy with stimulating activities and adventures. He was sweet, kind, and loved to make people smile, especially his sister, with whom he shared a unique bond.

    Watching her children grow into responsible young adults made Zona immensely proud. She had many wonderful memories of her family through the years. Because her kidney disease is genetic, and other family members suffered as well, she had worried that her children may inherit the gene, but neither did. Ryan was a very bright, energetic, healthy child. Throughout his childhood, Ryan’s well-child checkups always received A+ reports.

    However, when he was 15, his physician noted an incidental finding of minor scoliosis. Because Ryan did not complain of pain, the doctor decided to just keep an eye out for future changes. Ryan’s teenage years were happy. As he matured, his high energy settled down, and he became more introspective. He often spent his free time gaming on the computer, broadcasting on his YouTube channel, playing guitar, and enjoying life with his friends and family. Music was a major part of his world. He loved everything about it: listening, writing, and playing. He often shared his songs and favorite bands with his proud family.

    Ryan was a good student and took a local job after graduating from high school. He loved working and earning his own money. By all accounts, Ryan was a completely normal, functioning, and on-target, young adult. He was doing what most recent high school grads do – living life, having fun, and trying to decide what profession he might go into.

    He was also heavily involved in organ donor awareness. Although Zona had been doing remarkably well for years, during this time, her condition began to rapidly decline, and she was put on a kidney donor list. She had a calling to act and started a blog, which led to a passionate fight to spread awareness about the importance of donating organs and tissue. Ryan fought alongside her and made the decision to become a donor himself. Little did they know, Ryan’s decision would end up saving many precious lives, including his own mother’s.

    In May of 2013, Ryan began experiencing minor, intermittent headaches that were uncomfortable, but not debilitating. Zona made the logical assumption that Ryan was not wearing his glasses often enough. She continued to encourage him to wear his glasses, but the headaches became more severe over the next month. He visited his doctor who also believed it was due to his eyes, and advised Ryan to take Tylenol for the “migraines.” Stress was also considered, but the doctor was not a bit concerned.

    Sadly, glasses and Tylenol did nothing to prevent or relieve the pain. His headaches were constant and progressively painful, making it difficult for Ryan to function. He was in agony, but he tried to minimize his suffering as to not “burden or stress out his family.” The doctors assured them that “nothing serious” was going on with him. The doctors were horribly premature in that assessment of Ryan’s symptoms.

    One Friday, during a particularly bad flare up, Zona became very concerned that Ryan may have been suffering from a sinus infection and planned to take him to a walk-in clinic that following Monday. He never made it to that visit. On Sunday, May 12, 2013, Mother’s Day, Ryan was stricken, out of the blue, with an unbearable headache. He also complained of a stiff neck and collapsed in the bathroom. Zona and Crystal, who both heard a “thud” found Ryan unresponsive on the floor, and rushed him to the hospital.

    They waited anxiously, for tests to come back, wondering if Ryan’s symptoms pointed to meningitis. The doctors mentioned that he, “May have a brain tumor”, before all the results were back. The family was terrified. However, after an MRI scan and lab results were completed, the doctor came in and told Ryan that “luckily” it was not a tumor or bacterial brain infection, but that they had found a Chiari Malformation.

    Zona anxiously queried, “A what?”

    Her question was ignored, as her child was an adult. She asked again, but the doctor turned from her and explained the test results to Ryan directly. He told Ryan that a Chiari occurs when the brainstem becomes herniated, but they could easily “fix” it with brain decompression surgery. He also told him that unless he agreed to surgery, his headaches would worsen, and he would just keep coming back to the E.R. He was presented with consent forms and was informed that they wanted to do the surgery the following morning.

    Ryan had never dealt with illness or pain and he was terrified. After consulting with Zona, who felt that they should take some time to get more information, Ryan made the decision to undergo the operation. He just couldn’t bear the pain any longer; it was that debilitating. They were promising him relief and his symptoms were so severe, he trusted them and signed the consent forms. Zona was beside herself with worry. She thought to herself, “We just found out that he has something I have never even heard of, and they want to saw through his skull? I need more time!”

    But she didn’t have time. She also did not have the respect of the doctor simply based on Ryan’s age. This infuriated her, as while Ryan was over 18, she felt that his family should be able to have their questions answered as well. But she didn’t fuss. They were coming to prep him, so she hid her fear and frustration to be strong for her son. When they wheeled the gurney away, she had no idea she would never see her son the same way again.

    During Ryan’s first surgery, a temporary shunt was placed in an attempt to drain excess cerebrospinal fluid. When that failed, the surgeon made the call to do decompression surgery. Ryan went into this operation a very healthy and fit young man, but he came out with obvious signs of brain damage. Though it was clear that Ryan wasn’t well post-op, his family never again saw the surgeon who performed his decompression. There was no follow-up.

    Over the next few months, Ryan was rushed to the E.R. on several occasions due to cyclic, intractable, vomiting along with severe head and neck pain. During these dozen-plus visits to the E.R., he was turned away multiple times and labeled “drug-seeking, weak, and dramatic.” This was a slap in the face, as Ryan was advised to blindly have the surgery to prevent him from returning to the E.R. This painful irony was not lost on Zona, and it only added to her trauma and confusion.

    Ryan was having seizures, yet he was told he was faking them. When Zona protested, she was told by a nurse entrusted with Ryan’s care, “Your son is not having seizures. What is wrong with you? Do you want him to have seizures?”

    In all the E.R. visits, there was ONE brain scan. The family was told the surgery was successful and whatever was going on, if anything, was completely unrelated to his decompression surgery at their hospital.

    On the last visit to this particular hospital, the chief neurosurgeon refused to treat him neurologically and ordered a psychiatric evaluation instead. After speaking with Ryan, the psychiatrist said, “I do not believe you are crazy, but you are a bit of a wimp.”

    Zona was livid and chased everyone out of his room. She then immediately took Ryan to another, smaller hospital. It was obvious to the triage nurse that Ryan was in serious trouble. He was gaunt, having lost 30-plus pounds in three months. He had nystagmus, and his vital signs reflected the pain and distress he was experiencing. Scans showed brainstem slumping and his neck, literally, had no support. Zona was told that “too much bone had been removed,” and that he needed emergent intervention.

    The doctors recommended immediate surgery to correct the horribly botched decompression. However, they suspected that he had meningitis, due to a fever, so they wanted to confirm and aggressively treat that before opening him back up. They began I.V. antibiotics and Dilaudid.

    Again, Zona helplessly waited by his side for more test results. She was slightly relieved that there was finally a team of people looking after her child who believed them, but as she watched her child dozing from the pain medication, she barely recognized him. He was thin, with hollow, sunken eyes, and his weak, frail arms were drawn to his chest. Hands clenched in fists, he laid in a semi-fetal position. She wanted to know how this had happened. It had been a surreal, awful three months, and she wondered if there would be enough time to save him. Tragically, there was not.

    Ryan suffered a fatal seizure the following morning that collapsed his brainstem, and he never woke up. He was pronounced brain dead, August 11th, 2013.

    After Ryan’s death, it was discovered that he did not have an infection at all. According to an independent attorney’s assessment of Ryan’s medical records, there were at least nine opportunities for the health professionals, whom Zona trusted, to save Ryan’s life. The investigator called Ryan’s treatment barbaric and inconceivable. He, like all of us, want to know how this young man was so callously discarded and left to suffer until his untimely death. That question will never be answered. It is incomprehensible how the “professionals” who did have contact with Ryan, not only shunned him, but covered up evidence of medical injustice in order to protect their establishments, surgeons, and other health care workers.

    Ryan’s severe, post-decompression, decline was obvious. Ryan was aware that he was in critical condition. He knew he was not going to survive. Before he died, he told Zona, “Make sure everyone knows what happened.” She did that and more.

    Zona wanted the world to know who Ryan was and about the loving gifts he left behind. The medical establishment failed Ryan and his family, but he remains a true hero. Upon his death, several families received the gift of life through Ryan’s organ donation-including his mother, Zona. The day after Ryan died, she was in surgery receiving her child’s kidney.

    There are times when Zona, naturally, wondered what she could have done differently, but the answer to that is simple: Without advocacy and awareness, hindsight is 20/20. There was nothing more she could have done. She tried everything in her power that she knew to do at that time. Because this was being reiterated by the doctors, she had faith that he was in good hands and that he would recover fully. There was no playbook she could consult on how to advocate for her child. She was in a surreal state of shock, disbelief and fear. She had no frame of reference to show her that the medical professionals in charge of Ryan’s care were terribly wrong, and negligent in the very least. She had to believe the doctors whose opinions and advice we are taught to trust. After all, doctors are the ones who have the medical degrees and they know best, right? No.

    From the time Ryan was decompressed to the day he died, Zona made several calls to get Ryan help, but nobody would listen! Zona’s desperate attempts to alert the medical staff of Ryan’s worsening condition were to no avail. Nobody helped! Nobody cared! Nobody listened.

    Zona took the pain from this unimaginable nightmare and turned into an unrelenting drive to educate other families who are caught up in the trap of medical injustice. She became a fierce advocate for patient safety and rights with the hope that no other child will suffer the way Ryan did. She also helped parents navigate the medical system so that they may learn from her experience. She vowed to work feverishly to bring about awareness and authorized a documentary about Ryan’s life and struggle with Chiari Malformation.

    On Sunday, May 14th, 2017, Mother’s Day, Zona McGee, succumbed to metastatic lung cancer that she acquired from the anti-rejection drugs she was given to save Ryan’s kidney. Her death is a tremendous loss to our community. Her family and friends miss her more than any of my words can express.

    Zona’s worst fear was that Ryan would be forgotten and that her promise, to let everyone know his story, would end with her life. I promised we will never let that happen. We never will.

    Rest in peace, beautiful angels.

    Please support Zona’s Visions:

    Zona’s Blog Zona-Life On The Waitlist

    Ryan’s Awareness Page: Ryan’s Voice Chiari Patient Awareness

    Please support the documentary Writing For Ryan and view the documentary trailers and share the website link as well.
    www.chiaridocumentary.com

    Gianna Soares
    Writing For Ryan
    Updated 01-21-2018
    For the exclusive use of Chiari Bridges, as per Zona’s request.

  • Health & Fitness: Walking In Your Power!

    After years of having our symptoms dismissed, having our pleas for help and understanding seemingly fall on deaf ears by our doctors (and many times our friends and family as well), it can be a relief to finally have a name for what has gone so horribly wrong with us. The relief is short-lived however, as we begin to realize the full scope of all that is really wrong with us. Although surgery can be extremely successful for some, many of us are left with some degree of symptoms or complications to deal with. For those of us who also have a connective tissue disorder, such as Ehlers-Danlos Syndrome (EDS), the issues with our tissues can seem endless. The thought of “getting healthier” can seem like a daunting task. We do not have control over every aspect of our health, or every aspect of our fight, but we are not powerless! We do have control over some lifestyle choices, that can help improve our day-to-day lives.

    MAINTAIN A POSITIVE ATTITUDE:
    The single most important item within our control is our attitude! We don’t have to ignore our reality or turn a blind eye to the negative aspects of our conditions to have a positive attitude. We can choose to frame things in a positive light. For example, if I am no longer able to walk as far as I could this time last year, I can look upon that situation with an air of defeat… or I can remind myself that I was also unable to walk that far three years ago, but with determination, with time I made progress! It may be unfair that I must start over again, but I am worth every ounce of effort that it takes to do so. I can acknowledge the unfairness, and then choose to focus on making progress towards my goal. A positive attitude is not going to will Chiari or EDS away, but it can improve our experience of living with these conditions.

    CHOOSING FOODS WITH YOU IN MIND:
    With connective tissue disorders, and the myriad of effects they can have on our bodies, eating healthfully can feel like walking through a minefield. Mast cell issues can cause sudden or intermittent allergic reactions to a wide variety of foods. Dysautonomia can require us to consume large amounts of salt (and still may end in nausea and vomiting). We are more prone to gastroparesis, gastric dumping, Irritable Bowel Syndrome (IBS), and other gastrointestinal problems that limit our food choices. Despite all these challenges, most of us can make food choices with optimum health in mind. Many EDS experts recommend eating whole, nutritionally dense foods, and taking supplements to help mitigate the vitamin and mineral deficiencies many of us are prone to, due to malabsorption. If inflammation is an issue, we can avoid dairy, sugars, refined flour, fried foods, and replace them with foods that are known to reduce inflammation, such as: salmon, blueberries, beets, broccoli, spinach, and foods cooked in turmeric, ginger, garlic, and olive oil. Most importantly, we can educate ourselves on our various conditions and what the experts on those conditions recommend, discuss this information with our own doctors and develop an individualized plan for ourselves, and apply this knowledge to our everyday life. Knowledge is key with conditions such as ours! While eating well is not going to shrink our cerebellar tonsils or cause our bodies to make collagen differently, it can help improve energy levels, and reduce pain and other symptoms.

    MOVING IS ESSENTIAL TO MOBILITY:
    Despite the pain and the fear, we can choose to move every day and strengthen our bodies as much as possible. Deconditioning is a real issue for many of us who have had such debilitating pain and other symptoms, that even after a successful decompression surgery, we may find ourselves unable to function normally again. And while we may never be 100% again, we usually can gradually improve our strength and endurance through a good physical therapy and exercise program. Experts agree that strong muscles help reduce many of subluxations and soft tissue injuries that are common to us. It isn’t always easy to find the motivation to get up and take a walk or to do those exercises your physical therapist assigns, but we must remind ourselves that we are worth the effort, and that even the very slightest bit of progress, is still progress. As the adage goes, “A journey of a thousand miles begins with one step.”

    We encourage you to fight for better medical care, for more research, for doctors and loved ones to listen to you. But with that also comes a responsibility to do everything you can to take the best care of yourself possible. To follow your doctor’s recommendations (once you find a good one), to eat well, and to stay as active as you possibly can. But you don’t have to go this alone! If no other positive thing comes out of being diagnosed with Chiari or any of its comorbidities, we do promise you this; the Chiari community is full of amazing, inspiring, loving, encouraging people who will stand in your corner and cheer you on through all your challenges, even if no one else will. And we here at Chiari Bridges will be there along the way with tips and advice on living your best life possible with Chiari and all its ugly friends. Remember, pain is inevitable, but suffering is optional!

     

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  • The Chiari Malformation Ehlers-Danlos Connection

    The Chiari Malformation Ehlers-Danlos Connection

    CHIARI (KEE-AR-EE) MALFORMATIONS ARE FAR FROM RARE, THEY ARE JUST RARELY UNDERSTOOD, EVEN BY MOST MEDICAL PROFESSIONALS. A CHIARI MALFORMATION EXISTS WHEN THE LOWEST PART OF THE HIND BRAIN (THE CEREBELLAR TONSILS) PROLAPSES INTO THE HOLE AT THE BOTTOM OF THE SKULL (FORAMEN MAGNUM), ENTERS THE SPINAL CANAL AND OBSTRUCTS THE FLOW OF CEREBROSPINAL FLUID (CSF), PUTS PRESSURE ON THE BRAIN STEM AND SPINE, AND MAY RESULT IN VARYING DEGREES OF NERVE COMPRESSION.

    PREVALENCE OF CHIARI: Once thought to occur in 1 in 1000 people, it is now believed to be much more frequent of an occurrence. A 2016 pediatric study found it to occur in 1 in 100 children[1]. Since Chiari Malformation Type 1, the most common type, tends to become symptomatic during late teens and early adulthood, it is likely to be much more common when adults are factored in.

    THE CONNECTION: Chiari malformations were originally believed to be caused by a posterior fossa hypoplasia (small area inside the back of the skull) and doctors speculated that lack of maternal prenatal care or drug abuse caused the deformity. However, as studies continue, they are finding that many with this hind brain herniation have connective tissue disorders, such as Ehlers-Danlos Syndromes. Ehlers-Danlos Syndromes involve a mutation in one of the collagen genes. Collagen is a protein that is often described as a “cellular glue” that helps hold the body together. When that glue fails to hold, everything seems to go awry; specifically, as related to Acquired Chiari Malformations: organs tend to prolapse, and bones begin to shift as joint laxity increases (including the bones/vertebrae at the craniocervical junction). They are finding that these acquired Chiari malformations are far more common than originally thought. There are many pathological co-factors that can cause or attribute to the formation of a Chiari Malformation, and most can be linked to these Heritable Disorders of Connective Tissues (HDCTs), including a posterior fossa hypoplasia. In one large study, they found those with a Chiari malformation and no associated co-factors, with only slightly over 52% having a small Posterior Cranial Fossa (PCF). When other co-factors were present, the number of Chiarians found with a small PCF plummeted and therefore it is should be considered acquired until proven otherwise.[2]

    DIAGNOSES: A decade ago, it took 10-20 years from the onset of symptoms to be diagnosed and now it takes an average of 1-2 years, because medical professionals are slowly beginning to look for it. Magnetic Resonance Imaging (MRI) remains the best tool for diagnosis. Some medical professionals believe that a tonsillar herniation of less than 5mm is simply a tonsillar ectopia and only diagnose a Chiari malformation when the descent is > 5mm. However, the 5mm requirement is controversial and many doctors now base their diagnoses not solely on measurements, but rather on symptomology and a combination of other factors (including Cine MRI, a patient’s symptoms, and other relevant factors). Due to the prevalence of connective tissue issues, gravity often proves to be a significant factor and should be taken into account by use of an upright MRI whenever possible.[3] EDS should be diagnosed by a geneticist before surgery is considered.

    TREATMENT OPTIONS: There is no cure for a Chiari malformation, but there are treatment options. When symptoms are minimal and not life-altering, pain management is usually offered. However, it is important to know that while medications may ease some symptoms, Chiari symptoms tend to be progressive. Decompression surgery is the only treatment available to attempt to halt the progression of the damage being done to your Central Nervous System (CNS). The most common reason that decompression surgeries fail, is undiagnosed co-morbid conditions, especially those that can be etiological/pathological co-factors. More than one surgery might be necessary to successfully treat a Chiari malformation and any/all co-morbid conditions and there is a correlation between early surgical intervention and positive surgical outcomes[4].

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    References:

    1 Eltorai, Ibrahim M. “Rare Diseases and Syndromes of the Spinal Cord” Cham: Springer International Publishing: Imprint: Springer, 2016. Page 43, 15.2, <www.springer.com/us/book/9783319451466>.

    2 Milhorat, Thomas H., et al. “Mechanisms of Cerebellar Tonsil Herniation in Patients with Chiari Malformations as Guide to Clinical Management.” Acta Neurochirurgica, Springer Vienna, July 2010, <www.ncbi.nlm.nih.gov/pmc/articles/PMC2887504>.

    3 Henderson, Fraser C., et al. “Neurological and Spinal Manifestations of the Ehlers–Danlos Syndromes.” American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 21 Feb. 2017, <www.onlinelibrary.wiley.com/doi/10.1002/ajmg.c.31549/full>.

    4 Siasios, John, et al. “Surgical Management of Patients with Chiari I Malformation” International Journal of Pediatrics, Article ID 640127, Hindawi, 2012, <https://www.hindawi.com/journals/ijpedi/2012/640127>.

  • A Bruised Mind – Chiari & Depression

    A Bruised Mind – Chiari & Depression

    Depression is more than simply “feeling sad.” It is a deep dark tunnel of despair that seems to have no end. It manifests as a cohort of symptoms, seeking to wreak havoc in every facet of your life. The activities that you once found enjoyable seem to take more energy than it promises to be worth. Your energy levels plummet, often resembling that of a slug crawling through peanut butter. Insomnia, restlessness, changes in appetite, and memory loss are often present. Mood swings that change without permission, rational and irrational guilt, endless chronic pain, and suppressed emotions (“I’m fine, really.”), create an enormous obstacle that seems impossible to overcome. The chronic illness, loss of identity, and indifferent medical community make treatment challenging. The depression Chiarians feel can be overwhelming and isolating.

    Chronic pain is something Chiarians face on a daily basis. Disabling pain that reduces your quality of life can make once simple tasks difficult to accomplish. Things like taking a shower or cooking become incredibly challenging. Fatigue can set in quickly, that even when we have plans that we’re excited about, just getting ready for them can be enough to put us back in bed. All of this can give us an altered self-perception of feeling useless, which enhances the depression. Chronic pain is both a physical and psychological condition, thus making treatment complex and difficult. Pain can cause depression and depression causes pain; it’s a vicious cycle.[1]

    Beyond the pain aspect, damage to one’s cerebellum is known to have cognitive consequences as well, and that includes emotions. While much of the research is based on the cognitive effects of decompression surgery,[2] many Chiarians have reported a noticeable cognitive decline years before surgery. In some cases, they complained of cognitive issues even before their Chiari diagnosis. One study pinpoints a “reciprocal connection between the cerebellum and hypothalamus” that govern “intellect, emotion, autonomic function, and sensorimotor control.” Another article on Secondary ADHD (Attention Deficit and Hyperactivity Disorder) speaks of the cerebellum and its known connection to ADHD, and even though the cerebellum is almost exclusively thought of in terms of its motor control, “it is the most consistently implicated and also the most robustly abnormal structure in the pathophysiology of ADHD.”[3] The article attributes it to the fact that, the cerebellum is “second in size to only the cerebral cortex, contains more neurons than the rest of the brain combined, and is massively connected to the cerebral cortex.” Among Chiarians, we have long-known that we all suffer from memory issues (both long and short term), anomic aphasia (repeated trouble remembering words), and various other cognitive struggles, and it’s important to remember that all of our thoughts, including those that are depressive in nature, stem from our brains (even our cerebellum).

    Adjusting to the new normal is always a challenge, not only for us, but the ones we love as well. The loss of our former selves and our careers is very hard. Maybe you were a full-time parent or provider, caring for your family and you find yourself the one being cared for by loved ones. You find yourself depending on family and friends to do for you things that you once did for yourself, making you feel like a burden on those you love most. You may experience a sense of helplessness when trying to get friends and family to understand what you are going through. There will be friends and family who cannot or will not try to understand. They will think you are lazy or seeking attention. We must mourn the loss of old selves, careers, sometimes family and friends, as others must mourn their loss of your former self, and learn to embrace the new you in your new normal.

    The struggle to have the medical community work with us, rather than against us, feels like an impossible feat. The worst thing that happens to us when dealing with doctors is being told that everything is in our head (which at least isn’t 100% wrong, but not in the way they mean it). In their ignorance, our doctors often dismiss our symptoms as mere depression, being a hypochondriac, or a drug seeker. They tell you that losing weight will alleviate your problems. That may be true for some things, but no amount of weight loss is going to put your brain back into your skull and it’s hard to focus on exercise when every single step makes you feel like your neck is literally breaking. Instead of admitting that they have limited knowledge on Chiari, they attempt to make you feel stupid, inferior, and a bother to them. It’s so frustrating when those who are have taken an oath to help you and are charging you for that help, are not willing to learn about your condition. You become the educator, teaching those who are interested and willing to learn. You become your own best advocate!

    There is hope. There is a light in the tunnel. The depression may not go away completely, but it can be managed. There are things you can do to help alleviate the symptoms. Joining a support group (in person or online) to connect to those who experience the same things you do can be a tremendous source of support. Encourage family and friends to join support groups to get a better understanding of your condition and to join groups for caregivers so that they have somewhere they can connect with people that are going through the same fears and frustrations that they’re going through (because the Chiari isn’t just affecting you). Get to know others that are fighting your fight, learn from them, stand with them, and maybe even volunteer to help others new in their fight!

    There will be times when your body rails against you, making it difficult to get out of the house. But try to stay as active as you can with something! Try to continue with your favorite hobbies: reading, writing, crocheting and coloring books. Keep your memory working by utilizing crossword puzzles, Sudoku, puzzles (the box kind) and card games like Solitaire. The most important thing is keep talking with people: call a friend or make new ones if you need to. Find a therapist that you like. Share about what you’re going through and show concern for what others are going through. You are worth the fight!

     

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    References:

    1 “Depression and Chronic Pain.” Self Help Center, <www.selfhelpcenter.org/pdf-publications/Depression%20and%20Chronic%20Pain.pdf>.

    2 Allen, Philip A., et al. “Task-Specific and General Cognitive Effects in Chiari Malformation Type I.” PLoS ONE, Public Library of Science, 15 Apr. 2014, <www.ncbi.nlm.nih.gov/pmc/articles/PMC3988081/>.

    3 Eme, Robert, and Erin Sheffer. “The Cerebellum and Attention Deficit Hyperactivity Disorder A Case Study of a Cerebellar Chiari 1 Malformation.” The Practitioner Scholar: Journal of Counseling and Professional Psychology, 2012, <www.thepractitionerscholar.com/article/view/10503/7232>.

     

  • You The Advocate: Getting Started With Self Advocacy

    Self-advocacy starts with believing that you are worthy of love, respect, dignity, and autonomy. This belief will animate everything you do and will affect how others will believe, perceive, and respond to you. It will affect the degree to which others will be able to help you, including your medical team and support systems. Other people can only help us to the degree that we value ourselves and are willing to invest in our own personal well-being. Your self-image and appreciation will affect how well you are able to speak up for yourself and your rights as a well-deserving person and patient.  You deserve the time to express your concerns and ask questions, with an expectation of being listened to, supported, and respected without prejudice. And you have a right to be given all of your information regarding your health, so you can make informed decisions regarding your health and livelihood. Unfortunately, we don’t always get that from our medical professionals or the government agencies that we spend a lifetime paying into for such provisions, so we must be ready to fight for it!

     

    EMPOWER YOURSELF THROUGH EDUCATION

    Learn and understand your diagnosis. Researching and educating yourself is the single most important tool available to you in self-advocacy. Most of the information available is going to be found online in various articles, websites, videos, and within online support groups. Finding accurate, up-to-date, and reputable sources is paramount. Here at Chiari Bridges, we try to reference the studies and peer-reviewed articles behind our information, so you know the official sources that the information came from and will be better able to justify your requests and concerns to your doctors. Regardless of your source, be prepared to find a lot of conflicting information. These contradictions mainly exist because Chiari and its co-morbid conditions are being researched like never before, so it’s an exciting time, but that fails to give much comfort to those having to fight with their doctors on the existence of every symptom they face.

    Know your rights as a patient and your doctor’s legal responsibilities. Rights and responsibilities are often governed by state and federal laws and are outlined and included in the paperwork given to you from medical practices, health care systems, hospitals, and facilities. Your providers will likely require you to sign that you agree to and understand them. In doing so, these are legally binding for both parties. Thus, you will want to make sure you understand them fully before signing them and make sure you get a copy for your own records (if they don’t give them to you, don’t be afraid to ask for a copy).

    Learn and understand your health insurance. Know what your policy does and does not cover. Become familiar with which doctors, medical services, and facilities are covered. Find out about copays, deductibles, out-of-pocket costs, and other relevant information. Find out if your policy includes out-of-network benefits and associated costs; including out-of-state benefits. If no out of network/or state benefits exist, find out if exceptions can be made. Almost all insurance plans do have some form of exceptions and/or appeals process for this very purpose. There are commonly two stages of appeal, an internal review (your appeal is reviewed in-house) and an external review (where you are specifically asking for a review made by an outside organization that has not been a part of your provision of care and has no conflict of interest).

    Learn about Advance Directives, Living Wills, Durable Healthcare Power of Attorneys, etc. You will want to familiarize yourself with all of these and decide what, if any, is right for you.

     

    EMPOWER YOURSELF BY DEVELOPING SKILLS AND ACCESSING TOOLS

    Communication Skills and Tools. Learning to know when and how to communicate your needs and desires to others is important, especially when you have a limited amount of time with your doctor. Brevity, clarity, relevancy, problem solving, negotiating and preparation are key skills and tools. It might be beneficial to sit down beforehand and write the specific points that you want to address, and what your ultimate goal is in the appointment. Maintaining a respectful dialogue is always of utmost importance. Keeping your emotions under control is crucial.  Otherwise, your doctor might take you less seriously or assume your symptoms stem from psychological causes.

    Medical Records. As a patient, it is important to always obtain a copy of your medical records and review them for accuracy. It was once thought amongst medical professionals that a patient’s medical records were solely for doctors to communicate amongst themselves. Some medical professionals still hold to this antiquated ideology and become obviously disgruntled that you have chosen to exercise your patient right to not only obtaining your medical records but also, demanding they are 100% accurate. What is listed in those medical records will be used to treat you. It is important they are accurate and are corrected if they are not.

    Keep copies of all imaging and radiology reports. Images are not kept forever, nor are other medical records. Sometimes doctors do not tell you some of the things found in your imaging/reports and other tests because they deem them “incidental” or irrelevant. Sometimes, doctors miss what is obviously clear altogether. Many Chiarians go through years of misdiagnosis before properly being diagnosed. Often, a look back through your medical records will show patterns and assist in the discovery, diagnoses, and treatment.

    Patient Portals. With the advent of portals being used in many practices and facilities, patients have easier, free access to many of their medical records now. The same rules apply to the information retained in the portals in regard to how long they are kept there. Any conversations you might have with your provider through the portals should be saved as well.

    Organization and Preparation. Every person has their own way of “organizing.” This extends to your medical records keeping as well as preparation for appointments. There are some free online resources to help you with this organization. Some like to make a “chart” for their medical records by creating a binder with tabs. Some use digital charts/record-keeping tools for online free or for purchase. Many apps for phones exist to help as well. However you decide to organize is up to you, but is an invaluable tool available to arm and equip yourself in self-advocacy.

    Self-Care and Coping Skills. We often underestimate the necessity of self-care; as well as the power of developing positive, healthy coping skills and techniques. Self-care is pretty standard for all: getting proper nutrition, rest, appropriate and safe exercise, taking meds faithfully, taking time for recreation and refreshment, and tending to the beauty that is your body, mind, and spirit. Everyone has ways they “cope” in life in general and within the framework of chronic illness. It’s important to find the ones that work for you.

     

    EMPOWER YOURSELF BY FINDING THE RIGHT DOCTOR(S)

    Self-Education. Self-education precedes the ability to find a good doctor. If you are not aware and knowledgeable about your diagnoses and disorders, you will not recognize whether a doctor is the right one for you. Educate yourself on your conditions and on what your potential doctor has published on your conditions: What are their credentials, experience, affiliations, number of cases they have treated, and specialties and sub-specialties? Look for any official publications and scientific journals or other research that your provider may have written. Additional information can be found online through state records and other sources regarding your physician.

    Ask family, friends, and other medical professionals. Find others who have PERSONAL FIRST-HAND doctor/patient experience with the potential provider. Keep in mind a doctor can be a great fit for one patient but not for another. You can also ask for the opinion of your present doctors or other medical professionals.

    Getting 2nd Opinions and When to Find Another Doctor. It is never wrong, always wise, and completely within your rights as a patient to seek a second opinion (or more). If you are facing a potential surgery or procedure that could be risky and/or permanent, it is prudent to get multiple opinions. It is your right to ask for and change doctors at any time or facility. You do not need to give any reason nor explain yourself, though you will likely be asked to do so. Be careful not to burn bridges or become “blacklisted.” Always find a new doctor before leaving the old one.

     

    EMPOWER YOURSELF BY DEVELOPING YOUR SUPPORT SYSTEM AND GETTING HELP. Being a self-advocate does not mean “going it alone.” Developing and surrounding yourself with a support system is vitally important and many consider it to be “their lifeline” to keep going.

    Local or online support groups. Finding the right local or online group can be just as important as finding the right doctor and educating yourself. Remember, there is a lot of accurate and inaccurate info out there (even amongst our medical professionals). A support group is only as good the respect they have for you in your fight. If they respect the Chiari fight, it will be evident in the way they treat one another and in the accuracy of the information they espouse and share. Online groups each tend to have a different set of rules that members are expected to follow: some allow and encourage advice and recommendations amongst their members, and some do not allow it at all. Not every group will be the right fit for each Chiarian, but you can expect any good group to be kind, supportive, respectful, accurate in the information disseminated, gentle correction of inaccurate information shared respect of your autonomy, choices, and a zero-tolerance for bullying.

    Workplace Support. There are laws that protect you and that can even provide assistance and support within the workplace that you should familiarize yourself with. The Family and Medical Leave Act of 1993 (FMLA) is a federal law in the United States requiring employers to provide employees with up to 12 weeks of job-protected, unpaid leave for qualified medical and family reasons annually; but you must file it as FMLA leave to get the protection.

    School Support. There are programs and opportunities within schools that you should also familiarize and protect yourself with if your Chiarian is in school. In the United States, the US Department of Education has worked hard to incorporate federal laws to help reduce discrimination and increase structured programs to help ensure the success of students with disabilities. As a result, most schools, including colleges, have programs where students with disabilities can get special allowances for recording devices, note takers, removal of time limits on tests, etc. These programs are usually subsidized at a state level and have different names depending on your state, but a school counselor should be able to point you in the right direction. These protections may be limited in privately funded colleges and universities that do not receive any public funds.

    Support and Assistance Programs. There are hosts of programs, assistance, and support to be found in nearly every local area (through county trustees, charitable organizations, and churches), as well as state and federal programs. Just are few examples of help available are assistance with mortgage, rent, utilities, food, clothing, medical bills, medical insurance, free or reduced-cost prescriptions, holiday assistance, back-to-school, free or reduced-cost dental clinics, pro-bono legal help, cash assistance programs, etc.

    Professional Advocate Support. While self-advocacy is important, you might find that you are needing more help than you can accomplish alone. Managing your health can be confusing and overwhelming. Sometimes it can be hard to get your voice heard by the healthcare professionals around you. The healthcare system itself is very complicated. If you are having difficulty finding your way through the complex maze of healthcare, you might want to consider seeking the help of a professional advocate. There are hospital advocates, non-profit patient advocates, for-profit (employer-based) advocates, and independent advocates for you to turn to.

    Family and Friends Support. Chronic illness can take a huge toll on relationships. We all want and need the love and support of our family and friends. Not everyone has this support, making it all the more painful. No two families or friendships are alike. If you find a lack of support amongst your friends and family members, seek to restore it and in the meantime, find another means of support as Chiari is not something you want to fight alone. Support groups are a good alternative means to help find the support you need.

    Counseling Support. Sometimes we all find ourselves struggling to cope. Maybe we lack support or want to protect our relationships by not always talking about our problems to friends and family, yet need an outlet. Finding a therapist can be one of the best things we can do for ourselves. Doing so doesn’t mean you’re crazy or weak. It is a sign of strength and indicates that you value and respect yourself in every facet of your life; which brings us back to the reason we learn to self-advocate in the first place. Believe you are worth it – all of your body, mind, and spirit! If you ever find yourself in a life-threatening crisis, don’t be ashamed to contact a crisis hotline.

    When to get a lawyer. If you believe you are the victim of abuse, harm, malpractice, or neglect, you may need to seek the counsel of a malpractice attorney. If you suspect your workforce rights have been are in danger of being violated, you may want to contact an employment lawyer. If you find yourself no longer able to work, seek a Disability lawyer. Elder lawyers can often be helpful too and are not just for the elderly. If any of your rights have been violated, it may be time to seek counsel.

    Self-advocacy will empower you to know and speak up for yourself, make your own decisions, learn and exercise your rights and responsibilities, learn about your condition(s), and how to get accurate up-to-date information in order to make decisions concerning your care, treatment, and overall well-being. It will help you find the right doctors, support systems, options, resources, and get other help available to you. As you journey along in self-advocacy, you will grow both as a patient and a person. You will also discover many additional ways that self-advocacy benefits and empowers you, and in turn, you’ll be able to help pass those benefits on to others as well.

     

  • Overview: Cerebrospinal Fluid Leaks

    Overview: Cerebrospinal Fluid Leaks

    Cerebrospinal fluid (CSF) is the clear, colorless liquid that surrounds the brain and spinal cord and is contained within a lining called the dura. The cerebrospinal fluid protects and cushions the brain and central nervous system. Among other functions, this fluid provides buoyancy to the brain, allowing it to float and weigh less, thus reducing the pressure at the base of the brain. A cerebrospinal fluid (CSF) leak occurs when there is a tear or hole in the dura that then allows this fluid to escape[1]. When leaks occur, the overall volume and pressure within the skull drops, and the cushioning and buoyancy effect is reduced, causing the brain to slump. In many cases, this leads to a condition known as intracranial hypotension and a vast range of symptoms.

    The main symptom of a CSF leak is a headache that is worse when upright and improves when lying down horizontally. This is sometimes called a “positional” or “orthostatic” headache. However, not all positional headaches can be attributed to a CSF leak, and not all CSF leak headaches are positional. This is particularly the case in the chronic (vs acute) phase of CSF leaks, where the “positional” or “orthostatic” characteristic of symptoms may become more constant, lessen, or disappear entirely, including headache. Symptoms often worsen as the day goes on. Other leak symptoms can include, but are not limited to: nausea, vomiting, neck pain or stiffness, heaviness of head, pain between the shoulder blades, feeling of pressure within the head, changes in hearing (muffled or underwater sensation), tinnitus (ringing, buzzing, or pulsatile), feeling of liquid in the ears, sense of imbalance, sensitivity to light, sensitivity to sound, pain or numbness in the arms, changes in cognition (“brain fog,” memory loss, or loss of concentration), dizziness or vertigo, scalp sensitivity or tingling sensation within the scalp, visual changes (blurring, double vision, visual field defects), pain behind the eyes or when moving eyes, facial numbness or pain, sinus pressure, temporomandibular joint pain and stiffness, and subdural hematoma[2]. Cranial leak specific symptoms can vary even more and can include: fluid discharge from ears, nose (usually only one side) and to back of throat often reported as salty or metallic tasting, recurring or chronic meningitis, loss of sense of smell, change in hearing or ringing in the ears, and less frequently cognitive changes. Rare signs or complications of CSF leaks can include: quadriplegia, dementia (often mimicking Frontotemporal Lobe Dementia), Parkinsonism, other movement disorders, ataxia (unsteady gait), hypersomnolence, stupor, coma, stroke (hemorrhagic or ischemic), and even death.

    CSF leaks are often very hard to locate, if ever. Approximately 50% of leaks cannot be found on imaging. Imaging and other tests used to attempt to find leaks are often read as “normal” even when there is a leak present. Other times, especially (but not always) in the case of chronic leaks, the positional symptoms either lessen or go away altogether, including the headache. Many who are leaking are not even aware that they are leaking. Leaks are often misdiagnosed as well[3]. Some of those common misdiagnoses are Postural Orthostatic Tachycardia Syndrome (POTS), migraines, sinus headaches, Meniere’s Disease, Chronic Fatigue Syndrome, Parkinson’s Disease (sometimes other neurodegenerative diseases), Fibromyalgia, Ehlers-Danlos Syndrome, Tarlov Cyst, Chiari Malformation, Cervical Spine Disease, cervicogenic headache, tension headache, and Sinusitis. To make diagnosis even more complex and elusive, CSF leaks can and do often occur along with any of these disorders and perhaps several simultaneously. A leak can cause an acquired Chiari malformation or coexist and complicate an existing congenital Chiari malformation[4]. Some patients have had unnecessary decompression surgeries when the underlying, sole cause was a leak all along.

    Leaks can be caused by:

    1. Medical procedures (also called iatrogenic leaks) for various diagnostic or therapeutic reasons such as lumbar punctures to collect fluid for analysis if meningitis is suspected, lumbar puncture for injection of contrast (myelography), spinal anesthesia, epidural injections, epidural steroid injections, prior skull base or spinal surgery, CSF shunt over-drainage, prior sinonasal surgery, and chiropractic or other spinal manipulations.
    2. Traumatic injuries such as brachial plexus injuries falls, sports injuries, motor vehicle accidents, roller coaster rides, and other whiplash injuries.
    3. Spontaneous leaks that occur with minimal or no clear cause. Sometimes spontaneous leaks may be associated with some sort of spinal pathologies such as calcified disk material or bone spurs. These leaks are usually ventral (or in front of the spinal cord).

    There is growing evidence suggesting that a significant number of spontaneous CSF leaks occur as the result of a preexisting weakness in the dura[5]. Heritable Disorders of Connective Tissues (HDCT’s) such as Marfan Syndrome, Ehlers-Danlos Syndrome (both classical and hypermobility type), autosomal dominant Polycystic Kidney Disease, and other HDCT’s predispose patients to CSF leaks. One leak expert estimates that “slightly less than 100% of patients with spontaneous CSF leaks have an underlying connective tissue disorder.”[6] The dura is made out of connective tissue and patients with HDCT’s have thinner dura mater, that is more susceptible to tears and leaks. HDTC patients are more prone to spinal conditions such as perineural cysts, meningeal diverticula, and other HDCT defects such as aneurysms and dilatations. Oftentimes, a CSF leak is the first sign of an underlying HDCT.

    Lumbar punctures (LP’s or spinal taps) should be avoided in patients with Chiari Malformation and/or in patients with HDCT’s[7]. There is a risk of causing a herniation of the cerebellar tonsils or making an existing herniation worse from the pull-down mechanism involved in lumbar punctures. Unfortunately, lumbar punctures are not always avoidable and sometimes very necessary, especially in cases to rule out life-threatening viral or bacterial conditions such as meningitis, subarachnoid hemorrhage, encephalitis, or syphilis. In these cases, measures can be taken to minimize LP risks such as using a certain needle type and size, limit the number of cc’s collected (by spontaneous drip ONLY), and, of course, always done under fluoroscopy by a competent physician[8]. Additionally, it is important to be aware that patients with HDCT’s are at greater risk for the dura to fail to heal following an LP. Patient’s should be aware of post-dural puncture headache (PDPH) symptoms and speak with their physicians if they suspect a leak following an LP.

    The procedures and tests used to diagnose leaks will vary between patients and certain criteria are used to diagnose leaks[9]. Some of these tests and procedures might be: endoscopic exam and fluid collection and Beta-2-Trasnferrin testing (cranial leaks), Cisternography (including radioisotope cisternogram), Magnetic Resonance Imaging (MRI) including Magnetic Resonance (MR) myelography, Dynamic CT myelography, Digital Subtraction myelography, and Intrathecal saline infusion-enhanced myelography, a lumbar puncture to collect and test fluid and measure opening pressure. This imaging often includes both brain and spinal imaging. The normal opening pressure is not uncommon and does not rule out a leak. High pressure can also occur while leaking. Pre-existing intracranial hypertension can be related to the development of spontaneous spinal CSF leaks. Some reports suggest that spontaneous cerebrospinal fluid (CSF) leaks are strongly associated with idiopathic intracranial hypertension (IIH). There are 5 main findings on imaging that doctors look for, however, the absence of these findings does not rule out a CSF leak. The mnemonic SEEPS is used for most of these findings: subdural fluid collection, enhancement of pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain[10]. Other imaging findings that might be seen are small ventricles, cisterns might have less fluid, optic chasm might flatten over pituitary, pituitary might enlarge, empty sella, fluid in front of the pons, or pons might become flatter than normal. Repeat imaging is often necessary.

    Treatment of leaks can either be medical or surgical. Conservative treatment is often recommended, if possible. This can include bed rest and avoidance of coughing, sneezing, straining, bending, twisting, and lifting, increased fluid intake and caffeine, the use of an abdominal binder, and sometimes steroids are recommended. Others may have a lumbar drain placed in the low back to decrease the pressure of the CSF around the area of the leak in an attempt to allow this area to heal. Some patients may need an epidural blood patch. Where a blood patch is not successful, a fibrin glue patch may be tried. About 30-40% of leaks occur at multiple sites, especially in those with an HDCT. Multisite patches may be required. Higher volumes of blood may be needed in order to reach where it needs to go, and/or the position of the needle may need to vary from the standard placement (transparietal or lateral placement)[11]. It is not uncommon for several patches to be tried. Many doctors make the mistake that if an EBP fails, there was no leak as well. Sometimes when more conservative and less invasive treatments have failed, neurosurgery may be necessary. Surgical repairs vary and are tailored according to the type and location of the leak. Sometimes in a select set of patients, other procedures have been used including epidural saline infusions through an implanted epidural catheter or lumbar dural reduction surgery. A condition known as rebound intracranial hypertension (RHP) may occur following any of these treatments[12]. Usually, but not always, there is a different pattern to the headache where one feels worse when horizontal and better when upright. Sometimes, acetazolamide (Diamox) or a similar medication is prescribed to help treat RHP.

    Leaks are poorly recognized, poorly understood, under-researched, understudied, often misdiagnosed, can complicate existing conditions, are difficult to find, mimic many other disorders (including Chiari Malformation), and can be comprised of a vast array of symptoms. Most doctors are familiar with the symptoms of a leak in the acute phase. Very few doctors are familiar with how long-term, chronic CSF leaks “present” in regard to headaches and other leak symptoms and often miss the more subtle symptoms of chronic leaks. Like Chiari and other related disorders, no two patients with CSF leaks have the same symptoms and often experience misdiagnosis, delayed diagnosis, are disbelieved concerning their symptoms of the severity thereof, and all too often dismissed to suffer excruciating pain, decline, and debility. Educating yourself as much as possible about CSF leaks will help guide and empower you and those around you who may have existing, suspected or potential future complications that may arise due to CSF leaks.

    CSF Leak Symptoms List: https://chiaribridges.org/glossary/symptoms-of-intracranial-hypotension/

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    References:

    1 “CSF Leak: A Curable Cause of Headache.” A Non-Profit Hospital in Los Angeles, <www.cedars-sinai.edu/Patients/Programs-and-Services/Neurosurgery/Centers-and-Programs/Cerebrospinal-Fluid-Leak/CSF-Leak-A-Curable-Cause-of-Headache.aspx>.

    2 “Cerebrospinal Fluid (CSF) Leak.” A Non-Profit Hospital in Los Angeles, <www.cedars-sinai.edu/Patients/Health-Conditions/Cerebrospinal-Fluid-CSF-Leak.aspx>.

    3 Schievink, Wouter l. “Misdiagnosis of Spontaneous Intracranial Hypotension.” Archives of Neurology, American Medical Association, 1 Dec. 2003, <www.jamanetwork.com/journals/jamaneurology/fullarticle/785098>.

    4 Haider, Ali S., et al. “Spontaneous Intracranial Hypotension Presenting as a ‘Pseudo-Chiari 1.”Cureus, Cureus, 16 Feb. 2017, <www.ncbi.nlm.nih.gov/pmc/articles/PMC5354398/>.

    5 Reinstein, Eyal, et al. “Connective Tissue Spectrum Abnormalities Associated with Spontaneous Cerebrospinal Fluid Leaks: a Prospective Study.” European Journal of Human Genetics, Nature Publishing Group, Apr. 2013, <www.ncbi.nlm.nih.gov/pmc/articles/PMC3598315/>.

    6 Schievink, Wouter l. “Q & A With Dr. Schievink.” Spinal CSF Leak Foundation, 14 July 2014, <www.spinalcsfleak.org/q-a-with-dr-schievink/>.

    7 Erbay, Sami H., et al. “Is Lumbar Puncture Contraindicated in Patients with Chiari I Malformation?” American Journal of Neuroradiology, American Journal of Neuroradiology, 1 Apr. 2005, <www.ajnr.org/content/26/4/985>.

    8 Matas, Sandro Luiz de Andrade. “Why Should We Use Atraumatic Needles in Lumbar Puncture?” Arquivos De Neuro-Psiquiatria, <www.scielo.br/pdf/anp/v71n9B/0004-282X-anp-71-09b-681.pdf>.

    9 Schievink, W. l., et al. “Diagnostic Criteria for Spontaneous Spinal CSF Leaks and Intracranial Hypotension.” American Journal of Neuroradiology, American Journal of Neuroradiology, 1 May 2008, <www.ajnr.org/content/29/5/853>.

    10 Schievink, Wouter l. “Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension.” JAMA, American Medical Association, 17 May 2006, <www.jamanetwork.com/journals/jama/fullarticle/202849>.

    11 Griauzde, J., et al. “Large-Volume Blood Patch to Multiple Sites in the Epidural Space through a Single-Catheter Access Site for Treatment of Spontaneous Intracranial Hypotension.”American Journal of Neuroradiology, American Journal of Neuroradiology, 30 Apr. 2014, <www.ajnr.org/content/early/2014/04/30/ajnr.A3945>.

    12 Kranz, P. G., et al. “Rebound Intracranial Hypertension: A Complication of Epidural Blood Patching for Intracranial Hypotension.” American Journal of Neuroradiology, American Journal of Neuroradiology, 1 June 2014, <www.ajnr.org/content/35/6/1237>.

  • Overview: Complications Associated With A Chiari Decompression

    Overview: Complications Associated With A Chiari Decompression

    From Intracranial Hypertension (formerly known as Pseudotumor Cerebri), Hydrocephalus, Tethered Cord Syndrome, to conditions related to the presence of a connective tissue disorder, such as Ehler’s-Danlos Syndrome, the primary reason for post-decompression complications seen in the Chiari Patient Community continues to be largely related to undiagnosed and untreated comorbid conditions. Time and time again, we see decompression failure, or a recurrence of symptoms after decompression, because there are other underlying conditions that need to be addressed. For this reason, we strongly recommend that patients get evaluated for the possibility of these known comorbid conditions before undergoing decompression surgery, unless circumstances require emergency surgery. (More information about the testing we recommend can be found in “The Treatments” article). Potential complications of decompression surgery may vary, depending upon the specific technique used, such as whether a duraplasty is performed, and how much bone is removed during a suboccipital craniectomy. The most common complications are infection, CSF leak, and Pseudomeningocele in adult patients.


    INFECTIONS

    Surgical site infections:
    A surgical site infection is a risk of any surgery. While hospitals and surgical staff strive to maintain a sterile environment, hospitals are known for harboring pathogens, including many that are antibiotic resistant. Patient factors, including diabetes, age, being overweight, and being a smoker can also increase a patient’s risk of developing a post-operative infection.[1] Antibiotics are typically given post-surgically (and sometimes before surgery) in order to reduce the risk of infection. Some infections require wound revision surgery, to remove pus and infected tissue in order to improve healing.


    MENINGITIS

    Meningitis is an additional surgical risk when the dura is opened during a decompression. It is characterized by inflammation of the meninges, the linings of the brain. There are three main types of meningitis: aseptic, bacterial and chemical.

    CSF Meningitis/Blood (left); CSF Meningitis (middle); CSF (right)

    ♦ Aseptic Meningitis is by far the most common type, and is generally less severe than the bacterial type. Most cases of aseptic meningitis are caused by viruses, but may rarely be fungal, autoimmune, parasitic or drug-induced.[2] The treatment for aseptic meningitis is usually supportive care.[3] Chemical meningitis is also a risk any time surgery or other procedures or treatments are performed on the brain or spine.[4]

    ♦ Bacterial Meningitis is much more serious and can be life threatening. Three types of bacteria cause most cases: streptococcus pneumoniae, Group B streptococcus, and Neisseria meningitidis. Typical treatment includes antibiotics and supportive care.


    CSF LEAKS

    Duraplasty leak:
    Post-decompression CSF leaks are a risk of decompression surgery whenever the dura is opened. The risk of a CSF leak dramatically increases with the presence of untreated hydrocephalus[5], intracranial hypertension (IH)[6], and connective tissue disorders, such as Ehlers-Danlos Syndrome. Nationwide statistics indicate that the risk of a CSF leak post-duraplasty is 10-15%. However, some surgeons report a significantly lower incidence of CSF leaks in their patients.[7] The use of biologic glue to seal the dural suture line has greatly reduced the incidence of post-duraplasty CSF leaks. A common sign of a leak is clear fluid leaking from the incision site.

    Pseudomeningocele:
    A pseudomeningocele is a type of CSF leak, where the leak creates a pocket in the muscles in the back of the neck. It is one of the most common complications of duraplasty. While some surgeons have managed to keep the incidence of pseudomeningocele low in their patients, some report an incidence as high as 18%.[8] A study at Vanderbilt University at 2013 showed that the development of a pseudomeningocele after decompression significantly reduced the benefit of decompression at one-year post-op on pain, disability and quality of life.[9] A smaller pseudomeningocele may re-absorb on its own. However, with large and persistent PM’s, the duraplasty may adhere to the cerebellar tonsils, blocking flow and making a revision surgery more difficult. There is much debate among neurosurgeons as to whether doing routine duraplasty as part of decompression outweighs the risks. Some argue that duraplasty increases the risk of complications, while others say that failure to perform duraplasty often results in inadequate decompression, reduced benefit, and the need for additional surgeries. Some experts argue that duraplasty using the patient’s own pericranial tissue and using water-tight sutures and biologic glue minimizes the risk of a leak and makes routine duraplasty the best option for most patients. A squishy pocket of fluid is often seen near the base of the skull and a PM can be confirmed and monitored with an MRI. In some cases, a surgeon may try draining the pocket of fluid with a needle and syringe.


    BLEEDING AND ANESTHESIA-RELATED COMPLICATIONS

    Excessive Blood Loss:
    Excessive blood loss is a risk of any major surgery, but can be minimized by a careful surgical technique. Patients with connective tissue disorders may have an increased risk of bleeding complications, due to fragile blood vessels, particularly with vascular EDS or vascular crossover symptoms. Cessation of blood-thinning medications, such as warfarin, aspirin and NSAIDS also reduces the risk of bleeding.

    Anesthesia Risks:
    While risks of general anesthesia are quite low, the risk may be higher if you or someone related to you has had previous adverse interaction to general anesthesia. Some EDS patients are also prone to anesthesia issues, such as requiring more anesthesia or ineffectiveness of local anesthetics. Therefore, it is important to inform your anesthesiologist of your pertinent medical history.[10]


    BONY REGROWTH

    Regrowth of the bone removed during decompression is a risk associated with the pediatric patient population, particularly patients under the age of 2. Surgeons have reported as much as a 50% incidence of bony regrowth in patients under the age of 5, and as much as 80% in patients under age 2. Regrowth of bone may result in the need for future surgery.[5]


    CRANIOCERVICAL INSTABILITY

    While Craniocervical Instability is not uncommon among those with connective tissue disorders, it is pretty rare in the general population. However, aggressive bone removal during decompression surgery can create an unstable craniocervical junction. It is important to discuss with your surgeon how much bone they plan to remove, and the risks and benefits of laminectomy, particularly if you also have a connective tissue disorder, which increases your risk for developing instability.


    CEREBELLAR SLUMPING (PTOSIS)

    Cerebellar slumping (aka cerebellar ptosis) occurs as a result of too much bone being removed around the foramen magnum that there is no longer enough bone to support the weight of the cerebellum. The brain slumps downward toward the spine, re-herniating the cerebellar tonsils, and often compressing the cerebellum itself against the back of the skull and brain stem. This can often result in worse symptoms than the patient had before decompression. Surgical techniques have been developed to revise the decompression and provide more support to the cerebellum.[11]


    OCCIPITAL NEURALGIA

    Occipital neuralgia is nerve pain, often accompanied by numbness and/or tingling, of the occipital nerve in the back of the head. It can be caused by compression of or damage to the occipital nerve. While the presence of a Chiari malformation itself can cause compression of the cranial nerves, including the occipital nerve, decompression surgery can also cause occipital neuralgia. This can be due to compression of the nerve from the use of retractors to hold apart musculature during surgery, or the build-up of scar tissue around the nerve. More conservative treatment of occipital neuralgia may include medications, such as lidocaine patches and medication that target nerve pain, physical therapy, cutaneous nerve stimulators, and nerve root blocks. Severe and persisting occipital neuralgia may require surgical decompression of the nerve or occipital neurectomy, surgical removal of the occipital nerve.[12]


    SCAR TISSUE AND ADHESIONS

    Like with occipital neuralgia and pseudomeningocele, the development of scar tissue and adhesions can cause symptoms to return or failure to relieve symptoms after a decompression surgery. Adhesions and scar tissue can develop wherever tissue is cut, including the dural graft, cauterized tonsils and the skin incision. Scar tissue and adhesion can inhibit or block CSF flow and often require revision surgery to remove the scar tissue. A careful selection of the graft material used for a duraplasty may reduce the risk of developing adhesions and scar tissue.[13] 


    DECOMPRESSION FAILURE

    While perhaps technically not a complication, the failure rate of decompression surgery to alleviate symptoms deserves a mention here. While proper complications can often result in the failure of a decompression to relieve symptoms, or in fact, may make them worse than before decompression, even complication-free decompressions surgeries have a high rate of failure, as much as 40%, depending upon the study. Some reasons for decompression failure in the absence of the above-listed complications include failure to diagnose and treat comorbid conditions that may be causing symptoms, an inadequate decompression (failure to create enough space by removing bone and performing a duraplasty), and some or all of the symptoms being due to another cause, such as migraines. In cases of an inadequate decompression, a more aggressive decompression revision surgery may provide relief. In cases where a comorbid condition exists, that condition must be diagnosed and treated. However, there are still a small percentage of patients who do not get relief, even with further decompression and other treatments. The reason for this is not clearly understood.[5]

     

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    References:

    1 Torpy, Janet M. “Postoperative Infections.” JAMA, American Medical Association, 23 June 2010, <www.jamanetwork.com/journals/jama/fullarticle/186132>.

    2 Ramachandran, Tarakad S. “Aseptic Meningitis Treatment & Management.” Aseptic Meningitis Treatment & Management: Approach Considerations, Medical Care, Prevention, 22 Aug. 2017, <www.emedicine.medscape.com/article/1169489-treatment>.

    3 “Meningitis.” Meningitis | Brain & Spine Foundation, <www.brainandspine.org.uk/meningitis>.

    4 McDaniels, Edison. “Chiari Decompression Surgery.” Neurosurgery101-TheBlog, 3 Apr. 2013, <www.surgeonwriter.com/chiari-4/>.

    5 Trumble, Eric. “Chiari Overview & Surgical Issues.” Chiari and Syringomyelia Foundation, Chiari and Syringomyelia Foundation, 13 Oct. 2015, <www.csfinfo.org/videos/physician-lecture-videos/csf-lectures-archive/chiari-overview-surgical-issues/>.

    6 “Chiari Surgery.” Chiari Surgery | Mayfield Chiari Center, 10 Dec. 2017, <www.mayfieldchiaricenter.com/chiari_surgery.php>.

    8 “Pseudomeningocele Following Chiari Surgery Decreases Quality of Life.” CHIARI MEDICINE, 17 May 2015, <www.chiarimedicine.com/blog/2015/5/17/pseudomenigocele-following-chiari-surgery-decreases-quality-of-life>.

    9 Parker, S. L., et al. “Effect of Symptomatic Pseudomeningocele on Improvement in Pain, Disability, and Quality of Life Following Suboccipital Decompression for Adult Chiari Malformation Type I.” Journal of Neurosurgery., U.S. National Library of Medicine, Nov. 2013, <www.ncbi.nlm.nih.gov/pubmed/24010974>.

    10 “The Risks of Anesthesia and How to Prevent Them.” WebMD, WebMD, 2016, <www.webmd.com/a-to-z-guides/anesthesia-risks-what-patients-should-know>.

    11 “Surgical Technique Alleviates Cerebellar Slumping.” Cerebellar Slumping, 31 May 2007, <www.conquerchiari.org/articles/surgery/techniques/cerebellar-slumping.html>.

    12 Mueller, Diane. “Occipital Neuralgia and Chiari Malformation.” CHIARI MEDICINE, 4 Apr. 2013, <www.chiarimedicine.com/blog/2013/4/4/occipital-neuralgia-and-chiari-malformation>.

    13 Attenello, Frank J., et al. Suboccipital Decompression for Chiari I Malformation: Outcome Comparison of Duraplasty with Expanded Polytetrafluoroethylene Dural Substitute versus Pericranial Autograft. 4 Sept. 2008, <www.link.springer.com/article/10.1007/s00381-008-0700-y>.

  • One Painful Fight – Get Ready To Rumble!!!

    One Painful Fight – Get Ready To Rumble!!!

    “Make it stop!”

    “I can’t take this pain anymore!”

    How many times have you, or your loved one, cried out these very words?

    Pain from a Chiari headache can be brought on from the simplest of things – a sneeze, a cough, laughter, or bearing down when going to the bathroom. We never know when the headache is going to strike, how long it will last, or when it will end. We are unable to describe the intensity of the pain to others, and when asked to rate our pain on a scale of 1 – 10, we want to scream, “14!” The radiating, crushing pain of the headaches robs us of our ability to function for days on end. And depending on the extent of damage the Chiari has caused you may also have the burning, stabbing, and shooting involved with neuropathic pain and neuralgia. The frosting on the pain cake, perhaps? With the many co-morbid disorders that go hand in hand with Chiari, such as Ehlers-Danlos Syndrome, Intracranial Hypertension, Hydrocephalus, and Tethered Cord Syndrome, is it any wonder we cry out, “Make it stop!”?

    Once finally diagnosed, whether you feel like you are losing your mind, or rejoicing over finally having answers, I guarantee you, this emotional roller coaster will still prove to be the ride of your life! Even if they say your Chiari was an “incidental finding,” I can almost guarantee that when you look back in hindsight, you will see that some of the signs of Chiari or its comorbid conditions were always there and you thought they were just “normal.” If you have a history (or familial history) of headaches made worse when you cough, sneeze, laugh, flinch, strain, or bend over; neck pain; stomach aches; ankle/knee/hip/elbow problems; hypermobile joints; dislocations; scoliosis; bulging/herniated discs; miscarriages; aneurysms; numbness; muscle wasting (atrophy); vision loss; double vision; or unexplained muscle/eye spasms (and the list could go on); then they are all probably related to Chiari and its comorbidities. If you just got a new diagnosis of “Chiari Malformation,” you might feel fear, with a sigh of relief to finally have a diagnosis to go with the many symptoms you have complained about for years. Whatever you are feeling right now, be sure to take the time to breathe and take care of you, because the battle is an accumulation of long and tiring rounds and odds are, Chiari Malformation is not the only problem you have going on.

    By a wide margin, the hardest part of our fight is dealing with doctors. One would think it would be the never-ending pain, but when your doctors do not believe you, ridicule you, or outright verbally abuse you, it not only adds insult to injury, but it probably illustrates reasons that your doctor(s) just might be the ones that need counseling. As patients, we are paying for them to help us with our medical problems; what we get instead is usually a referral to a therapist because of their ineptitude. The absurd part of this circle of insanity is that when we make ourselves more knowledgeable about our condition(s), because we have no other choice, a doctor that understand the Hippocratic Oath would respond by making themselves more knowledgeable as well, so they can help their patients. Yet, what is far too common are doctors that do not want to know the results of studies, who are complacent with their fifteen minutes of Chiari education, and think if they talk a good game, patients can be manipulated into thinking maybe it’s all in their minds.

    In a distant second, would have to be the heart-wrenching feeling we get when our loved ones put more stock in the opinions of our morally bankrupt doctors, even once we have shared study after study and article after article showing you that our doctors are wrong. What we go through, feeling like our bodies have betrayed us, knowing that our doctors have betrayed us (even if it is because they do not know any better), we need you in our corner. This is the fight of our lives, for our lives, and we should never have to do it alone! The energetic, feisty, loving person that you have loved so much over the years is still inside of us! When your brain falls into your spinal canal and your connective tissue is wasting away, there is no measure of motivation that is going to help fix it! We need help with our battle, someone in our corner! We don’t need judgement or motivational speeches; we need love and understanding – and an occasional shoulder to cry on. We need you to help us stay grounded and remind us that despite the pain and brokenness, we still have value in this world! Without a shadow of a doubt, we really need you!

    What our bodies go through from head to toe really can only be understood by remembering the importance of your Central Nervous System in everything that you do. Every nerve in your body passes through the Foramen Magnum, where the Cerebellar Tonsils invaded, and in most cases, every single one of those nerves are damaged to some degree (and some of that damage is permanent). The headaches we get when we cough, sneeze, heave (or do anything that causes a bounce or even a slight movement of our skulls), can often only be compared to the pain of childbearing – rendering the pain rating scales useless for not having the angry face reaching around and trying to rip his skull out from the base. The neck pain consists of spasms (either continuous or intermittent). For most of us with HDCT, Craniocervical Instability makes our heads constantly feel like they weigh far too much for our weak necks to support (often described as a ‘bobblehead” feeling). Some might consider the pins and needles or ice pick stabbing pains behind our eyes, in our heads (neuralgia) or in our extremities (peripheral neuropathy) to be a crushing reality of life despite surgery.

    Finally, this lack of awareness, education and research makes it even more difficult for those of us who find ourselves no longer able to work. The Social Security Administration has yet to add Chiari Malformation to its list of impairments which would automatically qualify for disability benefits (apparently, they do not know the importance of the Central Nervous System either). Although benefits can still be fought for and awarded, the fight becomes far more difficult than it needs to be. Chiarians often must fight for years, filing appeal after appeal, to prove that their reality is the reality.

    Is their hope? Yes!

    Through it all, and despite all the challenges that face us, we are many, and together, we are powerful! We can change all of this by becoming our own advocates and by raising awareness and dollars for research and awareness information that strives to educate the medical professionals that are treating us. This is our war to fight and being the warriors that we are, we must rise to the occasion – because LOSING IS NOT AN OPTION!

     

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  • The Christopher Ellington Story – A Chiari Warrior’s Journey [Updated]

    The Christopher Ellington Story – A Chiari Warrior’s Journey [Updated]

    My introduction to Chiari malformation I (CM1) begins in 1994. I had been married about 7 months and we had just celebrated our first Christmas together as newlyweds. Shortly after the new year, I developed a bad headache that eventually evolved into losing my eyesight in one eye. I went to the eye doctor, who immediately sent me to the hospital. I was diagnosed with Pseudotumor Cerebri and Papilledema, which are known to often accompany Chiari (co-morbid conditions). At the time, we were told that it was likely due to a virus. I had five failed lumbar punctures and finally a successful sixth in radiology, was given Diamox, and the problems went away. Nothing was ever said about Chiari or an abnormal MRI. I also had no idea that I could or should get a copy of the MRI from the hospital, so I could keep my own records. I wasn’t even given any reason on why it might be necessary. I trusted my doctors and they helped resolve the problem with my sight. Little did I realize that it was only the beginning and I was in for the fight of my life!

    From 1994 until 2005, I had few further significant issues. I continued to have headaches which I treated with Excedrin and ringing in my ears (tinnitus), which was generally attributed to the aspirin in the Excedrin and sinus issues. In January of 2005, I started having jaw pain. I saw a number of dentists and doctors who couldn’t figure out the problem. I eventually ended up seeing a doctor specializing in pain management who indicated he thought it was Trigeminal Neuralgia (which is another co-morbid disorder of Chiari, but its connection wasn’t made known to us). I was sent to a neurologist, who pointed out I had a 2cm (20mm) herniation, which he said wasn’t enough to worry about, but it was a Chiari malformation. Again, he was the doctor, so we just trusted that it wasn’t something to worry about. The pain worsened:  it started lasting for longer periods of time and increased in both intensity and frequency, so I went to the ER on the advice of the neurologist for pain relief. When I arrived, the neurosurgical group that I had an appointment with had left word for me to go to their office, so I could see them. Since my appointment wasn’t for another several weeks, we were thrilled to get in so fast. We were also told I had Trigeminal Neuralgia and that Chiari wasn’t related and that Chiari couldn’t kill you; although they informed me that I would need surgery. I was scheduled for a decompression surgery almost immediately and thought I was cured. The neurosurgeons indicated that a 2cm (20mm) herniation was quite significant and that I was “in good hands.” The decompression was somewhat successful in that it resolved some of my symptoms, but the relief was short lived.

    I stopped taking the Gabapentin for Trigeminal Neuralgia but began having trouble with balance issues and nobody was sure why. I was told that the Chiari had nothing to do with any of this and that I was “just lucky” that all my conditions were minor. My surgeon considered Microvascular Decompression (MVD), but said I was “too tight” and the surgery wouldn’t be a good idea. In January 2007 and November 2007, I had rhizotomies performed to deaden the nerve. The rhizotomy only worked for about six months before the pain returned. I had a repeat rhizotomy in November 2007 and that has been successful to date. I was still having a lot of symptoms (that I now know to be Chiari symptoms) but they continued to assume them to be due to the Pseudotumor Cerebri, even though I didn’t have my pressure checked or any sign of a papilledema. In June 2008, I had a Ventriculoperitoneal (VP) shunt put in. It was ligated (tied off) in July 2010 since I had lost weight and the symptoms had switched from what was presumed to be high pressure to low pressure symptoms. Due to my new low-pressure symptoms, they tried several blood patches in an attempt to repair what was assumed to be a leak, even though it was never found on any of the testing. Initially, the blood patches worked well, but over time the blood patches were less effective, and I started getting headaches again.  Eventually, the doctors gave up on blood patches as they weren’t helping the headaches and finally, I stopped getting headaches (which we later found out wasn’t uncommon for those who have had long-term CSF leaks.

    Despite my lack of headaches, I started having neurodegenerative problems: trouble maintaining consciousness, hypersomnolence, severe balance problems, bouts with confusion and cognitive changes. My neurologist became convinced that I needed a second decompression. He discussed my case with my neurosurgeon who initially didn’t think that another decompression would help. He was convinced to perform the surgery and I had the decompression in January 2012. The decompression was very successful for 23 days. After that, I declined rapidly. Over the next year, I developed multiple lung infections, which they presumed to be from my history as a smoker, but in reality, it was due to dysphagia. In January 2013, I was admitted to the hospital for yet another lung infection and by May, I was given a feeding tube. My wife was brought into a meeting with my neurologist where he said I needed to go to a nursing home and that my death could be imminent. I went to the nursing home and did better than they expected. Instead of dying at the nursing home, I improved and was released to go home a month later. I continued to improve enough to have the feeding tube removed that July.

    Once home, my condition continued to decline. My wife continued researching and we decided to go and see a Chiari specialist since her research indicated it was the only real way to proceed, especially with a difficult case. In June 2014, we met with one such expert who was able to explain why the first two decompressions failed. Ehlers-Danlos Syndrome and Craniocervical Instability were two of the missing pieces to my puzzle. It was an eye-opening experience and finally, my issues made sense. We discussed several options for surgery, and eventually settled on a date, October 30, 2014. I had my third decompression and this time, a spinal fusion. It was a wild success! Many of my symptoms were resolved immediately. While it was not a cure, it certainly helped me substantially in restoring many functions and my quality of life.

    However, in September 2015, I went into a coma while hospitalized for a reduced state of awareness (which coincided with weaning off the Decadron) and the local doctors said it was another failed decompression. In October 2015, I had yet another MRI. While going over the radiologist report, my wife noticed something none of my doctors mentioned, it stated that I had severe Intracranial Hypotension. My wife sent my MRI images to a leak expert and my NY neurosurgeon for further assessment.

    In January 2016, I was in another hospital across the country having imaging for the known CSF leak. After the testing was done, a leak was found in my lumbar spine and a location they felt was suspicious on my thoracic spine (where I had old stress fractures and incredibly thin dura, believed to have been causing leaks). There were also bone fragments next to the fractures, so the doctor double reinforced my spine in that area and performed a dural reduction surgery in parts of my thoracic and lumbar spine. I got better until August 2016, when I started experiencing symptoms of a CSF leak. Upon consultation, we decided a blood patch would be the place to start and it resolved my symptoms quickly.  As of August 2018, the blood patch has continued to keep me from leaking and no leak symptoms have occurred.  While I’m going to be at risk for leaks, and likely leak periodically due to Ehlers-Danlos Syndrome, I will take the results I’ve seen thus far.  It’s also interesting to note that while I’ve had a number of unsuccessful patches, this time the post-patch recovery protocol was different in that I laid flat for 2 hours post patch, then 3 days lying flat except to go to the bathroom and eat.  I’m convinced that this protocol helped immensely, as the weight of the CSF Is much greater when upright thus increasing the chance of a leak.  Also, a blood patch doesn’t end the leak repair, it merely starts it.  Once the clotting effect has finished, the next stage occurs, which includes tissue growth to repair the opening.  With Ehlers-Danlos Syndrome, this process is often diminished and requires longer than the normal recovery time, which is why I believe many of us have had failed patches.

    I am still continuing to heal, and likely will never be returned to my old self.  I have been discharged from physical therapy as of December 2017, however I still exercise every day for at least an hour.  I know that this is a key part of my healing; there have been a few occasions when I was unable to do my exercises for a few days I notice difficulty in doing my daily activities.  In addition, I will not likely be able to work as a paid employee ever again, however, I have been able to provide some help to a variety of people.  I enjoy helping others and this works well as if I have a less than optimal day, I can just let anyone who needs my help know that I won’t be available to help them.

    My recovery hasn’t been without trouble, as I returned to the hospital once, in the spring of 2018, for what was presumed to be a gall bladder problem.  Since I’ve suffered issues with kidney stones, it’s not surprising to me that I have a lot of gall stones.  I suspect it has to do with some of the gastrointestinal issues that hEDS brings, but there is nothing definitive.  After 2 days of pretty significant pain, the pain subsided and nothing more came of it.

    Overall, there have been a number of positive outcomes and I wouldn’t change the decision to have my third decompression & fusion.  This has granted me the ability to lead a life, which while not “normal,” is fulfilling.

    I am not, and never will be, completely healed. Many of my symptoms have resolved to the point where I can tolerate them and at times, don’t even notice them. While there is no cure for Chiari or the Ehlers-Danlos Syndrome causing it all, there is more healing possible. They are difficult disorders for many reasons and one of the biggest issues is the way it presents itself; for each person, it can be entirely different, making the diagnosis very difficult. I will always have to be monitored for leaks each time the symptoms present themselves, but for now, I find myself thankful to be alive and so very lucky to have the support I do, especially from my wife, my hero!

    *Updated August 2018

  • The Diagnosis – Round One

    The Diagnosis – Round One

    One of the biggest hurdles a Chiari patient may face is that of simply being diagnosed. Some studies cite an average of 5 years between the onset of symptoms significant enough for a patient to seek medical care and the patient receiving an accurate diagnosis of Chiari Malformation. Sadly, however, online support groups and message boards are peppered with the stories of patients who went undiagnosed, or more often, misdiagnosed, for decades. Patients are frequently misdiagnosed with conditions such as Fibromyalgia, Multiple Sclerosis, Chronic Fatigue Syndrome, Chronic Migraine, and various autoimmune disorders. Even more disturbing is the fact that in a study by Dr. Thomas Milhorat of over 300 patients diagnosed with Chiari, 59% had been diagnosed with a psychosomatic illness.[1] Diagnoses such as Hypochondriasis, Somatoform Disorder, Conversion Disorder, and a tricky little term some doctors use to disguise the fact that they believe their patient’s symptoms are “all in their head,” called ‘Functional Somatic Syndrome’ (which by definition does not necessarily imply a psychosomatic cause but are often interpreted by other medical professionals in that manner) are frequently written in patient’s medical records to account for their very real, medically explainable symptoms.[2] This often further undermines a patient’s efforts to find a diagnosis when they decide to try a new doctor, with their defiled medical records in tow, often without even realizing what has been written in their charts or what it actually means in ‘doctor speak.’

    Diagnosis of Chiari Malformation is based upon the presence of Chiari symptoms, such as an occipital headache that is brought about or worsened by Valsalva maneuvers, neurological symptoms such as poor balance, numbness or tingling in the arms, weakness in the legs, etc. combined with the “gold standard” of imaging studies for Chiari, an MRI of the brain.[3] The MRI should show a tonsillar herniation that inhibits the normal flow of CSF fluid out of the Fourth ventricle of the brain and through the foramen magnum. When normal flow is in question, a CINE MRI may be conducted to determine how the CSF is flowing through the brain and upper spinal canal. There, are, however, controversial cases sometimes referred to as “Chiari Zero,” where no herniation exists, but interruption of flow and symptoms are present.[4]

    So, with all these wonderful tests available, why is it so difficult to get a diagnosis? Well, first of all, most primary care physicians and neurologists alike are under-educated or outright miseducated about Chiari Malformation. It has always been presumed to be a relatively rare disorder, and with over 7,000 rare diseases known to modern medicine, medical schools cannot give a thorough education to medical students on everyone. However, since the advent and now fairly commonplace use of the MRI, it is becoming apparent that Chiari is not quite as rare as it was once thought to be. When a primary care physician is stumped by a patient’s complaints of headaches and neurological symptoms, it is only natural to refer that patient to a neurologist for evaluation. But even many neurologists are grossly uninformed about Chiari. Many patients, even with an MRI that shows a herniation, are told that their many varied symptoms can’t possibly be due to the herniation of their brain, even with numerous studies available which show otherwise. Some patients have even been told by neurologists and even neurosurgeons that “Chiari doesn’t cause headaches [pain].” In fact, most symptomatic patients experience severe headaches, nerve pain, and pain from related disorders such as Syringomyelia.

    Furthermore, radiologists across the U.S. are using vastly different criteria from one another to determine whether a patient’s herniation constitutes a Chiari Malformation. Some are using criteria of a 3-5mm herniation, others a 7 mm herniation, and some are failing to look for a herniation altogether. The latest research, in fact, suggests that the size of the herniation does not matter at all. Some people with large herniations show no symptoms, while others with quite small herniations experience severe symptoms. Experts are now focusing more on whether the herniation blocks the normal flow of cerebrospinal fluid (CSF) in determining whether a patient may benefit from surgical intervention.

    It is important to address the situation of “Incidental Findings” of Chiari Malformation. It is true that sometimes while having an MRI for an unrelated matter, a completely asymptomatic patient is found to have a Chiari Malformation. Unless this type of patient were to become symptomatic later, no treatment is necessary in these situations. However, if you look at radiology reports with a claim of ‘incidental finding of Chiari Malformation,’ you are likely to see that the reason mentioned for the imaging being done was to look for a cause of headaches or other known symptoms of Chiari. In these cases, these are absolutely not ‘Incidental Findings.’ Again, this is an example of the lack of education about Chiari.

    For patients, the best piece of advice one can give on your road to diagnosis of your symptoms, whether  due to Chiari or something else, is to trust yourself and never give up seeking answers. If you believe your symptoms are due to Chiari or that your MRI may have been misread, get a second opinion from a neurosurgeon that specializes in treating Chiari Malformation.

     

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    References:

    1 Milhorat, T H, et al. “Chiari I Malformation Redefined: Clinical and Radiographic Findings for 364 Symptomatic Patients.” Neurosurgery., U.S. National Library of Medicine, May 1999, <www.ncbi.nlm.nih.gov/pubmed/10232534>.

    2 Mayou, Richard, and Andrew Farmer. “Functional Somatic Symptoms and Syndromes.” BMJ : British Medical Journal, BMJ, 3 Aug. 2002, <www.ncbi.nlm.nih.gov/pmc/articles/PMC1123778/>.

    3 “The Chiari I Malformation.” Chiari I | Chiari & Syringomyelia Foundation (CSF), <csfinfo.org/education/physician-information/chiari-i/>.

    4 Hofkes, S K, et al. “Differentiation between Symptomatic Chiari I Malformation and Asymptomatic Tonsilar Ectopia by Using Cerebrospinal Fluid Flow Imaging: Initial Estimate of Imaging Accuracy.” Radiology., U.S. National Library of Medicine, Nov. 2007, <www.ncbi.nlm.nih.gov/pubmed/17890352>.