Chiari malformations

[Crazy Pole]

Is anyone familiar with Chiari malformations? A patient was referred to me today, with MRI results showing this malformation. Apparently, it is a malunion of a cervical vertebra.

What frustrates me, and please let me know if you think I am wrong here, is that the referring doc (Sports Med), thinks it is benign and has nothing to do with his cervical muscular tenderness, tension, and pain. Rather, his pain and muscular activity is a result of poor posture and lower back strength. Regarding the increased cervical paraspinal activity, I ask defect, or defense? Perhaps someone with more knowledge of the condition can offer their insight.

Thanks,
Wes

[nari]

Arnold-Chiari malformations can be life-threatening or benign, depending, of course, on the site. It can result in symptoms at any age, but commonly as an adult.

Wes, can you tell us a bit more about your patient? Age? Areas of m. tenderness and pain? Is it at all dermatomal? (Not that dermatomal distribution is particularly reliable)

The sports doctor's recommendations sound a bit out of date, anyway...;)

Nari

[Crazy Pole]

Thanks Nari,

Actually this is not Arnold-Chiari, as I originally thought, but rather just Chiari. No influence from Arnold, I guess.

This kid is 15 years old and play soccer year-round. He has primarily left-sided cervical paraspinal tenderness. His greatest discomfort is with cervical extension or right rotation. Other than some discomfort while playing soccer, or doing housework, he is not too limited. He doesn't appear to be too worried about his discomfort overall. However, his father is concerned because any time that this kid gets a break in soccer action, he is self-massaging. My thought is that the muscular activity is more defensive than defective, and self-massage helps him feel better and isn't necessarily a bad thing. Any other thoughts?

And yes, this doc is quite out of date, but that's a whole other thread...

Wes

[Jon Newman]

Hi Wes,

Is there a difference how the fellow positions his hip while supine or signs/sx of an abnormal neurodynamic?

What led to the discovery of the Chiari malformation?

[Crazy Pole]

Thanks Jon,

Actually he lies with nice ER of the hips in supine. Not necessarily abducted. He apparently seems to feel free to assume whatever position(s) he wants because the doctor's note states that he had to be told 3 times to improve his posture, and every time the doc turned away, this kid moved out of the "ideal" posture. MRI and X-ray were obtained, with the MRI confirming the Chiari malformation. No UE symptoms are present, just pain in the neck, and the aforementioned muscular presentation. Diaphragmatic breathing is also pretty good. Hope this helps.

Wes

[Jon Newman]

Hi Wes,

So the finding of the Chiari malformation was incidental? What prompted the x-ray and MRI?

[Barrett Dorko]

Hi Wes,

If he were my patient I'd commit to treating him three times. Make sure he gets what it is you're looking for him to do. Holler at him if he doesn't do it and let it go if there isn't a distinct decrease in the frequency, intensity, duration and/or location of his complaint.

Change what you can, not the connective tissue.

[Diane]

Does he bounce the soccer ball off his head? That can't be a good idea..

[Jason Silvernail]

This malformation can lead to symptoms of cervical myelopathy. Any signs of that?
-hoffman sign present
-ataxic gait
-balance difficulty
-UMN signs

I think if you don't have any indication that he's got a myelopathy, then what Barrett suggests is reasonable - if he changes with early treatment great, but if not then you may be seeing a response to the mechanical strain on the nervous tissue from the Chiari malformation, and there's not much therapy can do for that.
I attached an abstract that is interesting reading about this

[nari]

Wes,

If there are no ominous signs, I would agree with Barrett. It seems that there are none, from what you write.

Nari

[Crazy Pole]

Jon,

As best I can tell, it was just the cervical pain that prompted the diagnostic imaging. Yes, the finding was incidental, but I'm not sure that it is as insignificant as has been suggested.

Diane,

That is what I thought.

Jason,

None of those seem to be present. Thanks for the abstract, I will have to look at that.

Wes

[Crazy Pole]

So, upon further review (thanks again, Jon), this patient's brains are sticking out of the bottom of his head. I was misled by the Sports Med doc. Subsequently, I apologize for any confusion related to Chiari vs. Arnold-Chiari.

For those interested, neck pain seems to be a common complaint with this condition. Currently, this kid doesn't present with much more than that, though I intend to ask more about tussive headaches (headaches with exertion). Jason, as usual, you were right on with other potential signs. Thank you all for your help.

Wes