Chiari malformation: Non-surgical alternatives to Chiari decompression surgery
Ross Hauser, MD
If you have been diagnosed with Chiari malformation, you may have found a great deal of relief in finally having someone figure out what was or is causing all the pain and fatigue, and fibromyalgia-type symptoms you have been suffering from. Unfortunately, you may have also been told that the only way to correct Chiari malformation is through brain surgery and that the surgery is not as successful as the patient and doctor would like or hope for.
In some patients, reports that after surgery and a period of improved symptoms, their brain fog, pain, vision problems, and other symptoms returned. Complicated brain surgery for them, in the end, did nothing for them. Some of these patients do report that their doctors had advised that them that the surgery may not reverse their problems, but instead slow down or pause their worsening symptoms. But the patients had hope. Now they are looking for other options besides a second brain surgery.
At this point, I would like to remind you, the reader, that many people have successful Chiari decompression surgery. They are extremely happy with the outcomes. This article is presented to help other people. Those who have been told that their surgery may not have a good chance of success or those who had the surgery and they did not have good success.
In this article, I will present an alternative treatment method that focuses on cervical spine manual adjustments as well as a comparision of cervical spine ligament injections. The goal of our treatments is to get the floating or unstable upper cervical vertebrae back into position and then strengthen the cervical ligaments to keep them there. Simply, our treatments stabilize the cervical spine.
Surgery addresses atlantoaxial instability. Doctors debate it.
In 2015 Atul Goel, MD was a doctor at the Department of Neurosurgery, King Edward VII Memorial Hospital, and Seth G.S. Medical College. His training specialty was skull-based surgery and he was according to the hospital trained in the United States and the United Kingdom. In 2015 he published a paper in the Journal of Neurosurgery. Spine (1) Here he described good surgical outcomes in patients with Chiari malformation. Here is what he wrote:
“On the basis of outcomes in this study, it appears that the pathogenesis of Chiari malformation with or without associated basilar invagination and/or syringomyelia is primarily related to atlantoaxial instability. The data suggest that the surgical treatment in these cases should be directed toward atlantoaxial stabilization and segmental arthrodesis (fusion). Except in cases in which there is the assimilation of the atlas, the inclusion of the occipital bone is neither indicated nor provides optimum stability. Foramen magnum decompression is not necessary and may be counter-effective in the long run.”
In brief, Dr. Goel suggests stabilization at C1-C2 would help patients with Chiari malformation symptoms.
Some doctors responded to this with letters to the editor of the Journal of Neurosurgery. (2) Spine to suggest that “Although the clinical manifestations improved with the treatment of atlantoaxial fixation in (Dr. Goel’s reported 65 case histories), there was no direct evidence that atlantoaxial instability was the main reason. The pathogenesis of Chiari malformation with or without associated basilar invagination and/or syringomyelia is very complex. ”
“Chiari malformation is only Nature’s protective “airbag-like” effect. “
Dr. Goel responded:
“Essentially, we have identified atlantoaxial instability in all patients having basilar invagination and Chiari malformation and have stated that both of these entities when presenting together or in isolation should be treated by atlantoaxial fixation. With our increasing experience with treating Chiari malformation, we are convinced that instability is the cause of the problem and Chiari malformation is only Nature’s protective “airbag-like” effect.”
This back and forth between doctors did not end there. The idea that the ‘secondary’ musculoskeletal abnormalities as protective devices such as a Chiari malformation serving like a protective airbag were continued by Dr. Goel in the journal Neurospine (3) in September 2020. He wrote:
“Chronic or longstanding atlantoaxial instability is associated with a host of ‘secondary’ musculoskeletal and neural ‘alterations.’ The term ‘basilar invagination’ in general is an umbrella term that includes a range of alterations. Short neck, torticollis, short spine, and dorsal kyphoscoliosis are external manifestations of basilar invagination. All the secondary manifestations are natural protective maneuvers. More importantly, it was identified that all the secondary musculoskeletal and neural alterations when present in a consort or in isolation indicate the presence of atlantoaxial instability and are reversible following atlantoaxial fixation.”
Atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination
In June 2020, neurosurgeons at the Technical University Munich School of Medicine and the Medical University Innsbruck in Austria weighed in by suggesting that the “best surgery” debate is far from over. Publishing in the neurosurgical journal Acta Neurochirurgica, (4) they write:
Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective.
In turn, C1-2 fusion is proposed as a single solution for all craniovertebral junction abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead of relying on the intraoperative assessment of the atlantoaxial joints to confirm instability.
The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with craniovertebral junction abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression Removing the bone from the back of the skull), occipitocervical fusion (the fusing of the occipital to the cervical spine), and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor (the only cause) for craniovertebral junction abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.”
So there is a thinking in the medical community that Chiari malformation decompression surgery is at best “ineffective” and that the C1-C2 fusion is the best and actually, the only way to proceed with surgery to help patients with Chiari malformation. Not only that but you do not even need MRI or radiographic evidence of instability to be cleared to undergo fusion.
In this paper, the neurosurgeons do not support atlantoaxial instability as the common cause for craniovertebral junction abnormalities and there is no reason to dump the Chiari malformation decompression surgery.
As stated, our preference is to present a nonsurgical option to align the vertebrae and strengthen the stability of the cervical spine by strengthening the spinal ligaments with injections. We also have identified atlantoaxial instability as the primary concern. We also believe that many of the conditions and symptoms of C1 instability can be a secondary cause and with the return of normal cervical stability and the natural curve, the symptoms can be reversed and alleviated.
Decompression surgery can improve neurologic status
There are times when surgery will be strongly recommended as the best course to take for a patient. A November 2021 paper in the journal Neurosurgery (6) comes to us from the University of Iowa Hospitals and Clinics, University of Iowa Stead Family Children’s Hospital. In this paper the Iowa researchers assessed cognitive and psychological functioning in Chiari Malformation Type I before and after decompression surgery.
In this study researchers who were not given any characteristics of the patients (the researchers were “blinded” as to not have a preconceived or bias opinion) were asked to assess symptomatic Chiari Malformation Type I patients ages who were over 18 years old, with a battery of neuropsychological and psychological tests. Testing was conducted preoperatively and 6 to 18 months postoperatively.
- A total of 26 patients were included, with 19 completing both pre- and post-op cognitive assessments.
- All patients had resolution of Valsalva-induced headaches and there was improvement in swallowing dysfunction, ataxia, and sleep apnea.
- Chiari Malformation Type I patients had below average performance in visuospatial and visuoconstructional abilities preoperatively. (Visuospatial and visuoconstructional the ability to recognize figures and shapes and make sense of them. Patients are asked to look at a figure and be able to draw it.)
- Collected data following surgery demonstrated improved neurologic status without any decline in cognition or psychological functioning.
“The pathogenesis of Chiari malformation with or without associated basilar invagination and/or syringomyelia is very complex.”
We also agree with the statement made above that this is a complex problem. When we see patients with problems of cervical spine instability, Chiari malformation, and syrinx, these patients come in with more symptoms than they can even list. Typically they will tell us of their quality of life limitations, described a lot of symptoms, sometimes almost an impossible amount of symptoms. When we go through a checklist of symptoms with these patients and ask about other symptoms such as heartburn, vomiting, the sensation of being bloated, nausea, blood pressure swings, and vision problems, they will often say, “yes, those too.”
This is also indicated in the emails we get from people looking for help. They will say things like:
I’ve been diagnosed with a Chiari malformation, syrinx, myofascial pain syndrome, Mast Cell Activation Syndrome with symptoms of hives, swelling, low blood pressure, difficulty breathing. I have dysautonomia with symptoms of tremor and lightheadedness; gastroparesis and hEDS. (Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders)
I had a Chiari decompression surgery (parts of the bone at the base of the skull are typically removed to widen the foramen magnum and create space for the brain). This surgery was performed after a high-speed car accident more than 10 years ago. Since then I still have neck pain that radiates into my upper back and shoulders. I have clear signs of Craniocervical Instability.
I had a Chiari decompression surgery that included the removal of cerebellar tonsils. My neurosurgeon wants to do more surgery which I know I will not be able to tolerate. I developed Cerebrospinal fluid leaks from the surgery. It took me a long-time to recover my health from these leaks. I had “lumbar drainage,” “more suturing,” and I ultimately developed brain herniation.
The extreme fatigue: Many people will also report that they suffer from Chronic Fatigue Syndrome or simply excessive fatigue.
As varied and many as these symptoms are, for some they are just the tip of their problems.
Ross Hauser MD and Brian Hutcheson, DC discuss Chiari malformation and syrinx
Ross Hauser MD and Brian Hutcheson, DC discuss Chiari malformation or in its less invasive or milder form, cerebellar tonsil ectopia. Cerebellar tonsil ectopia is usually described as a patient with a slight tonsillar protrusion thru the foramen magnum without the symptoms recognized of coming from Chiari malformation.
At 1:00 Dr. Hutcheson explains problems of Chiari malformation
- With Chiari malformation, you’ll have a descending of the cerebellum and the brain stem into the space of the foramen magnum. As the brain stem is thicker than the spinal cord the structures within the foramen magnum are under pressure and become condensed. Any motion of the head and neck can irritate and worsen symptoms.
At 2:00 Dr. Hauser explains how a syrinx can develop from the Chiari malformation.
- The cerebrospinal fluid gets blocked and we can see how a syrinx can form at C1/C2 or c2/C3
At 2:25 A case study:
- Increased T2 signal
- Patient has a small area with increased T2 signal. A positive increase in T2 signal intensity is typical of chronic compression of the spinal cord and that negative structural changes to the spinal cord may be occurring and causing widespread symptoms.
- The patient has increased T2 signal in the C3-C4 levels indicating spinal cord compression at these areas.
- Patient history of Syrinx
- The patient has a history of syrinx. One to 2 inches at C3-C4. They became our patients because their symptoms were getting worse.
- It was explained to them that the syrinx developed as a result of a build-up of pressure. The Cerebrospinal fluid was being pushed out into the spinal cord.
- DMX (Digital Motion X-ray) reveals problems is isolated to Anterolisthesis
- The C3 has slipped forward over the C4
- In the Digital Motion X-ray, it is revealed that when the patient was moving into flexion (chin lowered to chest) the C3 slipped 3.2 mm over the C4 and this was the only problem noted. Yet this isolated problem was causing the patient’s symptoms, Chiari malformation, and syrinx development.
At 4:45 of the video a discussion of surgery
At 4:45 of the video: Why does the spinal cord come under pressure? How did this patient’s case develop to Chiari malformation and syrinx?
- Dr. Hauser relays that cervical spine instability a structural problem in the neck, not a chemical cause, can cause these problems. This is where the surgical debate comes in. The failure rate for surgery to correct this problem can be as high as 40-50%
At this point we would like to include new research on surgery for Chiari malformation type I
At 6:40 of the video: Nerve tension and ligament damage from birth trauma to whiplash car injury, the development of Chiari malformations
Dr. Hutcheson explains:
- There could be a percentage of Chiari malformations that were from birth trauma. The baby was delivered in a wrong position or there was a tugging that caused injury enough to have Chiari malformation form later. Typically cerebellar tonsillar ectopia because it’s not congenital could have been caused by post-traumatic injury such as whiplash.
- Regardless these injuries cause constant tension on the spinal cord. This tension is reflected in the above-mentioned T2 signaling.
- In this situation, neurons aren’t going to fire correctly and so with the cord under tension your body is going to have compromised autonomic nervous system response.
- A compromised compromised autonomic nervous system response will impact and disrupt heart rate, digestion, respiratory rate, pupillary response (vision problems, sensitivity to light, pupil dilation), the ability to urinate.
At 7:45 of the video: Heart Rate Variable
In our neck center, we use Heart Rate Variability measurements for testing your autonomic nervous system
- There are a lot of people who suffer from Chiari malformations who have unexplained dizziness, balance problems, blood pressure swings, arrhythmia, palpitations, OR their heart rate can go really low.
- One of the medical specialists they will see is a cardiologist or several cardiologists. Many will typically say of this experience that no one seems to know the cause of their heart problems.
Autonomic nervous system (ANS) regulation and Heart Rate Variability
There is a difference between Heart Rate and Heart Rate Variability.
- Heart Rate measures the number of heartbeats per minute.
- Heart Rate Variability measures the time between individual heartbeats. Please see our article on Heart Rate Variability.
To understand what may be happening in these people we need to understand the autonomic nervous system. The autonomic nervous system operates automatically. That is why it is called the autonomic nervous system. By itself, without conscious instruction, the autonomic nervous system keeps your heart pumping, your blood flowing through your blood vessels, your lungs breathing, and a myriad of other activities that occur in your body all the time, every day of your life. Part of that myriad of duties includes the operation of the sympathetic nervous system and parasympathetic nervous system.
- The sympathetic nervous system is part of the autonomic nervous system. It helps make adaptations to your current situation. For instance, if you are witness to a crime or an accident, or something bad, your body shifts into “fight-or-flight mode.” Your heart rate, blood pressure, and breathing rate dramatically increase. The blood vessels shift blood away from the intestines into the muscles, enabling you to run or fight depending on the situation. This also happens automatically.
- The parasympathetic nervous system is an energy management center. When you are done being in “fight or flight mode,” or are using techniques to end a panic attack or to catch your breath, or calm yourself down. The parasympathetic nervous system helps automatically reduce heart rate and blood pressure. As opposed to “fight or flight,” the parasympathetic nervous system is often described as “rest and digest,” as it signals to send blood back into the gut and digestive system.
So here we have the autonomic nervous system and its components, the sympathetic nervous system and parasympathetic nervous system, that among its duties regulate your heart rate. Please see our article: Can cervical spine instability cause heart palpitations and blood pressure problems?
The c2 vertebra is moving and causing basilar invagination, reducing the size of the opening in the skull (the foramen magnum)
At 9:15 a discussion of loss of natural cervical curve (Cervical Dysfunction) leading to the Chiari malformation
- Dr. Hauser explains that currently a patient is being treated for a 9 mm Chiari malformation. How did this develop? Initially, the patient explored surgery with a specialist but the specialist informed the patient that at best, it is a 50-50 outcome.
- The patient also has basilar invagination.
In our article: Atlantoaxial instability treatment and repair without surgery we discuss the problems of a c2 vertebra is moving and causing basilar invagination and possibly the development of Chiari malformation.
In March 2019, a team of neurosurgeons wrote in the medical journal World Neurosurgery, (5) about cervical instability and osteoarthritis. What they found was the degenerative condition of the cervical spine could result in hypermobility of the atlantoaxial segment (excessive rotation, possible subluxations) and cause overstress in the transverse ligament and the lateral atlantoaxial joints.
The surgeons noted: “These changes explain the pathogenesis of atlantoaxial dislocation and basilar invagination associated with osteoarthritis.”
In other words, the c2 vertebra is moving and causing basilar invagination, (reducing the size of the opening in the skull (the foramen magnum)) where the spinal cord passes into the brain. This excessive motion is caused by an overstressing (wear and tear) degeneration of the transverse ligament. This is causing the symptoms we alluded to earlier including balance issues, vision issues, headache, hearing issues, among others.
In this patient to treat the Chiari and get the structures back to where they belong, we have to relieve the tension on the spinal cord. So how would we do that?
At 10:15, Dr. Hutcheson tells that he saw the patient, she had already had some improvement in her cervical curve just after one Prolotherapy treatment with Dr. Hauser.
In patients with Chiari and syrinx issues, as well as many patients with cervical spine instability, the curvature of the spine is a complex problem.
The curvatures of the neck
Repairing the ligaments and curve for a long-term fix
The goal of our treatment is to repair and strengthen the cervical ligaments and get your head back in alignment with the shoulders in a normal posture.
We will use this video to help you understand the treatment. This video jumps to 1:05 where the actual treatment begins. This video is on cervical spine instability. This patient does not suffer from Chiari malformation.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
- The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based around C1-C2 instability.
In the case history we are exploring in the 47-year-old woman:
- Dextrose prolotherapy was administered in the upper and lower cervical region at the initial visit, and three further treatments were provided 1, 2, and 4 months later (visits 2 – 4).
- Between visits 1 and 3, the patient also attended physical therapy sessions three times a week.
- Digital Motion X-ray (DMX – explained in the video below) was performed between visits 1 and 2. The DMX showed straightening of cervical lordosis and instability throughout the upper and lower cervical spine.
- At visit 2, the patient reported that tingling in the arm had abated and her neck crepitation had noticeably decreased (especially with neck rotation), but there was little change in pain intensity.
- At visit 3, she reported that she no longer had headaches. The pain had become more localized to the left side, particularly on the rapid rotation of the neck.
- At visit 4, the patient reported that pain intensity had decreased significantly, and there was now only an intermittent sensation of pressure in the upper cervical region. Crepitation had resolved completely and she had begun to exercise with a stationary bicycle. The patient expressed satisfaction with her progress (“95% improvement”).
In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine
- In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy.
- A before digital motion x-ray at 0:11
- At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
- At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
- At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
- At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
- At 1:14 the previously completely closed neural foramina are now opening normally during motion
In the patient being described with 9 mm Chiari malformation – Chiropractic exam
What we did in the chiropractic treatment was some specific instrument adjustments to areas of the spine without focusing on where the Chiari at C1 was but we were just improving some of the position of a body. Then we tested applying some weights with a halo where we put weight on the front of her head. This caused a change in her cervical spine curve. It was in full Lordosis. This is a severe case of Chiari, she had suffered from headaches for 8 years. So it was very promising that we saw her curve restored today and we’re working on getting that stable to take some of that pressure and tension off of her spinal cord and help her feel better
By correcting the curve getting the tension off of the spinal cord, the Chiari gets raised helping the C1 malalignment, we stabilize the spine, we can help this patient without surgery. what she’ll do plus she’ll help him with the Curve I do the stabilization and we can redo MRIs we can redo x-rays digital motion x-ray weekend show that while they’re getting treated the pressure inside the brain goes down as long as the patient’s feeling better then you know in the end then they get to keep their anatomy and they got a stable spine to get they got a good curve we’ve corrected the cerebrospinal fluid flow it’s very common.
Summary and contact us. Can we help you? How do I know if I’m a good candidate for treatment?
We hope you found this article informative and it helped answer many of the questions you may have surrounding chiari malformation and chiari decompression surgery. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
1 Goel A. Is atlantoaxial instability the cause of Chiari malformation? Outcome analysis of 65 patients treated by atlantoaxial fixation. Journal of Neurosurgery: Spine. 2015 Feb 1;22(2):116-27. [Google Scholar]
2 Yin YH, Yu XG. Letter to the Editor: Atlantoaxial facet dislocation and Chiari malformation. Journal of Neurosurgery: Spine. 2015 Sep 1;23(3):390-2. [Google Scholar]
3 Goel A. Basilar Invagination: Instability Is the Cause and Stabilization Is the Treatment. Neurospine. 2020 Sep;17(3):585. [Google Scholar]
4 Wagner A, Grassner L, Kögl N, Hartmann S, Thomé C, Wostrack M, Meyer B. Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis. Acta Neurochirurgica. 2020 Jun 6. [Google Scholar]
5 Lasswell TL, Cronin DS, Medley JB, Rasoulinejad P. Incorporating ligament laxity in a finite element model for the upper cervical spine. The Spine Journal. 2017 Jun 30. [Google Scholar]
6 Seaman SC, Streese CD, Manzel K, Kamm J, Menezes AH, Tranel D, Dlouhy BJ. Cognitive and Psychological Functioning in Chiari Malformation Type I Before and After Surgical Decompression-A Prospective Cohort Study. Neurosurgery. 2021 Dec;89(6):1087-96. [Google Scholar]