Chiari malformation: Non-surgical alternatives to Chiari decompression surgery

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 the 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 which focuses on cervical spine manual adjusts and well as cervical spine ligament injections. The goal of these 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 assimilation of the atlas, 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 patient 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 histopries), 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 present 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 was 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.”

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 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 strengthen 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 CI Instability can be secondary causes and with return to the normal cervical stability and natural curve can be reversed and alleviated.

“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, 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.

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.

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

At 2:00 Dr. Hauser explains how a syrinx can develop from the Chiari malformation.

At 2:25 A case study:

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?

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

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 a whiplash.

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 a whiplash.

Dr. Hutcheson explains:

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

Autonomic nervous system (ANS) regulation and Heart Rate Variability

There is a difference between Heart Rate and 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.

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

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 relive 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

In our practice we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to "S" shape curve.

In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to the “S” shape curve.

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. In this illustration we see the before an after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights, documented below.

In this illustration, we see the before and after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights.

At the start of this article, we stated that few people contact us describing their problems as one of a loss of spinal curvature. What they do contact us about is the many symptoms they are suffering from including chronic pain and neurological symptoms.

Prolotherapy treatment

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.

In the case history we are exploring in the 47-year-old woman:

In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine


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.


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]

 

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