A Surgical Cure for Fibromyalgia and Chronic Fatigue?
Reaction to an ABC News 20/20 Report
April 2000
An ABC News 20/20 TV segment titled "A Surgical Cure," aired on March 10, 2000, reported on a potentially new approach to treating patients with chronic fatigue syndrome (CFS) and fibromyalgia (FM). This report dealt with the "radical and controversial" suggestion that fatigue-ridden patients with CFS or FM may in fact have a surgically amenable condition affecting the base of the skull and/or cervical spine. This story highlighted the clinical histories of two disabled CFS patients (one of whom is a family practitioner), their newfound diagnoses and subsequent response to neurosurgical decompression of the cervical spine. Dr. Timothy Johnson reported on the unpublished experiences of two neurosurgeons - Drs. Michael Rosner and Dan Heffez - who have found a high percentage of CFS and FM among their patients diagnosed with either the Chiari I malformation or cervical spinal stenosis. They suggested that mechanical compression of the brain stem or cervical spinal cord may account for the symptoms of CFS and FM and that decompression may improve such symptomatology.
This report brings to light a several-year-old hypothesis that some patients with CFS and FM may have symptoms caused by compressive disorders affecting the brain stem or cervical spine. While this news has excited many patients to seek further evaluation from rheumatologists and neurosurgeons alike, it should be noted that a causative association and need for neuroradiologic imaging or surgery is hypothetical and highly speculative. Such an association has been disavowed by the American Association of Neurologic Surgeons (AANS), who have published a position statement that "...there is no scientific evidence that chronic fatigue syndrome is a neurological disorder or that it requires surgical intervention. Therefore, the AANS does not recognize the use of cervical decompression as a treatment alternative for chronic fatigue syndrome". A third neurosurgeon interviewed by 20/20 expressed concern that the surgery might encourage sufferers to rush to unproven treatment and pointed out the lack of a scientific study. There are no published studies currently available that demonstrate an association between CFS or FM and the Chiari syndrome or cervical spinal stenosis. This hypothesis has only been presented at specialty meetings and only in abstract form. A primary fault in the ABC News 20/20 broadcast lies with the suggested overlap in clinical symptoms between CFS or FM (wherein fatigue is a dominant symptom) and the hindbrain or cervical disorders (wherein fatigue is a minor symptom).
The Chiari malformation (also known as the Arnold-Chiari malformation) is a congenital or acquired disorder due to underdevelopment of the posterior fossa and a resultant downward herniation of the cerebellar tonsils through the foramen magnum, with or without herniation and compression of the brain stem. The more common Chiari I malformation is seen in adults and depicts a modest cerebellar herniation with a normal hindbrain. The Chiari I malformation is a common cause of syringomyelia. The rare Chiari II malformation (usually congenital and seen in children with meningomyelocele or spina bifida) describes a more substantial herniation of the cerebellum and medulla oblongata into the spinal canal. The Chiari malformation usually manifests as headache, cervical pain (burning and/or shooting pains in head and neck), Lhermites sign (electric shock-like pain down spine), vertigo, ataxia, sensorineural hearing loss, ocular symptoms (including orbital pain, blurred vision, diplopia), weakness, difficulty picking up objects, and pharyngeal dysphagia. Moreover, a recent review* of 364 Chiari I patients also reported symptoms of chronic fatigue (57.7%), sensory abnormalities (59%), impaired recent memory (39%), and low back pain (23.9%). Lastly, objective neurologic abnormalities of hyperreflexia, Babinski sign and cerebellar, upper motor neuron or myelopathic signs should suggest this entity.
In spinal stenosis, the spinal cord is compressed by surrounding bone. Narrowing of the cervical spinal canal may be congenital or the result of trauma or degenerative disease of the spine. As with the Chiari syndrome, symptoms suggesting myelopathic process should lead to the appropriate investigations and treatment. It should be noted that there are numerous reports in the medical literature of asymptomatic cervical stenosis and that in such patients neurosurgical decompression is only advised when pain as well as objective and appropriate neurologic findings are found.
Internet sites devoted to CFS and FM have generated a great deal of excitement over this report and others. Such sites report anecdotal testimonials in which patients describe improvement (not resolution) in their CFS or FM symptomatology following neurosurgical decompression. The unpublished "successful" results of Dr. Michael Rosner and others can be found at these sites. Despite the promising tone of this ABC News 20/20 report, Dr. Johnson stated that (1) this surgical approach should only be considered in those having abnormal neurologic examinations AND abnormal MRI findings at the base of the skull; and (2) that this surgical approach should be considered experimental.
Rheumatologists who discuss this report with their patients should note the importance of performing a careful neurologic examination (focused on the possibility of a myelopathy) when evaluating patients suspected to have FM or CFS and that only those patients demonstrating symptoms and signs suggesting the Chiari syndrome or cervical spinal stenosis should be further evaluated by a neurologist, neurosurgeon or imaging procedure.
April 13,
2000
John J. Cush, MD, and Robert Spiera, MD
Hotline editors
* Milhorat TH, et al. Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery 44(5):1005-17, 1999.
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