Michael J Rosner, MD, FACS, FCCM

After observing two patients with cervical stenosis whose “chronic fatigue syndrome” improved after surgery, we prospectively evaluated 48 patients diagnosed with chronic fatigue or fibromyalgia syndrome.

We tested the hypotheses that the spinal canal would be stenotic in patients with chronic fatigue and fibromyalgia syndromes, and that decompression of craniovertebral stenosis would lead to improvement in symptomatology and objective neurologic findings.

A detailed neurological history and examination were performed on all patients pre- and post operatively. In addition, those patients undergoing surgery were asked to complete a questionnaire with regard to symptomatology at two time points after surgery. Magnetic resonance scans were obtained on patients with a standardized protocol which allowed quantification of the AP diameter of the spinal canal, and AP and transverse spinal cord diameters at C1 through C7 levels. The AP compression ratio and spinal cord area were calculated for each patient. The foramen magnum was also studied and in selected patients a Cine-MR scan was used to help evaluate a small posterior fossa or Chiari syndrome. The level of the obex above the plane of the foremen magnum was measured.

For those patients with purely congenital cervical stenosis, a laminectomy was carried out based upon those levels which were in the stenotic range. If the cerebellar tonsils or foramen magnum were “tight” or abnormalities of CSF outflow from the posterior fossa were identified, the patient underwent suboccipital craniectomy with laminectomy of C1 and C2, usually with duraplasty. If both conditions were present the patient underwent simultaneous posterior fossa and cervical decompression. If purely anterior spinal cord compression was present then the patient was treated with anterior cervical decompression and fusion.

All patients had positive findings on neurologic history suggestive of myelopathy. Most patients were hyperreflexic and most demonstrated Babinski and other upper motor neuron findings. Seventy to 75% of this group had sensory and/or motor findings in the upper and lower extremities, abnormalities of gait, and other objective changes. The average spinal canal AP diameter in the mid-cervical region was less than 12mm from C3 through C6 and the average spinal cord size was below the lower limits of normal. Decompression of the cervical spinal canal lead to a statistically reliable increase in the AP diameter, AP compression ratio and spinal cord areas. Neurologic symptoms and signs reverted to normal or nearly normal in 60 to 65% of the patients with nearly all the remainder demonstrating improvement of some degree in sensory, motor, reflex, or extrapyramidal abnormalities. Two patients felt that some of their sensory symptoms had worsened. One felt weaker in the upper extremities and one felt their bladder had worsened. Four patients felt they had not changed in their neurologic symptoms.

By 24 + 2.7 weeks after surgery, 80% of the patients felt improved in most of a list of 18 symptoms. Fifteen to 20% felt that they were unchanged with fewer than 10% feeling that they had worsened in some symptoms.  By 78 +  26 weeks after surgery, the questionnaire was repeated with more detail. Approximately 10 to 15% reported they were worse in some types of symptomatology; 10 to 20% felt they were unchanged in some of their symptoms with the remainder reporting some degree of improvement. More than half felt 50% or more improved after surgery. Nearly all patients improved in some spheres.

There is a subset of patients with the diagnosis of chronic fatigue-immunodeficiency syndrome or fibromyalgia syndrome who suffer from some element of craniovertebral compression. This is primarily congenital in nature and appears relatively normal unless more highly quantified analysis of the spinal canal and posterior fossa are carried out. Detailed neurological history and physical findings in this group of patients are consistent with a chronic myelopathy. The majority of the signs and symptoms can be reversed in these patients with craniocervical decompression.

This study does not provide insight into how many patients with ID-CFS or FMS may actually suffer from craniovertebral radiological compression. The problem is potentiated by the relative lack of quantification of craniovertebral radiological evaluation.