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OBJECTIVE: While patients with fibromyalgia report symptoms consistent with cervical myelopathy, a detailed neurological evaluation is not routine. We sought to determine if patients with fibromyalgia manifest objective neurological signs of cervical myelopathy. METHODS: Two hundred and seventy patients, 18 years and older, who carried the diagnosis of fibromyalgia but who had no previously recognized neurological disease underwent detailed clinical neurological and neuroradiological evaluation for the prevalence of objective evidence of cervical myelopathy and radiological evidence of cerebellar tonsillar herniation (Chiari 1 malformation) or cervical spinal canal stenosis. RESULTS: Patients were primarily women (87%), of mean age 44 years, who had been symptomatic for 8 years (standard deviation, 6.3 years). The predominant complaints were neck/back pain (95%), fatigue (95%), exertional fatigue (96%), cognitive impairment (92%), instability of gait (85%), grip weakness (83%), paresthesiae (80%), dizziness (71%) and numbness (69%). Eighty-eight percent of patients reported worsening symptoms with neck extension. The neurological examination was consistent with cervical myelopathy: Upper thoracic spinothalamic sensory level (83%), hyperreflexia (64%), inversion of the radial periosteal reflex (57%), positive Romberg sign (28%), ankle clonus (25%), positive Hoffman sign (26%), impaired tandem walk (23%), dysmetria (15%) and dysdiadochokinesia (13%). MRI and contrast-enhanced CT imaging of the cervical spine revealed stenosis. The mean anteroposterior (AP) spinal canal diameter at C2/3, C3/4, C4/5, C5/6, C6/7 and C7/T1 was 13.5 mm, 11.8 mm, 11.5 mm, 10.4 mm, 11.3 mm and 14.5 mm respectively, (CT images). In 46% of patients, the AP spinal diameter at C5/6 measured 10 mm, or less, with the neck positioned in mild extension, i.e., clinically significant spinal canal stenosis. MRI of the brain revealed tonsillar ectopia >5mm in 20% of patients (mean=7.1±1.8 mm), i.e., Chiari 1 malformation. CONCLUSION: Our findings indicate that some patients who carry the diagnosis of fibromyalgia have both signs and symptoms consistent with cervical myelopathy, most likely resulting from spinal cord compression. We recommend detailed neurological evaluation of patients with fibromyalgia in order to exclude cervical myelopathy, a potentially treatable condition. OBJECTIVE: Abnormalities of central sensory processing may play a role in the pathogenesis of chronic pain. The Chiari I malformation is a congenital hindbrain anomaly characterized by protrusion of the cerebellar tonsils into the upper cervical canal, with variable effects on the lower brain stem and cervical cord. The purpose of this study was to compare sensory function and pain among patients with chronic pain who had these disorders incidentally diagnosed, to assess the effect on pain in these patients in comparison with those without central nervous system disease. DESIGN: Retrospective study in which pain, mood, and sensory function in 32 patients with chronic pain who had mild Chiari I malformation were compared with that in 53 patients with chronic pain who had moderate to severe compression of the cervical spinal cord and 52 patients with chronic pain who had no apparent central nervous system disorder. Data had been collected previously as part of standard clinical assessments, including clinical neurological examinations, quantitative sensory testing, pain drawings and psychometric testing with the Symptom Checklist 90. PATIENTS: All subjects were patients of a hospital-based pain management practice who had been accepted for treatment over a 5-year period. RESULTS: Both the Chiari I and cervical compression groups had long tract signs evident on clinical neurological examination. Quantitative sensory testing indicated elevations in the trigeminal territory among patients with Chiari I malformation and on the neck, hands, and feet in both the Chiari I and cervical compression groups. The extent of pain and mood disturbance was greatest in the Chiari I group and least in the group with no central nervous system disorder. Complex regional pain syndrome, fibromyalgia, and temporal mandibular joint disorder were more common among the Chiari I malformation group than among the other groups. CONCLUSIONS: Quantitative sensory analysis indicates sensory dysfunction associated with Chiari I malformation and cervical cord compression. The pattern of sensory abnormality is consistent with medullary dysfunction among the patients with Chiari I malformation and cervical cord dysfunction among cord compression patients. There were differences in the types and extent of pain and the associated disorders of mood observed among the cohorts defined above. These differences may be partly due to the presence and location of central sensory dysfunction.
INTRODUCTION: Individuals with FM have classically been described as having a completely normal physical examination except for the finding of tenderness. However, most studies of FM have been performed by rheumatologists, who may not always perform a detailed neurological evaluation as part of the physical exam. The purpose of this study was to do such an examination in both FM pts. and controls, to determine whether FM pts. exhibited abnormalities in physical exam, as well as to determine whether abnormalities were related to MRI findings in the cervical region. METHODS: Before beginning the study, three physicians from two different study sites were trained in the performance of a thorough neurological evaluation by a neurosurgeon. The examination took approximately 40 minutes to complete, and included comprehensive sensory, motor, cranial nerve, spinal and reflex evaluations. The results of these examinations were then summarized by a single observer, blinded to subject group, as being normal, mildly abnormal or markedly abnormal. RESULTS: 39 FM subjects and 20 controls had this evaluation performed. The FM subjects demonstrated significantly more abnormalities on many portions of the neurological exam, especially in motor (53% abnl. vs. 0 of controls), reflexes (31% abnl. vs. 10% of controls), gait (33% abnl. vs. 15% of controls) and sensory (23% abnl. vs. 5% controls) components. There was no relationship between MRI findings and physical examination findings in either group. CONCLUSIONS: FM patients often have abnormal neurological examinations. Such findings could have several explanations including: 1) structural or compressive lesions, 2) the effects of pain on motor performance and balance, 3) hyperreflexia secondary to hypervigilance, or 4) hyperalgesia/allodynia. Further studies will be necessary to determine the precise mechanism(s), and the appropriate diagnostic paradigms for individuals with symptoms of FM and an abnormal neurological examination. DISCLOSURE: This study was supported by the National Fibromyalgia Research Association.
Fibromyalgia is a syndrome characterized by diffuse chronic pain. The American College of Rheumatology has established diagnostic criteria, which have been helpful in distinguishing fibromyalgia from other chronic pain states but have not advanced the understanding of its etiology. The worldwide prevalence of fibromyalgia is estimated to be 2%. An estimated six million Americans are affected. In addition to the widespread pain, patients complain of a variety of symptoms, including overwhelming fatigue exacerbated by exertion, headache, dizziness, cognitive difficulties, instability of gait, limb numbness and paresthesiae. Some physicians have come to view the syndrome as a somatization disorder because of these numerous and apparently unrelated complaints and because fibromyalgia fails to fit the biomedical cause-effect model. Many of the symptoms reported by fibromyalgia patients are identical to those reported by patients diagnosed with either Chiari 1 malformation or with cervical myelopathy due to spinal stenosis, (spondylotic cervical myelopathy), two well-defined neurological disorders. Therefore, we evaluated a cohort of patients who carried the diagnosis of fibromyalgia for objective evidence of cervical myelopathy. Two hundred and seventy (270) consecutive patients who carried the diagnosis of fibromyalgia were evaluated between September 1998 and May 2001. The sole requirement for referral was that the patient carry the diagnosis of fibromyalgia. On initial evaluation, patients completed a questionnaire detailing their symptoms, current medications and past medical consultations. A diagram depicting the distribution of the patient’s body pain and an analogue pain severity scale were completed. In order to insure that every patient was assessed in the same manner, they were evaluated by a neurologist and/or a neurosurgeon who, independent of each other, performed a neurological examination and recorded the findings on a standardized form. All data including the results of the examinations were entered into a relational database. Every patient underwent magnetic resonance imaging of the brain with special attention to the foramen magnum in order to exclude a Chiari 1 malformation. For the purpose of determining the position of the cerebellar tonsils the lower lip of the foramen magnum was defined as extending from the lowest cortical bone of the clivus anteriorly (basion) to the lowest cortical bone at the position posteriorly on themed sagittal MRI image. The position of the most caudal point of the tonsil(s) relative to the inferior lip of the foramen magnum was measured from the midsagittal MRI slice. MRI scan of the cervical spine was performed in order to identify any intrinsic spinal cord lesion capable of causing myelopathy. Every patient also underwent computed tomographic (CT) imaging of the cervical spine following the intravenous infusion of 150 ml of non-ionic contrast (300 mg of iodine/ml). The CT scan was performed with the patient’s neck in the neutral and then in the extended position. The gantry anangle was altered to obtain images perpendicular to the spine at each level. The mid-sagittal anterior-posterior (AP) dimension of the spinal canal was determined at the level of the intervertebral disc space on both neutral CT and MRI images and on CT images with the neck extended. MRI and CT images were individually scanned into a Pentium III personal computer using a Umax Power Look III scanner. One of two independent observers, unrelated to the medical evaluation or treatment of the patients, made measurements of the position of the cerebellar tonsils and the mid-sagittal AP spinal canal diameters using SigmaScan Pro software, version 5.0. Eighty-six percent of the patients were women. Ninety-seven percent were Caucasian. The mean age was 44 years (SD=11 years). The mean duration of symptoms was 8 years (std dev 67.3 yrs). Fifty-nine percent of patients reported antecedent craniospinal trauma within 3-6 months of the onset of symptoms. On average, the patients had consulted 10 different medical specialists during the course of their illness. Patients were taking a mean of 4.8 medications, (including but not limited to opiate and non-opiate analgesics, benzodiazepines, antidepressants, sedative hypnotics and muscle relaxants), for the relief of symptoms related to fibromyalgia. Forty-one percent of patients had at least a college education. Sixty-eight percent of patients had left their job as a direct result of their illness. The predominant complaints were neck/back pain (95%), fatigue (95%), exertional fatigue (96%), cognitive impairment (92%), instability of gait (85%), subjective grip weakness (83%), paresthesiae (80%), dizziness (71%) and numbness of the hands/feet (69%). Eighty-eight percent of patients reported worsening symptoms with neck extension. The findings of neurological examination were diagnostic of cervical myelopathy. An upper thoracic spinothalamic sensory level (T3-T6) was noted in 83% of patients: Typically, we detected hyperalgesia and allodynia to a cold or lightly applied pinprick stimulus below a dermatome level. Rarely, a suspended band of hypesthesia to cold or pinprick stimulus was detected between the third and seventh thoracic dermatomes. The second most common neurological finding, (noted in 64%of patients), was hyper-reflexia. Recruitment, (the pathological spread of reflexes beyond the muscle being tested), including inversion of the radial periosteal reflex was observed in 357% of patients. Other objective neurological findings included positive Romberg sign (29%), varying degrees of ankle clonus (25%), positive Hoffman signs (26%), impaired tandem walk (23%), dysmetria 915%) and disdiadochokinesia (13%). The patients were examined first with the neck in the neutral and subsequently in the flexed and then in the extended positions. Neck extension and neck flexion resulted in immediate accentuation of the abnormal pyramidal track findings in 88% and 73% of patients respectively, suggesting a mechanical etiology for the abnormal neurological findings. The MRI images of the brain did not show any consistent intrinsic disease of the brain, parenchyma. The only consistent finding was the caudal displacement of the cerebellar tonsils. The mean position of the cerebellar tonsils as measured on the mid sagittal MFI image was 1.1 mm (SD=4.4mm) below the rim of the foramen magnum. In 38% of patients the tonsillar herniation exceeded 3mm, (mean 5.6, SD=2.1 mm). In 20% of patients tonsillar ectopia exceeded 5 mm (mean=7.1, SD=1.8mm). MRI and contrast enhanced CT imaging of the cervical spine revealed a narrow canal. I.e. stenosis. The mean AP spinal canal diameter at C2/3, C3/4, C4/5, C5/6, C6/7 and C7T1 was 13.2, 11.7, 11.8, 10.7, 11.5 and 14.9 mm respectively, (CT images). In 23% of patients, the AP mid-sagittal spinal canal diameter was 10mm or less at the C5/6 intervertebral disc space measured 10mm or less in 46% of patients when the neck was positioned in extension, (CT images). MR imaging of the cervical spine did not reveal any consistent intrinsic spinal cord disease with the exception of signal hyper-intensity at the level of spondylotic spinal cord compression noted on the T2 sequence images in some patients. Symptoms of myelopathy are variable and can be quite vague, often leading to initial misdiagnosis. We have identified neurological findings diagnostic of cervical myelopathy in a selected cohort of 270 patients previously diagnosed with fibromyalgia. An upper thoracic sensory level has been described as a false localizing sign of cervical myelopathy. Recruitment of deep tendon reflexes is an upper motor neuron sign of pyramidal tract dysfunction. Inversion of the radial periosteal reflex is felt to be virtually diagnostic of myelopathy due to extrinsic compression of the spinal cord at the level of the fifth or sixth cervical vertebra. Neuroradiological findings were consistent with a treatable structural cause(s) for the myelopathy –i.e. spondylotic cervical stenosis and/or Chiari type 1 malformation. In 20% of our patients a radiological diagnosis of the Chiari 1 malformation could be made based on tonsillar ectopia in excess of 5mm. Meadows et al (J Neurosurgery 2000; 96:920-926), reviewed the brain and cervical spine MRI’s of 22,591 patients and could identify only 175 patients in whom tonsillar ectopia exceeded 5 mm, i.e. a prevalence of .77%. The CT scan of the cervical spine revealed cervical stenosis, which was accentuated by neck extension. Neck extension is known to reduce the AP spinal canal diameter. The stenosis in myelopathic patients has been described by Muhle et al, (Acta Radiologica 1999; 40:146-153), and Graham et al, (Clinical Radiology 2001; 50:35-39). The AP mid-saggital diameter at the C5/6 intervertebral disc space measured 10mm or less in 46% of patients with the neck placed in extension. A mid-sagittal diameter of 10mm is acknowledged as stenotic and consistent with symptomatic spinal cord compression, i.e. cervical myelopathy. Spondylotic cervical myelopathy and the Chiari 1 malformation are treatable conditions. Therefore, we recommend that a detailed neurologic examination should be incorporated into the evaluation of all patients with fibromyalgia. Evidence of cervical myelopathy would warrant neuroradiological examination of the brain and cervical spine and appropriate neurological referral.
INTRODUCTION: Cervical myelopathy and fibromyalgia have a number of symptoms in common. It has been suggested that fibromyalgia may be incorrectly diagnosed in some patients who actually have cervical myelopathy or perhaps that cervical spinal cord dysfunction is the underlying cause of the fibromyalgia syndrome. In order to examine the possible relationship between cervical myelopathy and fibromyalgia, we undertook a prospective nonrandomized, case control outcome study of operative versus non-operative treatment of cervical myelopathy in patients who had previously been diagnosed with fibromyalgia. METHODS: Patients carrying the diagnosis of fibromyalgia were referred for neurological evaluation in order to exclude the possibility of myelopathy. Patients underwent a highly structured evaluation, which included a neurological examination by a neurologist and a neurosurgeon, a psychological interview and detailed neuroradiological imaging of the brain and cervical spine. The radiological evaluation included MRI of the cervical spine, MRI of the brain with the axial cuts through the plane of the foramen magnum and dynamic contrast enhanced CT of the cervical spine. Patients also completed an HADS and a SF-36 outcome questionnaire. All data was gathered prospectively and entered into a relational database. Patients were followed up every 3 months using a uniform mail-in questionnaire regardless of treatment prescribed. Cervical myelopathy was diagnosed in the face of symptoms consistent with myelopathy and in the presence of neurological signs indicative of cervical spinal cord dysfunction. Both symptoms and signs of myelopathy were required for inclusion in the outcome study. Cervical stenosis was diagnosed if the anteroposterior (AP) mid-sagittal spinal canal diameter measured 10 mm or less at 1 or more levels as determined from MRI or dynamic CT imaging of the cervical spine. Chiari 1 malformation was diagnosed if tonsillar herniation equaled or exceeded 5 mm as measured on the mid-sagittal MRI image. Surgical candidates met the following criteria: 1) the neruorlogical examination was abnormal and localized to the cervical spine or cervicomedullary junction, 2) the neuroradiological findings were consistent with compression of the cervical spinal cord or caudal brain stem and 3) non-operative measures, if appropriate, had failed over 3-6 months. Non-operative treatment consisted of analgesics, use of a cervical collar and posture and body mechanics training. Non-operative therapy was offered as primary treatment if the patient was unwilling to undergo surgery or if the radiological findings suggested that external cervical immobilization might be effective in minimizing spinal cord compression. RESULTS: There were 64 patients in the surgical group and 44 patients in the non-surgical group. While the patients were not randomized to the treatment arms, the 2 groups were virtually identical with regards to sex ratio, mean age, mean duration of illness, history of craniospinal trauma, level of education and work history The prevalence of those symptoms commonly associated with both cervical myelopathy and fibromyalgia, including pain, headache, numbness, tingling, instability of gait, dizziness and grip weakness was identical in the 2 groups of patients. The prevalence of those symptoms commonly associated with fibromyalgia but not with cervical myelopathy, such as fatigue, cognitive difficulties, irritable bowel syndrome, insomnia and depression did not differ between the 2 groups. The findings on neurological examination did not differ between the 2 groups. The most prevalent findings were high thoracic spinothalamic sensory level to a cold or pinprick stimulus, hyper-reflexia, recruitment of reflexes, Hoffman sign, ankle clonus and absent gag reflex. In both surgical and non-surgical patients, the pyramidal tract findings became more pathological when the patient was examined with the neck positioned in flexion or extension. There was no difference between the 2 groups in their initial responses to the SF36 quality of life questionnaire, nor in their level of anxiety or depression (HADS questionnaire). The mid-sagittal AP spinal canal diameter in both the surgical and non-surgical patients was distinctly smaller than that reported in the literature for normal men and women using similar imaging techniques. In both the surgical and non-surgical groups, 23% of patients had a mid-sagittal spinal canal diameter 10 mm or less at the C5/6 disc space as measured on CT or MRI images. With the neck positioned in extension, 46% of surgical and non-surgical patients were found to have mid-sagittal AP spinal canal diameter 10 mm or less at the C5/6 disc space as measured on CT images. Forty percent of patients in the surgical group had 3 mm or more of tonsillar ectopia (mean 5.6 mm) while 27% of the patients in the non-surgical group had a similar finding (mean 4.0 mm) as measured in the traditional manner on the mid-sagittal T1 weighted MRI image. No single structural cause for myelopathy was identified and therefore no single procedure was performed. The surgical treatment of myelopathy included suboccipital decompression, anterior cervical discectomy and fusion or cervical laminectomy with or without instrumented fusion as indicated by the neuroradiological findings. While we diagnosed and treated myelopathy, we monitored all symptoms. At the six month follow-up, there was a statistically significant improvement in the surgical group as compared to the non-surgical group regarding patient reported dizziness, limb numbness, pain, impaired balance and grip weakness (p=0.04 – p=0.000, Chi squared analysis). Improvement was noted in a number of symptoms associated with fibromyalgia and not usually associated with cervical myelopathy such as irritable bowel syndrome (p=0.003) and impaired memory (p=0.0007), impaired concentration (p=0.03) and disorientation (p=0.002). Headache improved in 90% of the surgical group and 45% of the non-surgical group (p=0.06). Patients in the surgical group were more likely to report an improvement in fatigue, depression, insomnia, limb paresthesiae, clumsiness and cold intolerance than were patients in the non-surgical group but the differences were not statistically significant. There was an improvement in all 9 subscales of the SF36 in the surgical as compared with the non-surgical group, (p=0.037 – p<0.0001, Wilcoxon rank sum test and Fisher’s exact test). Surgical treatment of cervical myelopathy associated with spondylotic cervical stenosis and/or the Chiari 1 malformation may result in the improvement of a vast array of symptoms usually attributed to fibromyalgia, with an associated improvement in patient quality of life. Despite non-randomization, the surgical and non-surgical patients were virtually identical in all measured parameters at the time of initial evaluation. However, as the patients were not randomized, the observed difference in outcome cannot be definitively or exclusively attributed to surgery. Nevertheless, our outcomes implicate a potential association between cervical myelopathy and fibromyalgia in some patients.
PART I: CLINICAL FINDINGS WITH NEURALLY MEDIATED HYPOTENSION. Fibromyalgia is a syndrome characterized by low pain thresholds, but which may occasionally be a manifestation of surgically treatable disease. The hallmark of this subset of patients will be objective neurological abnormality. OBJECTIVE: To define neurological abnormalities in patients who may be candidates for surgical decompression, to document symptomatic outcome at one-year after surgery (part II) and to document radiological differences between control and this subset of FMS patients (part III). METHODS: 37 patients underwent protocol neurological and tilt table examinations that included a detailed neurological history/review of system and assessment of cranial nerve, motor, sensory, extrapyramidal and reflex evaluations. Each underwent a tilt table examination to objectively assess at least the cardiovascular component of the autonomic nervous system to restrict this subset to those with objectively defined organic disease. RESULTS: Patients had been symptomatic for > 10 years and on disability for an average of 4.9 years. Cranial nerve deficits: 14/37 demonstrated unilateral or bilateral Horner’s syndrome. 21/37 had CN V abnormalities including absent corneal reflexes. 7/17 demonstrated CN VII abnormalities (not including dry eyes, dry mouth, or hyperacusis) and 17/37 had abnormalities of hearing (not including tinnitus). 20/37 had CN IX, X, XI abnormalities, most commonly absent gag reflex and oropharyngeal sensory changes. Abnormalities of convergence, nystagmus, head tilt, skew deviation, esophoria and tongue weakness were common. Upper extremity motor deficits were identified in 36/37 and 35/37 in the lower extremities. Hyper-, hypotonia and atrophy were frequent. 32/37 had abnormalities to pin, touch, vibration or temperature sensation. 24/37 demonstrated hyperreflexia, and 17/37 demonstrated hyporeflexia. 34/37 had abnormalities of gait, 27/37 a positive Romberg’s sign and Babinski’s and Hoffman’s sign were present in 18 and 8 of the 37 respectively. CONCLUSION: Neurological deficits can be identified in those patients with fibromyalgia syndrome and a positive tilt table examination. These deficits localize to the brainstem and upper cervical spinal cord and when identified should lead to a detailed radiological evaluation of these regions. INTRODUCTION: Fibromyalgia is a syndrome characterized by complaints of pain 2, and increasingly recognized as accompanied by neurological complaints of numbness, weakness, ataxia, dysphagia, tinnitus, visual changes and multiple dysautonomias. Particularly prominent amongst the latter are cardiovascular symptoms such as orthostasis, dizziness, palpitations, non-cardiac chest pain, Raynaud’s phenomena, and others. In order to establish a patient population with an objective characteristic which could not be mistaken for hysteria, malingering, depression or other psychosomatic manifestation, the study was limited to those with a positive tilt table test for neurally mediated hypotension (NMH), positional orthostatic tachycardia syndrome (POTS) or both. OBJECTIVE: To examine the occurrence of neurological deficit amongst individuals who had been previously diagnosed with FMS in the subset of tilt table proven dysautonomias. METHODS: Fifty-two patients with the diagnosis of fibromyalgia and referred for the possibility of surgical intervention underwent protocol neurological examinations (part 1), a protocol MR scan evaluation of the craniocervical region (part 2), questionnaires listing symptoms which the patient graded in severity (part 3), and dolorimetery (part 4). Cranial nerves and brainstem functions: Each nerve was assessed for normal versus impaired function. Additional observations included the presence or absence of Horner’s syndrome, convergence deficits and nystagmus. Hyperacusis, dry eyes, and dry mouth were not recorded as VII nerve abnormalities. Motor function was graded using the MRC scale of 0-5 for each major group of the upper and lower extremities. Data were summarized as showing normal or abnormal strength for the upper and lower extremities separately. Grip strength was measured as the average of each of three trials on a hand dynamometer. Sensory function included pinprick, light touch in each dermatome; temperature sensation (cool) and vibration for multiple points in each extremity. Data were recorded as normal or abnormal. Gait was assessed in terms of a standard walk, heel walking, tip-toe walking, and tandem gait. Data were summarized as normal or abnormal. Romberg’s test was recorded as “0” for normal, 1+ for a slight sway, 2+ for consistent sway, 3+ for severe unsteadiness which did not lead to a fall, and 4+ for those who fell or had to be caught. Reflexes were graded 0-4 with “2” being normal. Hyporeflexia and hyper-reflexia were summarized separately. Analysis was through Systat 7.0 and/or Microsoft Excel 2002.
RESULTS:
Usually fine or rotatory, more prominent in extension Often asymmetric left eye usually worse Uni- or bilateral Often intraoral Most apparent with testing of orbicularis oculi Usually included uni- or bilaterally absent gag reflex
Most often iliopsoas, usually bilateral
Deep tendon reflexes:
In patients with the dysautonomias, NMH/POTS and who have been classified as fibromyalgia syndrome, neurological abnormalities are common and localize to the brainstem and upper cervical spinal cord. These abnormalities are frequently subtle, and require significant time and experience to define. However, they point directly to a coherent anatomical focus, which can explain many of the symptoms of “fibromyalgia” and encourage the search for correctible lesions. The brainstem not only is adequate explanation for symptoms such as dysphagia, dysphonia, difficulty with balance and other, but it also harbors the centers for cardiovascular control, gastrointestinal control, respirations and the reticular activating system (see part 3 & 4). The latter is particularly important with regard to sleep, arousal, attention and the subsequent incorporation of memory. The lower medulla also is the source of origin for descending nociceptive control fibers, which originate in the nucleus raphe magnus and paragigantocellularis 1. Fibromyalgia is not an explanation for neurological deficit, no matter how subtle it may be. Neurological abnormalities should invoke a search for treatable lesions: That search should focus on the upper spinal cord and brainstem based upon the observations presented here.
CONCLUSIONS: Reference List
INTRODUCTION: Clinical observations suggest the upper spinal cord and brainstem may be involved in a subset of patients with FM like symptoms. OBJECTIVE: Test the hypothesis that there will be radiological differences related to the posterior fossa and/or cervical canal between control and the surgical subset of FMS patients. METHODS: 37 patients carrying the diagnosis of ‘fibromyalgia’ were selected based upon an abnormal tilt table examination defining cardiovascular/autonomic dysfunction (NMH/POTS) and abnor malities identified from the neurological examination. Protocol magnetic resonance (MR) scans of the craniocervical junction region were accomplished for each patient in sagittal, coronal and transaxial planes; cerebrospinal fluid (CSF) flow via phase contrast MR was assessed. Specific grading of tonsillar descent (midline and paramedian), obex height, tonsillar impaction within the foramen magnum, vertebral artery invagination of the brainstem, and AP diameter of the foramen magnum was carried out. The spinal cord and canal diameters were measured at each disk level with electronic calipers. These results were compared with those of asymptomatic control patients. Systat 7.0 and Excel were used for data analysis; all values X + SD.
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