The neurosurgical subset of fibromyalgia:  Part III:  Functional and symptomatic outcome at 12 months post-operatively.  .

Michael J. Rosner, Jorge Flechas, Royce K. Bailey

OBJECTIVE:  Test the hypothesis that symptoms and function will be improved at 12 months after surgery when compared to the same measures obtained preoperatively. Methods: 37 patients were selected based upon an abnormal tilt table examination defining cardiovascular/autonomic dysfunction, abnormalities identified from the neurological examination, and supported by radiographic changes at the foramen magnum and or cervical canal.  Patients then underwent decompression of the involved region.  They were followed longitudinally with repeat neurological examinations, questionnaires for grading of symptoms including incremental and visual analog scales of outcome and/or symptomatic improvement.  Systat 7.0 and Excel were used for data analysis (all values X + SD). Results:  Ten measures of pain including joint pain, muscle pain, neck pain, headache, burning legs and others improved dramatically (p = 0.017-0.0000002).               
Dolorimetry is reported separately.  Six cardiovascular symptoms including palpitations, SOB, dizziness, non-cardiac chest pain all improved (p= 0.016-0.000009). Excess fatigue decreased from a severe problem to a mild problem at 12 months (p=1.5E-9) along with three other measures of fatigue (p=0.00059-0.000007). Alimentary symptoms, cognitive complaints, sexual function, depression and others improved in a highly reliable fashion. The number of days/week patients felt “good” increased from 1.0 + 1.5 to 3.9 + 2.3 (p= 1.7E-11) at 12 months; only about 30% of patients were working pre-operatively compared with 80% at one year (p= 0.000015); this was paralleled by a large reduction in “days missed from work”.  There were no surgical deaths, nor serious complications.  No patient worsened neurologically. Conclusion: There is a subset of patients with radiological changes consistent with neurological abnormalities who can undergo posterior fossa and/or cervical decompression with important and long lasting improvement in quality of life as measured by their assessments of pain, multiple somatic symptoms, and the ability to function within the home and workplace.  The risks of surgical decompression should be minimal. Fibromyalgia syndrome should not be used as a diagnosis for those with neurological findings. INTRODUCTION:  The purpose of identifying posterior fossa and/or cervical cord compression is to provide direction in surgical decompression.  Such decompression can be achieved with standard cervical laminectomy and/or forms of posterior fossa craniectomy.  However, the array of symptoms with which those with the diagnosis of FMS complain is often considered ‘non-anatomical’ and probably psychosomatic in origin by most surgeons and they doubt that significant improvement in well being or function can be achieved for most of these individuals.  OVERALL HYPOTHESIS: Symptoms will improve when compared with those of the preoperative state by 12 months after surgery.  Hypothesis statement and testing was of the form:

                H1: μ1 ≠ μ0

                H0: μ1 = μ0

METHODS:  52 patients with the established diagnosis of fibromyalgia and NMH/POTS were prospectively given questionnaires dealing with their symptoms and ability to perform activities of daily living, including their occupation.  The questionnaires were administered preoperatively and at each post-operative visit, typically at 6 weeks, 6 months and 12 months (or longer) after surgery.  The questionnaire asked the patient to grade symptoms as none, mild, moderate or severe.  Other symptoms were graded on a visual analog scale of severity and converted to a 0-100 scale.  Data were entered into Excel and/or Systat 7.0 for statistical analysis.  Because of the sample size, most analyses were done with parametric statistics such as Student’s t-test for matched pairs.  “Not a symptom” was coded as ‘0’; mild symptoms were coded ‘1’; moderate symptoms were coded ‘2’ and severe symptoms were coded as ‘3’.  For double checks and entries splitting lines, answers were coded as 1.5, 2.5, etc. 

Results:  Symptoms (all values X + SC; [median]) 

Pain Outcome Symptom	Pre-Op	12 mo Post	P value
Neck Pain	2.5 + 0.9 [3.0]	1.9 + 0.9 [2.0]	P = 0.00076
Headache	2.5 + 0.8 [3.0]	1.6 + 1.0 [2.0]	P = 0.0000002
Tender skin	1.8 + 1.1 [2.0]	0.8 + 0.8 [1.0]	P = 0.0000017
Burning legs	1.4 + 1.2 [1.0]	0.8 + 1.0 [0.0]	P = 0.017
Keeps awake	2.1 + 1.1 [2.0]	1.2 + 1.1 [1.0]	P = 0.00014
Joint Pain	1.8 + 1.1 [2.0]	1.0 + 1.0 [1.0]	P = 0.00092
Muscle Pain	2.2 + 1.1 [3.0]	1.3 + 1.0 [1.0]	P = 0.0001
Exertional Pain	2.1 + 1.0 [2.0]	1.3 + 1.2 [1.0]	P = 0.00032
Night Pain	2.1 + 1.1 [2.0]	1.2 + 1.1 [1.0]	P = 0.017
Back Pain	2.2 + 1.0 [2.0]	1.5 + 1.0 [2.0]	P = 0.0014
Cardiovascular Symptoms
Palpitations	1.0 + 1.1 [0.0]	0.47 + 0.72 [0.0]	P =0.0051
SOB	1.4 + 1.0 [1.0]	0.67 + 0.82 [0.5]	P =0.00077
Flushing	1.2 + 1.0 [1.0]	0.69 + 0.93 [0.0]	P =0.016
Dizziness	1.8 + 1.0 [2.0]	0.90 + 0.80 [1.0]	P =0.000092
Cold Hands	1.1 + 1.1 [1.0]	0.50 + 0.80 [0.0]	P =0.016
Chest Pain	1.0 + 1.0 [1.0]	0.33 + 0.61 [0.0]	P =0.00036
Alimentary Symptoms
Abdomin cramps	0.9 + 1.0 [1.0]	0.3 + 0.5 [0.0]	P = 0.001
GERD	1.1 + 1.2 [1.0]	0.5 + 0.9 [0.0]	P = 0.015
Dysphagia	1.2 + 1.0 [1.0]	0.6 + 0.8 [0.0]	P = 0.0036
Diarrhea	1.1 + 1.1 [1.0]	0.4 + 0.8 [0.0]	P = 0.0004
Constipation	1.3 + 1.1 [1.0]	1.0 + 1.1 [0.5]	P = 0.07
Nausea	1.3 + 0.9 [1.0]	0.8 + 0.9 [0.0]	P = 0.050
Fatigue Outcome
Excess Fatigue	2.5 + 0.8 [3.0]	1.4 + 1.2 [1.0]	P = 1.5E –9
Awaken tired	2.4 + 0.9 [3.0]	1.5 + 1.1 [1.0]	P = 0.000010
Poor sleep	2.3 + 1.0 [3.0]	1.3 + 1.0 [1.0]	P = 0.0000073
Insomnia	.0 + 1.1 [2.0]	1.2 + 1.0 [1.0]	P = 0.00059
Cognitive Outcome
Concentration	2.0 + 1.1 [2.0]	1.3 + 0.9 [1.0]	P = 0.00073
Reasoning	1.2 + 1.2 [1.0]	0.4 + 0.6 [0.0]	P = 0.00027
Memory	1.8 + 1.1 [2.0]	1.4 + 0.9 [1.0]	P =0.041

 

Symptom	Pre-Op	12 mo Post	P value
Functional Outcome
Days felt good	1.0 + 1.5 [0.0]	3.9 + 2.3 [4.0]	P = 1.7E -11
Working	0.3 + 0.4 [0.0]	0.8 + 0.4 [1.0]	P = 0.000015
Days missed work	3.5 + 2.7 [3.0]	1.8 + 2.1 [1.0]	P = 0.0085
Miscellaneous Symptoms
Anger	1.2 + 1.0 [1.0]	0.8 + 1.0 [0.0]	P = 0.027
Depression	1.7 + 1.0 [2.0]	1.1 + 1.2 [1.0]	P = 0.0075
Nervousness	1.6 + 1.1 [2.0]	1.0 + 1.1 [0.75]	P = 0.00077
Poor libido	1.4 + 1.3 [1.0]	0.9 + 1.1 [0.0]	P = 0.032
Poor orgasm	1.2 + 1.2 [1.0]	0.7 + 1.0 [0.0]	P = 0.039
Irritability	1.7 + 1.0 [2.0]	1.0 + 1.0 [1.0]	P = 0.000196

DISCUSSION: The cardinal symptom of fibromyalgia is pain.  These data suggest that in the patient’s view of himself/herself, pain expressed in numerous fashions and manifestations improves throughout the year after surgery.  Similarly, the cardiovascular symptoms related to NMH/POTS also improve in important and consistent ways.  The relationship of the upper spinal cord and brainstem to cardiovascular symptoms is clear cut, and it is no surprise that gastrointestinal symptoms should also improve: The GI tract is integrated in its activity at the level of the lower brainstem.  Improvement in fatigue and the ability to focus and concentrate probably relate to the reticular activating system, which is prominent at this (medullary) level.  More importantly than any given ‘symptom’ is the concept that the upper cervical spinal cord/medulla is capable of causing dysfunction in multiple vegetative systems which lead to a plethora of somatic complaints. All too often, physicians dismiss these complaints as psychosomatic/non-organic/non-an-atomic and refer the patient for psychiatric evaluation—a dead end for most.  The brainstem and upper cord are the one area of the nervous system where all of these functions coincide, including pain control. The importance of this issue lies in the ability to improve functional outcome.  By one year, about 78-80% of patients had resumed work.  Pre-operatively, only about 30% were still employed and this was often tenuous. This figure is paralleled by improvements in feelings of well-being.

CONCLUSIONS: 
1.  Surgical decompression of the posterior fossa and or cervical spine significantly reduces somatic complaints. 2. The reduction in pain, fatigue and multiple other complaints persists and actually improves through at least the first post-operative year. “Placebo” effect of surgery is highly unlikely.
3.   The reduction in complaints and symptoms leads to important increases in employment and ability to function both within and without the home environment.
4.   The improvement in patients’ symptoms includes a large improvement in autonomic dysfunction such as the array of GI complaints often called ‘Irritable Bowel Syndrome’, bladder function improves as well as the symptoms associated with NMH/POTS.
5.   Brainstem and upper cervical cord involvement should be suspected in the face of multiple dysautonomias with or without somatic complaints of numbness, weakness, ataxia, etc.

National Fibromyalgia Research Association
Neuro and New Treatment Modalities in FM
Symposium—Portland, OR—Oct. 2002