Why does a Chiari Malformation go Unreported?
For all the severe nature of the conditions I’ve just described, you may be wondering how it is possible for Chiari Malformations to go unreported as often as they do. This is a special type of MRI that looks at the flow of blood from the brain.
The pink arrows are pointing to the Internal Jugular Veins. See how much bigger the one on the right is? This is sometimes considered to be a "normal variant" ... BUT if you have a Chiari Malformation, it means that your body's ability to drain fluid from your brain can be compromised.
As I explain, I’d like you to keep two things in mind. Because my focus in the upper cervical spine and its impact on the central nervous system, I aim to keep up-to-date with advanced research that usually attracts only specialized neurologists. What I’m basically saying is that I don’t blame anyone - and neither should you - for not knowing this stuff. It's simply not within their realm of expertise.
C'mon Aussies. We can do better!
It is my experience in Australia that many standard MRI series do not include all the necessary views to see exactly what is going on. A complete MRI series is taken from three angles: from the side, from the front, and from the top.
However, most MRIs that people bring for me to see are missing the frontal views, which are the best for identifying tonsillar herniations. Adding insult to injury, many brain MRIs stop right at the base of the skull … and main neck MRIs don’t start until the mid-body of the C2 vertebra. In other words, sectional views may end up completely missing the exact area where we could see the Chiari Malformation!
In Australia, we also don’t have access to the best technology for identifying Chiari Malformations, which is a FONAR upright MRI. At the time of writing this article, there are only 2 of these machines in all Australia: one in Melbourne, the other in Sydney. … Sorry Queensland: you’re behind the times!
I can summarise the difference with a standard recumbent (lying down) MRI and a weight-bearing MRI with one word: gravity. When you lie down, there is less axial pressure loading your spine. But when you stand up, the pressure increases dramatically.
As a result, it is possible to identify all kinds of additional things that a standard MRI completely misses. This is the same MRI from the previous article ... and it is a recumbent (lying down) MRI.
If this patient was to have an upright MRI, it is very likely that the Chiari Malformation would appear way bigger! As it relates to Chiari Malformations, the CSF and blood-drainage dynamics are completely different when you lie down versus stand upright.
Moreover, standing actually causes your brain to descend a little more anyway! Remember the illustration with the balloon and the string? What I’m saying is that when you stand up, it is normal to increase the tug on the string. Practically, it means that those undiagnosed Type 0 Chiari Malformations are suddenly abundantly clear! Impossible to miss!
Do you want to know how much of a difference an MRI actually makes? One study involving 1200 MRIs examined the prevalence of Chiari Malformation in the recumbent versus upright position. For people without a history of neck trauma, Chiari Malformations were discovered 5.7% of the time in the recumbent position … but 9.8% in the upright position.
Almost double! Way more alarming, for people with a history of neck trauma (whiplash), Chiari Malformations were discovered 5.3% of the time in the recumbent position … but a shocking 23.3% in the upright position. Almost 4x greater! (3) For this reason, when I see an MRI with a borderline case of a Chiari Malformation (Type 0 < 4mm herniation), I have no hesitation identifying it as the major culprit for the adverse symptoms that the patient is experiencing … and that’s even in the radiology report makes no mention of it.
What are the Treatment Options for a Chiari Malformation?
From the traditional medical viewpoint, Chiari Malformations are congenital (i.e., you are born with it, and there isn’t too much you can do about it). Therefore, the only option to reduce the physical pressure on the brain is surgery: namely a craniotomy of the occipital bone (base of the skull) or a laminectomy of the C1 vertebra. In cases with a CSF flow obstruction, a shunt may also be inserted into the brainstem to reduce the pressure.
When a Chiari Malformation becomes life-threatening, such drastic action may be necessary … but is surgery the only option? Recall that there is an increasing body of science indicating that many cases of Chiari Malformation may be created by whiplash injuries. (9) Previously, I used the metaphor of a string tugging on a balloon to illustrate how a whiplash injury can lead to a Chiari Malformation. Now imagine someone physically squeezing the sides of the balloon.
The Cranio-Dental Connection
I would make the additional case that is the way a skull or jaw injuries that happened 1) when you were still in the womb or 2) when you were growing up (including braces and pulling teeth, which may have narrowed the shape of your head) may cause the same problem.
The sutures between the bones that form your skull are designed to move microscopically. If they fuse prematurely, however, the skull itself may prohibit normal brain development and/or CSF flow. As a result, a person can develop a condition called “Normal Pressure Hydrocephalus,” which may be a precursor to neurodegenerative conditions … or even cause the brain to bulge into the spinal canal in the first place. (4,5)
If either a skull or neck injury is related to the development of a Chiari Malformation, it is possible that specific treatment to address those issues may also help reduce many symptoms associated with it. Remember that 30% of people with confirmed Chiari Malformations > 5mm are completely asymptomatic.
It is very possible that upwards of 5% of the normal population have a Chiari Malformation and don’t even know it! When it comes to addressing the skull element, that is where a cranial chiropractor or osteopath may be able to help.
The purpose of their treatment is to facilitate movement through the cranial sutures, which may allow your skull to “breathe” easier, thereby reducing the intracranial pressure causing the brain herniation. You may also need to see a specialized dentist who works to widen the upper palate (i.e., maxilla) using orthopedic appliances. (Note: The dentistry side of the equation is a massive topic in itself that I will write about at a future date. For now, let it suffice that the normal position of the jaw has a massive impact on the health of your brain.)
The Upper Neck Connection
And last - but certainly not least - is the role that I have in helping people with Chiari Malformations. When it comes to addressing the neck elements, that is where an upper cervical (aka atlas specific) chiropractor may be able to help.
The purpose of my adjustment is the correct the alignment and motion of the top vertebrae in the neck, which are physically tethered onto the spinal cord and may produce that metaphorical “tugging on the balloon.” A research team from the USA is currently demonstrating how a specific, vectored alignment to the upper neck can
1) reduce brain swelling associated with post-concussion syndrome
2) improve the flow of cerebrospinal fluid
3) reverse the amount of plaquing associated with Multiple Sclerosis
4) reduce in the size of Chiari Malformations
Although the research is preliminary, it provides a viable non-surgical option for people with Chiari Malformations … that the potential cause and also solution for their health issues may be in correcting the alignment of the top vertebra in their neck.
The C1 (atlas) vertebra tethers directly onto the brainstem. If it is misaligned, it may create tension that can pull on the brain, exacerbating the effects of a Chiari Malformation. I hope these articles have been valuable if you have been diagnosed with a Chiari Malformation … especially if the problem has been there for a while but no one has identified it before.
It is a serious condition, but certainly not the end of the world. And with the right care, it can make all the right difference in your life. That said, the work that I do is not a direct treatment for a Chiari Malformation. I have worked with dozens of people over the years with known Chiari Malformations (… many where I was the person who first identified them).
Some have had amazing success after getting their atlas adjusted. Other people have had only minimal changes. That is part of the reason why I wanted to be sure to mention the cranial/dental side of the equation in this article too, and why I know that atlas care is of critical importance, but depending on the severity of the condition may not be the only treatment required.
What I do know is this: the proper alignment of the C1 (atlas) vertebra is of paramount importance for the normal health and function of your nervous system and may make a significant difference in helping you if you are healing with health issues stemming from a Chiari Malformation.
- Chiari and Syringomyelia Foundation. What is Chiari Malformation? http://csfinfo.org/education/patient-information/chiari-malformation/. Accessed 5 June 2018.
- Smith FW. Upright magnetic resonance imaging of the craniocervical junction. Smith FW, Dworkin JS (eds): The Craniocervical Syndrome and MRI. Basel, Karger, 2015, pp 33-47.
- Freeman MD, Rosa S, Harshfield D, et al. A case-control study of cerebellar tonsillar ectopia (Chiari) and head/neck trauma (whiplash). Brain Inj. 2010;24(7-8):988-94.
- Flanagan MF. The Downside of Upright Posture. Two Harbors Press, 2010.
- Flanagan MF. The role of the craniocervical junction in craniospinal hydrodynamics and neurodegenerative conditions. Neurology Research International, 2015; Article ID 794829: http://dx.doi.org/10.1155/2015/794829.
- Bradley WG. Cerebrospinal fluid physiology and its role in neurologic disease. Smith FW, Dworkin JS (eds): The Craniocervical Syndrome and MRI. Basel, Karger, 2015, pp 1-8 (DOI:10.1159/000365470).
- Elster AD, Chen MY. Chiari I malformations: a clinical and radiologic reappraisal. Radiology 1992;183:347-353.
- Rosa S, Baird JW. The craniocervical junction: observations regarding the relationship between misalignment, obstruction of cerebrospinal fluid flow, cerebellar tonsillar ectopia, and image-guided correction. Smith FW, Dworkin JS (eds): The Craniocervical Syndrome and MRI. Basel, Karger, 2015, pp 48-66 (DOI:10.1159/000365470).
- Wan MJ, Nomura H, Tator CH. Conversion to symptomatic Chiari I malformation after minor head or neck trauma. Neurosurgery. 2008 Oct;63(4):748-53; discussion 753. doi: 10.1227/01.NEU.0000325498.04975.C0.