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Craniocervical Decompression, Cerebral Blood Flow and Neuropsychological Dysfunction in FMS and CFS

 Michael J. Rosner, M.D., F.A.C.S., F.C.C.M., Sharon E. Guin, C.R.N.P.,
Alice Johnson, R.N and Sheila D. Rosner, B.S.N., M.S.N.

Acknowledgements
The authors gratefully acknowledge Drs. J. M. Mountz and E. San Pedro of the Division of Nuclear Medicine at the University of Alabama at Birmingham for SPECT scan data.

Introduction: Because others have reported that rCBF measured by SPECT scan was abnormal in patients with fibromyalgia syndrome, the hypothesis was tested that rCBF as measured by SPECT scan would improve after craniovertebral surgery in similar patients.

Methods: Sixteen patients underwent pre-operative rCBF SPECT scan who had been offered decompressive craniovertebral surgery for Chiari syndrome, congenital cervical stenosis, or both.  Detailed neurologic history and physical examination were recorded in a prospective standardized interview and examination.  Pre-operative grip strength was measured and the spinal cord was measured in its AP and transverse diameters.  After surgery, the interviews, standardized exams, grip strength, the spinal cord measurements, and the rCBF SPECT scan were repeated.  A parallel group of patients later were given a more detailed questionnaire pre- and post-operatively which included a number of questions related to neuropsychological complaints.  These were graded by the patients for severity using a 0-3 scale where 0 = no problem and 3 was severe, or a visual analog scale of 0-100 where 100 represented the worst imaginable degree of severity.  A group of well controls completed the same instrument.

Results: Generalized bi-hemispheric increases in rCBF SPECT measures of blood flow occurred in a statistically reliable fashion.  Generalized blood flow increases averaged 3 to 4 percent for global cortical measures.  The left frontal lobe increased by approximately 10 percent and the right occipital and parietal regions by 4 and 12 percent respectively (p<.05--.001).

The neurologic complaints and exams of this group generally improved with reduction in hyperreflexia, Babinski responses, improvement in strength, etc.  Grip strength improved from 23.2 ± 5.9 Kg. to 30.3 ± 11.4 Kg. (p = .03).  In those patients undergoing cervical decompression (n = 8), spinal cord area increased by as much as 40 percent (p < .001).

Complaint	Pre-Op (n=36)			Post-Op (n=20)			Control (n=6)
Neuropsychological
	Mean	SD	Median	Mean	SD	Median	Mean	SD	Median
Memory	1.5	(1.1)	[2]	0.5	(0.8)	[0]	0.0	(0.0)	[0]
Concentration	1.8	(1.4)	[2]	0.7	(0.8)	[0]	0.0	(0.0)	[0]
Abnl logic	0.9	(1.0)	[1]	0.3	(0.6)	[0]	0.2	(0.4)	[0]
Anxiety	1.2	(1.1)	[1]	0.5	(0.8)	[0]	0.2	(0.4)	[0]
Depression	1.4	(1.1)	[1.5]	1.1	(1.0)	[1]	0.5	(0.8)	[0]
Irritability	1.6	(1.0)	[2]	1.0	(1.0)	[1]	0.7	(0.8)	[0.5]
Abnl Fatigue	1.9	(1.1)	[2]	1.4	(1.1)	[1]	0.2	(0.4)	[0]
Sleep
Insomnia	1.9	(1.2)	[2]	1.2	(1.2)	[1]	0.3	(0.5)	[0]
Poor sleep	2.2	(1.0)	[3]	1.4	(1.2)	[1]	0.3	(0.5)	[0]
Awaken tired	2.2	(0.9)	[3]	1.4	(1.1)	[1]	1.0	(0.6)	[1]
Pain awakens	1.9	(1.1)	[2]	1.3	(1.2)	[1]	0.0	(0.0)	[0]
Visual Analog Scales
Feel Rested	71	(35)	[90]	42	(34)	[32]	32	(16)	[36]
Awaken Tired	74	(34)	[90]	49	(38)	[43]	10	(17)	[17]
Nervous	44	(31)	[49]	19	(23)	[49]	5	(9)	[9]
Depressed	44	(35)	[37]	22	(28)	[7]	4	(10)	[6]

There is substantial improvement in Neuropsychological/neurocognitive complaints after surgery, which parallels the improvements seen in a separate but otherwise similar population of FMS/CFS patients.

Conclusion: Abnormalities of rCBF are present in a group of FMS/CFS patients and provide an objective, physiological basis for complaints of decreased cognition, and related “neuropsychological” complaints.  rCBF abnormalities may resolve with craniovertebral decompression in parallel with neuropsychological improvement; these data strengthen the concept of a physiological basis in the majority of patients for such complaints.  Since rCBF studies provide objective evidence for such complaints, they may help guide the need for adjunctive therapy when rCBF abnormalities resolve but complaints persist.  However, persistence of such abnormalities may suggest persist structural disease, or inadequate therapy and warrant reinvestigation of the patient.

Presented at the National Fibromyalgia Research Association's Subgroups in Fibromyalgia Symposium, September 26-27, 1999, in Portland, Oregon.

National Fibromyalgia Research Association
PO Box 500, Salem, OR 97302