Positional cervical spinal cord compression and Fibromyalgia Syndrome

FibroAction Professional Advisory Board member Dr Andrew Holman MD is investigating a possibly important new factor in Fibromyalgia Syndrome: positional cervical spinal cord compression (compression of the spine in the neck when the head is tilted back). His initial paper on the research was published in the Journal of Pain last year.

Dr Holman says in this paper

"...fundamental concerns about defining [Fibromyalgia Syndrome] as a single entity abound, but little consideration has been apportioned to the concept that variability in patient presentation and treatment response may be relatedto unsuspected comorbidities."¹

Dr Holman believes that positional cervical spinal cord compression is one unsuspected comorbidity that has important implications for Fibromyalgia Syndrome and its treatment.¹

Recognition of cervical comorbidity with Fibromyalgia Syndrome was describedby Rosner and Heffez when decompression of Chiari I deformity (where the brainstem extends into the spinal canal, compressing the spinal cord) was found to reduce fatigue and global pain in some patients with both conditions. However, Chiari malformations are not common in the general population and many people with Fibromyalgia Syndrome do not have any evidence to suggest that surgery could be beneficial. There are also genuine concerns about the promotion of any surgical intervention for Fibromyalgia Syndrome.¹

What began as an attempt by Heffez to document spinal cord compression from a congenital abnormality, Chiari I, developed into an initiative to recognize cord compression and abutment related to cervical position. Heffez foudn that, by including flexion and extension views (tilting the patient's head forward and back) when doing a cervical spine MRI, he was able to view and document cord compression and abutment that was not visible on a traditional MRI view (where the patient lies flat).¹

Since January 2003, these 2 extra views have been done as well when doing a traditional cervical spine MRI in order to identify the presence of positional cervical spinal cord compression among patients referred for rheumatology consultation with Dr Holman.¹

For the pilot study, Dr Holman carried out a retrospective chart review, looking at a randomly selected 2-month period (January and February 2006).¹

This pilot study was undertaken to evaluate the concept of positional cervical spinal cord compression in patients that did not require surgery (e.g. for Chiari I), promote discussion of its possible relevance, and consider future research initiatives related to this potential comorbidity with Fibromyalgia Syndrome.¹

Positional cervical spinal cord compression was defined as cord abutment, compression or flattening with a spinal canal diameter of less than 10 mm when measured by flexion, neutral, and extension MRI images.¹

Of 107 referrals during the 2-month period, 53 had Fibromyalgia Syndrome, 32 had a connective tissue disease (CTD) without Fibromyalgia Syndrome, and 22 had chronic widespread pain (CWP) without meeting the criteria for Fibromyalgia Syndrome.¹

These patients were then assessed as to whether a cervical MRI was required to check for cervical spinal cord issues, using questions and examinations, such as an extended Hoffmann test (feet together, eyes closed and see if the patient wobbles or falls) and whether they got pain from a haidressers sink.¹

The dynamic cervical spine images were obtained in 70 patients: 49 out of 53 with Fibromyalgia Syndrome, 20 of 22 with CWP and 1 of 32 with CTD.¹

Among those who received magnetic resonance imaging [MRI], 52 patients met the criteria for positional cervical spinal cord compression (71% of FM group [35/49], 85% of CWP group [17/20]). Two Fibromyalgia Syndrome patients were found to have a Chiari malformation, 1 Chronic Widespread Pain patient had multiple sclerosis, and 1 Chronic Widespread Pain patient had multiple myeloma.¹

The new extension views (where the patient's head is tilted back) were required for diagnosis of positional cervical spinal cord compression for 71% of the subjects, as well as for 8 patients who also had cervical spinal cord flattening. With a normal MRI view, these findings would have been missed.¹

Dr Holman concluded that:

"It is not yet clear whether recognition of positional cervical spinal cord compression will be considered as an intriguing source of widespread pain or as an important comorbidity among patients with FM or as a common incidental finding. But, these preliminary data suggest that additional resources should be allocated to evaluate this concept further."

For further discussion of this research by Dr Holman, including some of the MRI images, please see the Videos and Podcast section here where there is a recording of a lecture Dr Holman made on December 22nd 2008 at Guy's Hospital, London.

References:

1. Holman AJ. Positional cervical spinal cord compression and fibromyalgia: a novel comorbidity with important diagnostic and treatment implications. J Pain. 2008 Jul;9(7):613-22. Epub 2008 May 22.