Adult Age Differences in Self-Reported Pain and Anterior CSF Space in Chiari Malformation

García, Maitane; Eppelheimer, Maggie S.; Houston, James R.; Houston, Michelle L.; Nwotchouang, Blaise Simplice Talla; Kaut, Kevin P.; Labuda, Richard; Bapuraj, Jayapalli Rajiv; Maleki, Jahangir; Klinge, Petra M.; Vorster, Sarel J.; Luciano, Mark; Loth, Francis; Allen, Philip A.

doi:10.1007/s12311-021-01289-w

Cited by 7 publications

(6 citation statements)

References 47 publications

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“…Our results of an optimal bifactor model with a general and a specific factor applied to Chiari patients have implications for both research and application of the assessment of pain using the SF-MPQ-2. Conceptually, the pattern of findings here might point to a general factor attributable to the acute experience of pain associated with tissue damage, encroachment, or inflammation (i.e., nociceptive), whereas the more specific pain factor (i.e., affective) may reflect more chronic centralized pain (e.g., Allen et al, 2018 [ 20 ]; 2022 [ 25 ]). Evidence supporting this dichotomy may be found in the pattern of less optimal post-surgical improvement observed among Chiari patients when there is greater than a two-year interval between initial diagnosis and surgery (Labuda et al, 2022 [ 48 ]).…”

Section: Discussionmentioning

confidence: 92%

“…It is also worth noting that Gholampour and Taher (2018) [ 49 ] and Gholampour and Gholampour (2020) [ 50 ] have implicated cerebrospinal fluid (CSF) pressure with degree of headache pain in Chiari malformation patients (as measured by phase contrast MRI, or cine-flow). In support of this, Garcia et al (2022) [ 25 ] found that a smaller anterior cervical CSF space (between C2 and the foramen magnum in the upper spine) was associated with increased pain in Chiari patients as adult age increased. As such, future research should assess whether CSF pressure in Chiari patients is differentially related to acute (e.g., Val Salva) and chronic (i.e., centrally sensitized) pain.…”

Section: Discussionmentioning

confidence: 92%

“…Etiological, diagnostic, and treatment considerations continue to emerge, particularly in the context of modern neuroimaging advances [ 21 , 23 , 24 ]. Not uncommonly, reduced cerebrospinal fluid volume in the posterior portions of the skull (i.e., posterior cranial fossa, beneath the occipital lobes) and the anterior cerebrospinal fluid (CSF) space in the upper cervical region of the spinal canal exacerbate cervico-medullary compression by the cerebellum, thereby exerting pressure (i.e., particularly during diastolic cardiac cycles) on underlying brainstem and cervical spine regions [ 21 , 25 , 26 ]; see also [ 24 ]. Also, pain levels (as assessed by the SF-MPQ-2) in CM relative to healthy age- and education-matched controls are associated with significantly different levels of white-matter integrity as indexed by diffusion tensor imaging (DTI, Houston et al, 2020 [ 27 ]) as well as intrinsic functional connectivity as indexed via resting-state functional magnetic resonance imaging (fMRI) (Houston et al, 2021 [ 28 ]).…”

Section: Methodsmentioning

confidence: 99%

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Revisiting the factor structure of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2): Evidence for a bifactor model in individuals with Chiari malformation

Tokar,

Kaut,

Allen

2023

PLoS ONE

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The Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2; Dworkin et al., 2009) is intended to measure the multidimensional qualities of pain (i.e., continuous, intermittent, neuropathic, and affective) as well as total pain. Using structural equation modeling, we evaluated the fit of four competing measurement models of the SF-MPQ-2—an oblique 4-factor model, a 1-factor model, a higher-order model, and a bifactor model—in 552 adults diagnosed with Chiari malformation, a chronic health condition whose primary symptoms include head and neck pain. Results revealed the strongest support for the bifactor model, suggesting that SF-MPQ-2 item responses are due to both a general pain factor and a specific pain factor that is orthogonal to the general pain factor. Additional bifactor analyses of the SF-MPQ-2’s model-based reliability and dimensionality revealed that most of the SF-MPQ-2’s reliable variance is explained by a general pain factor, and that the instrument can be modeled unidimensionally and scored as a general pain measure. Results also indicated that the general and affective pain factors in the bifactor model uniquely predicted pain-related external criteria (e.g., depression, anxiety, and stress); however, the continuous, intermittent, and neuropathic factors did not.

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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 92%

Section: Methodsmentioning

confidence: 99%

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Revisiting the factor structure of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2): Evidence for a bifactor model in individuals with Chiari malformation

Tokar,

Kaut,

Allen

2023

PLoS ONE

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“…Lower age was a protective factor for prognosis in our adult cohort. As adult CMI patients age, their surgical outcome scores consistently decline [ 31 ], and this decline may be attributed to decreased anterior CSF space with aging and makes decompression more challenging [ 32 ]. Thus, early decompression is recommended for symptomatic adult CMI patients [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Individualized Functional Decompression Options for Adult Chiari Malformation With Syringomyelia and A Novel Scale for Syringomyelia Resolution: A Single-Center Experience

Han,

Hou,

et al. 2023

Neurospine

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Objective: To compare outcomes of posterior fossa bony decompression alone (PFD) versus PFD with duraplasty (PFDD) versus PFDD with additional obex exploration (PFDDO) in patients with Chiari malformation type I (CMI) combining syringomyelia.Methods: Clinical records of adult patients who underwent decompressions from 2014 to 2022 were retrospectively analyzed. The decompression procedure was individualized based on the cerebrospinal fluid pulse in the surgical field. The Chicago Chiari Outcome Scale (CCOS) was used to assess the prognosis of the patients and a novel syringomyelia resolution scale, based on 3-dimensional volume, was introduced. The percentage change in the cervical syrinx volume was classified as follows by resolution: ≥ 70%, 30%–70%, and < 30%.Results: Seventy-eight individuals were enrolled, of which 22, 20, and 36 underwent PFD, PFDD, and PFDDO, respectively. The three decompression groups had no significant difference in the preoperative characteristics and postoperative prognosis. Multivariate analyses revealed that better CCOS was significantly correlated with younger age at surgery (p = 0.018), syrinx originated from lower cervical levels (p = 0.037), narrower preoperative cerebral aqueduct (p = 0.005), and better syrinx volume resolution (p = 0.004). Additionally, a better cervical syrinx volume resolution was significantly correlated with higher CCOS (p = 0.017), narrower cerebral aqueduct (p = 0.035), and better tonsillar descent resolution (p = 0.007).Conclusion: Individualized functional decompression induced an equal effect on CCOS and syrinx volume resolution for all CMI patients with syringomyelia. Our syringomyelia resolution scale facilitates communication and prediction of CMI prognosis.

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“…Further, based on receiver operator characteristic curves, ILI was more predictive of cough associated headaches than tonsillar position [ 39 ]. In addition, our group has recently shown that a smaller anterior CSF space was related to an increase in pain [ 40 ]. From this, it is reasonable to conclude that the Chiari headache is due at least in part to the altered pulse pressure environment irritating nerve roots, pain receptors in the dura, and/or the blood vessels of the skull base.…”

Section: Discussionmentioning

confidence: 99%

A new hypothesis for the pathophysiology of symptomatic adult Chiari malformation Type I

Labuda¹,

Nwotchouang

Ibrahimy

et al. 2022

Medical Hypotheses

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Chiari malformation Type I (CMI) is characterized by herniation of the cerebellar tonsils through the foramen magnum. The pathophysiology of CMI is not well elucidated; however, the prevailing theory focuses on the underdevelopment of the posterior cranial fossa which results in tonsillar herniation. Symptoms are believed to be due to the herniation causing resistance to the natural flow of cerebrospinal fluid (CSF) and exerting a mass effect on nearby neural tissue. However, asymptomatic cases vastly outnumber symptomatic ones and it is not known why some people become symptomatic. Recently, it has been proposed that CMI symptoms are primarily due to instability of either the atlanto-axial (AA) or the atlanto-occipital (AO) joint and the cerebellar tonsils herniate to prevent mechanical pinching. However, only a small percentage of patients exhibit clinical instability and these theories do not account for asymptomatic herniations. We propose that the pathophysiology of adult CMI involves a combination of craniocervical abnormalities which leads to tonsillar herniation and reduced compliance of the cervical spinal canal. Specifically, abnormal AO and/or AA joint morphology leads to chronic cervical instability, often subclinical, in a large portion of CMI patients. This in turn causes overwork of the suboccipital muscles as they try to compensate for the instability. Over time, the repeated, involuntary activation of these muscles leads to mechanical overload of the myodural bridge complex, altering the mechanical properties of the dura it merges with. As a result, the dura becomes stiffer, reducing the overall compliance of the cervical region. This lower compliance, combined with CSF resistance at the same level, leads to intracranial pressure peaks during the cardiac cycle (pulse pressure) that are amplified during activities such as coughing, sneezing, and physical exertion. This increase in pulse pressure reduces the compliance of the cervical subarachnoid space which increases the CSF wave speed in the spinal canal, and further increases pulse pressure in a feedback loop. Finally, the abnormal pressure environment induces greater neural tissue motion and strain, causing microstructural damage to the cerebellum, brainstem, and cervical spinal cord, and leading to symptoms. This hypothesis explains how the combination of craniocervical bony abnormalities, anatomic CSF restriction, and reduced compliance leads to symptoms in adult CMI.

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Adult Age Differences in Self-Reported Pain and Anterior CSF Space in Chiari Malformation

Cited by 7 publications

References 47 publications

Revisiting the factor structure of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2): Evidence for a bifactor model in individuals with Chiari malformation

Revisiting the factor structure of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2): Evidence for a bifactor model in individuals with Chiari malformation

Individualized Functional Decompression Options for Adult Chiari Malformation With Syringomyelia and A Novel Scale for Syringomyelia Resolution: A Single-Center Experience

A new hypothesis for the pathophysiology of symptomatic adult Chiari malformation Type I

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