Finding a fix
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By Mark Andersen
The compression fracture wasn't serious, but she ought to get a CT scan because of the concussion.
Like so many people, Julie Sloggett was about to discover a chiari malformation by accident, in her case falling from a spirited horse named Lilly.
Sloggett of Culbertson can't recall the fall. She does recall a family physician talking about some spots on her brain, enough to warrant an MRI and a referral to North Platte neurologist Karen Lin.
The spots were insignificant, but the MRI did show a probable cause of her brief, severe headaches, terrible dizziness and ringing in her ears - a chiari malformation.
Sloggett, 44, had blamed aging.
"You think, that, yeah, you're getting old, and everybody else has these symptoms," she said. Or perhaps these maladies were a new feature of her fibromyalgia, diagnosed 10 years earlier.
Instead, her spinal fluid was bottling up at the exit to her skull. Portions of her cerebellum - a part of the brain that coordinates complex movement - was acting like a cork.
Unlike Sloggett, 61-year-old Sylvia Carruth, a Grand Island semi-truck driver, learned of her chiari malformation through a frustrating 18-month search for the cause of strange and sudden head pains.
"The headaches just kept getting worse over time," Carruth said. She had no other symptoms. No numbness.
"Just the headache, bang, when I would cough or sneeze," she said.
"It never lasted long, but there was times I never would have cared if I had died when it hit," she said.
A Kearney physician blamed sinus problems. Her daughter's doctor eventually sent Carruth to Christopher Kent, a Lincoln neurosurgeon.
Operating on people with a chiari is gratifying, Kent said. In so many back surgeries, it's judged a success when severe pain is reduced.
In 80 percent of people with chiari malformations, "You change their life," he said.
Kent treats eight to 10 chiari malformations every year but suspects many go undiagnosed.
In 2000, a Johns Hopkins study of 22,591 MRI images found suspected chiari malformations in one of every 130 cases. At that rate, Nebraska would have 13,169.
Surgery isn't warranted for all suspected malformations.
"In 80 percent of cases," Kent said, "there is nothing to do."
That would then leave 2,600 Nebraskans who might find surgical relief from puzzling numbness, weak hands and moments when they feel their head will blow off.
Of the four types of chiari malformations, pronounced kee-ar-ee and named for Austrian discoverer Hans Chiari, two predominate.
One occurs in children, usually in those with birth defects like spina bifida or other improper neural development. In spina bifida, fetal tissues that form the spinal column do not close in the first month of pregnancy.
Adult cases have different characteristics. Symptoms occur slightly more often in women and usually as people reach their 40s.
Two tonsil-like tails hang down from the cerebellum, effectively plugging the spinal cord and the hole at the base of the skull. An investigation is warranted when the cerebellum descends an extra 5 millimeters or about a quarter inch below normal.
The tails sometimes hang as much as 3 inches too low.
To fix these, a surgeon must drill into neck vertebrae.
That's rare, Kent said.
Most surgeries consist of widening the hole at the base of the skull to let fluid pass.
Without relief, the fluid pressure can push the brain stem into the hole or force fluid into the central space of the spinal cord, inflating it like a clown's skinny balloon - called a syrinx.
A syrinx frequently causes numbness on shoulders, loss of muscle size in fingers and hands and the loss of ability to tell pain. Kent recalled one woman who placed her hand on a hot burner and removed it only when she noticed the smell. A syrinx also can cause difficulties with walking and urinating.
Symptoms not related to syrinxes include a headache brought on by movement, coughing or sneezing, or from straining on a toilet.
"One woman," Kent said, "every time she tied her shoe, she had a severe pain radiating from the back of her head."
Additional symptoms may include ringing in the ears and difficulty swallowing or gagging.
Sloggett, who fell from her horse in October, underwent surgery in December. Carruth's was nearly a year ago.
It's a painful process. Surgeons must peel aside the thick muscles at the back of the head. They remove part of the skull and patch the dura, the thick flexible covering of the brain and cord.
The surgery carries a small risk of death, stroke, brain stem damage and infection. Spinal fluid sometimes leaks from the patch and may require additional surgery. Studies say the possibility of all symptoms disappearing is best if they have existed less than two years.
Sloggett's neck is still tender to the touch but her strange headaches have disappeared. The severe dizziness is gone and she has regained mental clarity. She reads and understands something rather than rereading it several times, she said.
She hopes to climb aboard a horse again in mid- to late summer, maybe sooner.
Carruth has healed completely from her surgery. She still gets headaches from eye strain and stress, but nothing worse.
She regrets waiting so long before forcing the issue by changing doctors.
"I feel great," she said.
Reach Mark Andersen at 473-7238 or mandersen@;journalstar.com.
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