Neck Pains and Widespread Problems like Fibromyalgia(FM) – When and Where To get an Upright Flexion/Extension MRI..

The only traumatic cause of Fibromylagia is Motor Vehicle Accidents .  see Fibromyalgia Is Only Induced by Motor Vehicle Trauma ?Whiplash Disease
Makes one think whiplash and neck damage are involved in FM. Neurolgical findings of neck spine damage (cervical myelopathy) are not uncommon in FM. So when does one decide to go ahead and have that looked into?

Neurological symptoms are common in FM:

in:
Arthritis Rheum. 2009 September; 60(9): 2839–2844.
Neurological Signs and Symptoms in Fibromyalgia
Nathaniel F. Watson, MD,1 Dedra Buchwald, MD,2 Jack Goldberg, PhD,3 Carolyn Noonan, MS,2 and Richard G. Ellenbogen, MD free article here

Most important finding in my opinioin, would be finding there are symptoms that occur in arms or legs when the patient flexes or extends head. Some doctors sluff this off as being only  folding of the longitudinal spinal ligament and of no consequence but I doubt that.

In Heffez’s original article,
Eur Spine J. 2004 Oct;13(6):516-23.
Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia.
Heffez DS, Ross RE, Shade-Zeldow Y, Kostas K, Shah S, Gottschalk R, Elias DA, Shepard A, Leurgans SE, Moore CG.  abstract here

For important signs, he found:

• Numbness and paresthesias (funny feelings) 80-95%
• Instability of gait 86%  – I consider that an important warning sign
• grip weakness 85%  – Heffez found this predominantly in the dominant arm
• Skin hypersensitive below a certain level 83%  – often around T5
• Hyper and Abnormal reflexes:- Hoffman test (¼ positive)
  
  •Hold middle finger between the thumb and index finger
  •Relaxed
  •Press down your thumbnail on the patient’s fingernail and move downward until your nail “clicks” over the end of the patient’s nail
  •Positive – other fingers flex-
• Romberg test – • 1/4 – 1/3 cases (only 9%  of controls)
  • Stand
  • Feet together
  • 7 seconds
  • Eyes Closed
  • See if become unbalanced
• – Inverted (opposite direction) Radial Reflex at wrist – the forgotten reflex:
  
  •Radial reflex normal make hand go up
  • In FM cervical myelopathy – “Inverted” – goes opposite seen in  ½ cases FM myelopathy – considered Pathognomonic for FM myelopathy
• Alteration of reflexes with neck movement – ankle jerks can changed(often hyper)  with 1 min or so of putting neck in position that duplicates symptoms
• Babinski no help
• Cervical Collar – a remarkably useful suggestion I got from Dr. Heffez once when I talked to him – put patient in a rigid cervical collar and see if improves symptoms

Chiari Cause

• I have a pateint that went one leg paralysed with known syringomyelia and yet no MRI Xrays here showed her chiari – even her CSF flow study was misinterpreted. When she finally had surgery, considerable archnoiditis and denting of the spinal cord was seen. She is some better but still uses a wheelchair. It appears that no good comes from the poor quality (and inpreciseness of recumbent films) MRI films here.
  
• One finding that seems to be very significant is the effect of manual cervical traction – the patient will feel better when neck is stretched but when you let go and brain re-herniates down spinal canal – they get sudden sometimes excruciating pain – and will never let you do it again…

Positional Cervical Stenosis

• Much of the pain for disc herniations is not from the mechanical presssure but from the inflammatory chemicals (like tumor necrosis factor) that are secreted into the spinal canal and irritate the spine and spinal nerves – “chemical radicultis”. It seems that many doctors are unaware of that though N. Bogduk published a CME update for neurologist some years ago on this subject.
       
• Having said that, positional disc herniation could play a real role in FM:

Positional Cervical Spinal Cord Compression and Fibromyalgia: A Novel Comorbidity With Important Diagnostic and Treatment Implications.
Andrew J. Holman.
The Journal of Pain 9(7) (July), 2008:613-622  abstract here

• Found in this issue in 35/53 cases of FM but only 1/33 cases on connective tissue diseases
• Found this in 17/20 cases of widespread pain not specifically diagnosable as FM
• Generally caused by disk protrusion, and ligamentum flavum buckling worse in the extension

Comment – This seems to be potentially a real issue if Fibromyalgia and widespread pain. If your symptoms are made worse by neck flexion or extension and you have other symptoms like:

• “a recent or prolonged history of positional cervical pain in prolonged extension, such as in a hairdresser’s sink or dentist chair” [ seen in 1/2  – 2/3]
• Poor dominant hand grip [seen in 1/3 – 1/4]
• Complaints of dizziness and unsteadiness with normal gait [seen in 1/3 – 1/4]

– consider getting an upright MRI in flexion or extension.

Question is where do you get it done? I am having one patient travelling to Las Vegas because it is of good quality and cheaper than Kamloops. I will report back about that…