FIBROMYALGIA
MUSCLE PAIN

The hype around this story was ratcheted up a notch when Dr. rim Johnson interviewed the same two neurosurgeons as well as Sam Banner on the March 12, 2000 installment of 20/20. Barbara Walters introduced the segment with the announcement about “a radical treatment. . . surgery could be the answer and the cure.” Banner, a family physician in Alabama, had been felled by chronic fatigue for five years and had to quit his practice. He serendipi-tously discovered that after Dr. Rosner had operated on patients for Chiari syndrome, many of their symptoms that were similar to Banner’s improved. Putting two and two together. Banner ordered an MRI on himself and it revealed spinal cord compression. He was on Dr. Rosner’s operating table two days later and Tim Johnson said “that surgery led to a miraculous recovery for Dr. Banner.” Banner said, “I went to the chapel and got down on my hands and knees and thanked God.” Dr. Banner then began referring fibromyalgia patients to Dr. Rosner and together they reported that 50 to 80 percent of people with fibromyalgia improved with surgery. Banner also organized a support group and Web site for fibromyalgia and chronic fatigue sufferers. Via these sites and newspaper ads, the notion that surgery might be a cure for many people spread like wildfire.
The 20/20 program did not explain that the symptoms of Chiari malformation and spinal cord compression are very different from the chronic pain and exhaustion that characterize fibromyalgia and CFS. Nor did the program discuss research that was underway designed to see if these surgeon’s observations held up to scientific scrutiny. A study, now completed, compared head and spinal cord MRIs of fibromyalgia patients to those of healthy age- and sex-matched individuals. There was no difference in the prevalence of Chiari malformation or spinal stenosis in the two groups. Nearly 50 percent of completely healthy individuals with no pain as well as 50 percent of people with fibromyalgia had evidence of some narrowing at the base of the skull. This is reminiscent of the initial enthusiasm in regard to back surgery for herniated lumbar discs. Needless and potentially dangerous surgery was based on overzealous interpretation of new technology such asMRIs.
How can I account for the miraculous results claimed by Dr. Banner and these two neurosurgeons? Some people with fibromyalgia and chronic fatigue syndrome may also have spinal] canal compression. Neurologic symptoms such as weakness, abnormal reflexes, vertigo, and paresthesias might improve if the pressure is relieved. There is also a powerful placebo effect from any intervention as dramatic as surgery. I can state unequivocally that the vast majority of people with fibromyalgia and CFS do not have a surgically curable problem.
Of the more than twenty thousand patients with fibromyalgia that I have examined, physical trauma such as an injury at work or a motor-vehicle accident has been the most common precipitating event. The next most common is an infection, usually described as a viral illness or the flu. Denise told me that her symptoms started with a viral illness: It felt like I had the flu that never got better.

Two years after a relatively minor “whiplash” accident, twenty percent of people will complain of chronic neck, shoulder, and upper back pain. They also suffer from headaches, fatigue, sleep disturbances, and sensitivity to light and sounds. Many of my patients with fibromyalgia tell me that their symptoms began after a head or neck injury. A study done by Dr. Dan Buskila and his coworkers in Israel found that fibromyalgia was thirteen times more likely to develop following a neck injury compared to after a leg fracture. Is there something peculiar about trauma to the neck region compared to trauma in other parts of the body? Or is the greater incidence of fibromyalgia after such trauma a manifestation of social and cultural phenomena? In Israel, disability and litigation play a minor role in medical issues. Therefore the striking incidence of fibromyalgia following neck injury cannot be simply attributed to potential disability issues. Nevertheless, the role of blame and victimization in people’s perception of pain and injury cannot be ignored. People are more likely to blame an accident for their misery if they are the victim rather than if they caused the accident.
Many of my patients became alarmed when they read the front page article on fibromyalgia in The Wall Street Journal (November 11, 1999). The article was titled “High Hopes: Surgery on the Skull for Chronic Fatigue? Doctors Are Trying It.” Dr. Sam Banner and Ms. Jozan Plaza claimed that brain surgery had cured | their fibromyalgia and chronic fatigue: “Jozan Plaza, a forty-five-year-old Alabama woman, visited Chicago recently to have part of the back of her skull drilled off. Was this a good idea? Ms. Plaza is ‘ among the roughly 8 million Americans diagnosed with a condition called fibromyalgia syndrome, which involves widespread muscle pain, sleeplessness, fatigue, and depression. It is poorly understood and controversial. Many doctors aren’t convinced it is | a disease at all, suspecting in some patients it is really depression with physical manifestations. Patients who are told they have fibromyalgiaor the closely related chronic fatigue syndrome are usually just prescribed sleeping pills, antidepressants, and physical therapy. Treating patients with these diagnoses, in short, isn’t brain surgery,”
I agreed with their assessment up to that point, but then this news article discussed the contention of two neurosurgeons that a | too-tight skull or spinal canal was the cause of fibromyalgia. This spinal narrowing could be congenital, called Chiari syndrome, or | acquired from arthritis in the neck. For about $30,000 a case, they were able to relieve the excess pressure on the brain by cutting out pieces of bone in the back of the skull.
I was shocked that such a prestigious newspaper would report such unproven medical concepts. Granted, medical experts such as Dr. Dan Clauw were quoted in The Wall Street Journal that such surgery was unlikely to be helpful except in very rare circumstances. Yet, Ms. Plaza’s surgeon countered: “This is like telling the story of the discovery of insulin. You’re talking about a completely new insight that has baffled people since the beginning of the modern world.” This Chicago neurosurgeon declared that 100 percent of his patients had improved with this radical new approach. Dr. Michael Rosner, an Alabama neurosurgeon, was the first to suggest that such surgery could help many people with
fibromyalgia. He claimed that he had cured hundreds of patients. I began picturing thousands of needless and potentially dangerous brain surgeries performed on people with fibromyalgia.

CYNTHIA, a thirty-nine-year-old computer programmer, was referred to me by a lawyer to confirm that she had fibromyalgia. She had been involved in two motor-vehicle accidents in the past three years, each time suffering a “whiplash” neck injury. She recovered and went back to work after the first, although she still experienced neck pain. After the second accident, she developed generalized pain throughout her body and had been out of work ever since.
Cynthia was convinced that the trauma had permanently damaged her spine. She had seen orthopedic surgeons, neurosurgeons, and chiropractors. Some told her that there was no structural damage. Others diagnosed post-concussive brain damage, carpal tunnel syndrome, wrist tenosynovitis, subluxed cervical vertebrae, cervical and lumbar degenerative disc disease, scoliosis, and nerve entrapment. During the previous eighteen months, Cynthia underwent carpal tunnel surgery as well as cervical spine surgery without any improvement in her pain.
On examination, I found no evidence of spinal or nerve damage. Each of the characteristic fibromyalgia tender points was present.
Cynthia also was complaining of exhaustion, pounding daily headaches, insomnia, depression, abdominal pain, and diarrhea. I reviewed the X-rays, MRIs, and CAT scans and found no evidence of bone or joint damage. Cynthia’s symptoms were compatible with fibromyalgia, muscular headaches, and IBS.
I explained to Cynthia that fibromyalgia may be precipitated by trauma, be it physical or emotional, major or minor. However, her widespread pain was a result of alterations in pain perception rather than from tissue damage. Cynthia adamantly disagreed: My other doctors told me that my spinal column had been damaged. The MRl was proof of this. The chiropractor showed me how my neck vertebrae had gone out of place on my X~rays. Why would the doctors have done surgery on my neck if there was no permanent damage? When I interrupted her to suggest that we explore chronic pain mechanisms, Cynthia stormed out of my office with the comment, you are just like some other doctors who think that I’m making this all up for insurance purposes.