It's More Than A Headache

Abstract

HISTORY: 15yo male high school soccer player with headache and dizziness following injury 1 month prior. Event was soccer ball striking right temporal area with fall to the ground without secondary head trauma or loss of consciousness. On rising, patient was knocked down by the opponent. He removed himself from the game due to symptoms of headache, balance problems, dizziness, sensitivity to light and noise, irritability, feeling slowed down, feeling mentally foggy, difficulty concentrating, and having visual problems. He had associated neck pain, numbness and tingling in the left upper extremity and left lower extremity after the injury. No weakness in the upper or lower extremities. No retrograde or anterograde amnesia reported. He continued to play the game. Reported his symptoms to the coach and licensed athletic trainer (LAT) when the game finished. History of congenital C2-C3 autofusion, concussion 4 years prior with loss of consciousness, and posterior tension-like headaches with coughing and laughing. PHYSICAL EXAM: NECK: Neck supple without rigidity. FROM without tenderness on movement or palpation NEURO: alert, oriented, normal speech. Normal neurological exam of arms. Normal DTRs, motor, sensory exam. No focal findings or movement disorder noted. Finger to nose testing normal. Cranial nerves II-XII intact. Motor and sensory grossly normal bilaterally, normal muscle tone, no tremors, strength 5/5 GAIT: normal Post Concussion Symptom Scale: 46 DIFFERENTIAL DIAGNOSIS: 1. Post-concussion syndrome 2. Cervical Spinal Stenosis 3. Cerebral Herniation TEST & RESULTS: MRI of brain & C-spine: Chiari 1 malformation with cerebellar tonsils extending 2 cm below the foramen magnum. Dens angled posteriorly, increasing the degree of crowding at and below the foramen magnum. There is associated slight indentation of the ventral aspect of the upper cervical spinal cord. Congenital partial fusion of C2 and C3. The posterior arch of C1 appears incomplete. No spondylolisthesis. FINAL WORKING DIAGNOSIS Chiari Type 1 malformation TREATMENT & OUTCOMES 1. Avoid athletic activities and referred to neurosurgery for treatment. 2. Neurosurgery performed posterior fossa decompression and duraplasty procedure successfully. 3. Discharged from hospital to home after 3 days with full resolution of headaches and symptoms.