Working Diagnosis:
Chiari 1.5 malformation with syringomyelia

Treatment:
Hospital admission for surgical decompression with C1 laminectomy with subsequent revision due to post operative swallow and gait dysfunction. Brief course of midodrine due to persistent post-operative orthostatic hypotension that was weaned as an outpatient.

Outcome:
She experienced markedly improved neurologic symptoms and function by the one-month follow-up visit. Despite complete resolution of her symptoms and return to light aerobics at her three-month visit, surveillance MRI revealed persistent C2-C7 syrinx. She continues to receive surveillance MR imaging at six-month intervals.

Author's Comments:
Once considered an absolute contraindication to sports participation, literature is mixed on management and return to play especially in asymptomatic patients with known Chiari I malformation pathology. A thorough shared decision-making discussion should be had with athletes and families regarding treatment course and return to sport expectations/risks.

Editor's Comments:
This case emphasizes the importance of re-evaluation of symptoms. While initially the athlete presented with less severe symptoms, the symptoms escalated. This shows the importance of urgent imaging for more severe neurologic symptoms or escalation of those symptoms. Chiari Malformation can be asymptomatic especially in children, but symptoms may develop in adolescence or adulthood. Headaches are the most common presenting symptoms. Cerebellar dysfunction may also occur. Radicular symptoms such in this case are fairly uncommon but can occur due to compression of the cervical spinal cord.

References:
1. Tubbs RS, Iskandar BJ, Bartolucci AA, Oakes WJ. A critical analysis of the Chiari 1.5 malformation. J Neurosurg. 2004 Nov;101(2 Suppl):179-83. doi: 10.3171/ped.2004.101.2.0179. PMID: 15835105.
2. Turk ML, Schmidt K, McGrath ML. Diagnosis, Management, and Return to Sport of a 16-Year-Old Patient With a Chiari I Malformation: A Case Report and Literature Review. J Athl Train. 2022 Feb 1;57(2):177-183. doi: 10.4085/1062-6050-0001.21. PMID: 34185839; PMCID: PMC8876886.
3. Kirschen MP, Illes J. Ethical implications of an incidentally discovered asymptomatic Chiari malformation in a competitive athlete. Continuum (Minneap Minn). 2014 Dec;20(6 Sports Neurology):1683-7. doi: 10.1212/01.CON.0000458965.17777.b0. PMID: 25470168; PMCID: PMC4274168.
4. Meehan WP 3rd, Jordaan M, Prabhu SP, Carew L, Mannix RC, Proctor MR. Risk of athletes with Chiari malformations suffering catastrophic injuries during sports participation is low. Clin J Sport Med. 2015 Mar;25(2):133-7. doi: 10.1097/JSM.0000000000000107. PMID: 24905537; PMCID: PMC4257888.
5. Spencer R, Leach P. Asymptomatic Chiari Type I malformation: should patients be advised against participation in contact sports? Br J Neurosurg. 2017 Aug;31(4):415-421. doi: 10.1080/02688697.2017.1297767. Epub 2017 Mar 2. PMID: 28637118.
6. Harrell, Brian R MD; Barootes, Bryan G MD, Dip Sport Med. The Type I Chiari Malformation in a Previously Asymptomatic College Athlete: Addressing the Issue of Return to Athletic Participation. Clinical Journal of Sport Medicine 20(3):p 215-217, May 2010. | DOI: 10.1097/JSM.0b013e3181dafc14
7. Vaccaro AR, Klein GR, Ciccoti M, Pfaff WL, Moulton MJ, Hilibrand AJ, Watkins B. Return to play criteria for the athlete with cervical spine injuries resulting in stinger and transient quadriplegia/paresis. Spine J. 2002 Sep-Oct;2(5):351-6. doi: 10.1016/s1529-9430(02)00202-4. PMID: 14589466.

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