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I Was the Clumsy One
Exploring the Central Nervous System through Type I Chiari Malformation
By Philomena M. Behmer, Stacy A. Ropp, Angela Z. Shertzer
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This interrupted case study explores the central nervous system (CNS) by comparing normal CNS anatomy and physiology to the true story of a woman with type I Chiari malformation (CM). Type I CM is a condition involving anatomical anomalies of the hindbrain that may cause the protrusion of cerebellar tissue into the spinal cavity. These defects can compromise brain and cranial nerve function and disrupt the normal flow of cerebral spinal fluid (CSF). Stacy Ropp, a patient with type I CM, narrates her experience with this condition in four parts. In Part I, she discusses her signs, symptoms, and initial diagnosis; in Part II, she explains her initial treatment; in Part III, she reveals recurring symptoms, and in Part IV, she shares how a second opinion results in a more successful treatment of her condition. Specific concepts addressed in the case study include skull and vertebral bones associated with the CNS, CSF flow, neural reflexes, neural pathways, and cranial nerves. The case is appropriate for use in a variety of human biology courses with an emphasis on anatomy and physiology, neuroscience, pathophysiology, or radiography.
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- List the components and functions of the central nervous system and major brain regions.
- Describe type I CM skeletal anomalies and relate them to the signs and symptoms of type I CM.
- Identify the steps of a neural reflex and explain abnormal reflexes associated with type I CM.
- List the layers of CNS meninges, describe cerebrospinal fluid (CSF), and explain the impact of CSF flow interruption in type I CM.
Chiari; Chiari malformation; CM; central nervous system; CNS; cerebral spinal fluid; CSF; skull anatomy; vertebral anatomy; neural reflexes; cranial nerves; neural pathways
Subject Headings
EDUCATIONAL LEVEL
Undergraduate lower division
TOPICAL AREAS
TYPE/METHODS
Teaching Notes & Answer Key
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Materials & Media
Supplemental materials.
- I Was the Clumsy One This video features Dr. Max Lowden, a neurologist employed at Penn State Medical Center, and Stacy Ropp, a patient with Chiari malformation. Dr. Lowden explains the anatomy and physiology of Chiari Malformation and Stacy shares what it is like to live with this condition. Running time: 10:38 min. Produced by P. Behmer, S. Ropp, and A. Shertzer, 2019.
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In this case study, Stacy Ropp, a patient with Chiari malformation, narrates her experience with this condition in four parts. In Part I, she discusses her signs, symptoms, and initial diagnosis. In Part II, she explains her initial treatment; in Part III, she reveals recurring symptoms, and in Part IV, she shares how a second opinion results in the more successful treatment of her condition. Begin this case study by using the following link to watch a video of Stacy explaining her experiences with type I Chiari malformation: <https://pacollege.techsmithrelay.com/ixIy>
Part I – Signs/Symptoms and Initial Diagnosis
As a child, I was the “clumsy” one. The family joke is that I could fall off a chair while sitting on it. I experienced other symptoms over the years, but for me, they were “normal,” such as intense pressure at the base of my skull with sneezing and coughing, the inability to raise my head for an extended period without getting dizzy, and difficulty with memory or concentration. I would gag every time I brushed my teeth and often suffered from severe headaches that started at the base of my skull.
As an adult, my condition finally reached a point that I could no longer disregard my symptoms. In February of 2010, I fell down the steps carrying a carpet cleaner. By the next day, I had severe pain and back spasms, which made stand-ing upright difficult. Since I was seven months pregnant, I opted to see a physiatrist rather than usstand-ing pharmacological interventions. A physiatrist specializes in the musculoskeletal system and uses exercise and adaptive devices to help patients become functional and pain-free. Since I was pregnant, I could not take most pain-relieving types of drugs because they are contraindicated and could potentially harm the fetus. Contraindications are conditions that prevent a patient from receiving treatment, and pregnancy is a common contraindication for many treatment options.
A physical examination revealed an abnormal Hoffman’s reflex (finger flexor reflex) and hyper-reflexivity (over-responsive reflex activity). These results point to muscular sclerosis (MS) or another central nervous system issue. The plan was to have a complete brain MRI after I delivered my daughter in June 2010.
In July 2010, I underwent brain magnetic resonance imaging (MRI; see Figure 1 on p. 3 below). The initial diagnosis was MS. However, after reviewing the images, the physiatrist questioned a diagnosis of MS because I had a nine-millimeter cerebellar tonsillar herniation. The cerebellar tonsils are on the undersurface of the cerebellum, and cerebel-lar tonsilcerebel-lar herniation is the elongation of the tonsils through the foramen magnum of the skull and into the spinal cavity. I also had a syrinx of the spine, which is an enlarged fluid-filled cavity in the central canal of the spinal cord. The physician finally diagnosed me with type I Chiari malformation. The physiatrist immediately referred me to a
local neurologist. After researching my new diagnosis, I understood the symptoms I experienced over the years. In the summer of 2014, I had increased dizziness, which affected my ability to do yoga and personal training. I man-aged to work through the dizziness with yoga and knew what yoga positions I was unable to do for long periods. The neurologist referred me to physical therapy (PT) as he thought my symptoms were unrelated to Chiari. However, after
Philomena M. Behmer, Stacy A. Ropp, and Angela Z. Shertzer
Department of science and humanities, pennsylvania college of health sciences, lancaster, pa.
NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Page 2 “I Was the Clumsy One” by Behmer, Ropp, & Shertzer
doing the course of PT, I did not have any improvement. Indeed, I added dizziness to the symptoms I would have to cope with for the rest of my life.
In February 2015, while doing my routine yoga practice, I had a near syncopal episode (short-term loss of conscious-ness). Each time I would go into a downward position, I would get lightheaded and feel as though I would pass out. I stopped doing yoga … one more thing I would not be able to do.
1. Stacy’s MRI image results indicate abnormalities of the cerebellum of the brain and spinal cord. In what division of the nervous system are the brain and spinal cord?
2. Fill in the table below by listing the six major brain regions and describing their functions.
Brain Region Functions
3. Use Figure 1 to answer the following questions:
a. What sectional plane did clinicians use to obtain this view of the brain and spinal cord (frontal, transverse or sagittal)?
b. What is the normal curvature of the cervical spine, and how does this compare to Stacy’s cervical spine?
c. Note the difference in the location of the cerebellum between Stacy and the healthy image. Clinicians refer to this defect as cerebellar tonsillar herniation of the brain. Use Figure 1 and a credible source to explain why patients with Type I Chiari malformation present with cerebellar tonsillar herniation.
d. Note the white patches on the spinal cord of Figure 1(A). This is an indication of syrinx of the spine (syringomyelia). Use Figure 1 and a credible source to describe the syrinx of the spine and compare it to a healthy spinal cord.
4. Stacy had an abnormal Hoffman’s reflex (finger flexor reflex), which indicates issues with the central nervous system. Clinicians conduct this reflex test by applying pressure to the middle fingernail bed of a patient’s middle
TIONAL CENTER FOR C
ASE STUDY TEA CHING IN SCIENCE as the Clumsy O ne ” b y B ehmer , R opp , & S her tz er
Figure 1. MRI image (A) depicts Stacy’s spinal cord, which clinicians used to diagnose her with Chiari malformation. Image (B) is an MRI scan of a healthy spinal cord. The cerebellar
location shown in (A) is indicative of a tonsillar herniation. Also, (A) has white patches throughout the spinal cord, which indicate the presence of a spinal syrinx; additionally, the cervical spine is straight. Note that these three abnormalities are absent on the normal (B) image and fit the diagnosis of Chiari malformation.
Page 4 “I Was the Clumsy One” by Behmer, Ropp, & Shertzer
finger. An abnormal test is the flexion of any phalange and possible adduction of the thumb. Considering this, answer the questions below.
a. Define neural reflex:
b. Use the following terms to label the different components of a neural reflex illustrated below in Figure 2: motor neuron, sensory neuron, interneuron (CNS), and peripheral effector.
Figure 2. Neural reflex. (Licensed image ©stihii | Shutterstock, id 214510006.)
c. Indicate on Figure 2 above where Stacy’s abnormal reflex may originate.
d. Hoffman’s reflex test (finger flexor reflex) can be associated with problems involving the corticospinal tract. What type of information travels the corticospinal tract, and how does this relate to Hoffman’s reflex test?
5. Describe syncope and list some common causes.
6. Use the information you have learned from this part of the case study (Part I) and a credible source to describe and list signs/symptoms of type I Chiari malformation.
Part II – The Doctor Visit and Initial Treatment
In March 2015, I began to have neck pain while attending a conference in North Carolina. I assumed it was due to the plane and bus ride. By the fifth day, the pain was so severe that I could not sit up after lying prone. It took about 10–15 minutes to roll over to the side of my bed, lower my legs to the floor in a kneeling position, and only then
could I stand. By the time I could stand, the pain was so bad I was in tears.
Desperate, I decided to make an appointment with a chiropractor. Unfortunately, the visit resulted in little relief of my pain. I contacted my primary care physician (PCP), who ordered a cine MRI, a special MRI used to observe cerebro-spinal fluid (CSF) flow. The MRI showed that I had minimal CSF flow, my tonsillar herniation was now at 18 mm, and the syrinx was much larger, encompassing much of my spinal cord from spinal cord sections C3–T4 (see Figure 3, next page). I saw a neurosurgeon that Friday. He recommended surgery within 72 hours due to the size of the syrinx pressing on my spinal cord and the lack of CSF. The operation would include partial decompression, which consisted of shaving off some of my C1 vertebra (atlas) and removing a piece of my occipital bone to allow more room for the CSF to flow naturally and thus minimize the syrinx. This surgery is less invasive compared to a complete decompres-sion surgery process and, therefore, a shorter recovery time. Total decompresdecompres-sion surgery involves cutting into the dura mater of the brain, which increases the chance of infection. I opted for the less invasive partial decompression, which went well, and I was able to return to work full time within one month. I completed a 5 K obstacle course two months after surgery. Although my progress was exciting, the surgeon did not cover the space once protected by bone with a metal plate, and the soft tissue of my brain was vulnerable to injury.
1. List Stacy’s signs and symptoms before her surgery. What do her signs/symptoms and MRI scans indicate regarding the progression of her condition?
2. What does C3–T4 mean in the above text?
3. What are the functions of cerebral spinal fluid (CSF), and what is the typical sequence of CSF flow in the CNS?
4. How is the CSF interrupted in Stacy’s central nervous system?
5. How does the interruption of Stacy’s CSF impact the neural tissue of the spinal cord?
6. List the structures that protect the brain from superficial to deep and explain how a full decompression surgery without any protective patches or plates covering the brain could have compromised Stacy’s brain.
ASE STUDY TEA CHING IN SCIENCE Page 6 “I W as the Clumsy O ne ” b y B ehmer , R opp , & S her tz er
Figure 3. MRI image (A) is of Stacy’s posterior brain and inferior spinal cord (July 2010). Image (B) is an MRI scan of the same region (March 2015). Notice the increased size of the tonsillar
Part III – Recurring Symptoms
In February 2016, I began having increased dizziness while raising or lowering my head or while walking. Then one day, I had a sudden bout of severe head pain. Up until this point, I had been headache free since my surgery, so I decided to head to the emergency room. The MRI of the brain noted some improvement in the tonsillar herniation; it decreased from 18 mm to 16 mm. However, the emergency room physician did not order a cervical MRI to check the syrinx. I returned to my neurosurgeon, who thought the headaches and dizziness were unrelated to the Chiari. He could not explain the reason for the reoccurrence of the headaches or dizziness but stated my surgery was a success. I contacted my PCP, and together we decided to contact John Hopkins Hospital (JHH) to see a Chiari specialist and assess the syrinx. At this time, I started experiencing tingling and numbness in both arms and legs.
1. What is your response to the neurologist’s opinion that the headaches, dizziness as well as tingling and numbness in Stacy’s limbs were unrelated to her Chiari condition?
2. Medical professionals often recommend a second medical opinion. List possible obstacles patients may encounter trying to obtain a second medical opinion and explain why it is vital for Stacy to overcome these obstacles.
Page 8 “I Was the Clumsy One” by Behmer, Ropp, & Shertzer
Part IV – Second Opinion
In mid-April 2016, the neurosurgeon at JHH recommended having a full decompression surgery because the MRI illustrated poor improvement of the syrinx from the prior surgery. At the beginning of May, I had a complete decompression surgery, which included removing more of the occipital bone and stretching the arachnoid meninges. Surgeons placed a patch and metal plate over my brain and my occipital bone, respectively. The recovery period for this surgery took much longer, and I was unable to return to work until August 2016. And, I was unable to participate in strenuous activity for the next 12 months.
Since the second surgery, my headaches have greatly improved. I do get headaches when the barometric pressure drops or with any significant change in the weather. The numbness and tingling have improved as well. Many of my other symptoms, dizziness when raising my head, lack of balance, gagging when brushing teeth, I will always have because of the Chiari. The newest symptom, my head feeling like a 1,000-pound weight at the end of the day, will improve overtime as I re-strengthen my neck muscles. The muscles that attach to my occipital bone were cut and are no longer naturally attached to my skull. I will need to have regular MRI scans to monitor the syrinx, but the hope is that the second surgery was enough that the herniation and the syrinx will not worsen or cause further nerve damage.
1. Describe the location of the occipital bone and list the brain regions protected by this bone.
2. Explain why Stacy’s headaches, numbness, and tingling improved as a result of the decompression surgery. 3. As a group, fill in the table below with information about the cranial nerves responsible for the gag reflex.
Nerve Name and
Number Location Function tion relate to Stacy’s signs and symptoms? How does the nerve location and
func-4. List the layers of the brain meninges from superficial to deep. Include in your answer the function of the arachnoid meninges and speculate why the surgeon stretched her arachnoid meninges during the decompression surgery. 5. Many muscles originate in the occipital bone. Collectively, what are their muscle actions? How does this
contribute to her head “… feeling like 1000 pounds …”? 6. Compare and contrast the procedures of the two surgeries.
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What is the main conflict in the clumsy one by ernest buckler?
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Daniel went to the city to go to schol while david his brother stayed home and worked on the farm because he didn't have the brains that daniel had. Daniel didn't have the strength of David. David always was quite nice and would nonchalantley give daniel breaks during manual labour without embarrasing Daniel. Daniels friends visited the farm one day and daniel didn't introduce David as his brother so his friends thought he was a worker. David thought that daniel was embarrased of him. The next day they are doing some manual labour and david doesn't nonchalentley let david take a break (kind of like payback). Daniel always thought that david was not as smart as daniel and therefore clumsy. But in the end, he realizes that what he finds a burden for david (being not as smart) is actually something he has in common but in a different aspect (not being strong). He comes to the realization that was being rude to david based on a characteristic that daniel himself held (being clumsy).
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Main conflict definition?
A main conflict is the main problem that a character has in a story, or the main problem of the story
What is a secondary conflict?
A secondary conflict is a an event that is important but isn't part of the main conflict. It's still important but secondary to the main.
What is the conflict of hudhud hi aliguyon?
[object Object]
What is the conflict in Specials by Scott Westerfeld?
The main conflict is between Tally (the main character) and the government, over the brainwashing of society.
What is the conflict in the book house of nights marked?
I think the main conflict in so be it was
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While searching our database we found 1 possible solution for the: Clumsy one crossword clue. This crossword clue was last seen on May 23 2024 Thomas Joseph Crossword puzzle . The solution we have for Clumsy one has a total of 3 letters.
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Study with Quizlet and memorize flashcards containing terms like Stacy's MRI image results indicate abnormalities of the cerebellum of the brain and spinal cord. In what division of the nervous system are the brain and spinal cord?, Type 1 Chiari Malformation, Syrinx and more.
Quizlet has study tools to help you learn anything. Improve your grades and reach your goals with flashcards, practice tests and expert-written solutions today. Flashcards. 1 / 40" I was the Clumsy One" Case Study Review. Log in. Sign up. Get a hint. Stacy's MRI image results indicate abnormalities of the cerebellum of the brain and spinal cord ...
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Specific concepts addressed in the case study include skull and vertebral bones associated with the CNS, CSF flow, neural reflexes, neural pathways, and cranial nerves. The case is appropriate for use in a variety of human biology courses with an emphasis on anatomy and physiology, neuroscience, pathophysiology, or radiography.
NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE. Page 8 "I Was the Clumsy One" by Behmer, Ropp, & Shertzer Part IV - Second Opinion. In mid-April 2016, the neurosurgeon at JHH recommended having a full decompression surgery because the MRI illustrated poor improvement of the syrinx from the prior surgery.
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Question: NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE I Was the Clumsy One: Exploring the Central Nervous System through Type Chiari Malformation by Philomena M. Behmer, Stacy A. Ropp, and Angela Z. Shertzes Department of Science and Humanities Pennsylvania College of Health Sciences, Lancaster, PA In the cards Stary Popp a patient i Chiari malfermanos, as her
NATIONAL CENTER FOR CASE STUDY TEACHIN IN SCIENCE "I Was the Clumsy One" by Behmer, Ropp, & Shertzer Page 3. Figure 1. MRI image (A) depicts Stacy's spinal cord, which clinicians used to diagnose her with Chiari malformation. Image (B) is an MRI scan of a healthy spinal cord. The cerebellar location shown in (A)
The Clumsy Graduate Student. upper motor neuron. Click the card to flip 👆. a neuron whose cell body lies inthe motor area of the cerebral cortex or in certain brain stem nuclei (red nucleus, lateral and medial vestibular nuclei, pontine and medullary reticular formations, superior and inferior colliculi) Click the card to flip 👆. 1 / 26.
The main conflict in "The Clumsy One" is the protagonist's struggle to overcome their clumsiness and prove themselves in a world that values grace and skill. This internal conflict leads to ...
The main conflict in "The Clumsy One" is the protagonist's struggle to overcome their clumsiness and prove themselves in a world that values grace and skill.
Study with Quizlet and memorize flashcards containing terms like Kenny: Teenager with uncontrollable body and facial movements, odd spinning behaviors, and compulsions to touch objects and wash hands. Movements decreased with age but compulsions did not. What condition or conditions (there may be more than one possibility) are being described in this case? Does this involve brain damage, a ...
The Octopus wrapped its limber body around the rock. The grating noise from the street ended the meeting early. The scrappy youngster was not the teachers favorite. Study free ASVAB flashcards about ASVAB created by apontep to improve your grades. Matching game, word search puzzle, and hangman also available.
Clumsy one. While searching our database we found 1 possible solution for the: Clumsy one crossword clue. This crossword clue was last seen on May 23 2024 Thomas Joseph Crossword puzzle. The solution we have for Clumsy one has a total of 3 letters. Answer.
Study with Quizlet and memorise flashcards containing terms like Body system affected, Nutritional or genetic cause?, Affected biochemical pathway and others. Scheduled maintenance: June 29, 2024 from 11:00 PM to 12:00 AM