Child's Nervous System

, Volume 32, Issue 3, pp 527–530 | Cite as

Do the cerebellar tonsils move during flexion and extension of the neck in patients with Chiari I malformation? A radiological study with clinical implications

  • R. Shane TubbsEmail author
  • Christina M. Kirkpatrick
  • Elias Rizk
  • Joshua J. Chern
  • Rod J. Oskouian
  • W. Jerry Oakes
Original Paper



In the past, diagnosis of the Chiari I malformation has primarily been made on midsagittal MRI. We hypothesized that based on the frequent presentation of opisthotonos in patients with hindbrain hernia (primarily Chiari II malformation but sometimes Chiari I malformation) that the hyperextension might be a compensatory technique used by such patients to bring the cerebellar tonsils up out of the cervical spine.

Patients and methods

This prospective study reviewed imaging of patients with Chiari I malformation who underwent flexion/extension MRI for evaluation of their hindbrain herniation. Age-matched controls were used for comparison.


In general, there was elevation of the cerebellar tonsils with extension and increased descent with flexion of the cervical spine. In 72 % of patients, flexion of the neck resulted in descent of the cerebellar tonsils. In 64 % of patients, extension of the neck resulted in ascent of the cerebellar tonsils. In the 14 patients with an associated syrinx, 71 % were found to have caudal movement of the cerebellar tonsils with neck flexion, and only 43 % were observed to have any movement of the cerebellar tonsils in neck extension compared to patients without a syrinx where ascent of the tonsils was seen in only nine during neck extension. Two patients were observed to have the reverse finding of ascent of the cerebellar tonsils with neck flexion and descent of the cerebellar tonsils with neck extension. Five patients had no movement of the cerebellar tonsils in either flexion or extension of the neck, and one of these had a small syrinx.


Although minimal and not in all patients, we observed elevation of the herniated cerebellar tonsils with extension of the cervical spine in patients with Chiari I malformation. This finding provides evidence as to why some patients with hindbrain herniation present with opisthotonos and supports earlier findings that CSF flow is reduced at the craniocervical junction in flexion in patients with Chiari I malformation.


Chiari I malformation Tonsils Motion Movement Foramen magnum 


Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to report.


  1. 1.
    Tubbs RS, Griessenauer CJ, Hendrix P, Oakes P, Loukas M, Chern JJ, Rozzelle CJ, Oakes WJ (2015) Relationship between pharyngitis and peri-odontoid pannus: a new etiology for some Chiari I malformations? Clin Anat 28:602–607CrossRefPubMedGoogle Scholar
  2. 2.
    Cesmebasi A, Loukas M, Hogan E, Kralovic S, Tubbs RS, Cohen-Gadol AA (2015) The Chiari malformations: a review with emphasis on anatomical traits. Clin Anat 28:184–194CrossRefPubMedGoogle Scholar
  3. 3.
    Enzmann DR, Pelc NJ (1992) Brain motion: measurement with phase-contrast MR imaging. Radiology 185:653–660CrossRefPubMedGoogle Scholar
  4. 4.
    Cousins J, Haughton V (2009) Motion of the cerebellar tonsils in the foramen magnum during the cardiac cycle. AJNR Am J Neuroradiol 30:1587–1588CrossRefPubMedGoogle Scholar
  5. 5.
    Horsburgh A, Kirollos RW, Massoud TF (2014) No significant displacement of basal brain structures upon head movement: kinematic MRI morphometry relevant to neuroendoscopy. J Neurol Surg A Cent Eur Neurosurg 75:98–103CrossRefPubMedGoogle Scholar
  6. 6.
    Doursounian L, Alfonso JM, Iba-Zizen MT, Roger B, Cabanis EA, Meininger V, Pineau H (1989) Dynamics of the junction between the medulla and the cervical spinal cord: an in vivo study in the sagittal plane by magnetic resonance imaging. Surg Radiol Anat 11:313–322CrossRefPubMedGoogle Scholar
  7. 7.
    Ji S, Margulies SS (2007) In vivo pons motion within the skull. J Biomech 40:92–99CrossRefPubMedGoogle Scholar
  8. 8.
    Tachibana S, Iida H, Yada K (1992) Significance of positive Queckenstedt test in patients with syringomyelia associated with Arnold-Chiari malformations. J Neurosurg 76:67–71CrossRefPubMedGoogle Scholar
  9. 9.
    Bunc G, Vorsic M (2001) Presentation of a previously asymptomatic Chiari I malformation by a flexion injury to the neck. J Neurotrauma 18:645–648CrossRefPubMedGoogle Scholar
  10. 10.
    Tubbs RS, Oakes WJ (2013) The Chiari Malformations. Springer, New YorkCrossRefGoogle Scholar
  11. 11.
    Anderson RC, Emerson RG, Dowling KC, Feldstein NA (2011) Attenuation of somatosensory evoked potentials during positioning in a patient undergoing suboccipital craniectomy for Chiari I malformation with syringomyelia. J Child Neurol 16:936–939CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • R. Shane Tubbs
    • 1
    Email author
  • Christina M. Kirkpatrick
    • 1
  • Elias Rizk
    • 2
  • Joshua J. Chern
    • 3
  • Rod J. Oskouian
    • 4
  • W. Jerry Oakes
    • 5
  1. 1.Seattle Science FoundationSeattleUSA
  2. 2.Neurological SurgeryPenn State Hershey Medical CenterHersheyUSA
  3. 3.Pediatric Neurosurgery AssociatesChildren’s Healthcare of AtlantaAtlantaUSA
  4. 4.Swedish Neuroscience InstituteSeattleUSA
  5. 5.Pediatric NeurosurgeryChildren’s of AlabamaBirminghamUSA

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