If it is a type 1, they will probably grant him a medical certificate. Here is an article from the latest Federal Air Surgeon's Bulletin:
Chiari I Malformation
Case Report
By Nicole Powell-Dunford, MD, MC FS
History
A 51-YEAR-OLD, third-class airman
with 50 flight hours developed a
“new onset” headache and neck strain
with exercise. His headaches were frontal
in nature and increased in severity
with core body training exercises such
as push ups and sit-ups, which the
aviator performed while training for
a “half-iron” triathlon. The airman
also reported mild neck discomfort
and occasional photophobia.
On further questioning, he admitted
to mild headache symptoms for
years, which he had ignored until
recently, when exercise caused the
symptoms to worsen. Most recently,
the airman had experienced exceptionally
severe bilateral retro orbital pain,
which was associated with marked
photophobia, prompting him to seek
medical attention.
Neurological examination was
normal. An MRI revealed a 1.4 cm
tonsillar herniation consistent with
a Chiari I malformation. There was
no associated syrinx or mylomeningocele.
This aviator underwent uncomplicated
surgical decompression in
June 2008 with C1 laminectomy
and duraplasty. He had an uncomplicated
post- operative recovery with
full resolution of headaches and
normal post- operative neurological
examinations.
Aeromedical Concerns
Pre-operatively, the aeromedical
concerns of a Chiari I malformation
stem from symptomatic compression.
Headache, photophobia, urinary
frequency, lower extremity spasticity,
and neck pain are typical Chiari
I symptoms.1
Pain from headaches can significantly
distract from performance of
flight duties. Photophobia interferes
with adequate visual scan and collision
avoidance. Neck pain leads to a reduction
in visual scan range, as well as
distraction from flight duties.
Although not experienced by our
airman, sleep interference symptoms
secondary to either pain symptoms or
central sleep apnea can contribute to
daytime somnolence. Although less
common than other symptoms, severe
sleep apnea symptoms are experienced
by nearly a quarter of adult Chiari
malformation.2
Urinary frequency is a common
symptom of Chiari I malformation
and can be very distracting, especially
when leading to a requirement for inflight
symptom relief in a confined
area. Lower extremity spasticity can
adversely affect pedal inputs to the
rudder system, causing unpredictable
flight.
To address in-flight impairment
in an aviator with mild symptoms
who has declined surgery, the aviation
medical examiner (AME) must
consider the potential for symptom
exacerbation with physical exertion.
These exacerbations may be more likely
to occur with stressful events such
as in-flight emergencies, leading to
potentially catastrophic outcomes.
Syncope and cardiac arrest attributable
to Chairi I malformations
have also been occasionally reported
in the medical literature1, both of
which conditions have significant
flight safety implications.
Aeromedical concerns following
neurosurgical intervention include the
potential for focal neurological deficits
from parenchymal trauma, deep venous
thrombosis, pulmonary embolism,
atelectasis, infection, and seizure.
Rare complications include pneumocephalus
and CSF fistula.3 The
risk for sudden incapacitation while
at the flight controls with any of
these post-operative complications is
obvious. Relative hypoxia at altitude
may further exacerbate post-operative
complications such as pulmonary embolism,
pneumonia and/or atelectasis,
while gas expansion with altitude can
cause sudden deterioration of an unrecognized
pneumocephalus.
Role of the AME
AMEs are charged to determine
whether airmen meet physical standards
for aviation duties, as annotated
in Title 14 of the Code of Federal
Regulations (CFR) part 67.4 The
ability of airmen to satisfactorily perform
duties is paramount to aviation
safety. The Guide for Aviation Medical
Examiners5 outlines the standard
examination procedures that should
be used to evaluate the applicant’s
neurological system.
A neurologic evaluation should
consist of a thorough review of the
applicant’s history prior to the actual
neurological examination. The AME
should specifically inquire concerning
a history of weakness or paralysis,
disturbance of sensation, loss of coordination,
or loss of bowel or bladder
control.
Certain laboratory studies, such as
scans and imaging procedures of the
head or spine, electroencephalograms,
or spinal paracentesis, may suggest
significant medical history.6 These
studies are not generally requested
by the AME.
Recall from your AME seminar legal lectures that there
is no physician-patient relationship between an AME and
the airman applicant; however, requesting tests and/or
prescribing treatment could change that relationship. You
must note (in Item 60 of FAA Form 8500-8) any condition
found in the course of the examination: facts—dates,
frequency, and severity of occurrence, along with any
established diagnosis.5
Until this case, no previous applicant with Chiari
syndrome had ever presented to an AME for certification
or recertification, and Chiari malformations are not specifically
referenced within the AME Guide. However, the Guide
does state that “a history or the presence of any neurological
condition or disease that potentially may incapacitate an
individual” should be regarded as disqualifying.6
Outcome
Due to the unique nature of his condition, this airman’s
case underwent a formal review by the Federal Aviation
Administration’s neurology consultant. Based upon an
uncomplicated recovery, full resolution of symptoms, and
a normal neurological examination, he was recertified for
full flight duties following surgical decompression after 90
post-operative days.
References
1. Goetz CW. Textbook of clinical neurology, 3rd ed.2007. www1.
Devereaux, M.W. Anatomy and examination of the spine. Neurol
Clin, May 2007; 25 (2):331.
2. Dauvilliers Y. Chairi malformation and sleep related breathing
disorders. J Neurol Neurosurg Psychiatry, Dec 2007; 78(12):
1344-8.
3. Cummings CW. Otolaryngology: Head & neck surgery, 4th ed.
2005 Mosby.
4. 14 CFR, part 67. Medical standards and certification.
www.faa.
gov/about/office_org/headquarters_offices/avs/offices/aam/
ame/guide/standards/. Accessed 13 Nov 2008.
5. Guide for Aviation Medical Examiners. Application process for
medical certification.
www.faa.gov/about/office_org/headquarters_
offices/avs/offices/aam/ame/guide/app_process/exam_
tech/. Accessed 12 Nov 2008.
6. Aerospace medical considerations, Item 46 Neurologic. www.
faa.gov/about/office_org/headquarters_offices/avs/offices/aam/
ame/guide/app_process/exam_tech/item46/amd/. Accessed 12
Nov 2008.
