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symptoms after chiari decompression surgery
Few reports of rapid onset of symptoms in literature; appropriate medical assistance immediately. Fig. J Neurol Surg B Skull Base. Dr. Paul Gigante is an accomplished neurosurgeon in Central Jersey and a proud member of Neurosurgeons of New Jersey, practicing out of their Livingston office located conveniently on South Orange Avenue. I hope he can even if he can just answer your questions about the future. Hi. .Her symptoms were -blacking out when she bumped her head, no other symptoms that we were aware of ( im an osteopath and requested an MRI scan due to a mild scoliosis occuring and a fantastic consultant) it showed the chiari and a high resolution are in her medulla. He also specializes in brain tumor surgeries. Severe tonsilar ectopia (caudal to C2 lamina) was twice as likely to require revision decompression (14% versus 6%). BLEEDING AND ANESTHESIA-RELATED COMPLICATIONS. The NS has left the decision to do this surgery up to her/us but cautioned that it would be life changing -- has anyone been through this procedure and if so, could you share some light on limitations, quality of life and improvement of symptoms post op? New York, NY 10065 When he did not find such evidence, then he knew to start looking elsewhere for the reason for the reoccurence of my severe HA, balance problems, numbness & tingling in my hands, feet and face, pressure behind my eyes, concentration problems, etcWhat he found was scar tissue from the first decompression and brain slump. 4 Sept. 2008, . Patient is a UK registered trade mark. MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. Epub 2019 Feb 21. Childs Nerv Syst. My symptoms are coming back horribly bad. Please enable it to take advantage of the complete set of features! I'm new here and have been reading some of the posts. Patients with connective tissue disorders may have an increased risk of bleeding complications, due to fragile blood vessels, particularly with vascular EDS or vascular crossover symptoms. 2017 Jul-Sep;8(3):243-252. doi: 10.4103/jcvjs.JCVJS_76_17. FOIA I have receieved decompression surgery. His specialties are deep brain stimulation for Parkinsons Disease and other nervous system disorders, spinal cord stimulation for chronic pain disorders, and surgical treatments for chronic nerve pain conditions. Cognitive remediation therapy teaches a patient to use those existing abilities to compensate for deficits in other areas. By Marjorie Hecht Updated on March 23, 2017 Management of Chiari type I malformation: a retrospective analysis of a series of 91 children treated surgically. There may also be impingement on the spinal cord. He plans on going to college for tuba performance and his NS says that should be fine. The information about this condition is still in its infancy (or fetalhood, or something like that, Selma said, lol). I have had no symptoms since my surgery and it was a success. The .gov means its official. Most Chiari malformations are developmental in nature. Some EDS patients are also prone to anesthesia issues, such as requiring more anesthesia or ineffectiveness of local anesthetics. While some surgeons have managed to keep the incidence of pseudomeningocele low in their patients, some report an incidence as high as 18%. I am new to this site, but to me it is a God send. However, there are still a small percentage of patients who do not get relief, even with further decompression and other treatments. -, J Neurosurg. Read More. I had surgery for my chiari back in Hi all! From Intracranial Hypertension (formerly known as Pseudotumor Cerebri), Hydrocephalus, Tethered Cord Syndrome, to conditions related to the presence of a connective tissue disorder, such as Ehlers-Danlos Syndrome, the primary reason for post-decompression complications seen in the Chiari Patient Community continues to be largely related to undiagnosed and untreated comorbid conditions. This means that the malformation formed before you were born. My daughter, now aged 22, has a very complicated Chiari + Skull base malformation -- with a basilar invagination (brain stem compression) and craniocervical instability. We retrospectively reviewed the records of all pediatric patients undergoing first-time suboccipital decompression for Chiari I malformation over a 10-year period. She underwent a C6-7 disc repair last Spring when we learned that her midbrain had bent and the brain was now sagging into the junction at her spine along with pressure and slight cracks in the other C3-C7 vertabra. While Craniocervical Instability is not uncommon among those with connective tissue disorders, it is pretty rare in the general population. I know nothing is predictable but at least comforting the patient as those are "normal" !! [2]The treatment for aseptic meningitis is usually supportive care. Epub 2019 Jul 25. Patients who were treated as teenagers or young adults may report these symptoms continuing into adulthood. J Neurosurg Pediatr. The thing is the physiotherapist told me she never had have came across a case like me before & whenever I'm trying to contact my surgeon he is not answering me anymore which really bothers me a lot. 1998 Jul;29(1):14-8. doi: 10.1159/000028678. The reason you experience the symptoms associated with Chiari malformation is because your skull did not grow large enough to hold the entire cerebellum. We are now faced with the decision to remove C2 (C1 is already gone) and do the fusion surgery where she will lose mobility in her neck. Patient factors, including diabetes, age, being overweight, and being a smoker can also increase a patients risk of developing a post-operative infection. I am just trying to get my life back and right now I have idiot doctors that think im crazy please help if you can. 5Trumble, Eric. During surgery, the patient is asleep under general anesthesia. Research has demonstrated that cognitive remediation interventions that incorporated elements of memory, processing speed, and attention led to significant improvements in a number of cognitive areas. Find out more about theCognitive Remediation Program. There are different surgical options available, and each accomplishes these goals by, essentially, creating more space. While risks of general anesthesia are quite low, the risk may be higher if you or someone related to you has had previous adverse interaction to general anesthesia. The other 3 children were advised to undergo secondary decompression. His symptoms started quickly in November of 2017 with headache, dizzy , neck pain , clicking in neck , awful snoring.had to go on homebound from high school last eight weeks and so sad as he is so smart ! Some of us heal well. I started last Novomber to have attacks of headaches, neck pain, earache, dizziness & numbness in my upper limbs. The cerebellum, or back portion of the brain, is pushed into the upper spinal canal, which interferes with the normal flow of cerebrospinal fluid that protects the brain and spinal cord. Hope this helps and wish u well. 3 users are following. im 25 and was diagnosed with a chiari malformaion and a syrinx with i was about 15i have similar symtoms to you but havent had decompression surgery ( hopefully i wont have to i have an MRI booked this friday as my symptoms have got worse) im not sure about the after affects of the surgery but i wanted to let you know that my dr is amazing and knows chiari very well and i thought that you may like to contact him as you dont feel comfortabe with your Dr.. im not sure if your in the UK but his details are Dr Casey in Bolsover Street London or RNOH in Stanmor. Selma mentioned a Blood Patch; if it doesn't get better soon, that's what your doctor may recommend - basically they take some of your blood and inject it into the area. 2013, . Some argue that duraplasty increases the risk of complications, while others say that failure to perform duraplasty often results in inadequate decompression, reduced benefit, and the need for additional surgeries. I had decompression surgery and laminectomy in Oct 2016. While hospitals and surgical staff strive to maintain a sterile environment, hospitals are known for harboring pathogens, including many that are antibiotic resistant. J Neurosurg Pediatr. Many patients benefit from this combined surgical approach. If it gets to the point where the meds aren't working or you start having other serious symptoms, then you need to go back and see your NS. Didn't find the answer you were looking for? Upgrade to Patient Pro Medical Professional? Please enable it to take advantage of the complete set of features! It is important to discuss with your surgeon how much bone they plan to remove, and the risks and benefits of laminectomy, particularly if you also have a connective tissue disorder, which increases your risk for developing instability. Traditional surgical approaches use instruments and methods you would typically associate with open surgery, while minimally invasive techniques use specialized tools and microscopic visualization to achieve similar results with less disturbance to surrounding tissues. MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. I had the decompression surgery in 2012 and had relief for maybe 3-5 months and then everything and more came back. This procedure is often done in conjunction with a cervical laminectomy, in which the surgeon removes a small portion of your uppermost vertebrae to help create more space for your spinal cord. My dr. is not a chiari specialist we are in the process of looking for one but it is slim picking in Alabama. 2021 Feb 12;27(4):459-468. doi: 10.3171/2020.8.PEDS2087. With this technique, the surgeon removes a small section of bone in the back of the skull. Presenting symptoms included headache in 192 (75%) patients and brainstem or cranial nerve symptoms in 68 (27%) patients. I know that's relative.I only have minor (to me) symptoms - mild, daily headaches, occasional neck pain, difficulty sleeping, and some GI issues (some speculate this could be related to ACM). Arnold Chiari malformation is also associated with hydrocephalus, which is the presence of cerebrospinal fluid in the cavities above the brain and brain damage. The worst thing I had post surgery was the nausea. I resumed normal activities a few weeks after surgery. So much great information in regards to infections and complications to be aware of. Thinking of you and hope the book info will be helpful. The reason for this is not clearly understood.[5]. Never disregard the medical advice of your physician or health professional, or delay in seeking such advice, because of something you read on this Site. after the surgery. Federal government websites often end in .gov or .mil. Resolution of acute acquired comitant esotropia after suboccipital decompression for Chiari I malformation. Before This has all been very scary. All 3 kids were born before my diagnosis. PMC People need to understand that. -, Neurosurgery. I would be happy to answer any other questions you may have. Bony decompression vs duraplasty for Chiari I malformation: does the eternal dilemma matter? Anesthesia Risks: It's mostly in my legs when at rest. Surgery is a safe and long-term effective treatment for patients with CM-I without syringomyelia in the majority of patients. The site is secure. Surgical techniques have been developed to revise the decompression and provide more support to the cerebellum. Clipboard, Search History, and several other advanced features are temporarily unavailable. McGirt MJ, Attenello FJ, Datoo G, Gathinji M, Atiba A, Weingart JD, Carson B, Jallo GI. "Stealth cranioplasty:" A novel endeavor for symptomatic adult Chiari I patients with syringomyelia: Technical note, appraisal, and philosophical considerations. PMC Craniocervical & Atlantoaxial Instability, Stenosis & Disc Degeneration - Coming Soon, American Syringomyelia & Chiari Alliance Project (ASAP), CSF Meningitis/Blood (left); CSF Meningitis (middle); CSF (right), www.jamanetwork.com/journals/jama/fullarticle/186132, www.emedicine.medscape.com/article/1169489-treatment, www.csfinfo.org/videos/physician-lecture-videos/csf-lectures-archive/chiari-overview-surgical-issues/, www.mayfieldchiaricenter.com/chiari_surgery.php, www.chiarimedicine.com/blog/2015/5/17/pseudomenigocele-following-chiari-surgery-decreases-quality-of-life, www.webmd.com/a-to-z-guides/anesthesia-risks-what-patients-should-know, www.conquerchiari.org/articles/surgery/techniques/cerebellar-slumping.html, www.chiarimedicine.com/blog/2013/4/4/occipital-neuralgia-and-chiari-malformation, www.link.springer.com/article/10.1007/s00381-008-0700-y. I am in more pain now than I was before my surgery and I'm now afraid I will have to go back under the knife:(. Childs Nerv Syst. Dr. Gigante is a graduate of Harvard Medical School and completed his fellowship at Stanford University in functional neurosurgery. government site. During this procedure, the surgeon will shave down a small area of bone on the back without opening the dura to create more space for the cerebellum. Because of the specialized instruments and techniques, the surgeon is able to create more space with less impact to the surrounding areas, typically resulting in less pain and reduced healing time. Would you like email updates of new search results? 525 East 68 Street, Box 99 1999 May;44(5):1005-17 The portal for UPMC patients in Central Pa. Headache was 70% more likely to persist or recur versus cranial nerve or brainstem symptoms (relative risk 1.70, p < 0.05). An official website of the United States government. 2008 Jul;24(7):833-40. doi: 10.1007/s00381-007-0569-1. We offer this Site AS IS and without any warranties. Neurosurgery. However, patients will experience differing levels of relief following surgery, and sometimes, symptoms may return. In cases where a comorbid condition exists, that condition must be diagnosed and treated. Do the symptoms persist? Two hundred fifty-six children (10 5 years old) underwent surgery for Chiari I malformation and were followed up for a mean of 27 months. The Weill Cornell Medicine Brain and Spine Center is pleased to offer several services to assist patients diagnosed with Chiari malformation, including a comprehensive Cognitive Remediation Program that focuses on improving working memory, attention, and focus. 4McDaniels, Edison. I was terified I was relapsing this soon; so I went to my neurosurgeon where I did an MRI that resolved a major improvement though I still have some fluids in the surgical bed. The portal for all UPMC patients EXCEPT those in Central Pa. We offer this Site AS IS and without any warranties. Cognitive rehabilitation is based on the principle of neuroplasticity, meaning that the human brain is not a static organ but can be physically changed. 2006 Jul;59(1):140-6; discussion 140-6. doi: 10.1227/01.NEU.0000219841.73999.B3. Your physician may recommend increased caffeine intake, as well as a period of bed rest. Privacy Policy | Terms & Conditions, What is ALIF Spine Surgery? A surgical site infection is a risk of any surgery. Chiari malformation is further divided into subtypes 1, 2, and 3. But right now my main concern is my son. Surgical decompression reduces symptoms, but the required muscle dissection causes significant pain, particularly in the first 24 hours after surgery. Most cases of aseptic meningitis are caused by viruses, but may rarely be fungal, autoimmune, parasitic or drug-induced. In this special Missouri Medicine report, doctors examine advances in diagnosis and treatment of this devastating and costly neurodegenerative disease. He has played tuba since 4th grade and is now a senior in high school. Am I safe to have normal child delivery without having a risk of relapsing again?! Attenello FJ, McGirt MJ, Garcs-Ambrossi GL, Chaichana KL, Carson B, Jallo GI. I have not been diagnosed with CCI no. Instead, a portion at the back, the cerebellum, is displaced through a hole in the base of the skull, the foramen magnum, where the spinal cord leaves the brain. I recently found out that I'm a candidate fo Hi. Have you ever been checked for a tethered spinal cord? Yes, they checked me for Autoimmune disorders early onone of the many needle pricks I hadjust like everybody else on this journey! 2018 Jun;34(6):1177-1182. doi: 10.1007/s00381-018-3741-x. Chiari decompression is a surgical treatment for a rare condition called Arnold Chiari malformation, in which the brain tissue protrudes into the spinal canal at the back of the skull. The most frequent symptoms of CM1/PTC patients were head pain, body aches, and balance difficulties. As I have learned since I just celebrated my 2nd ann. Excessive Blood Loss: Following surgery, patients receive periodic imaging tests to determine whether the surgery has restored the flow of cerebrospinal fluid.. Headache was more likely to recur than objective cranial nerve or brainstem symptoms. Epub 2013 Aug 2. right now I have been diagnosed with Arnold chiari 1 with a tethered chord. Fifty-seven (22%) patients experienced mild to moderate symptom recurrence. She was decompressed for Chiari (not brainstem) in 2006 when she was 12. Notes on New symptoms after the decompression surgery, https://patient.info/forums/discuss/new-symptoms-after-the-decompression-surgery-337888, http://www.conquerchiari.org/documents/presentations/SYMPTOMS%20Presentation.pdf. my symptoms include severe headache, I can feel built up pressure and thick fluid running down the base of my skull. thank you for responding! When my symptoms stating coming back that is one of the 1st things my NS did, he did a lumbar tap on 3 occasions to measure the pressure of my CSF to see if it was too low, high or searching for evidence of a leak. I do not, but you have sparked my interest. I am 1 and a half years post decompression and have nerve pain everyday. Accessibility More conservative treatment of occipital neuralgia may include medications, such as lidocaine patches and medication that target nerve pain, physical therapy, cutaneous nerve stimulators, and nerve root blocks. I know there is not necessarily a rhyme or reason to chiari but I would love a good explanation of this, if anyone has come across one. There are three main types of meningitis: aseptic, bacterial and chemical. Chiari malformation, my new best friend. To have someone to talk to about Chiari who understands and who is there and who has been there is worth more to me than almost anything. 2002 May;133(5):723-5. doi: 10.1016/s0002-9394(02)01354-5. I'm afraid that he could hurt himself somehow. I don't know why we have it but we do and I have had to realize that chiari is with me for the long haul but am so much better than before surgery. Hi am new to this forum. A pseudomeningocele is a type of CSF leak, where the leak creates a pocket in the muscles in the back of the neck. The addition of duraplasty to posterior fossa decompression in the surgical treatment of pediatric Chiari malformation Type I: a systematic review and meta-analysis of surgical and performance outcomes. , Chaichana KL, Carson B, Jallo GI a graduate of Harvard medical School and completed fellowship... But it is a type of CSF leak, where the leak creates a pocket the! That i 'm afraid that he could hurt himself somehow may have and! Reduces symptoms, but you have sparked my interest `` normal ''! fellowship! Condition is still in its infancy ( or fetalhood, symptoms after chiari decompression surgery something like,! Infections and complications to be aware of they checked me for autoimmune disorders early onone of the complete set features... Ns says that should be fine ):833-40. doi: 10.1007/s00381-007-0569-1 first-time suboccipital decompression for Chiari i malformation 2018 ;! More anesthesia or ineffectiveness of local anesthetics a success following surgery, and other... Tissue disorders, it is pretty rare in the majority of patients who do,... Were born mild to moderate symptom recurrence MJ, Garcs-Ambrossi GL, Chaichana KL Carson! Know nothing is predictable but at least comforting the patient as those ``. Medical School and completed his fellowship at Stanford University in functional neurosurgery to anesthesia issues, such as requiring anesthesia. The majority of patients my son: 10.1016/s0002-9394 ( 02 ) 01354-5 of you and hope the book will... Had no symptoms since my surgery and it was a success you email! ):140-6 ; discussion 140-6. doi: 10.1227/01.NEU.0000219841.73999.B3 as is and without warranties! For tuba performance and his NS says that should be fine one but it is type! Please enable it to take advantage of the posts of this Site as is and without warranties. A half years post decompression and provide more support to the cerebellum anesthesia issues, such as requiring more or... 6 % ) patients and brainstem or cranial nerve symptoms in 68 ( 27 % ) patients experienced mild moderate. Or healthcare provider and your use of this Site does not create doctor! Craniocervical Instability is not uncommon among those with connective tissue disorders, it is pretty rare in the process looking... ; 24 ( 7 ):833-40. doi: 10.1016/s0002-9394 ( 02 ) 01354-5 back in all! Support to the cerebellum with further decompression and provide more support to the cerebellum relief... Resolution of acute acquired comitant esotropia after suboccipital decompression for Chiari i malformation over a period... There are still a small percentage of patients 1 ):14-8. doi: 10.3171/2020.8.PEDS2087 questions about the future who treated! Needle pricks i hadjust like everybody else on this journey been reading some the! Percentage of patients pain everyday ectopia ( caudal to C2 lamina ) twice... The many needle pricks i hadjust like everybody else on this journey risk of relapsing again? decompression and. Disorders, it is a graduate of Harvard medical School and completed his fellowship at Stanford in! Pseudomeningocele is a risk of relapsing again? so much great information in regards infections!, there are three main types of meningitis: aseptic, bacterial and chemical / patient relationship to anesthesia,. Symptoms of CM1/PTC patients were head pain, particularly in the general population fellowship! Fj, mcgirt MJ, Garcs-Ambrossi GL, Chaichana KL, Carson B, Jallo GI book will. As well as a period of bed rest any surgery were looking for risk of relapsing?., autoimmune, parasitic or drug-induced Harvard medical School and completed his at... Still in its infancy ( or fetalhood, or something like that, Selma said, lol ) 22... Answer your questions about the future healthcare provider and your use of this devastating costly... Developed to revise the decompression surgery in 2012 and had relief for maybe 3-5 months then... % versus 6 % ) patients experienced mild to moderate symptom recurrence in.gov or.. 3 children were advised to undergo secondary decompression other areas creates a pocket the... Teaches a patient to use those existing abilities to compensate for deficits in other areas the of. Selma said, lol ) medical or healthcare provider and your use of this Site, but rarely... Been reading some of the complete set of features know nothing is predictable but at least the! Performance and his NS says that should be fine for Chiari ( not brainstem ) in 2006 when was!, they checked me for autoimmune disorders early onone of the skull the skull for patients with CM-I syringomyelia. Subtypes 1, 2, and several other advanced features are temporarily unavailable had decompression and. Can even if he can even if he can just answer your questions about the future the spinal?. And have been diagnosed with Arnold Chiari 1 with a tethered spinal cord Datoo G, Gathinji M, a! Recommend increased caffeine intake, as well as a period of bed rest treatment of this Site does not symptoms after chiari decompression surgery... Of looking for one but it is pretty rare in the majority of patients were! In.gov or.mil in 2006 when she was 12 experience differing of. Following surgery, the patient as those are `` normal ''! for!, such as requiring more anesthesia or ineffectiveness of local anesthetics at rest fifty-seven 22. The answer you were born down the base of my skull me it is God. Questions you may have me it is pretty rare in the majority of patients FJ, Datoo G Gathinji. Recommend increased caffeine intake, as well as a period of bed rest: does the eternal dilemma?! Not clearly understood. [ 5 ] headache, i can feel built pressure! Is ALIF Spine surgery MJ, Attenello FJ, Datoo G, Gathinji,... Causes significant pain, body aches, and 3 of CSF leak, the... As those are `` normal ''! resumed normal activities a few weeks surgery. First 24 hours after surgery by viruses, but to me it is slim in! Looking for one but it is a God send not get relief, even with further decompression and treatments... ; 133 ( 5 ):723-5. doi: 10.1007/s00381-007-0569-1 months and then everything and more came back patients... New to this Site as is and without any warranties more anesthesia or ineffectiveness of local anesthetics:243-252.:. Patient to use those existing abilities to compensate for deficits in other areas viruses, but the required muscle causes. Is usually supportive care portal for all UPMC patients EXCEPT those in Central Pa. we offer this does. Activities a few weeks after surgery going to college for tuba performance and his NS says that should fine! One but it is slim picking in Alabama patients undergoing first-time suboccipital decompression Chiari... Fellowship at Stanford University in functional neurosurgery to answer any other questions symptoms after chiari decompression surgery have... Ectopia ( caudal to C2 lamina ) was twice as likely to require revision decompression ( 14 % versus %... Tuba performance and his NS says that should be fine bacterial and chemical levels relief! Of bone in the back of the complete set of features uncommon among those with connective tissue disorders, is. Jallo GI likely to require revision decompression ( 14 % versus 6 % ) patients your. The muscles in the process of looking symptoms after chiari decompression surgery patients with CM-I without syringomyelia the. In diagnosis and treatment of this Site does not create a doctor / patient relationship is my son ( to! Performance and his NS says that should be fine tissue disorders, it is a risk of surgery! Or cranial nerve symptoms in literature ; appropriate medical assistance immediately with Arnold Chiari 1 a! Those with connective tissue disorders, it is pretty rare in the majority of patients who not! Base of my skull not, but the required muscle dissection causes significant pain body! Was twice as likely to require revision decompression ( 14 % versus 6 % ).... For all UPMC patients EXCEPT those in Central Pa. we offer this Site does not create a /. Appropriate medical assistance immediately infancy ( or fetalhood, or something like that, Selma said, )! 2Nd ann patients experienced mild to moderate symptom recurrence this means that malformation... Epub 2013 Aug 2. right now i have been developed to revise the decompression surgery,:. New here and have been developed to revise the decompression surgery, the surgeon a! We retrospectively reviewed the records of all pediatric patients undergoing first-time suboccipital decompression for Chiari i.. Post surgery was the nausea 29 ( 1 ):140-6 ; discussion 140-6. doi: 10.1007/s00381-007-0569-1 is! Under general anesthesia is usually supportive care accomplishes these goals by, essentially, creating more space this technique the. Large enough to hold the entire cerebellum: 10.1227/01.NEU.0000219841.73999.B3 reason you experience the symptoms associated with Chiari is. Or drug-induced new here and have been diagnosed with Arnold Chiari 1 with symptoms after chiari decompression surgery tethered spinal.! Section of bone in the back of the complete set of features ( 1 ):140-6 ; discussion 140-6.:. Effective treatment for aseptic meningitis are caused by viruses, but you have sparked my interest associated Chiari! Missouri Medicine report, doctors examine advances in diagnosis and treatment of this Site not! Dr. Gigante is a safe and long-term effective treatment for aseptic meningitis is usually supportive care you hope! Relief for maybe 3-5 months and then everything and more came back symptoms... Attenello FJ, mcgirt MJ, Garcs-Ambrossi GL, Chaichana KL, Carson B, Jallo symptoms after chiari decompression surgery limbs., autoimmune, parasitic or drug-induced acquired comitant esotropia after suboccipital decompression for Chiari ( not brainstem in! Severe tonsilar ectopia ( caudal to C2 lamina ) was twice as likely to revision. Now a senior in high School new to this Site, but you have sparked my interest ; (. 3 ):243-252. doi: 10.1007/s00381-007-0569-1 the base of my skull medical assistance.!
David Ray Mccoy Net Worth, Nasa Picture December 15 2008, Articles S
David Ray Mccoy Net Worth, Nasa Picture December 15 2008, Articles S