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Moncho D, Poca MA, Rahnama K, Sánchez Roldán MÁ, Santa-Cruz D, Sahuquillo J. The Role of Neurophysiology in Managing Patients with Chiari Malformations. J Clin Med 2023; 12:6472. [PMID: 37892608 PMCID: PMC10607909 DOI: 10.3390/jcm12206472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Chiari malformation type 1 (CM1) includes various congenital anomalies that share ectopia of the cerebellar tonsils lower than the foramen magnum, in some cases associated with syringomyelia or hydrocephalus. CM1 can cause dysfunction of the brainstem, spinal cord, and cranial nerves. This functional alteration of the nervous system can be detected by various modalities of neurophysiological tests, such as brainstem auditory evoked potentials, somatosensory evoked potentials, motor evoked potentials, electromyography and nerve conduction studies of the cranial nerves and spinal roots, as well as brainstem reflexes. The main goal of this study is to review the findings of multimodal neurophysiological examinations in published studies of patients with CM1 and their indication in the diagnosis, treatment, and follow-up of these patients, as well as their utility in intraoperative monitoring.
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Affiliation(s)
- Dulce Moncho
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Maria A. Poca
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Kimia Rahnama
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
| | - M. Ángeles Sánchez Roldán
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
| | - Daniela Santa-Cruz
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
| | - Juan Sahuquillo
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
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Post-traumatic syringomyelia resolution following surgical treatment: the moniliform syrinx with a better prognosis. Acta Neurol Belg 2023:10.1007/s13760-023-02233-x. [PMID: 36930392 DOI: 10.1007/s13760-023-02233-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Post-traumatic syringomyelia (PTS) presented as a serious delayed complication after spinal cord injury (SCI). In our preliminary pathological investigation of PTS in an animal model, the endogenous repair was activated during the early stage of the central canal expansion. We thought about whether there might be an "early syringomyelia state" with a better outcome. OBJECTIVE This study aimed to further understand the pathophysiological basis of PTS's occurrence, development, and outcome. MATERIALS AND METHODS A cross-sectional observational study from a single-center syringomyelia database prospectively maintained at China International Neuroscience Institute (CHINA-INI). A consecutive series of 28 PTS patients at our institution for surgical treatment met the inclusion criteria of this study. Their clinical and imaging data in a long-term follow-up were reviewed retrospectively. We compared the surgical outcome between moniliform and distended syringomyelia based on high‑resolution MRI and syringomyelia-related symptoms. American Spinal Injury Association (ASIA) impairment scale (AIS) grade to assess their neurological status. RESULTS Through a series of phenotypic comparisons, we found that moniliform-like syrinx belongs to a special morphological state with a shorter natural history. The patients in the moniliform group had a better surgical outcome compared with those in the distended group (P = 0.028): more obvious symptom improvement as shown in Kaplan-Meier analysis (P = 0.033, Chi square = 4.523) and a higher syringomyelia resolution rate (P = 0.024). CONCLUSION We consider the delayed post-traumatic syringomyelia with moniliform type with a better surgical outcome and emphasize the importance of timely intervention to restore cerebrospinal fluid circulation.
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Heiss JD. Cerebrospinal Fluid Hydrodynamics in Chiari I Malformation and Syringomyelia: Modeling Pathophysiology. Neurosurg Clin N Am 2023; 34:81-90. [PMID: 36424067 PMCID: PMC9708110 DOI: 10.1016/j.nec.2022.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anatomic MRI, MRI flow studies, and intraoperative ultrasonography demonstrate that the Chiari I malformation obstructs CSF pathways at the foramen magnum and prevents normal CSF movement through the foramen magnum. Impaired CSF displacement across the foramen magnum during the cardiac cycle increases pulsatile hindbrain motion, pressure transmission to the spinal subarachnoid space, and the amplitude of CSF subarachnoid pressure waves driving CSF into the spinal cord. Central canal septations in adults prevent syrinx formation by CSF directly transmitting its pressure wave from the fourth ventricle to the central canal.
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Affiliation(s)
- John D Heiss
- Clinical Unit, Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, MSC-1414, Bethesda, MD 20892, USA.
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Abstract
In the pre-MR era syringomyelia often presented late, as a crippling neurological disorder. Today, most cases are diagnosed earlier, with less pronounced deficits. We are therefore presented with new challenges, including understanding the significance of various presenting symptoms, knowing when surgery might help and being aware of other treatments that could benefit someone living with the effects of syringomyelia, or its underlying cause.
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Affiliation(s)
- Graham Flint
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
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Young BA, Adams J, Beary JM, Mardal KA, Schneider R, Kondrashova T. Variations in the cerebrospinal fluid dynamics of the American alligator (Alligator mississippiensis). Fluids Barriers CNS 2021; 18:11. [PMID: 33712028 PMCID: PMC7953579 DOI: 10.1186/s12987-021-00248-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/04/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Studies of mammalian CSF dynamics have been focused on three things: paravascular flow, pressure and pulsatility, and "bulk" flow; and three (respective) potential motive forces have been identified: vasomotor, cardiac, and ventilatory. There are unresolved questions in each area, and few links between the different areas. The American alligator (Alligator mississippiensis) has pronounced plasticity in its ventilatory and cardiovascular systems. This study was designed to test the hypothesis that the greater cardiovascular and ventilatory plasticity of A. mississippiensis would result in more variation within the CSF dynamics of this species. METHODS Pressure transducers were surgically implanted into the cranial subarachnoid space of 12 sub-adult alligators; CSF pressure and pulsatility were monitored along with EKG and the exhalatory gases. In four of the alligators a second pressure transducer was implanted into the spinal subarachnoid space. In five of the alligators the CSF was labeled with artificial microspheres and Doppler ultrasonography used to quantify aspects of the spinal CSF flow. RESULTS Both temporal and frequency analyses of the CSF pulsations showed highly variable contributions of both the cardiac and ventilatory cycles. Unlike the mammalian condition, the CSF pressure pulsations in the alligator are often of long (~ 3 s) duration, and similar duration CSF unidirectional flow pulses were recorded along the spinal cord. Reduction of the duration of the CSF pulsations, as during tachycardia, can lead to a "summation" of the pulsations. There appears to be a minimum duration (~ 1 s) of isolated CSF pulsations. Simultaneous recordings of cranial and spinal CSF pressures reveal a 200 ms delay in the propagation of the pressure pulse from the cranium to the vertebral canal. CONCLUSIONS Most of the CSF flow dynamics recorded from the alligators, are similar to what has been reported from studies of the human CSF. It is hypothesized that the link between ventilatory mechanics and CSF pulsations in the alligator is mediated by displacement of the spinal dura. The results of the study suggest that understanding the CSF dynamics of Alligator may provide unique insights into the evolutionary origins and functional regulation of the human CSF dynamics.
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Affiliation(s)
- Bruce A Young
- Department of Anatomy, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, 63501, USA.
| | - James Adams
- Department of Anatomy, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, 63501, USA
| | - Jonathan M Beary
- Behavioral Neuroscience, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, 63501, USA
| | | | - Robert Schneider
- Family Medicine, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, 63501, USA
| | - Tatyana Kondrashova
- Family Medicine, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, 63501, USA
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Factors associated with postoperative axial symptom after expansive open-door laminoplasty: retrospective study using multivariable analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2838-2844. [PMID: 32524286 DOI: 10.1007/s00586-020-06494-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 04/30/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of the present study was to investigate the factors associated with axial symptom using multivariable analysis. METHODS The authors retrospectively assessed 249 patients treated by open-door laminoplasty. The patients were classified into two groups: axial symptom and no axial symptom group. The possible factors included demographic variables (age, sex, BMI, smoking, heart disease, diabetes, preoperative neck pain, preoperative JOA scores, preoperative NDI, course of disease and pathogenesis) and surgical and radiological variables [operation time, intraoperative blood loss, collar wear time, preoperative cervical curvature, postoperative cervical curvature, T1 slope, preoperative and postoperative C2 sagittal vertical axis (C2 SVA)]. RESULTS The prevalence of axial symptom was 34.9% (89/249). The collar wear time, preoperative and postoperative C2 SVA were risk factors for axial symptom. A cutoff value of 22.6 mm for preoperative C2 SVA and 3.5 weeks for collar wear time predicted the development of axial symptom. CONCLUSIONS The longer collar wear time, larger preoperative and postoperative C2 SVA were positively correlated with the higher incidence of axial symptom.
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Bertram CD, Heil M. A Poroelastic Fluid/Structure-Interaction Model of Cerebrospinal Fluid Dynamics in the Cord With Syringomyelia and Adjacent Subarachnoid-Space Stenosis. J Biomech Eng 2017; 139:2552971. [PMID: 27617710 DOI: 10.1115/1.4034657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Indexed: 11/08/2022]
Abstract
An existing axisymmetric fluid/structure-interaction (FSI) model of the spinal cord, pia mater, subarachnoid space, and dura mater in the presence of syringomyelia and subarachnoid-space stenosis was modified to include porous solids. This allowed investigation of a hypothesis for syrinx fluid ingress from cerebrospinal fluid (CSF). Gross model deformation was unchanged by the addition of porosity, but pressure oscillated more in the syrinx and the subarachnoid space below the stenosis. The poroelastic model still exhibited elevated mean pressure in the subarachnoid space below the stenosis and in the syrinx. With realistic cord permeability, there was slight oscillatory shunt flow bypassing the stenosis via the porous tissue over the syrinx. Weak steady streaming flow occurred in a circuit involving craniocaudal flow through the stenosis and back via the syrinx. Mean syrinx volume was scarcely altered when the adjacent stenosis bisected the syrinx, but increased slightly when the syrinx was predominantly located caudal to the stenosis. The fluid content of the tissues over the syrinx oscillated, absorbing most of the radial flow seeping from the subarachnoid space so that it did not reach the syrinx. To a lesser extent, this cyclic swelling in a boundary layer of cord tissue just below the pia occurred all along the cord, representing a mechanism for exchange of interstitial fluid (ISF) and cerebrospinal fluid which could explain recent tracer findings without invoking perivascular conduits. The model demonstrates that syrinx volume increase is possible when there is subarachnoid-space stenosis and the cord and pia are permeable.
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Affiliation(s)
- C D Bertram
- School of Mathematics and Statistics, University of Sydney, New South Wales 2006, Australia
| | - M Heil
- School of Mathematics, University of Manchester, Manchester M13 9PL, UK
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8
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Spontaneous regression of post-traumatic syringomyelia: A case report and literature review. J Clin Neurosci 2017; 44:249-253. [DOI: 10.1016/j.jocn.2017.06.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/21/2017] [Indexed: 11/22/2022]
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Affiliation(s)
- D. Greitz
- Department of Neuroradiology, Karolinska Institute, Stockholm, Sweden
| | - O. Flodmark
- Department of Neuroradiology, Karolinska Institute, Stockholm, Sweden
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Abstract
Chiari-like malformation is a condition of the craniocervical junction in which there is a mismatch of the structures of the caudal cranial fossa causing the cerebellum to herniate into the foramen magnum. This herniation can lead to fluid buildup in the spinal cord, also known as syringomyelia. Pain is the most common clinical sign followed by scratching. Other neurologic signs noted are facial nerve deficits, seizures, vestibular syndrome, ataxia, menace deficit, proprioceptive deficits, head tremor, temporal muscle atrophy, and multifocal central nervous system signs. MRI is the diagnostic of choice, but computed tomography can also be used.
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Khanna AR, Coumans JV. Spontaneous Improvement of Chiari I Malformation and Syringomyelia in a Patient With Cystic Fibrosis. Neurosurgery 2015; 78:E305-8. [DOI: 10.1227/neu.0000000000000980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
ABSTRACT
BACKGROUND AND IMPORTANCE:
Syringomyelia is highly associated with Chiari I malformation, but the pathophysiologic mechanism of syrinx formation and its relation to downward cerebellar tonsillar displacement remains elusive. Cough, Valsalva maneuver, and other physiological strains transiently exacerbate the clinical symptoms of these conditions, exert profound effects on the flow dynamics across the craniospinal junction, and are thought to play an important role in the pathogenesis of syringomyelia.
CLINICAL PRESENTATION:
We report the case of a patient with cystic fibrosis who presented during an exacerbation of bronchiectasis and was found to have a Chiari I malformation with associated syringomyelia. Eight months later, when the patient had returned to baseline pulmonary status, repeat imaging showed interval improvement in both the size of the syrinx and descent of cerebellar tonsils.
CONCLUSION:
This rare case of spontaneous improvement of syringomyelia and Chiari I malformation attributable to relief from chronic cough offers interesting insight into the mechanism of these disorders.
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Affiliation(s)
- Arjun R. Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jean-Valery Coumans
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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12
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The roads to mitochondrial dysfunction in a rat model of posttraumatic syringomyelia. BIOMED RESEARCH INTERNATIONAL 2015; 2015:831490. [PMID: 25685811 PMCID: PMC4309244 DOI: 10.1155/2015/831490] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/13/2014] [Indexed: 11/26/2022]
Abstract
The pathophysiology of posttraumatic syringomyelia is incompletely understood. We examined whether local ischemia occurs after spinal cord injury. If so, whether it causes neuronal mitochondrial dysfunction and depletion, and subsequent energy metabolism impairment results in cell starvation of energy and even cell death, contributing to the enlargement of the cavity. Local blood flow was measured in a rat model of posttraumatic syringomyelia that had received injections of quisqualic acid and kaolin. We found an 86 ± 11% reduction of local blood flow at C8 where a cyst formed at 6 weeks after syrinx induction procedure (P < 0.05), and no difference in blood flow rate between the laminectomy and intact controls. Electron microscopy confirmed irreversible neuronal mitochondrion depletion surrounding the cyst, but recoverable mitochondrial loses in laminectomy rats. Profound energy loss quantified in the spinal cord of syrinx animals, and less ATP and ADP decline observed in laminectomy rats. Our findings demonstrate that an excitotoxic injury induces local ischemia in the spinal cord and results in neuronal mitochondrial depletion, and profound ATP loss, contributing to syrinx enlargement. Ischemia did not occur following laminectomy induced trauma in which mitochondrial loss and decline in ATP were reversible. This confirms excitotoxic injury contributing to the pathology of posttraumatic syringomyelia.
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13
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Conley RN, Longmuir GA. Brain and Spinal Cord. Clin Imaging 2014. [DOI: 10.1016/b978-0-323-08495-6.00033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Drøsdal IN, Mardal KA, Støverud K, Haughton V. Effect of the central canal in the spinal cord on fluid movement within the cord. Neuroradiol J 2013; 26:585-90. [PMID: 24199820 DOI: 10.1177/197140091302600513] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 10/09/2013] [Indexed: 11/17/2022] Open
Abstract
Computational studies are used to demonstrate the effect of oscillating CSF flow on pressures within the spinal cord. We tested the hypothesis that the central canal in the spinal cord affects spinal cord pressure gradients resulting from oscillatory CSF flow. Two computational models of the spinal cord were created with the same dimensions. Model 1 had a homogeneous porous structure. Model 2 had the same structure with the addition of a central fluid filled space, representing the central canal of the cord. We simulated oscillatory flow in the fluid space using standard computational fluid dynamics tools. For all phases of the CSF flow cycle and for specific projections through the model we calculated pressure gradients and fluid movement in the cord models. Pressures in the models varied through the flow cycle. Model 1 had linearly varying pressure along its long axis that varied with the cycle and had no pressure gradients across the cord. Model 2 had nonlinear varying pressure along its long axis varying with the time in the cycle and had transient centrifugal and centripetal pressure gradients with a central fluid space. The radial pressures varied linearly with distance from the fluid space. Centrifugal and centripetal pressure gradients resulted in radially directed fluid flow in the cord. The central canal within the spinal cord alters the pressure fields occurring during oscillatory CSF flow and creates centrifugal and centripetal fluid flux in the cord.
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Driver CJ, Volk HA, Rusbridge C, Van Ham LM. An update on the pathogenesis of syringomyelia secondary to Chiari-like malformations in dogs. Vet J 2013; 198:551-9. [PMID: 23938004 DOI: 10.1016/j.tvjl.2013.07.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 06/19/2013] [Accepted: 07/09/2013] [Indexed: 11/16/2022]
Abstract
Syringomyelia (SM) is a spinal cord disease that can cause neuropathic pain in dogs. The pathogenesis of SM secondary to Chiari-like malformation (CM) has been the focus of intense research in recent years. The gulf in our understanding of CM/SM in dogs relative to the analogous human condition has progressively narrowed. CM is primarily a disease of abnormal geometric morphometry affecting the caudal cranial fossa and the brain parenchyma contained within it. This review describes how advanced imaging techniques have revealed a series of morphometric abnormalities associated with CM/SM. The series is presented in a logical order to help describe the pathogenesis of CM and the subsequent formation of syringes, with particular reference to the concepts of craniospinal compliance and cerebrospinal fluid pulse pressure timing.
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Affiliation(s)
- C J Driver
- Department of Veterinary Clinical Sciences, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA, UK.
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Klekamp J. Treatment of Syringomyelia Related to Nontraumatic Arachnoid Pathologies of the Spinal Canal. Neurosurgery 2012. [DOI: 10.1227/neu.0b013e31827fcc8f] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Abstract
BACKGROUND:
Disturbances of cerebrospinal fluid (CSF) flow are the commonest cause of syringomyelia. Spinal arachnopathies may lead to CSF flow obstructions but are difficult to diagnose. Consequently, associated syringomyelias are often categorized as idiopathic.
OBJECTIVE:
To present and analyze the diagnosis of and long-term outcomes in an observational study of patients with nontraumatic arachnopathies from 1991 to 2011.
METHODS:
A total of 288 patients (mean age, 47 ± 15 years; follow-up, 54 ± 46 months) were evaluated. Decompression with arachnolysis, untethering, and duraplasty for restoration of CSF flow was recommended to patients with neurological progression. Neurological examinations, magnetic resonance images, and follow-up data were evaluated. Individual symptoms were analyzed during the first postoperative year, and long-term outcomes were analyzed with Kaplan-Meier statistics to determine rates of progression-free survival.
RESULTS:
In total,189 patients either refused an operation or were managed conservatively for lack of progression. Among 79 unoperated patients with follow-up information available for up to 8 years, 2 patients deteriorated. Ninety-nine patients with progressive symptoms underwent 116 operations: 108 decompressions and 8 other surgeries. Three months postoperatively, 53% considered their status improved and 37% were unchanged. In the long term, surgery on arachnopathies limited to 2 spinal segments was followed by progression-free survival for 78% over 10 years, in contrast to 31% with extensive arachnopathies.
CONCLUSION:
Surgery on nontraumatic arachnopathies related to syringomyelia should be reserved for patients with progressive symptoms. Arachnolysis, untethering, and duraplasty provide good long-term results for focal arachnopathies. For extensive pathologies with a history of subarachnoid hemorrhage or meningitis, treatment remains a major challenge.
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Affiliation(s)
- Jörg Klekamp
- Christliches Krankenhaus, Department of Neurosurgery, Quakenbrück, Germany
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Heiss JD, Snyder K, Peterson MM, Patronas NJ, Butman JA, Smith RK, Devroom HL, Sansur CA, Eskioglu E, Kammerer WA, Oldfield EH. Pathophysiology of primary spinal syringomyelia. J Neurosurg Spine 2012; 17:367-80. [PMID: 22958075 PMCID: PMC3787878 DOI: 10.3171/2012.8.spine111059] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECT The pathogenesis of syringomyelia in patients with an associated spinal lesion is incompletely understood. The authors hypothesized that in primary spinal syringomyelia, a subarachnoid block effectively shortens the length of the spinal subarachnoid space (SAS), reducing compliance and the ability of the spinal theca to dampen the subarachnoid CSF pressure waves produced by brain expansion during cardiac systole. This creates exaggerated spinal subarachnoid pressure waves during every heartbeat that act on the spinal cord above the block to drive CSF into the spinal cord and create a syrinx. After a syrinx is formed, enlarged subarachnoid pressure waves compress the external surface of the spinal cord, propel the syrinx fluid, and promote syrinx progression. METHODS To elucidate the pathophysiology, the authors prospectively studied 36 adult patients with spinal lesions obstructing the spinal SAS. Testing before surgery included clinical examination; evaluation of anatomy on T1-weighted MRI; measurement of lumbar and cervical subarachnoid mean and pulse pressures at rest, during Valsalva maneuver, during jugular compression, and after removal of CSF (CSF compliance measurement); and evaluation with CT myelography. During surgery, pressure measurements from the SAS above the level of the lesion and the lumbar intrathecal space below the lesion were obtained, and cardiac-gated ultrasonography was performed. One week after surgery, CT myelography was repeated. Three months after surgery, clinical examination, T1-weighted MRI, and CSF pressure recordings (cervical and lumbar) were repeated. Clinical examination and MRI studies were repeated annually thereafter. Findings in patients were compared with those obtained in a group of 18 healthy individuals who had already undergone T1-weighted MRI, cine MRI, and cervical and lumbar subarachnoid pressure testing. RESULTS In syringomyelia patients compared with healthy volunteers, cervical subarachnoid pulse pressure was increased (2.7 ± 1.2 vs 1.6 ± 0.6 mm Hg, respectively; p = 0.004), pressure transmission to the thecal sac below the block was reduced, and spinal CSF compliance was decreased. Intraoperative ultrasonography confirmed that pulse pressure waves compressed the outer surface of the spinal cord superior to regions of obstruction of the subarachnoid space. CONCLUSIONS These findings are consistent with the theory that a spinal subarachnoid block increases spinal subarachnoid pulse pressure above the block, producing a pressure differential across the obstructed segment of the SAS, which results in syrinx formation and progression. These findings are similar to the results of the authors' previous studies that examined the pathophysiology of syringomyelia associated with obstruction of the SAS at the foramen magnum in the Chiari Type I malformation and indicate that a common mechanism, rather than different, separate mechanisms, underlies syrinx formation in these two entities. Clinical trial registration no.: NCT00011245.
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Affiliation(s)
- John D Heiss
- National Institute of Neurological Disorders and Stroke, Surgical Neurology Branch, National Institute of Health, Bethesda, Maryland, USA.
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18
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Elliott NSJ. Syrinx fluid transport: modeling pressure-wave-induced flux across the spinal pial membrane. J Biomech Eng 2012; 134:031006. [PMID: 22482686 DOI: 10.1115/1.4005849] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Syrinxes are fluid-filled cavities of the spinal cord that characterize syringomyelia, a disease involving neurological damage. Their formation and expansion is poorly understood, which has hindered successful treatment. Syrinx cavities are hydraulically connected with the spinal subarachnoid space (SSS) enveloping the spinal cord via the cord interstitium and the network of perivascular spaces (PVSs), which surround blood vessels penetrating the pial membrane that is adherent to the cord surface. Since the spinal canal supports pressure wave propagation, it has been hypothesized that wave-induced fluid exchange across the pial membrane may play a role in syrinx filling. To investigate this conjecture a pair of one-dimensional (1-d) analytical models were developed from classical elastic tube theory coupled with Darcy's law for either perivascular or interstitial flow. The results show that transpial flux serves as a mechanism for damping pressure waves by alleviating hoop stress in the pial membrane. The timescale ratio over which viscous and inertial forces compete was explicitly determined, which predicts that dilated PVS, SSS flow obstructions, and a stiffer and thicker pial membrane-all associated with syringomyelia-will increase transpial flux and retard wave travel. It was also revealed that the propagation of a pressure wave is aided by a less-permeable pial membrane and, in contrast, by a more-permeable spinal cord. This is the first modeling of the spinal canal to include both pressure-wave propagation along the spinal axis and a pathway for fluid to enter and leave the cord, which provides an analytical foundation from which to approach the full poroelastic problem.
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Affiliation(s)
- N S J Elliott
- Fluid Dynamics Research Group,Department of Mechanical Engineering, Curtin University, Perth WA, Australia.
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Abstract
Object
This paper presents results of a prospective study for patients undergoing surgery for posttraumatic syringomyelia between 1991 and 2010.
Methods
A group of 137 patients with posttraumatic syringomyelia were evaluated (mean age 45 ± 13 years, mean follow-up 51 ± 51 months) with pre- and postoperative MRI and clinical examinations presenting in this period and followed prospectively by outpatient visits and questionnaires. Surgery was recommended for symptomatic patients with a progressive course. Short-term results were determined within 3 months of surgery, whereas long-term outcomes in terms of clinical recurrences were studied with Kaplan-Meier statistics.
Results
Three groups were distinguished according to the type of trauma: Group A, patients with spinal trauma but without cord injury (ASIA E, n = 37); Group B, patients with an incomplete cord injury (ASIA C or D, n = 55); and Group C, patients with complete loss of motor function or a complete cord injury (ASIA A or B, n = 45). Overall, 61 patients with progressive symptoms underwent 71 operations. Of these operations, 61 consisted of arachnolysis, untethering, and duraplasty at the trauma level (that is, decompression), while 4 ASIA A patients underwent a cordectomy. The remaining procedures consisted of placement of a thecoperitoneal shunt, 2 opiate pump placements, and 2 anterior and 1 posterior cervical decompression and fusion. Seventy-six patients were not treated surgically due to lack of neurological progression or refusal of an operation. Neurological symptoms remained stable for 10 years in 84% of the patients for whom surgery was not recommended due to lack of neurological progression. In contrast, 60% of those who declined recommended surgery had neurological progression within 5 years. For patients presenting with neurological progression, outcome was better with decompression. Postoperatively, 61% demonstrated a reduction of syrinx size. Although neurological symptoms generally remained unchanged after surgery, 47% of affected patients reported a postoperative improvement of their pain syndrome. After 3 months, 51% considered their postoperative status improved and 41% considered it unchanged. In the long-term, favorable results were obtained for Groups A and C with rates for neurological deterioration of 6% and 14% after 5 years, respectively. In Group B, this rate was considerably higher at 39%, because arachnolysis and untethering to preserve residual cord function could not be fully achieved in all patients. Cordectomy led to neurological improvement and syrinx collapse in all 4 patients.
Conclusions
The technique of decompression with arachnolysis, untethering, and duraplasty at the level of the underlying trauma provides good long-term results for patients with progressive neurological symptoms following ASIA A, B and E injuries. Treatment of patients with posttraumatic syringomyelia after spinal cord injuries with preserved motor functions (ASIA C and D) remains a major challenge. Future studies will have to establish whether thecoperitoneal shunts would be a superior alternative for this subgroup.
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Abstract
PURPOSE The objective of this study was to review past studies that have used engineering analysis to examine cerebrospinal fluid hydrodynamics in cranial and spinal subarachnoid spaces in both healthy humans and those affected by type I Chiari malformation. METHODS A PubMed search of literature pertaining to cerebrospinal fluid hydrodynamics was performed with a particular focus on those that utilized methods such as computational fluid dynamics or experimental flow modeling. DISCUSSION From the engineer's perspective, type I Chiari malformation is an abnormal geometry of the cerebellum that causes increased resistance to cerebrospinal fluid flow between the intracranial and spinal subarachnoid space. As such, understanding the hydrodynamics of cerebrospinal fluid in the craniospinal subarachnoid space has long been thought to be important in the diagnosis and management of type I Chiari malformation. Hydrodynamic quantification of cerebrospinal fluid motion in the subarachnoid space may better reflect the pathophysiology of the disorder and serve as a prognostic indicator in conjunction with geometric magnetic resonance measurements that are currently used clinically. This review discusses the results of studies that have sought to quantify the hydrodynamics of cerebrospinal fluid motion using computational and experimental modeling and critiques the methods by which the results were obtained. CONCLUSION Researchers have found differences in cerebrospinal fluid velocities and pressures in type I Chiari malformation patients compared to healthy subjects. However, further research is necessary to determine the causal relationship between changes to hydrodynamic parameters such as cerebrospinal fluid velocity, pressure, resistance to flow, and craniospinal compliance and clinical aspects such as neurological symptoms, radiological evidence of severity, and surgical success.
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Affiliation(s)
- Nicholas Shaffer
- Department of Mechanical Engineering, University of Akron, OH 44325-3903, USA
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Silva JAGD, Melo LRS, Araújo AFD, Santos AAD. Resolution of syringomyelia in ten cases of "up-and-down Chiari malformation" after posterior fossa decompression. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 68:694-9. [PMID: 21049177 DOI: 10.1590/s0004-282x2010000500004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Accepted: 03/12/2010] [Indexed: 11/21/2022]
Abstract
The authors describe ten cases of syringomyelia without hindbrain herniation depicted by preoperative magnetic resonance imaging (MRI) in supine position. However, the herniation was observed in all cases during the operation with the patient in sitting position. The postoperative MRI revealed an intense reduction of the syrinx in all patients, as well as it was also observed a clinical amelioration in all cases. The surgical treatment was based on a large craniectomy with the patient in sitting position, tonsillectomy, large opening of the fourth ventricle and duraplasty with creation of a large cisterna magna.
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Martin BA, Labuda R, Royston TJ, Oshinski JN, Iskandar B, Loth F. Spinal subarachnoid space pressure measurements in an in vitro spinal stenosis model: implications on syringomyelia theories. J Biomech Eng 2011; 132:111007. [PMID: 21034148 DOI: 10.1115/1.4000089] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Full explanation for the pathogenesis of syringomyelia (SM), a neuropathology characterized by the formation of a cystic cavity (syrinx) in the spinal cord (SC), has not yet been provided. It has been hypothesized that abnormal cerebrospinal fluid (CSF) pressure, caused by subarachnoid space (SAS) flow blockage (stenosis), is an underlying cause of syrinx formation and subsequent pain in the patient. However, paucity in detailed in vivo pressure data has made theoretical explanations for the syrinx difficult to reconcile. In order to understand the complex pressure environment, four simplified in vitro models were constructed to have anatomical similarities with post-traumatic SM and Chiari malformation related SM. Experimental geometry and properties were based on in vivo data and incorporated pertinent elements such as a realistic CSF flow waveform, spinal stenosis, syrinx, flexible SC, and flexible spinal column. The presence of a spinal stenosis in the SAS caused peak-to-peak cerebrospinal fluid CSF pressure fluctuations to increase rostral to the stenosis. Pressure with both stenosis and syrinx present was complex. Overall, the interaction of the syrinx and stenosis resulted in a diastolic valve mechanism and rostral tensioning of the SC. In all experiments, the blockage was shown to increase and dissociate SAS pressure, while the axial pressure distribution in the syrinx remained uniform. These results highlight the importance of the properties of the SC and spinal SAS, such as compliance and permeability, and provide data for comparison with computational models. Further research examining the influence of stenosis size and location, and the importance of tissue properties, is warranted.
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Affiliation(s)
- Bryn A Martin
- Integrative Bioscience Institute, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.
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Elliott NSJ, Lockerby DA, Brodbelt AR. A lumped-parameter model of the cerebrospinal system for investigating arterial-driven flow in posttraumatic syringomyelia. Med Eng Phys 2010; 33:874-82. [PMID: 20833093 DOI: 10.1016/j.medengphy.2010.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 05/30/2010] [Accepted: 07/19/2010] [Indexed: 11/19/2022]
Abstract
Fluid transport in syringomyelia has remained enigmatic ever since the disease was first identified some three centuries ago. However, accumulating evidence in the last decade from animal studies implicates arterial pulsations in syrinx formation. In particular, it has been suggested that a phase difference between the pressure pulse in the spinal subarachnoid space and the perivascular spaces, due to a pathologically disturbed cerebrospinal fluid (CSF) or blood supply, could result in a net influx of CSF into the spinal cord (SC). A lumped-parameter model is developed of the cerebrospinal system to investigate this conjecture. It is found that although this phase-lag mechanism may operate, it requires the SC to have an intrinsic storage capacity due to the collapsibility of the contained venous reservoir. This net flux is associated with a higher mean pressure in the SC than the SSS which is maintained in the periodic steady state. According to our simulations the mechanical perturbations of arachnoiditis exacerbate the phase-lag effect, which may be partially alleviated by the presence of a posttraumatic syrinx and more completely by a syringo-subarachnoid shunt.
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Affiliation(s)
- N S J Elliott
- Department of Mechanical Engineering, Curtin University, Perth, WA, Australia.
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Pathogenesis of syringomyelia associated with Chiari type 1 malformation: review of evidences and proposal of a new hypothesis. Neurosurg Rev 2010; 33:271-84; discussion 284-5. [PMID: 20532585 DOI: 10.1007/s10143-010-0266-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 03/23/2010] [Accepted: 05/02/2010] [Indexed: 02/08/2023]
Abstract
The exact pathogenesis of syringomyelia associated with Chiari type 1 malformation is unknown, although a number of authors have reported their theories of syrinx formation. The purpose of this review is to understand evidences based on the known theories and to create a new hypothesis of the pathogenesis. We critically review the literatures on clinicopathological, radiological, and clinical features of this disorder. The previously proposed theories mainly focused on the driven mechanisms of the cerebrospinal fluid (CSF) into the spinal cord. They did not fully explain radiological features or effects of surgical treatment such as shunting procedures. Common findings of the syrinx in clinicopathological studies were the communication with the central canal and extracanalicular extension to the posterior gray matter. Most of the magnetic resonance imaging studies demonstrated blockade and alternated CSF dynamics at the foramen magnum, but failed to show direct communication of the syrinx with the CSF spaces. Pressure studies revealed almost identical intrasyrinx pressure to the subarachnoid space and decreased compliance of the spinal CSF space. Recent imaging studies suggest that the extracellular fluid accumulation may play an important role. The review of evidences promotes a new hypothesis of syrinx formation. Decreased absorption mechanisms of the extracellular fluid may underlie the pathogenesis of syringomyelia. Reduced compliance of the posterior spinal veins associated with the decreased compliance of the spinal subarachnoid space will result in disturbed absorption of the extracellular fluid through the intramedullary venous channels and formation of syringomyelia.
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Martin BA, Loth F. The influence of coughing on cerebrospinal fluid pressure in an in vitro syringomyelia model with spinal subarachnoid space stenosis. Cerebrospinal Fluid Res 2009; 6:17. [PMID: 20043856 PMCID: PMC2806373 DOI: 10.1186/1743-8454-6-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 12/31/2009] [Indexed: 01/30/2023] Open
Abstract
Background The influence of coughing, on the biomechanical environment in the spinal subarachnoid space (SAS) in the presence of a cerebrospinal fluid flow stenosis, is thought to be an important etiological factor in craniospinal disorders, including syringomyelia (SM), Chiari I malformation, and hydrocephalus. The aim of this study was to investigate SAS and syrinx pressures during simulated coughing using in vitro models and to provide information for the understanding of the craniospinal fluid system dynamics to help develop better computational models. Methods Four in vitro models were constructed to be simplified representations of: 1) non-communicating SM with spinal SAS stenosis; 2) non-communicating SM due to spinal SAS stenosis with a distensible spinal column; 3) non-communicating SM post surgical removal of a spinal SAS stenosis; and 4) a spinal SAS stenosis due to spinal trauma. All of the models had a flexible spinal cord. To simulate coughing conditions, an abrupt CSF pressure pulse (~ 5 ms) was imposed at the caudal end of the spinal SAS by a computer-controlled pump. Pressure measurements were obtained at 4 cm intervals along the spinal SAS and syrinx using catheter tip transducers. Results Pressure measurements during a simulated cough, showed that removal of the stenosis was a key factor in reducing pressure gradients in the spinal SAS. The presence of a stenosis resulted in a caudocranial pressure drop in the SAS, whereas pressure within the syrinx cavity varied little caudocranially. A stenosis in the SAS caused the syrinx to balloon outward at the rostral end and be compressed at the caudal end. A >90% SAS stenosis did not result in a significant Venturi effect. Increasing compliance of the spinal column reduced forces acting on the spinal cord. The presence of a syrinx in the cord when there was a stenosis in the SAS, reduced pressure forces in the SAS. Longitudinal pressure dissociation acted to suck fluid and tissue caudocranially in the SAS with a stenosis. Conclusions Pressures in the spinal SAS during a simulated cough in vitro had similar peak, transmural, and longitudinal pressures to in vivo measurements reported in the literature. The pressure wave velocities and pressure gradients during coughing (longitudinal pressure dissociation and transmural pressure) were impacted by alterations in geometry, compliance, and the presence of a syrinx and/or stenosis.
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Affiliation(s)
- Bryn A Martin
- Ecole Polytechnique Fédérale de Lausanne, Integrative Bioscience Institute, Laboratory of Hemodynamics and Cardiovascular Technology, Lausanne, Switzerland
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Scholsem M, Scholtes F, Belachew S, Martin D. Acquired tonsillar herniation and syringomyelia after pleural effusion aspiration: case report. Neurosurgery 2008; 62:E1172-3; discussion E1173. [PMID: 18580789 DOI: 10.1227/01.neu.0000325884.05871.aa] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We present a case of brachial plexus avulsion and reconstructive surgery with cerebrospinal fluid leak between the cervical subarachnoid space and the pleural cavity responsible for tonsillar herniation and syringomyelia. CLINICAL PRESENTATION A 17-year-old man presented with headaches when he was positioned upright, simultaneously with a persistent right pleural effusion for about 4 months after reconstructive surgery for a right brachial plexus avulsion. In addition, the headaches had worsened considerably after two aspirations of the pleural effusion. Magnetic resonance imaging (MRI) demonstrated signs of chronic intracranial hypotension and tonsillar herniation with a presyrinx cavity from vertebral level C1 to C7. None of those abnormalities were seen on the MRI scan obtained a few days after the initial trauma 7 months previously. Plexus brachial MRI confirmed the presence of a cerebrospinal fluid leak between the avulsed root of C8 and the pulmonary apex. INTERVENTION The leak was treated by surgical closure of the dural tear of the C8 root. Postoperatively, the patient's headaches immediately resolved, and MRI 4 months later showed resolution of cerebellar tonsil herniation and regression of the syrinx. CONCLUSION Resolution of acquired tonsillar herniation and syringomyelia can be achieved by closure of the dural tear responsible of the cerebrospinal fluid leak.
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Affiliation(s)
- Martin Scholsem
- Department of Neurosurgery, University Hospital, University of Liège, Liège, Belgium
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Scholsem M, Scholtes F, Belachew S, Martin D. ACQUIRED TONSILLAR HERNIATION AND SYRINGOMYELIA AFTER PLEURAL EFFUSION ASPIRATION. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000313570.12085.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Berciano J, Poca MA, García A, Sahuquillo J. Paroxysmal cervicobrachial cough-induced pain in a patient with syringomyelia extending into spinal cord posterior gray horns. J Neurol 2007; 254:678-81. [PMID: 17410326 DOI: 10.1007/s00415-006-0412-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 09/14/2006] [Indexed: 11/28/2022]
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Uemura K, Matsumura A, Isobe T, Anno I, Kawamura H, Minami M, Tsukada A. Perfusion-weighted magnetic resonance imaging of the spinal cord in cervical spondylotic myelopathy. Neurol Med Chir (Tokyo) 2006; 46:581-8. [PMID: 17185883 DOI: 10.2176/nmc.46.581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Principles of echo shifting with a train of observations was used to perform magnetic susceptibility-weighted magnetic resonance imaging with bolus-tracking in 14 patients with spondylotic myelopathy to assess changes in perfusion parameters of the spinal cord before and after decompression surgery for cervical spondylotic myelopathy. The mean transit time (MTT), bolus arrival time (T0), and time to peak (TTP) were obtained from regions of interest (ROIs) and assessed as the ratio between the spinal cord and the pons (MTT index = MTT(ROI)/MTT(pons), T0 index = T0(ROI)/T0(pons), TTP index = TTP(ROI)/TTP(pons)). The patients were divided into two groups according to percentage improvement on the Neurosurgical Cervical Spine Scale. The MTT index in patients with good recovery (> or =50%) was significantly reduced. The T0 index and TTP index showed no significant change in both groups. Reduction of MTT index may indicate improved perfusion of the spinal cord following surgery for cervical spondylotic myelopathy.
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Affiliation(s)
- Kazuya Uemura
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Bogdanov EI, Heiss JD, Mendelevich EG. The post-syrinx syndrome: stable central myelopathy and collapsed or absent syrinx. J Neurol 2006; 253:707-13. [PMID: 16511636 PMCID: PMC4294185 DOI: 10.1007/s00415-006-0091-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Revised: 06/09/2005] [Accepted: 07/01/2005] [Indexed: 10/25/2022]
Abstract
Among 168 cases with neurologic findings of cervicothoracic syringomyelia and MRI findings of Chiari 1 malformation and/or underdevelopment of the posterior cranial fossa, 15 patients (9.1 %) had collapsed, flat syrinxes and 14 patients (8.3 %) did not have syrinxes. Both groups of patients had clinical findings of central myelopathy that had been stable for at least 3 years. Magnetic resonance imaging detected atrophy of the cervical spinal cord in both groups and spontaneous communications between the syrinx and the subarachnoid space in 3 patients of the group with collapsed syrinxes. Analysis of these results and review of the literature suggest that patients with clinical signs of syringomyelia and Chiari 1 malformation or underdeveloped posterior fossa, but with small or absent syringomyelitic cavities, have the "postsyrinx" state as a result of spontaneous collapse of distended syrinxes.
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Affiliation(s)
- E. I. Bogdanov
- Dept. of Neurology and Rehabilitation, Kazan State Medical University, Butlerov str. 49, Kazan, Russia 420012, Tel.: +7-8432/353308, Fax: +7-8432/360693
| | - John D. Heiss
- Surgical Neurology Branchk, National Institute of Neurological Disease and Stroke, National Institutes of Health, Bethesda, MD 20892-1414, USA, Tel.: +1-301/594-8112, Fax: +1-301/402-0380
| | - E. G. Mendelevich
- Dept. of Neurology and Rehabilitation, Kazan State Medical University, Butlerov str. 49, Kazan, Russia 420012, Tel.: +7-8432/353308, Fax: +7-8432/360693
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Greitz D. Unraveling the riddle of syringomyelia. Neurosurg Rev 2006; 29:251-63; discussion 264. [PMID: 16752160 DOI: 10.1007/s10143-006-0029-5] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2005] [Revised: 03/03/2006] [Accepted: 03/08/2006] [Indexed: 12/15/2022]
Abstract
The pathophysiology of syringomyelia development is not fully understood. Current prevailing theories suggest that increased pulse pressure in the subarachnoid space forces cerebrospinal fluid (CSF) through the spinal cord into the syrinx. It is generally accepted that the syrinx consists of CSF. The here-proposed intramedullary pulse pressure theory instead suggests that syringomyelia is caused by increased pulse pressure in the spinal cord and that the syrinx consists of extracellular fluid. A new principle is introduced implying that the distending force in the production of syringomyelia is a relative increase in pulse pressure in the spinal cord compared to that in the nearby subarachnoid space. The formation of a syrinx then occurs by the accumulation of extracellular fluid in the distended cord. A previously unrecognized mechanism for syrinx formation, the Bernoulli theorem, is also described. The Bernoulli theorem or the Venturi effect states that the regional increase in fluid velocity in a narrowed flow channel decreases fluid pressure. In Chiari I malformations, the systolic CSF pulse pressure and downward motion of the cerebellar tonsils are significantly increased. This leads to increased spinal CSF velocities and, as a consequence of the Bernoulli theorem, decreased fluid pressure in narrow regions of the spinal CSF pathways. The resulting relatively low CSF pressure in the narrowed CSF pathway causes a suction effect on the spinal cord that distends the cord during each systole. Syringomyelia develops by the accumulation of extracellular fluid in the distended cord. In posttraumatic syringomyelia, the downwards directed systolic CSF pulse pressure is transmitted and reflected into the spinal cord below and above the traumatic subarachnoid blockage, respectively. The ensuing increase in intramedullary pulse pressure distends the spinal cord and causes syringomyelia on both sides of the blockage. The here-proposed concept has the potential to unravel the riddle of syringomyelia and affords explanations to previously unanswered clinical and theoretical problems with syringomyelia. It also explains why syringomyelia associated with Chiari I malformations may develop in any part of the spinal cord including the medullary conus. Syringomyelia thus preferentially develops where the systolic CSF flow causes a suction effect on the spinal cord, i.e., at or immediately caudal to physiological or pathological encroachments of the spinal subarachnoid space.
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Affiliation(s)
- Dan Greitz
- Department of Neuroradiology and MR Research Center, Karolinska University Hospital, S-171 76, Stockholm, Sweden.
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Muzumdar D, Ventureyra ECG. Tonsillar herniation and cervical syringomyelia in association with posterior fossa tumors in children: a case-based update. Childs Nerv Syst 2006; 22:454-9. [PMID: 16397818 DOI: 10.1007/s00381-005-0027-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Indexed: 01/05/2023]
Abstract
BACKGROUND Posterior fossa tumors most commonly occur in children. They frequently present with raised intracranial pressure and may have tonsillar herniation. The symptomatology is predominantly directed towards the tumor. The occurrence of syringomyelia in such cases is most unusual. Symptomatic syringomyelia is rare. CASE REPORT We describe a case of a pilocytic astrocytoma of the cerebellum in a 13-year-old girl who presented with clinical features of progressively worsening raised intracranial pressure and secondary tonsillar herniation and cervical syringomyelia. Magnetic resonance (MR) imaging showed a large midline inhomogenously enhancing vermian tumor causing moderate obstructive hydrocephalus. In addition, the cerebellar tonsils herniated down to the C2 level, and there was a centrally located syrinx from C2-T1. The tumor was resected through a suboccipital craniectomy. At follow-up after 3 months, MR imaging demonstrated total resolution of tonsillar herniation and cervical syringomyelia. CONCLUSIONS The occurrence of tonsillar herniation and syringomyelia in association with a slow growing benign tumor like pilocytic astrocytoma of the cerebellum is uncommon. The blockade of normal cerebrospinal fluid circulation pathway at the foramen magnum is the crucial factor. Surgical extirpation of the tumor restores the normal cerebrospinal fluid circulation at the foramen magnum and produces an excellent outcome. The need for an additional surgical procedure for treatment of associated tonsillar herniation and syringomyelia can be avoided. Volumetric assessment of the posterior fossa may provide a better understanding of the pathophysiology of syringomyelia in such patients.
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Affiliation(s)
- Dattatraya Muzumdar
- Division of Neurosurgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, K1H 8 L1, Ontario, Canada
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Abstract
✓Cordectomy is an effective treatment option in patients in whom posttraumatic syringomyelia develops following complete spinal cord injuries. Since the introduction of cordectomy, numerous approaches to the surgical treatment of posttraumatic syringomyelia have been developed. These newer developments have drawn the attention of surgeons and researchers away from cordectomy. In this report, the authors encourage a reconsideration of cordectomy for the treatment of posttraumatic syringomyelia after complete spinal cord injury. They describe four patients with posttraumatic syringomyelia who were treated successfully with cordectomy and review appropriate literature, examining the effectiveness of cordectomy in the treatment of posttraumatic syringomyelia. The findings of this review indicate that neurological improvement or stabilization occurred in 88% of patients in published reports of posttraumatic syringomyelia treated with cordectomy. The indications for cordectomy as well as factors that may contribute to the procedure’s success are discussed.
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Affiliation(s)
- Adrian W Laxton
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Ontario, Canada
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Fox B, Muzumdar D, DeMonte F. Resolution of tonsillar herniation and cervical syringomyelia following resection of a large petrous meningioma: case report and review of literature. Skull Base 2005; 15:89-97; discussion 98. [PMID: 16148987 PMCID: PMC1151707 DOI: 10.1055/s-2005-868168] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe a case of a large, petrous meningioma associated with tonsillar herniation and cervical syringomyelia. The patient, a 53-year-old woman, had a 6-month history of a dull, aching pain in the occipital region associated with numbness in the right C2 dermatome and left gaze evoked nystagmus. Magnetic resonance imaging (MRI) revealed a large tumor in the right posterior fossa associated with moderate supratentorial hydrocephalus. Secondary tonsillar herniation and cervical syringomyelia extending from C2 to C6 were also identified. The tumor, later confirmed to be a meningioma originating from the petrous region, was resected completely via a retrosigmoid approach. Postoperative MRI demonstrated total resolution of the tonsillar herniation and cervical syringomyelia. The radiological features, potential pathophysiological mechanisms, and treatment strategies are discussed in relation to the recent literature.
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Affiliation(s)
| | - Dattatraya Muzumdar
- Department of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai, India
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas, M.D. Anderson Cancer Center, Houston, Texas
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Amato VG, Assietti R, Morosi M, Arienta C. Acute brainstem dissection of syringomyelia associated with cervical intramedullary neurinoma. Neurosurg Rev 2004; 28:163-7. [PMID: 15789252 DOI: 10.1007/s10143-004-0362-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Accepted: 09/20/2004] [Indexed: 11/28/2022]
Abstract
Intramedullary tumors and syringomyelia typically present with slowly progressing deficits. More rarely, they are characterized by acute presentation or worsening, at times mimicking other more common etiologies. The acute onset of syringomyelia is most likely attributable to an acute increase in cerebrospinal fluid and epidural venous pressure that results in impulsive fluid movement and, ultimately, in the rupture of the syrinx and dissection into the spinal cord or brainstem. Reported here is a case of acute presentation of a small cervical intramedullary neurinoma due to the upward dissection of its associated syrinx. Critical questions are: (1) how can a small tumor produce a large syrinx? and (2) in the absence of craniospinal interferences, which mechanism underlies the acute expansion of the cavity, resulting in a rapid onset? The authors examined the pathophysiology of syrinx formation and enlargement in intramedullary tumors and reviewed the literature, emphasizing the relationship between spinal cord movements and intramedullary pressure. On the basis of current pathogenetic concepts, the authors concluded that tumor-related syringomyelia might be caused by an association of mechanisms, both from within (obstruction of perivascular spaces; increase in extracellular fluid viscosity due to the tumor itself; intramedullary pressure gradients among different cord levels and between the cord and the subarachnoid space) and from without (the cerebrospinal fluid entering the tissue). All these factors may be amplified, as in the reported case, by a tumor located dorsally at the cervical level. Abnormal postures of the spine, such as a prolonged and excessive flexed neck position, may ultimately contribute to the acute dissection of the syrinx.
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Affiliation(s)
- Vincenzo G Amato
- Department of Neurosurgery, Fatebenefratelli Hospital, Milan, Italy.
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Perrin RG, Fehlings M. The etiology of syringomyelia in association with lesions of the foramen magnum. J Neurol Sci 2004; 220:1-2. [PMID: 15140599 DOI: 10.1016/j.jns.2004.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2004] [Accepted: 02/24/2004] [Indexed: 11/30/2022]
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Levine DN. The pathogenesis of syringomyelia associated with lesions at the foramen magnum: a critical review of existing theories and proposal of a new hypothesis. J Neurol Sci 2004; 220:3-21. [PMID: 15140600 DOI: 10.1016/j.jns.2004.01.014] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2003] [Revised: 01/23/2004] [Accepted: 01/26/2004] [Indexed: 12/20/2022]
Abstract
Syringomyelia is frequently accompanied by an extramedullary lesion at the foramen magnum, particularly a Chiari I malformation. Although syringomyelia associated with foramen magnum obstruction has characteristic clinical, radiological, and neuropathological features, its pathogenesis remains unclear. Currently prevalent hydrodynamical theories assert that obstruction of the subarachnoid space at the foramen magnum interferes with flow of cerebrospinal fluid (CSF) between the spinal and the intracranial subarachnoid compartments. As a result, spinal CSF is driven into the spinal cord through the perivascular spaces to form a syrinx. These theories are implausible biophysically because none postulates a pump adequate to drive fluid through these spaces. None of the theories can explain why syrinx pressure is higher than CSF pressure; why extensive gliosis, edema, and vascular wall thickening regularly occur; and why the composition of syrinx fluid is not identical with that of CSF. A new theory of pathogenesis is proposed to address these difficulties. In the presence of subarachnoid obstruction at the foramen magnum, a variety of activities, such as assuming the erect posture, coughing or straining, and pulsatile fluctuations of CSF pressure during the cardiac cycle, produce transiently higher CSF pressure above the block than below it. There are corresponding changes in transmural venous and capillary pressure favoring dilation of vessels below the block and collapse of vessels above the block. The spatially uneven change of vessel caliber produces mechanical stress on the spinal cord, particularly caudal to the block. The mechanical stress, coupled with venous and capillary dilation, partially disrupt the blood-spinal cord barrier, allowing ultrafiltration of crystalloids and accumulation of a protein-poor fluid. The proposed theory is consistent with the neuropathological findings in syringomyelia and with the pressure and composition of syrinx fluid. It also accounts for the prolonged course of syringomyelia and its aggravation by cough, strain, and assumption of an erect posture. It contributes to understanding the low incidence and the morphology of syringobulbia. It explains the poorly understood presentation of foramen magnum meningiomas with symptoms of a mid- to low-cervical myelopathy. The theory also affords an understanding of the late recurrence of symptoms in children with hydromyelia who are treated with a ventricular shunt.
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Affiliation(s)
- David N Levine
- Department of Neurology, New York University Medical School, 400 East 34th Street, RIRM-311, New York, NY 10016, USA.
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Carpenter PW, Berkouk K, Lucey AD. Pressure Wave Propagation in Fluid-Filled Co-Axial Elastic Tubes Part 2: Mechanisms for the Pathogenesis of Syringomyelia. J Biomech Eng 2004; 125:857-63. [PMID: 14986411 DOI: 10.1115/1.1634281] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Our aim in this paper is to use a simple theoretical model of the intraspinal cerebrospinal-fluid system to investigate mechanisms proposed for the pathogenesis of syringomyelia. The model is based on an inviscid theory for the propagation of pressure waves in co-axial, fluid-filled, elastic tubes. According to this model, the leading edge of a pressure pulse tends to steepen and form an elastic jump, as it propagates up the intraspinal cerebrospinal-fluid system. We show that when an elastic jump is incident on a stenosis of the spinal subarachnoid space, it reflects to form a transient, localized region of high pressure within the spinal cord that for a cough-induced pulse is estimated to be 50 to 70 mm Hg or more above the normal level in the spinal subarachnoid space. We propose this as a new mechanism whereby pressure pulses created by coughing or sneezing can generate syrinxes. We also use the same analysis to investigate Williams’ suck mechanism. Our results do not support his concept, nor, in cases where the stenosis is severe, the differential-pressure-propagation mechanism recently proposed by Greitz et al. Our analysis does provide some support for the piston mechanism recently proposed by Oldfield et al. and Heiss et al. For instance, it shows clearly how the spinal cord is compressed by the formation of elastic jumps over part of the cardiac cycle. What appears to be absent for this piston mechanism is any means whereby the elastic jumps can be focused (e.g., by reflecting from a stenosis) to form a transient, localized region of high pressure within the spinal cord. Thus it would seem to offer a mechanism for syrinx progression, but not for its formation.
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Affiliation(s)
- P W Carpenter
- Fluid Dynamics Research Center, University of Warwick, Coventry CV4 7AL, UK
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Brodbelt AR, Stoodley MA, Watling A, Rogan C, Tu J, Brown CJ, Burke S, Jones NR. The role of excitotoxic injury in post-traumatic syringomyelia. J Neurotrauma 2003; 20:883-93. [PMID: 14577866 DOI: 10.1089/089771503322385818] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Fifty percent of patients with neurological deterioration from post-traumatic syringomyelia do not respond to treatment. Treatment failure is due in part to an incomplete understanding of the underlying aetiology. An animal model that mimics the human disease is required to investigate underlying pathophysiology and treatment options. A previous study was designed to mimic trauma-induced effects on the spinal cord that result in syringomyelia, combining an excitotoxic insult with kaolin-induced arachnoiditis. In this excitotoxic model, syringes were produced in 82% of animals. The aims of the current study were to improve the model to produce syringes in all animals treated, to examine the relative influences of excitotoxic injury and neuronal loss on syrinx formation, and to use magnetic resonance imaging (MRI) to examine syringes non-invasively. A temporal and dose profile of intraparenchymal quisqualic acid (QA) and subarachnoid kaolin was performed in Sprague Dawley rats. MRI was used to study four syrinx and six control animals. In one subgroup of animals surviving for 6 weeks, 100% (eight of eight) developed syringes. Syrinx formation and enlargement occurred in a dose and time dependent manner, whilst significant neuronal loss was only dose dependent. Animal syrinx histology closely resembled human post-traumatic syringomyelia. Axial T2-weighted MR images demonstrated syrinx presence. The results suggest that the formation of an initial cyst predisposes to syrinx formation in the presence of subarachnoid adhesions.
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Affiliation(s)
- Andrew R Brodbelt
- Prince of Wales Medical Research Institute, University of New South Wales, Sydney, Australia.
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da Silva JAG, Holanda MMDA. Basilar impression, Chiari malformation and syringomyelia: a retrospective study of 53 surgically treated patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2003; 61:368-75. [PMID: 12894269 DOI: 10.1590/s0004-282x2003000300009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The present study shows the results of 53 patients who have been treated surgically for basilar impression (BI), Chiari malformation (CM), and syringomyelia (SM). The patients were divided into two groups. Group I (24 patients) underwent osteodural decompression with large inferior occipital craniectomy, laminectomy from C 1 to C 3, dural opening in Y format, dissection of arachnoid adhesion between the cerebellar tonsils, medulla oblongata and spinal cord, large opening of the fourth ventricle and dural grafting with the use of bovine pericardium. Group II patients (29 patients) underwent osteodural-neural decompression with the same procedures described above plus dissection of the arachnoid adherences of the vessels of the region of the cerebellar tonsils, and tonsillectomy (amputation) in 10 cases, and as for the remainning 19 cases, intrapial aspiration of the cerebellar tonsils was performed. The residual pial sac was sutured to the dura in craniolateral position. After completion of the suture of the dural grafting, a thread was run through the graft at the level of the created cisterna magna and fixed to the cervical aponeurosis so as to move the dural graft on a posterior- caudal direction, avoiding, in this way, its adherence to the cerebellum.
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Doblas P, Herrera J, Larracoechea J, Barber M, Eguiluz I. Siringomielia y malformación de Arnold-Chiari durante la gestación. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2003. [DOI: 10.1016/s0210-573x(03)77273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Effect of Spinal Cord Abnormalities on the Function of the Lower Urinary Tract in Patients With Anorectal Abnormalities. J Urol 2002. [DOI: 10.1097/00005392-200209000-00076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Taskinen S, Valanne L, Rintala R. Effect of spinal cord abnormalities on the function of the lower urinary tract in patients with anorectal abnormalities. J Urol 2002; 168:1147-9. [PMID: 12187257 DOI: 10.1016/s0022-5347(05)64613-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE We evaluated the effect of spinal cord abnormalities on lower urinary tract function in patients with anorectal abnormalities. MATERIALS AND METHODS We examined 30 patients with anorectal anomalies mainly because of fecal or urinary incontinence. All patients underwent spinal magnetic resonance imaging and urodynamic investigation. RESULTS Major lumbosacral abnormalities were detected in 57% of patients, including 13, 4 and 3 with a tethered cord, syringomyelia and caudal regression, respectively. Significant dysfunction of the lower urinary tract in 57% of the cases involved an overactive detrusor in 11, detrusor-sphincter dyssynergia in 4, distended bladder in 4 and lazy bladder in 1. When the spinal cord was normal, 54% of the patients had abnormal urodynamic findings but when the spinal cord was abnormal, 59% had abnormal urodynamics. When the bony spine was normal, 33% of the patients had an abnormal spinal cord but when the bony spine was abnormal, 69% had an abnormal spinal cord. CONCLUSIONS Patients with anorectal abnormalities and fecal or urinary incontinence problems often have an abnormal spinal cord and abnormal urodynamic findings. However, the state of the spinal cord is not the only factor explaining lower urinary tract function. Thus, the possibility of lower urinary tract dysfunction should be considered in each patient with anorectal abnormalities. If the patient has symptoms or findings suggesting abnormal lower urinary tract function urodynamic evaluation should be performed.
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Affiliation(s)
- Seppo Taskinen
- Department of Pediatric Surgery, Helsinki University Hospital, Helsinki, Finland
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Bogdanov EI, Mendelevich EG. Syrinx size and duration of symptoms predict the pace of progressive myelopathy: retrospective analysis of 103 unoperated cases with craniocervical junction malformations and syringomyelia. Clin Neurol Neurosurg 2002; 104:90-7. [PMID: 11932037 DOI: 10.1016/s0303-8467(01)00189-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE the clinical course of syringomyelia associated with craniocervical junction abnormalities is variable. About half of the unoperated patients have benign course. This is difficult to explain on the basis of the present pathogenetic theories. Therefore, to understand the mechanism of syrinx progression better, we studied the value of syrinx size, syrinx morphology, and the syrinx/spinal cord size ratio in predicting the rate of progression and the severity of myelopathy in these patients. METHODS 103 adult patients with syringomyelia associated with Chiari 1 malformation and/or radiographic signs of underdeveloped posterior cranial fossa were clinically and MRI examined. Patients were subdivided according to the type of disease progression. Severity of neurological deficits, and MRI features (the extent of cerebellar tonsillar displacement, anteroposterior diameter of cavities, the spinal cord and cyst/cord ratio and the shape of cavities) were measured. RESULTS a significant relationship was found between the mid-sagittal diameter of the syrinxes and the type of disease course; patients with short duration and rapid progression had the largest diameters of cavities, whereas patients with longer duration as well as with slow rate of progression had smaller diameters (chi(2)=28.90, P<0.05; chi(2)=29.89, P<0.01; r=-0.24, P<0.05). In addition, a correlation was found between the anteroposterior diameter of the spinal cord and cyst/cord ratio and the disease duration (r=0.52, P<0.05 and r=0.48, P<0.05, respectively). CONCLUSIONS the initial years for the development of symptomatic syringomyelia associated with CCJ malformations are characterized by relatively rapid clinical progression accompanied with distended cavities. In the later periods of unoperated syringomyelia, some patients show delay in the progress of syrinxes accompanied with collapse of cavities, probably either due to a spontaneous formation of drainage between the syrinx and the subarachnoidal space, or due to the restoration of abnormal CSF dynamics at the CCJ level.
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Affiliation(s)
- E I Bogdanov
- Department of Neurology and Rehabilitation, Kazan State Medical University, 49 Butlerov Street, 420012 Kazan, Russia.
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Kyoshima K, Kuroyanagi T, Oya F, Kamijo Y, El-Noamany H, Kobayashi S. Syringomyelia without hindbrain herniation: tight cisterna magna. Report of four cases and a review of the literature. J Neurosurg 2002; 96:239-49. [PMID: 12450289 DOI: 10.3171/spi.2002.96.2.0239] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Idiopathic syringomyelia, which is not associated with any definite pathogenic lesions, has been treated mainly by shunting of the syrinx and rarely by craniocervical decompression. The authors report four cases of syringomyelia thought to be idiopathic syringomyelia but treated by craniocervical decompression with favorable results. Syringomyelia was present without hindbrain herniation. In such cases, the subarachnoid space anterior to the brainstem at the level of the foramen magnum is usually open but the cisterna magna is impacted by the tonsils, a condition the authors term "tight cisterna magna." All patients underwent foramen magnum decompression and C-1 laminectomy, and the outer layer of the dura was peeled off. Further intradural exploration was performed when outflow of cerebrospinal fluid (CSF) from the fourth ventricle was deemed to be insufficient. Postoperatively, improvement in symptoms and a reduction in syrinx size were demonstrated in three patients, and a reduction in ventricle size was shown in two. Syringomyelia associated with tight cisterna magna should not be classified as idiopathic syringomyelia; rather, it belongs to the category of organic syringomyelia such as Chiari malformation. A possible pathogenesis of cavitation is obstruction of the CSF outflow from the foramen of Magendie, and the cavity may be a communicating dilation of the central canal. Ventricular dilation may depend on the extent to which CSF drainage is impaired from the foramina of Luschka. These cavities may respond to craniocervical decompression if it results in sufficient CSF outflow from the foramen of Magendie, even in cases with concomitant hydrocephalus.
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Affiliation(s)
- Kazuhiko Kyoshima
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
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Thompson FJ, Reier PJ, Uthman B, Mott S, Fessler RG, Behrman A, Trimble M, Anderson DK, Wirth ED. Neurophysiological assessment of the feasibility and safety of neural tissue transplantation in patients with syringomyelia. J Neurotrauma 2001; 18:931-45. [PMID: 11565604 DOI: 10.1089/089771501750451848] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The feasibility and safety of a procedure involving fetal spinal cord tissue transplantation in patients with syringomyelia was assessed using a neurophysiological protocol designed to quantitate peripheral nerve function, spinal cord reflex excitability, and spinal cord conduction pathways essential for somatosensory evoked potentials. We report here data obtained before and for 18 months following the transplantation procedure performed on the first two patients in this study. The neurophysiological assessment protocols included measures of cortical and spinal cord evoked potentials, H-reflex excitability, and peripheral nerve conduction. Prior to the procedure, both patients had significant deficits on some of the neurophysiological measures, for example, lower extremity cortical evoked potentials. However, robust measures of intact pathways, such as upper extremity cortical evoked potentials, were also observed preoperatively in both patients. Thus, it was anticipated that conduction in these intact pathways could be at risk either from complications from the transplantation procedure and/or from continued expansion of the syrinx. Following the transplantation procedure, no negative changes were observed in any of the neurophysiological measures in either patient. In addition, patient 1 showed a decrease in the rate potentiation of tibial H-reflexes on the right side and an increase in the response probability of left tibial H-reflexes. The results of this postoperative longitudinal assessment provide a first-level demonstration of the safety of the intraspinal neural tissue transplantation procedure. However, the consideration of safety is currently limited to the grafting procedure itself, since the long-term fates of the donor tissue in these two patients remain to be shown more definitively.
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Affiliation(s)
- F J Thompson
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, USA.
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Klekamp J, Völkel K, Bartels CJ, Samii M. Disturbances of Cerebrospinal Fluid Flow Attributable to Arachnoid Scarring Cause Interstitial Edema of the Cat Spinal Cord. Neurosurgery 2001. [DOI: 10.1227/00006123-200101000-00031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Klekamp J, Völkel K, Bartels CJ, Samii M. Disturbances of cerebrospinal fluid flow attributable to arachnoid scarring cause interstitial edema of the cat spinal cord. Neurosurgery 2001; 48:174-85; discussion 185-6. [PMID: 11152344 DOI: 10.1097/00006123-200101000-00031] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Spinal arachnoid scarring may be caused by trauma, inflammation, surgery, spinal instability, degenerative diseases, or malformations and may lead to progressive neurological deficits and syringomyelia. We wanted to investigate the effects of focal arachnoid scarring in the cervical spinal canal of cats on pressures in the subarachnoid space and spinal cord tissue, as well as on spinal cord histological features. METHODS Twenty-nine adult cats were used for this study. Nine animals served as control animals, whereas 20 animals received a focal arachnoid scar at C1-C2, which was produced by placement of a kaolin-soaked fibrin sponge on the posterior surface of the spinal cord. After 4 months, pressure recordings above and below the scar, in the subarachnoid space and spinal cord, were performed. Elasticity measurements were performed with small bolus injections. Morphometric analyses of brain and ventricle volumes, sizes of the central canal, and sizes of the perivascular spaces in gray and white matter were also performed. RESULTS No animal developed clinical or neurophysiological evidence of neurological symptoms at any time. In the kaolin-treated group, pressure recordings revealed a significant increase in the subarachnoid pressure at C1, because of the cerebrospinal fluid flow obstruction. Pressure gradients tended to increase at all measuring points. A significant difference was detected between the spinal cord and subarachnoid space at C2, where the intramedullary pressure exceeded the subarachnoid pressure. Elasticity was significantly increased in the spinal cord at C2. Intracranially, no evidence of hydrocephalus was observed. In the spinal cord, perivascular spaces were significantly enlarged in the posterior white matter above the arachnoid scar and in the central gray matter below the area of scarring in the cervical cord. CONCLUSION Arachnoid scarring at C1-C2 produces an interstitial type of edema in the central gray matter below the area of scarring in the cat cervical cord, because of altered cerebrospinal fluid and extracellular fluid flow dynamics. These changes may be interpreted as the initial stage in the development of syringomyelic cavities.
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Affiliation(s)
- J Klekamp
- Department of Neurosurgery, Nordstadt Krankenhaus, Medizinische Hochschule, Hannover, Germany
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Young WF, Tuma R, O'Grady T. Intraoperative measurement of spinal cord blood flow in syringomyelia. Clin Neurol Neurosurg 2000; 102:119-23. [PMID: 10996707 DOI: 10.1016/s0303-8467(00)00082-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The role of spinal cord ischemia in the pathophysiology of syringomyelia remains undetermined. Previous reports in the literature suggest that shunting of syringes can improve spinal cord blood flow. In order to determine the effects of syrinx decompression on spinal cord blood flow in patients with syringomyelia, we prospectively measured regional spinal cord blood flow (RSCBF) intraoperatively pre and post shunting in patients with symptomatic syringomyelia using laser doppler flowmetry. Six patients with MRI documented syringomyelia were studied (three with Arnold Chiari I malformation and associated syrinx and three with post-traumatic syringomyelia). Surgery was performed on all patients with either a syringopleural or syringoperitoneal shunt. Laser doppler blood flow and somatosensory evoked potentials were monitored prior to myelotomy and after shunt insertion. Results indicate that there was a significant increase in RSCBF after decompression of the syrinx. This study supports the hypothesis that spinal cord ischemia is important in the pathophysiology of syringomyelia and confirms previous reports in the literature regarding RSCBF in syringomyelia.
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Affiliation(s)
- W F Young
- Department of Neurosurgery, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Erkan K, Unal F, Kiris T, Karalar T. Treatment of terminal syringomyelia in association with tethered cord syndrome: clinical outcomes with and without syrinx drainage. Neurosurg Focus 2000; 8:E9. [PMID: 16676932 DOI: 10.3171/foc.2000.8.3.9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Object
Current use of magnetic resonance (MR) imaging has led to increased awareness of the frequency of terminal syringomyelia in patients with tethered cord syndrome. However, that the surgical treatment of terminal syringomyelia is necessary remains unclear.
In this study the authors attempted to assess the clinical impact, if any, brought after syrinx decompression on the clinical outcome of tethered cord syndrome.
Methods
They randomly assigned 30 cases of pediatric tethered cord into two treatment groups: those in whom an untethering procedure was performed (Group I) and those in whom this procedure was combined with syrinx decompression (Group II). The 1-year follow-up clinical results obtained in the two groups, in correlation with MR imaging findings, were compared to evaluate the benefit of added syrinx drainage.
Clinical follow-up evaluation revealed that surgical drainage of the syrinx, when combined with spinal cord untethering, resulted in better outcomes in terms of resolution of sensory deficits (p = 0.036) and bladder dysfunction (p = 0.05). The improvement in clinical outcome correlated with the radiologically documented resolution of the syrinx cavity; however, response rates of symptoms differed for each tethering subgroup.
Conclusions
Preliminary results of this study indicated that terminal syringomyelia should be considered as a comorbidity that contributes to the clinical outcome of patients with tethered cord syndrome. A better clinical outcome is achieved following successful decompression of the syrinx in addition to untethering the spinal cord. These findings emphasize the importance of recognizing, evaluating, and treating this pathological entity.
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Affiliation(s)
- K Erkan
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul,Turkey
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