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Cui S, Li J, Zhang C, Li Q, Jiang C, Wang X, Yu X, Li K, Feng Y, Jian F. Glial scarring limits recovery following decompressive surgery in rats with syringomyelia. Exp Neurol 2025; 385:115113. [PMID: 39667655 DOI: 10.1016/j.expneurol.2024.115113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 11/28/2024] [Accepted: 12/08/2024] [Indexed: 12/14/2024]
Abstract
Syringomyelia is a neurological disease that is difficult to cure, and treatments often have limited effectiveness. In this study, a rat model of syringomyelia induced by epidural compression was used to investigate the factors that limit the prognosis of syringomyelia. After we treated syringomyelia rats with surgical decompression alone, MRI revealed that the syringomyelia rats did not show the expected therapeutic effect. Through cerebrospinal fluid (CSF) tracing experiments, we found that the CSF flow in the subarachnoid space (SAS) of rats was restored after decompression. This shows that the poor prognosis of syringomyelia rats in this study is not caused by CSF circulation disorders, suggesting the existence of other factors. Further, immunofluorescence revealed that there were extensive glial scars characterized by increased expression of glial fibrillary acidic protein (GFAP) and chondroitin sulfate proteoglycans (CSPGs) around the syrinx in the non-improved group compared to the improved group. To verify the limiting role of glial scarring in the prognosis of syringomyelia, we intervened with the selective astrocyte inhibitor fluorocitrate (FC). Intrathecal injection of FC significantly inhibited the formation of glial scar after decompression in syringomyelia rats and promoted the reduction of syrinx. This scar-inhibiting effect significantly improved neuronal survival, promoted axonal and myelin recovery, and showed better recovery in sensory function and fine motor control functions. These findings suggest that glial scarring around syrinx is a key factor limiting recovery of syringomyelia. By inhibiting glial scar formation, the prognosis of syringomyelia can be significantly improved, which provides a new strategy for improving clinical treatment effects.
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Affiliation(s)
- Shengyu Cui
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Jinze Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Can Zhang
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qian Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xinyu Wang
- Baylor College of Medicine, Houston, TX, USA
| | - Xiaoxu Yu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Kang Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuxin Feng
- Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China; Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, Beijing, China.
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Zisakis A, Sun R, Pepper J, Tsermoulas G. Chiari Malformation Type 1 in Adults. Adv Tech Stand Neurosurg 2023; 46:149-173. [PMID: 37318574 DOI: 10.1007/978-3-031-28202-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The term Chiari malformation refers to a heterogeneous group of anatomical abnormalities at the craniovertebral junction. Chiari malformation type 1 (CM1) refers to the abnormal protrusion of cerebellar tonsils through the foramen magnum and is by far the commonest type. Its prevalence is estimated approximately 1%; it is more common in women and is associated with syringomyelia in 25-70% of cases. The prevalent pathophysiological theory proposes a morphological mismatch between a small posterior cranial fossa and a normally developed hindbrain that results in ectopia of the tonsils.In most people, CM1 is asymptomatic and diagnosed incidentally. In symptomatic cases, headache is the cardinal symptom. The typical headache is induced by Valsalva-like maneuvers. Many of the other symptoms are nonspecific, and in the absence of syringomyelia, the natural history is benign. Syringomyelia manifests with spinal cord dysfunction of varying severity. The approach to patients with CM1 should be multidisciplinary, and the first step in the management is phenotyping the symptoms, because they may be due to other pathologies, like a primary headache syndrome. Magnetic resonance imaging, which shows cerebellar tonsillar decent 5 mm or more below the foramen magnum, is the gold standard investigative modality. The diagnostic workup may include dynamic imaging of the craniocervical junction and intracranial pressure monitoring.The management of CM1 is variable and sometimes controversial. Surgery is usually reserved for patients with disabling headaches or neurological deficits from the syrinx. Surgical decompression of the craniocervical junction is the most widely used procedure. Several surgical techniques have been proposed, but there is no consensus on the best treatment strategy, mainly due to lack of high-quality evidence. The management of the condition during pregnancy, restriction to lifestyle related to athletic activities, and the coexistence of hypermobility require special considerations.
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Affiliation(s)
- Athanasios Zisakis
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Rosa Sun
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Joshua Pepper
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Dien Esquivel MF, Gupta N, Wilson N, O'Brien CA, Gladkikh M, Barrowman N, Bijelić V, Tu A. Pediatric Chiari I malformation: novel and traditional measurements associated with syrinx and surgery. Childs Nerv Syst 2022; 38:2119-2128. [PMID: 35962220 DOI: 10.1007/s00381-022-05644-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 08/03/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Multiple imaging parameters have been examined to estimate the presence of syrinx and the need for surgery in Chiari I patients (CM1); however, no consistent or definitive criteria have been proposed. The objective of this study was to review existing and identify novel radiological and clinical characteristics of CM1 patients that associate syrinx development and surgical intervention. METHODS Patients with Chiari I malformation diagnosed on imaging between 0 and 18 years were retrospectively reviewed from January 1, 2007 to February 12, 2020. Participants were included if they had a baseline MRI of the head and spine prior to surgical intervention if required. Forty age-matched controls with cranial imaging were identified for comparison. Imaging parameters and clinical symptoms were recorded. RESULTS A total of 122 CM1 patients were included in this study. Of the 122 patients, 28 (23%) had syrinx, and 27 (22%) had surgery. The following imaging parameters associated with syrinx and surgical intervention were identified: midbrain length (P < 0.001; P = 0.032), the obex position (P = 0.002; P < 0.001) and medullary kinking (P = 0.041; P < 0.001). Among the clinical features, the presence of overall pain (P = 0.017; P = 0.042), neck pain (P = 0.005; P = 0.027), and sensory dysfunction (P < 0.001) were found to be strongly associated with syrinx and surgery. CONCLUSION While further investigation is needed, these specific radiological and clinical parameters should be considered when evaluating CM1 patients and may be used to guide further management.
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Affiliation(s)
- Maria F Dien Esquivel
- University of Ottawa, Ottawa, ON, Canada. .,Department of Medical Imaging, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
| | - Neetika Gupta
- University of Ottawa, Ottawa, ON, Canada.,Department of Medical Imaging, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Nagwa Wilson
- University of Ottawa, Ottawa, ON, Canada.,Department of Medical Imaging, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Christian Alfred O'Brien
- University of Ottawa, Ottawa, ON, Canada.,Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | | | - Nick Barrowman
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Vid Bijelić
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Albert Tu
- University of Ottawa, Ottawa, ON, Canada.,Division of Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Research Institute, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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Ahn H, Lee SY, Jung WJ, Lee KH. Treatment of syringomyelia using uncultured umbilical cord mesenchymal stem cells: A case report and review of literature. World J Stem Cells 2022; 14:303-309. [PMID: 35662863 PMCID: PMC9136562 DOI: 10.4252/wjsc.v14.i4.303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/28/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Syringomyelia is a disease caused by the formation of a cavity inside the spinal cord and is accompanied by such symptoms as pain, paresthesia, and urination and defecation disorders, and in severe cases causes various paralyses. Currently, there are only surgical methods for the treatment of syringomyelia, but these methods carry the possibility of failure, recurrence, and side effects.
CASE SUMMARY The patient was a 59-year-old woman who suffered from pain due to syringomyelia. For treatment, the patient received transplant of uncultured umbilical cord-derived mesenchymal stem cells. As intended, the patient's pain was relieved after treatment. Interestingly, an additional benefit was found in that the size of the cavity also decreased. After 2 years from the last treatment, the patient's cavity had almost completely disappeared and her syringomyelia was deemed cured.
CONCLUSION Using uncultured umbilical cord-derived mesenchymal stem cells may be a new treatment alternative for syringomyelia.
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Affiliation(s)
- Hyunjun Ahn
- Stem Cell Treatment and Research Institute (STRI), bio Beauty and Health Company (bBHC), Seoul 04420, South Korea
| | - Sang Yeon Lee
- Stem Cell Treatment and Research Institute (STRI), bio Beauty and Health Company (bBHC), Seoul 04420, South Korea
| | - Won-Ju Jung
- Stem Cell Treatment, 97.7 Beauty and Health Clinic, Seoul 04420, South Korea
| | - Kye-Ho Lee
- Stem Cell Treatment and Research Institute (STRI), bio Beauty and Health Company (bBHC), Seoul 04420, South Korea
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Factors Associated With Patient Reported Post-surgical Symptom Improvement in Adult Females with Chiari Malformation Type I: A Report from the Chiari1000 Dataset. World Neurosurg 2022; 161:e682-e687. [DOI: 10.1016/j.wneu.2022.02.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
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Bhatjiwale M, Bhatjiwale M. Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report. World J Surg Proced 2021; 11:1-9. [DOI: 10.5412/wjsp.v11.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/06/2021] [Accepted: 12/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.
CASE SUMMARY A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.
CONCLUSION We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.
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Affiliation(s)
- Mrudul Bhatjiwale
- Department of Neurosurgery, Narayana Health City, Bangalore 560099, Karnataka, India
- Neurological Science, Neuro Health Foundation, Mumbai 400091, India
| | - Mohinish Bhatjiwale
- Department of Neurosurgery, Rotary Medical Center, Mumbai 400068, India
- Department of Neurosurgery, Manav Kalyan Kendra & Navneet Hitech Hospitals, Mumbai 400068, India
- Department of Neurosurgery, Neuro Health Foundation, Mumbai 400091, India
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Tran TM, Lee MS, McClelland CM. Downbeat nystagmus: a clinical review of diagnosis and management. Curr Opin Ophthalmol 2021; 32:504-514. [PMID: 34456290 DOI: 10.1097/icu.0000000000000802] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN). RECENT FINDINGS Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies. SUMMARY DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic.
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Affiliation(s)
- Tu M Tran
- Department of Ophthalmology and Visual Neurosciences
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences
- Department of Neurology
- Department of Neurosurgery, University of Minnesota, Minneapolis, USA
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Arnautovic KI, Qaladize BF, Pojskic M, Gienapp AJ, Splavski B, Boop FA. The 270° Circumferential Microsurgical Decompression of the Foramen Magnum in Adult Chiari Malformation Type I: Single Surgeon Series of 130 Patients with Syringomyelia, Neurologic, and Headache Outcomes. World Neurosurg 2020; 146:e1103-e1117. [PMID: 33249219 DOI: 10.1016/j.wneu.2020.11.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Chiari malformation type I (CM-I) is a craniocervical junction disorder associated with descent of the cerebellar tonsils >5 mm. The prevalence of CM-I is common, including 0.5%-3.5% in the general population, 0.56%-0.77% on magnetic resonance imaging, and 0.62% in anatomic dissection studies. We sought to measure our surgical outcomes related to resolution/improvement of headaches, neurologic outcomes, and syringomyelia compared with reported adult CM-I studies from 2000-2019. METHODS From December 2003 to June 2018, the first author (K.I.A.) performed 270° circumferential decompression on adult (>18 years) patients with CM-I. At admission and follow-up, all parameters were numerically evaluated; headaches were self-reported on the visual analog scale, neurologic condition was evaluated using Karnofsky Performance Status and European Myelopathy Score, and syrinx width (if present) was measured on magnetic resonance imaging by grades I-IV. All parameters were analyzed, compared, and statistically tested. We compared results with our previously reported and updated systematic review of operative adult CM-I studies (studies from 2000 to 2019). RESULTS In our series, 118/121 (98%) experienced headache improvements and 100% experienced neurologic improvements. Complete syrinx resolution was experienced by 35/43 (81%); 8 (19%) showed significant improvement. In data from reported studies (2000-2019), only 79% experienced headache resolution, 77% improvement of neurologic status, and 74% resolution/improvement of syrinx (mean). CONCLUSIONS Our modified 270° circumferential microsurgical foramen magnum decompression for adult CM-I appears to be beneficial in improvement of outcomes, namely in resolution of the syrinx, neurologic symptoms, and headaches. We also confirm the association of body mass index with CM-I. Further studies are needed to confirm our results.
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Affiliation(s)
- Kenan I Arnautovic
- Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA; Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA.
| | | | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Marburg, Germany; Medicinski Fakultet Osijek, Sveučilište Josip Juraj Strossmayer, Osijek, Croatia
| | - Andrew J Gienapp
- Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA; Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Bruno Splavski
- Department of Neurosurgery, Sisters of Mercy University Hospital Center, Zagreb, Croatia; Department of Neurosurgey, University School of Medicine, Osijek, Croatia
| | - Frederick A Boop
- Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA; Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
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Spontaneous Resolution of Syringomyelia with a 16-Year Serial Magnetic Resonance Imaging Follow-Up: A Case Report and Literature Review. World Neurosurg 2019; 130:432-438. [DOI: 10.1016/j.wneu.2019.07.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 11/18/2022]
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10
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Sparks CR, Gorney A, Williams K, Griffith EH, Cerda-Gonzalez S, Lascelles BDX, Olby NJ. Investigation of sensory thresholds in Cavalier King Charles Spaniels with and without Chiari-like malformations and syringomyelia. J Vet Intern Med 2018; 32:2021-2028. [PMID: 30307645 PMCID: PMC6272044 DOI: 10.1111/jvim.15297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/01/2018] [Accepted: 07/17/2018] [Indexed: 11/29/2022] Open
Abstract
Background Cavalier King Charles Spaniels (CKCS) suffer pain associated with Chiari‐like malformation and syringomyelia (CMSM). People suffer from a similar condition and describe numerous sensory abnormalities. Sensory changes have not been quantified in affected CKCS. Objectives To use quantitative sensory testing (QST) to quantify thermal and mechanical thresholds in CKCS and to compare QST in dogs with and without syringomyelia (SM). Animals Forty‐four CKCS. Methods Prospective study. Dogs underwent neurological examinations and craniocervical magnetic resonance imaging (MRI). Thermal testing was performed over the humerus and thorax (n = 32); mechanical testing was performed on the paw and neck (n = 44). Latencies, thresholds, and response rates were compared with presence and severity of SM on MRI, presence of pain reported by the owner and pain identified on examination. Results Thirty dogs had SM, 30 were painful on examination, 29 were owner‐reported symptomatic. Thermal and mechanical variables were not significantly different based on presence or severity of SM. Dogs with pain on examination had decreased mechanical thresholds on the paw (0.38 kg, SD = 0.18) and neck (2.05 kg, SD = 0.74) compared to thresholds of dogs without pain on examination on the paw (0.60 kg, SD = 0.30) and neck (2.72 kg, SD = 0.57; P = .021). Conclusions and Clinical Importance Mechanical and thermal sensitivity does not appear to be related to the presence of SM, but mechanical sensitivity appears to be related to the presence of pain and clinical signs. Mechanical testing may be useful for assessing sensory abnormalities during clinical trials.
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Affiliation(s)
- Courtney R Sparks
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Angela Gorney
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Kim Williams
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Emily H Griffith
- Department of Statistics, North Carolina State University, Raleigh, North Carolina
| | - Sofia Cerda-Gonzalez
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York
| | - B Duncan X Lascelles
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina.,Comparative Pain Research and Education Center, North Carolina State University, Raleigh, North Carolina
| | - Natasha J Olby
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Comparative Pain Research and Education Center, North Carolina State University, Raleigh, North Carolina
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11
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Thakar S, Sivaraju L, Jacob KS, Arun AA, Aryan S, Mohan D, Sai Kiran NA, Hegde AS. A points-based algorithm for prognosticating clinical outcome of Chiari malformation Type I with syringomyelia: results from a predictive model analysis of 82 surgically managed adult patients. J Neurosurg Spine 2017; 28:23-32. [PMID: 29125433 DOI: 10.3171/2017.5.spine17264] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although various predictors of postoperative outcome have been previously identified in patients with Chiari malformation Type I (CMI) with syringomyelia, there is no known algorithm for predicting a multifactorial outcome measure in this widely studied disorder. Using one of the largest preoperative variable arrays used so far in CMI research, the authors attempted to generate a formula for predicting postoperative outcome. METHODS Data from the clinical records of 82 symptomatic adult patients with CMI and altered hindbrain CSF flow who were managed with foramen magnum decompression, C-1 laminectomy, and duraplasty over an 8-year period were collected and analyzed. Various preoperative clinical and radiological variables in the 57 patients who formed the study cohort were assessed in a bivariate analysis to determine their ability to predict clinical outcome (as measured on the Chicago Chiari Outcome Scale [CCOS]) and the resolution of syrinx at the last follow-up. The variables that were significant in the bivariate analysis were further analyzed in a multiple linear regression analysis. Different regression models were tested, and the model with the best prediction of CCOS was identified and internally validated in a subcohort of 25 patients. RESULTS There was no correlation between CCOS score and syrinx resolution (p = 0.24) at a mean ± SD follow-up of 40.29 ± 10.36 months. Multiple linear regression analysis revealed that the presence of gait instability, obex position, and the M-line-fourth ventricle vertex (FVV) distance correlated with CCOS score, while the presence of motor deficits was associated with poor syrinx resolution (p ≤ 0.05). The algorithm generated from the regression model demonstrated good diagnostic accuracy (area under curve 0.81), with a score of more than 128 points demonstrating 100% specificity for clinical improvement (CCOS score of 11 or greater). The model had excellent reliability (κ = 0.85) and was validated with fair accuracy in the validation cohort (area under the curve 0.75). CONCLUSIONS The presence of gait imbalance and motor deficits independently predict worse clinical and radiological outcomes, respectively, after decompressive surgery for CMI with altered hindbrain CSF flow. Caudal displacement of the obex and a shorter M-line-FVV distance correlated with good CCOS scores, indicating that patients with a greater degree of hindbrain pathology respond better to surgery. The proposed points-based algorithm has good predictive value for postoperative multifactorial outcome in these patients.
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Affiliation(s)
- Sumit Thakar
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | - Laxminadh Sivaraju
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | | | - Aditya Atal Arun
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | - Saritha Aryan
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | - Dilip Mohan
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | | | - Alangar S Hegde
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
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Arnautovic A, Splavski B, Boop FA, Arnautovic KI. Pediatric and adult Chiari malformation Type I surgical series 1965-2013: a review of demographics, operative treatment, and outcomes. J Neurosurg Pediatr 2015; 15:161-77. [PMID: 25479580 DOI: 10.3171/2014.10.peds14295] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECT Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia. METHODS The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included. RESULTS The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series. CONCLUSIONS Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.
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Affiliation(s)
- Aska Arnautovic
- George Washington University School of Medicine, Washington, DC
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Arnautovic KI, Muzevic D, Splavski B, Boop FA. Association of increased body mass index with Chiari malformation Type I and syrinx formation in adults. J Neurosurg 2013; 119:1058-67. [DOI: 10.3171/2013.4.jns122011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper the authors describe an association between increased body mass index (BMI) and Chiari malformation Type I (CM-I) in adults, as well as its relationship to the development of syringomyelia.
Methods
In the period between January 2004 and December 2011, the senior author reviewed the data for all CM-I patients with or without syringomyelia and neurological deficit. Analyzed factors included clinical status (headaches and neurological signs), radiological characteristics of syringomyelia (diameter and vertical extent of syrinx), BMI, and relationship of age to BMI, syrinx diameter, and vertical extent of syrinx.
Results
Sixty consecutive adults had CM-I, 26 of whom also had syringomyelia. The mean BMI among all patients was 30.35 ± 7.65, which is Class I obesity (WHO), and was similar among patients with or without syringomyelia. Extension of the vertical syrinx was greater in overweight patients (p = 0.027) than in those with a normal body weight. Evidence of de novo syrinx formation was found in 2 patients who gained an average BMI of 10.8 points. After repeated decompression and no change in holocord syrinx width or vertical extent, a reduction in the syrinx was seen after BMI decreased 11.7 points in one individual. No correlation was found between patient age and BMI, age and vertical extension of the syrinx, and age and diameter of the syrinx.
Conclusions
An association between increased BMI and CM-I in adults was recognized. Gaining weight may influence the de novo creation of a syrinx in adults who previously had minimally symptomatic or asymptomatic CM-I, and reducing weight can improve a syrinx after unsuccessful surgical decompression. Therefore, a reduction in body weight should be recommended for all overweight and obese patients with CM-I.
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Affiliation(s)
- Kenan I. Arnautovic
- 1Semmes-Murphey Clinic
- 2Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Dario Muzevic
- 3Department of Neurosurgery, Osijek University School of Medicine, Clinical Hospital Center, Osijek, Croatia
| | - Bruno Splavski
- 3Department of Neurosurgery, Osijek University School of Medicine, Clinical Hospital Center, Osijek, Croatia
| | - Frederick A. Boop
- 1Semmes-Murphey Clinic
- 2Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee; and
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Nakamura M, Tsuji O, Iwanami A, Tsuji T, Ishii K, Toyama Y, Chiba K, Matsumoto M. Central neuropathic pain after surgical resection in patients with spinal intramedullary tumor. J Orthop Sci 2012; 17:352-7. [PMID: 22573215 DOI: 10.1007/s00776-012-0236-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 04/11/2012] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To examine central neuropathic pain after surgical resection of intramedullary spinal cord tumor (IMSCT). Because of the rarity of IMSCT, there is little information about postoperative neuropathic pain after surgical resection. METHODS Eighty-five of 105 patients treated surgically for IMSCT at our hospital between 2000 and 2008 completed the Neuropathic Pain Symptom Inventory (NPSI) and the short form (SF)-36 health inventory. The NPSI score was analyzed against the tumor type and the postoperative Japanese Orthopaedic Association (JOA) score for neurological symptoms. RESULTS The mean NPSI score of the patients was 13.5. The subscore for paresthesia/dysesthesia was significantly higher than the other subscores. Analysis of the NPSI scores by tumor type revealed no significant differences among patients with ependymoma, astrocytoma, and vascular tumors. The postoperative JOA score showed a weak negative correlation with the NPSI score in patients with thoracic spinal cord tumor, and no correlation in those with cervical tumor. In the 11 patients with hemangioblastoma, intense pain was reported at the level of the tumor, although postoperative paralysis was mild. All the postoperative SF-36 subscores of our study patients were significantly lower than the national average, and a significant negative correlation was observed between the SF-36 and the NPSI subscores. CONCLUSION Neuropathic pain after surgical resection reduces the QOL of patients with IMSCTs, and pain severity varies with the tumor's location and histological features, the severity of paralysis, and the location of pain relative to the tumor.
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Affiliation(s)
- Masaya Nakamura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
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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: 4.7] [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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Clinical and radiological outcome of craniocervical osteo-dural decompression for Chiari I-associated syringomyelia. Neurosurg Rev 2010; 33:297-303; discussion 303-4. [DOI: 10.1007/s10143-010-0260-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 03/07/2010] [Accepted: 03/08/2010] [Indexed: 02/02/2023]
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Syringomyelia associated with Chiari I malformation. Neurol Sci 2009; 30:525-6. [PMID: 19768371 DOI: 10.1007/s10072-009-0133-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2008] [Accepted: 08/25/2009] [Indexed: 10/20/2022]
Abstract
An 18-year-old man with progressive paraparesis, thermal hypoesthesia, sweating abnormalities, bladder dysfunction, severe orthostatic hypotension, bilateral Babinski sign, underwent a brain MRI scan that showed downward displacement of cerebellar tonsils through the foramen magnum, consistent with Chiari I malformation, compression of the brainstem-spinal cord junction, and C1-D11 syringomyelia (6.5 mm diameter at C2 level) consistent with Chiari I syndrome. Suboccipital craniectomy and duraplasty were performed. A C2 partial laminectomy and ablation of posterior arch of the atlas was performed. MRI scans 4 days and 1 month after surgery showed a dramatic syringomyelia reabsorption (2.5 and 1 mm, respectively) associated with complete clinical recovery.
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Prat R, Galeano I. Pain improvement in patients with syringomyelia and Chiari I malformation treated with suboccipital decompression and tonsillar coagulation. J Clin Neurosci 2009; 16:531-4. [DOI: 10.1016/j.jocn.2008.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 06/24/2008] [Accepted: 06/25/2008] [Indexed: 02/02/2023]
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Dynamics of neurological deficit after surgical decompression of symptomatic vertebral metastases. Spine (Phila Pa 1976) 2009; 34:566-71. [PMID: 19282735 DOI: 10.1097/brs.0b013e31819a825d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We conducted a retrospective study to examination the influence of preoperative duration of symptoms on the clinical outcome of patients that underwent surgical decompression because of neurologic deficit in metastatic disease of the spine. OBJECTIVES.: Our aim was to investigate possible correlations between the duration of neurologic deficit before surgery and postoperative outcome with respect to neural recovery in patients with spinal metastases, and second, based on those results, propose criteria for the timing of surgery in these patients. SUMMARY OF BACKGROUND DATA It has not yet been determined whether the duration of preoperative symptoms has an influence on the postoperative outcome of patients with vertebral metastases. A standardized treatment or protocol defining a strategy of surgical treatment has yet to be designed. METHODS This study includes 194 patients. The duration of symptoms before surgical treatment and the neurologic status before and after operation were determined and classified according to the Frankel score. RESULTS Of 401 patients, who underwent surgery due to metastases to the spine, 194 suffered from neurologic deficit. Analyzing the postoperative neurostatus in these patients revealed an improvement in 78 patients (40%), impairment in 13 patients (7%), and in 103 patients it did not change. The relation of duration of neurologic symptoms before surgery, and the outcome after an operation was highly significant (P < 0.001). In patients with less than 3 days of neurologic deficit, the probability of improvement in neurostatus was highly significantly higher (P < 0.001) than in patients with neurologic deficit existing for more than 15 days. CONCLUSION Patients with neurologic deficit because of spinal bone metastases benefit from early operative intervention. Urgent surgery is indicated in patients with less than 3 days of neurologic deficit.
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Peterson MM, Craciun L, Heiss JD. Long-term result of the Echols procedure for treating syringomyelia. J Neurosurg Spine 2009; 10:73-8. [PMID: 19119937 DOI: 10.3171/2008.10.spi08291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In 1974, a 9-year-old girl with syringomyelia and scoliosis was treated using the Echols procedure, a surgical technique that makes use of a metal stent to maintain drainage of fluid from the syrinx into the subarachnoid space. The patient presented to the authors' institution 34 years later with a history of progressive myelopathy and surgically treated deformities of the thoracic spine, lumbar spine, and right foot. Computer-assisted myelography indicated that the metal wire remained in place and that the syrinx had collapsed. Neurological examination and neurophysiological testing confirmed the presence of thoracic myelopathy, which may have been due to the wire tethering the thoracic spinal cord to the dorsal dura. This case is believed to be the only long-term report of the effects of the Echols procedure. The history of direct treatment of syringomyelia is reviewed and is contrasted with indirect treatment of syringomyelia, which relieves the condition by opening obstructed CSF pathways within the foramen magnum or spine.
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Affiliation(s)
- Matthew M Peterson
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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Attenello FJ, McGirt MJ, Gathinji M, Datoo G, Atiba A, Weingart J, Carson B, Jallo GI. OUTCOME OF CHIARI-ASSOCIATED SYRINGOMYELIA AFTER HINDBRAIN DECOMPRESSION IN CHILDREN. Neurosurgery 2008; 62:1307-13; discussion 1313. [PMID: 18824997 DOI: 10.1227/01.neu.0000333302.72307.3b] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Frank J Attenello
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Attenello FJ, McGirt MJ, Gathinji M, Datoo G, Atiba A, Weingart J, Carson B, Jallo GI. OUTCOME OF CHIARI-ASSOCIATED SYRINGOMYELIA AFTER HINDBRAIN DECOMPRESSION IN CHILDREN. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000316848.55059.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Prestor B, Benedicic M. Electrophysiologic and clinical data support the use of dorsal root entry zone myelotomy in syringosubarachnoid shunting for syringomyelia. ACTA ACUST UNITED AC 2008; 69:466-72; discussion 472-3. [PMID: 17707492 DOI: 10.1016/j.surneu.2007.02.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Accepted: 02/24/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND The objectives of this study were to correlate preoperative changes in SEPs with clinical sensory dysfunction and to establish their importance in planning the microsurgical approach, either by DM myelotomy or by DREZ myelotomy, for patients with syringomyelia. METHODS In addition to conducting clinical sensory examination, we evaluated the N13 potential after median nerve stimulation and CPs after tibial nerve stimulation intraoperatively before performing myelotomy on patients with syringomyelia (N = 14). RESULTS Eleven patients with intact DS presented with unilateral PTD, and 9 had distressing unilateral dermatomal pain. Deep sensibility was affected in 3 patients (bilaterally in 1 patient) without PTD. Patients with PTD were likely to have spontaneous pain (P = .005). A significant correlation between preoperative PTD and the absence of the N13 potential was demonstrated on the right (P = .015) and left (P = .004) sides. In patients with PTD, DREZ myelotomy on the symptomatic side is suggested as the treatment of choice, whereas DM myelotomy might be superior in patients without PTD. CONCLUSIONS Absence of pain or temperature sensation in patients with syringomyelia is usually accompanied by same-sided loss of the N13 potential, suggesting damage to the DH gray matter. Deep sensibility is typically normal, and DREZ myelotomy with preservation of DCs is proposed as the treatment of choice. Conducted potentials are usually distorted in patients with normal pain or temperature sensation and affected vibration and posture sensation, suggesting damage to DCs and making DM myelotomy the treatment of choice. Electrophysiologic and clinical data support the use of DREZ myelotomy in syringosubarachnoid shunting for syringomyelia in patients whose DCs have an intact function.
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Affiliation(s)
- Borut Prestor
- Department of Neurosurgery, University Medical Center, 1000 Ljubljana, Slovenia.
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O’Toole JE, Eichholz KM, Fessler RG. Minimally Invasive Insertion of Syringosubarachnoid Shunt for Posttraumatic Syringomyelia: Technical Case Report. Oper Neurosurg (Hagerstown) 2007; 61:E331-2; discussion E332. [PMID: 18091225 DOI: 10.1227/01.neu.0000303990.03235.81] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Symptomatic posttraumatic syringomyelia affects up to 10% of patients with spinal cord injuries and manifests in a delayed manner as progressive sensorimotor changes below the level of the syrinx. Syrinx shunting, and in particular syringosubarachnoid shunting (SSAS), provides neurological improvement or stabilization in at least 50% of these patients. Given the debilitated condition of many of these patients, a minimally invasive approach to the insertion of these devices is desirable. We provide the first report of an SSAS inserted in a minimally invasive fashion through a tubular retractor.
Patients and Methods:
A 27-year-old woman presented 4 years after C6 to C7 fracture dislocation and incomplete spinal cord injury with increasing pain and spasticity below the midthoracic region. Magnetic resonance imaging scan revealed a midthoracic syrinx that had enlarged on serial imaging. SSAS was inserted using a minimally invasive technique via the X-Tube retractor (Medtronic Sofamor Danek, Memphis, TN). Through a 2.5-cm incision, hemilaminotomy was performed, and a midline durotomy and myelotomy were opened for SSAS insertion under microscopic visualization.
Results:
Intraoperative ultrasonography revealed successful syrinx decompression after SSAS insertion. The operative time was 150 minutes and estimated blood loss was less than 100 mL. The patient was mobilized on postoperative Day 1 and was discharged 38.5 hours after surgery with resolution of her preoperative symptoms. Postoperative magnetic resonance imaging scan revealed excellent decompression of the syrinx, and through 1 year of follow-up, the patient has had no recurrence of her syrinx-related symptoms.
Conclusion:
This is the first report of minimal-access insertion of an SSAS. The minimally invasive technique appears to be a safe and effective means of implanting an SSAS. This approach allows for diminished blood loss and early mobilization and transfer to rehabilitation units for these patients.
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Affiliation(s)
- John E. O’Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Kurt M. Eichholz
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard G. Fessler
- Department of Neurosurgery, Northwestern Memorial Hospital, Chicago, Illinois
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Sahin S, Comert A, Akin O, Ayalp S, Karsidag S. Painless burn injury caused by post-traumatic syringomyelia. Ir J Med Sci 2007; 177:405-7. [PMID: 17965909 DOI: 10.1007/s11845-007-0088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 09/10/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Syringomyelia, which is generally related to congenital malformations and tumors, may lead to paresthesia and dysfunctions in thermo-algesic perception. Post-traumatic syringomyelia (PTS) is a rare type of this disease characterised by the development of a cystic formation containing cerebrospinal fluid (CSF), which develops inside the spinal cord after spinal trauma. AIM The description of a case diagnosed as painless burn injury caused by PTS. METHOD One case report. CONCLUSION Although there are a number of reports regarding the formation of neuropathic ulcers related to syringomyelia, painless burn injury descriptions are very rare. Despite available limited data related to this subject, it is important to warn patients about traumas-especially burns-after a diagnosis of PTS.
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Affiliation(s)
- S Sahin
- Department of Neurology, Faculty of Medicine, Maltepe University, Baglarbasi Mh. Gumus Sk. Nr: 6/5, Maltepe/Istanbul, Turkey.
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Attal N, Bouhassira D. Chapter 47 Pain in syringomyelia/bulbia. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:705-713. [PMID: 18808869 DOI: 10.1016/s0072-9752(06)80051-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Mavinkurve GG, Sciubba D, Amundson E, Jallo GI. Familial Chiari type I malformation with syringomyelia in two siblings: case report and review of the literature. Childs Nerv Syst 2005; 21:955-9. [PMID: 15821947 DOI: 10.1007/s00381-005-1146-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Familial cases of Chiari malformation with syringomyelia are rare. The majority of the reported series and case reports detail sporadic cases. The authors report two siblings who presented with Chiari type I malformation and syringomyelia (CMI+S). CLINICAL PRESENTATION We report two sisters who each presented with scoliosis on routine school physicals. Their clinical examination was unremarkable; however, imaging studies demonstrated a Chiari malformation with syringomyelia. Both underwent cervicomedullary decompression, and follow-up imaging studies revealed resolution of the syringomyelia. CONCLUSION A review of the literature reveals fewer than ten previous reports of familial CMI+S in the past 30 years. Although rare, the existence of familial cases of CMI+S suggests a genetic component to the pathogenesis of this condition in at least a proportion of patients. Neurosurgeons should be aware of the familial aggregation of CMI+S.
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Affiliation(s)
- Gaurav G Mavinkurve
- Division of Pediatric Neurosurgery, Johns Hopkins Hospital, Harvey 811, Baltimore, MD 21287, USA
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