Syringomyelia: diagnosis and management

'Tumour-like' lesion caused by cervical discal instability

We present the case of a man in his 40s who sought medical attention due to central cord syndrome. MRI findings demonstrated contrast uptake, spinal swelling, syrinx formation and narrowing of the spinal canal. We encountered two potential scenarios:when malignancy is suspected, the patient would undergo a biopsy. However, if the lesion is ultimately determined to be benign, the patient would have been subjected to an avoidable risk of neurological damage associated with the procedure. Conversely, addressing the lesion as a result of a degenerative process (discal instability), performing an anterior approach for interbody fusion with an underlying malignant process could lead to substantial delays in the diagnosis, finally producing a poor outcome. A comprehensive imaging workup was conducted to rule out malignancy. We hypothesised that discal instability was responsible for the observed findings. The patient was successfully treated with anterior cervical decompression and fusion, without complications. Follow-up evaluations confirmed remission of the condition.

Clinical predictors of syringomyelia in Cavalier King Charles Spaniels with chiari-like malformation based on owners' observations

BACKGROUND

Syringomyelia (SM) is a prevalent inherited developmental condition in Cavalier King Charles Spaniels (CKCSs) with Chiari-like malformation (CM), accompanied by a variety of clinical manifestations, including signs of neuropathic pain. Magnetic resonance imaging (MRI) is the gold standard in SM diagnosis. However, it is desirable to establish clinical predictors that can identify CKCSs with a large clinical syrinx that needs treatment, as some owners cannot afford or lack access to MRI. The aims of the study were to investigate owner-reported clinical signs of SM and clinical predictors of a large clinical syrinx, using predictive values of significant signs, individually and in combinations. Eighty-nine CKCSs participated in this retrospective study. Based on MRI diagnosis, dogs were distributed into three groups: CM without syrinx or with a maximum transverse width < 2 mm (n = 13), CM with small syrinx 2.00-3.99 mm (n = 26) and CM with large syrinx ≥4 mm (n = 50). A structured investigator-owner interview using a standardized questionnaire was used to collect data regarding clinical signs of CM and SM. The statistical tests Pearson's chi-square, Fisher's Exact and Spearman's rank order were used to assess the difference in owner-reported signs between groups. For signs with significant differences, positive and negative predictive values (PPV and NPV) were calculated.

RESULTS

Following clinical signs were reported significantly more frequent in dogs with a large syrinx: phantom scratching, bilateral scratching of the neck or shoulder, aversion when that area is touched, or exacerbation of clinical signs when the dog is emotionally aroused. Each individual sign had a high PPV, indicative of a large clinical syrinx. The PPV increased further when the signs phantom scratching, aversion to touch to the head, neck or shoulder, and a preferred head posture during sleep were present in combination.

CONCLUSIONS

Specific clinical signs can be used individually and in combination as clinical predictors of a large clinical syrinx in CKCSs with CM and SM. General practitioners can utilize this information to identify CKCSs with a large syrinx to initiate necessary treatment. This is particularly useful in cases where access to or affordability of an MRI diagnosis is limited.

Structural Myelopathies

OBJECTIVE

This article illustrates the clinical importance, diagnosis, and management of degenerative and nondegenerative structural myelopathies. It also aims to create a diagnostic approach for the evaluation of patients with suspected degenerative myelopathies.

LATEST DEVELOPMENTS

There is considerable interest in developing diagnostic methods that can assist in deciding if surgery is indicated in patients with structural myelopathy and the optimal timing for surgery. Diffusion tensor imaging has emerged as a promising imaging modality although it is not used routinely in clinical practice. Neuroprotective medications and interventions are being studied in patients with degenerative myelopathies.

ESSENTIAL POINTS

Structural myelopathies and particularly degenerative myelopathies are common disorders that are routinely encountered in clinical practice, with symptoms that frequently overlap with other neurologic disorders. The prompt diagnosis and treatment of patients are essential in achieving good functional outcomes.

Radiographic Absence of the Left Humeral Head

An older patient with history of surgical decompression for syringomyelia, poor mobility, and frequent falls presented with pain, numbness, and paresthesias in his left upper extremity. Radiograph showed complete absence of the left humeral head. What is the diagnosis, and what would you do next?

Syringomyelia: A New Phenotype of SPG11-Related Hereditary Spastic Paraplegia?

Hereditary spastic paraplegia (HSP) refers to a group of neurodegenerative disorders affecting motor neurons in the central nervous system. HSP type 11 is the most frequent subtype of autosomal recessive HSPs. Caused by pathogenic variants in SPG11, HSP type 11 has a heterogeneous clinical presentation, including various degrees of cognitive dysfunction, spasticity and weakness predominantly in the lower extremities among other features. An 8-year-old boy visited our rehabilitation clinic with a chief complaint of intellectual impairment. Motor weakness was not apparent, but he exhibited a mild limping gait with physical signs of upper motor neuron involvement. Next generation sequencing revealed biallelic pathogenic variants, c.2163dupT and c.5866+1G>A in SPG11, inherited biparentally which was confirmed by Sanger sequencing. Brain imaging study showed thinning of corpus callosum, consistent with previous reports, however whole spine imaging study revealed extensive syringomyelia in his spinal cord, a rare finding in HSP type 11. Further studies are needed to determine whether this finding is a true phenotype associated with HSP type 11.

Suppression of TGFβR-Smad3 pathway alleviates the syrinx induced by syringomyelia

BACKGROUND

Syringomyelia is a cerebrospinal fluid (CSF) disorder resulted in separation of pain and temperature, dilation of central canal and formation of syrinx in central canal. It is unclear about mechanisms of the dilation and syrinx formation. We aimed to investigate roles of ependymal cells lining central canal on the dilation, trying to reduce syrinx formation in central canal.

METHODS

We employed 78 Sprague-Dawley (SD) rats totally with syringomyelia to detect the contribution of ependymal cells to the dilation of central canal. Immunofluorescence was used to examine the activation of ependymal cells in 54 syringomyelia rat models. BrdU was used to indicate the proliferation of ependymal cells through intraperitoneal administration in 6 syringomyelia rat models. 18 rats with syringomyelia were injected with SIS3, an inhibitor of TGFβR-Smad3, and rats injected with DMSO  were used as control. Among the 18 rats, 12 rats were used for observation of syrinx following SIS3 or DMSO administration by using magnetic resonance imaging (MRI) on day 14 and day 30 under syringomyelia without decompression. All the data were expressed as mean ± standard deviation (mean ± SD). Differences between groups were compared using the two-tailed Student's t-test or ANOVA. Differences were considered significant when *p < 0.05.

RESULTS

Our study showed the dilation and protrusions of central canal on day 5 and enlargement from day 14 after syringomyelia induction in rats with activation of ependymal cells lining central canal. Moreover, the ependymal cells contributed to protrusion formation possibly through migration along with central canal. Furthermore, suppression of TGFβR-Smad3 which was crucial for migration reversed the size of syrnix in central canal without treatment of decompression, suggesting TGFβR-Smad3 signal might be key for dilation of central canal and formation of syrinx.

CONCLUSIONS

The size of syrinx was decreased after SIS3 administration without decompression. Our study depicted the mechanisms of syrinx formation and suggested TGFβR-Smad3 signal might be key for dilation of central canal and formation of syrinx.

Retrospective Analysis of Associated Anomalies in 636 Patients with Operatively Treated Congenital Scoliosis

BACKGROUND

Congenital scoliosis is frequently associated with anomalies in multiple organ systems. However, the prevalence and distribution of associated anomalies remain unclear, and there is a large amount of variation in data among different studies.

METHODS

Six hundred and thirty-six Chinese patients who had undergone scoliosis correction surgery at Peking Union Medical College Hospital from January 2012 to July 2019 were recruited, as a part of the Deciphering disorders Involving Scoliosis and COmorbidities (DISCO) study. The medical data for each subject were collected and analyzed.

RESULTS

The mean age (and standard deviation) at the time of presentation for scoliosis was 6.4 ± 6.3 years, and the mean Cobb angle of the major curve was 60.8° ± 26.5°. Intraspinal abnormalities were found in 186 (30.3%) of 614 patients, with diastematomyelia being the most common anomaly (59.1%; 110 of 186). The prevalence of intraspinal abnormalities was remarkably higher in patients with failure of segmentation and mixed deformities than in patients with failure of formation (p < 0.001). Patients with intraspinal anomalies showed more severe deformities, including larger Cobb angles of the major curve (p < 0.001). We also demonstrated that cardiac anomalies were associated with remarkably worse pulmonary function, i.e., lower forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). Additionally, we identified associations among different concomitant malformations. We found that patients with musculoskeletal anomalies of types other than intraspinal and maxillofacial were 9.2 times more likely to have additional maxillofacial anomalies.

CONCLUSIONS

In our cohort, comorbidities associated with congenital scoliosis occurred at a rate of 55%. To our knowledge, our study is the first to show that patients with congenital scoliosis and cardiac anomalies have reduced pulmonary function, as demonstrated by lower FEV1, FVC, and PEF. Moreover, the potential associations among concomitant anomalies revealed the importance of a comprehensive preoperative evaluation scheme.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Neuropathic arthropathy of the shoulder secondary to operated syringomyelia: a case-based review

Neuropathic arthropathy (NA) is a long-term progressive disorder that causes joint destruction in the existence of a neurologic deficit. Minor injuries and fractures are commonly overlooked until the visible joint deterioration becomes persistent. Syringomyelia is one of the important causes of NA. The appearance of clinical signs in syringomyelia is caused by longitudinal cysts formed in the cervical and cervicothoracic regions of the spinal cord. Depending on the existence of the underlying disorder, the number and localization of the syrinxes, a range of symptoms, involving pain, sensation deficit, loss of motor function, and deep tendon reflex abnormality, emerge. The case is here described of a 68-year-old female patient with shoulder NA following syringomyelia, who partially responded to the rehabilitation program. Furthermore, the available case reports were comprehensively reviewed on Web of Science, Scopus, and PubMed/Medline. Furthermore, the available case reports were comprehensively evaluated on Web of Science, Scopus, and PubMed/Medline. Thus, we aimed to present the demographic characteristics, symptoms, physical examination signs, treatment, and follow-up parameters of syringomyelia-related shoulder NA cases.

Chiari Malformation Type 1 in Adults

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.

Coexisting ossification of the posterior longitudinal ligament, intramedullary hemangioblastoma, and syringomyelia of the cervical spine: illustrative case

BACKGROUND

Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of severe spinal cord compression and degenerative cervical myelopathy. Because OPLL is rarely accompanied by prominent syringomyelia, when both are observed, other causes of syringomyelia should be considered. Simultaneous presentation of OPLL and hemangioblastoma of the cervical spine is a rare encounter and has never been reported in the English-language literature.

OBSERVATIONS

The authors present a case of a 64-year-old man with muscle weakness of the right upper limb and worsening dysesthesia of the right thumb and index finger. Noncontrast magnetic resonance imaging (MRI) of the cervical spine from another institution revealed OPLL from the C2 to C6 levels with severe spinal cord compression and prominent syringomyelia. Repeated MRI with contrast showed an intramedullary tumor, about 11 mm in diameter, at the right posterior aspect of the C4 level. The authors performed laminectomies from C1 to C6 with posterolateral fusion and removed the C4 tumor. Pathohistological examination of the tumor demonstrated hemangioblastoma.

LESSONS

Careful evaluation of the preoperative imaging study is extremely important in surgical decision making. Although rare, concomitant cervical hemangioblastoma should be listed in the differential diagnosis when OPLL is accompanied with prominent syringomyelia.

Outcome evaluation of decompression surgery combined with cerebellar tonsillectomy compared without cerebellar tonsillectomy for Chiari type I malformation patients

BACKGROUND

Surgical intervention is an important treatment option to improve the prognosis for Chiari type I malformation (CM-I) patients. However, there is no consensus about surgical strategies. The article intends to evaluate the effect of decompression combined with or without cerebellar tonsillectomy in the treatment of CM-I.

METHOD

Following PRISMA's principles, Embase, PubMed, Web of Science, and Cochrane databases and references to relevant articles were searched to include only original articles on decompression combined with or without cerebellar tonsillectomy in CM-I patients. Through meta-analysis, the data on clinical improvement, radiological improvement, and complications were pooled.

RESULTS

Nine articles, including 399 CM-I patients undergoing decompression alone and 343 undergoing decompression with cerebellar tonsillectomy, meet the inclusion standard. In comparison, the improvement rate of clinical symptoms or signs in patients with cerebellar tonsillectomy is higher and statistically significant (RR: 0.85, 95% CI: 0.75-0.95; P = 0.006). However, decompression with cerebellar tonsillectomy is also significantly higher in the incidence of postoperative complications (RR: 0.54, 95% CI: 0.36-0.80; P = 0.002). No statistical difference is discovered between the two groups in the improvement rate of syringomyelia (RR: 0.77, 95% CI: 0.57-1.03; P = 0.08).

CONCLUSIONS

Although decompression with cerebellar tonsillectomy is superior than decompression alone in clinical improvement for CM-I patients, it also faces a higher risk of postoperative complications. The reduction of syringomyelia in the two groups can be considered equally effective without significant differences. In the future, the results of the research require multicenter and large-scale randomized controlled trials to verify in clinical practice.

TRIAL REGISTRATION

CRD42022321750 (PROSPERO).

Treatment of syringomyelia using uncultured umbilical cord mesenchymal stem cells: A case report and review of literature

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.