Syringomyelia of the distal spinal cord in children

Clinical Significance of Terminal Syringomyelia and Accompanying Congenital Anomalies of Neurosurgical Interest in Adult and Pediatric Patients with Tethered Cord Syndrome

Magnetic resonance imaging (MRI) can be used to examine tethered cord syndrome (TCS) and terminal syringomyelia (TS). Additionally, there is increasing evidence of an association between congenital anomalies and TCS. We aimed to identify the clinical and radiological characteristics of syringomyelia and other anomalies in pediatric and adult patients with TCS. This study included 54 TCS patients (mean age, 17.37 ± 15.83 years; 31 females) admitted to our department between 2010 and 2019. The patients were divided into two age groups: pediatric (<18 years; 63%) and adult (>18 years). Clinical findings, direct vertebrae radiographs, lower extremity radiographs, and spinal/cranial MRI findings were used to evaluate all patients. Computed tomography (CT) was performed to reveal the structure of the septum in patients with Diastematomyelia. Cranial ultrasonography or CT was performed if the fontanel was open or closed, respectively, in pediatric hydrocephalus cases. Pelvic ultrasonography and urodynamic tests were performed to evaluate other comorbid anomalies and urinary system pathologies. A thick filum terminale (73.3%) and diastematomyelia (44.4%) were found to cause spinal tension. The most common accompanying pathology was syringomyelia (78%). The common symptoms were urinary incontinence and bowel problems (71%), scoliosis (68%), and progressive lower extremity weakness (64.4%). It is difficult to distinguish the exact cause of symptoms in patients with TCS and TS. Due to the greater occurrence of other congenital spinal anomalies accompanying TCS, both preoperative symptoms and clinical findings are more severe in the pediatric group than in the adult group, and postoperative results may be more negative.

Radiographic and clinical outcome of syringomyelia in patients treated for tethered cord syndrome without other significant imaging abnormalities

OBJECT

The surgical management of patients with symptoms of tethered cord syndrome (TCS) who lack significant radiographic abnormalities is controversial. One potential MRI marker for TCS is a spinal cord syrinx or syringomyelia. Alternatively, a syrinx may be a benign and incidental finding. In this report the authors evaluated a highly selected cohort of patients with symptoms of TCS with minimal radiographic abnormalities other than syringomyelia. They analyzed clinical and radiographic outcomes after tethered cord release (TCR).

METHODS

A retrospective review of data from 16 children who met the study inclusion criteria was performed. All patients had been surgically treated at Riley Hospital for Children in Indianapolis, Indiana, between 2006 and 2011. All children had clinical symptoms of TCS as well as available pre- and postoperative MRI data.

RESULTS

The most common presentation (12 [75%] of 16 patients) was urinary dysfunction, defined as symptoms of urgency or incontinence with abnormal urodynamic studies. Clinical follow-up data were available in 11 of these 12 patients. All 11 had improvement in symptoms at an average follow-up of 17 months. Seven (87.5%) of 8 patients presenting with back or leg pain had improvement. Three patients had progressive scoliosis; 2 had stabilization of the curve or mild improvement, and 1 patient had worsening deformity. Radiographic follow-up data were obtained an average of 14.5 months after surgery. Twelve patients (75%) had stable syringomyelia after TCR. Four patients showed improvement, with 2 having complete radiographic resolution.

CONCLUSIONS

Highly selected patients with symptoms of TCS did very well clinically. Patients with abnormal urodynamic studies, pain, and gait disturbances showed a high rate of symptomatic improvement. However, a smaller percentage of patients had radiographic improvement of the syrinx. Therefore, the authors suggest that the decision to perform TCR should be based on clinical symptoms in this population. Symptomatic improvement was not necessarily related to radiographic resolution of the syrinx.

The value of postoperative MR in tethered cord: a review of 140 cases

PURPOSE

This study aimed to determine the justification for routine postoperative MRI (POMR) following surgical release of tethered cord (TC) given that an MR, in this situation, mostly serves as a baseline and rarely has immediate clinical implications. Furthermore, later in the course of the disease, the presence of retethering is mostly assessed by clinical parameters, rather than imaging.

METHODS

A single-center retrospective review of patients who underwent tethered cord release surgery between the years 1997 and 2009 at the Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Israel was performed. Collected data including basis for diagnosis, pathology, associated clinical and radiologic findings, surgical procedure and outcome, postoperative follow-up and morbidities, and postoperative MRI findings were recorded and analyzed.

RESULTS

One hundred forty patients operated upon between 1997 and 2009 for tethered cord syndrome were reviewed. Routine postoperative MR was performed in all cases 6-18 months after surgery. All cases were fully untethered. MR revealed relevant information in eight cases, two with residual dermoid, and six with significant terminal syrinx. None of these findings led to repeat surgery or special treatment. Retethering operations were performed in two cases in which retethering was diagnosed based on clinical evaluation.

CONCLUSIONS

Based on analysis of our series of 140 consecutive patients who all underwent POMR 6-18 months after TC release, we suggest that POMR as routine clinical practice is not justified for uncomplicated cases of TC release. In cases of high risk for retethering, or significant preoperative syrinx or dermoid, POMR is recommended to establish a baseline for future clinical follow-up.

Diastematomyelia in children: treatment outcome and natural history of associated syringomyelia

OBJECTIVE

To quantify the long-term outcome of children with diastematomyelia and the implication of syringomyelia in the natural history.

MATERIALS

Retrospective study of 17 children (nine girls and eight boys) with diastematomyelia operated during 1989-2004. Mean age at diagnosis was 3.4 years (range 5 days-12 years), mean follow-up was 5 years; 14 had excision of spur and cord untethering, 3 had excision of spur alone.

RESULTS

The bony spur was in the lumbar region in 12 and thoracic in 5 patients. Syringomyelia was present in eight (47%), associated with bony spur between L1 and 4 (p=0.088), spina bifida occulta in ten (58.8%), and spinal lipoma in one (6%). Preoperative Necker Enfants Malades (NEM) scores were 17 in eight patients, 16 in four, 15 in three, 13 in one, and 12 in one patient. Presenting neurological deficits were motor in eight, sensory deficits in three, and anal incontinence in one patient. There was improvement of NEM scores postoperatively in five patients only, but still with residual deficit. Repeat spur excision and cord untethering was performed in three patients for neurological deterioration 1-4 years after first operation. On postoperative MRI scans syringomyelia remained unchanged in all eight patients. There were one skin infection, one transient motor deterioration, and one patient with sensory deficit after surgery.

CONCLUSION

Prophylactic operations were associated with the best clinical outcome. Despite improvement, all patients with established preoperative deficit still had residual neurological deficits at their last follow-up. The associated syringomyelia remained unchanged after surgery, indicating that it does not contribute to the neurological syndrome.

[Charcot-Marie-Tooth disease associated with syringomyelia revealed by urinary disorders]

PURPOSE

Charcot-Marie-Tooth (CMT) disease is characterized by genetic and clinical heterogeneity. The occurrence of urinary disorders is unusual and requires further investigation. CMT disease and syringomyelia are not usually associated. Moreover, primary urinary signs in syringomyelia are not frequent.

CASE REPORT

An 11-year-old girl with CMT disease 1A duplication presented with motor deficit of the leg associated with urinary disorders. Urodynamic study revealed neurogenic detrusor overactivity, and magnetic resonance imaging confirmed syringomyelia extending from T11 to an L1 located conus.

DISCUSSION

Review of the literature confirmed the possibility of primary urinary signs in syringomyelia, with only one case of CMT and urinary signs described. In this case, the diagnosis was radicullar and medullar compression by a hypertrophic nerve formation called an "onion bulb" reflecting the demyelinisation and remyelinisation cycle.

CONCLUSION

Urinary signs in CMT disease are exceptional and require investigation into the possibility of a central lesion.

Evaluation and management of the Chiari malformation type 1 for the primary care pediatrician

Diagnosis and treatment of CMI is undergoing reexamination that includes redefinition of the anatomic Chiari malformation and refinement and redefinition of the clinical syndrome. Children with SMI present with head pain of some kind, a neurologic deficit, or with signs of spinal cord dysfunction from syrinx. Some will present with no clinical syndrome at all. Presence of anatomic Chiari malformation or compelling clinical Chiari syndrome should lead to evaluation by a neurologist or neurosurgeon experienced with the syndromes and their treatment. Treatment options are varied but usually result in resolution of symptoms. When symptoms persist after surgery, management is complex and not uniformly successful, even in the most experienced hands.

Treatment of terminal syringomyelia in association with tethered cord syndrome: clinical outcomes with and without syrinx drainage

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.

Terminal syringomyelia in association with the tethered cord syndrome

OBJECTIVE

With the increasing use of magnetic resonance imaging, terminal syringomyelia (segmental cystic dilation of the caudal one-third of the spinal cord) in association with the tethered cord syndrome has become an appreciable finding. This study attempted to define the clinical significance of this associated pathological condition by describing its clinical and radiological characteristics and its contribution to the clinical status of patients with tethered spinal cords.

METHODS

Of 132 consecutive patients with tethered cord syndrome who presented to our department between 1990 and 1997, 32 patients with terminal syringomyelia were enrolled in this study. Clinical findings were correlated with syrinx morphological features, as defined using magnetic resonance imaging. Surgical treatment used two basic approaches, i.e., simple untethering or untethering with concurrent syrinx drainage.

RESULTS

Analysis of the neurological deficits established a contribution of segmental symptoms, which were correlated with the extension and dilation of the syrinx cavity. Magnetic resonance imaging scans revealed the frequency of sacral tethering (40.6%), the intramedullary paracentral position of the syrinx (75%), and disturbances in regional cerebrospinal fluid flow (42%). The clinical outcomes seemed to be correlated with syrinx shrinkage; all patients who experienced collapse of the cavity achieved better symptom resolution.

CONCLUSION

Radiologically significant terminal syringomyelia affects the clinical presentation of tethered cord syndrome, by increasing or inducing neurological deficits. Better clinical outcomes after syrinx decompression emphasize the importance of the recognition and treatment of this pathological condition.

Spondylolysis associated with Arnold-Chiari malformation and syringomyelia. A report of two cases

STUDY DESIGN

This is a report of two cases.

OBJECTIVE

To document the occurrence and association of spondylolysis and Arnold-Chiari malformation Type I.

SUMMARY OF BACKGROUND DATA

The association of spinal dysraphism has been reported with Arnold-Chiari Type II, but not with Arnold-Chiari Type I.

METHODS

The senior author was involved in the care of these patients. All medical records, laboratory and radiologic investigations, and related literature were reviewed.

RESULTS

The presence of cephalic and caudal neuropore maldevelopment may be present in various combinations. The presence of spondylolysis, with or without spina bifida occulta, associated with Arnold-Chiari malformation type I and syringohydromyelia, is demonstrated.

CONCLUSIONS

In some patients, the presence of spondylolysis may represent a congenital anomaly and may be associated with cephalic neuropore maldevelopment, such as cerebromedullary malformation syndrome (i.e., Arnold-Chiari malformation Type I).