Surgical Treatment of Posttraumatic Syringomyelia

Epidemiological aspects of syringomyelia in a 19-year old cohort of spinal cord injury patients

OBJECTIVE

To determine the prevalence, clinical and radiological risk factors, and surgical management of post-traumatic syringomyelia (PTS) in a 19-year cohort study of Spinal Cord Injury (SCI) patients treated at a SCI rehabilitation center.

METHODS

Retrospective study of SCI patients in whom PTS was radiologically confirmed between January 2000 and December 2018. Protocols for assessing signs and symptoms of PTS were applied prior to PTS diagnosis and treatment and later at neurosurgical and rehabilitation reviews. The variables analyzed were prevalence, demographic data, trauma event, clinical and radiological risk factors, location and size of the syrinx, and effectiveness of the surgical procedures.

RESULTS

Over the 19-year period, review of 920 SCI patients revealed 85 patients who met the clinical and neuroradiological criteria for the diagnosis of PTS and who were prospectively followed. Road traffic accidents were the leading cause of injury (n = 58; 68.2%), syringomyelia was most commonly observed in the thoracic spine (n = 56; 65.9%), and upper extremity paresis was the most common indication for surgical treatment (n = 27; 45%). Surgical treatment was indicated in 48 patients and the operative procedures included 29 syringopleural shunts (60.4%), 17 adhesiolysis (35.4%), and two syringosubarachnoid shunts (4.1%). The prevalence of PTS was 9% and was higher in patients with ASIA impairment scale grade A injuries. Most patients with PTS (63/85, 74.1%) were treated surgically at the time of injury. There was a significant reduction both in the extent (p = 0.05) and largest area (p = 0.001) of the syrinx after surgical treatment. Reoperation rates were 47% and 37.9% for adhesiolysis and syringopleural shunting, respectively.

CONCLUSION

Follow-up and routine clinical examination of SCI patients is critical for the diagnosis of PTS in patients with late neurological deterioration. Surgical treatment has a positive impact in reducing the size of the syrinx as seen on postoperative MRI.

Long-Term Impairment of the Blood-Spinal Cord Barrier in Patients With Post-Traumatic Syringomyelia and its Effect on Prognosis

STUDY DESIGN

Cohort study.

OBJECTIVE

The aim of this study was to explore the association between blood-spinal cord barrier (BSCB) markers and other factors associated with an unfavorable outcome among patients with post-traumatic syringomyelia (PTS) who achieved successful intradural adhesion lysis (IAL).

SUMMARY OF BACKGROUND DATA

Only approximately half of PTS patients receiving IAL have a favorable outcome.

PATIENTS AND METHODS

Forty-six consecutive patients with PTS and 19 controls (CTRL) were enrolled. All PTS patients underwent physical and neurological examinations and spinal magnetic resonance imaging before and 3 to 12 months after IAL. All patients underwent myelography before surgery. BSCB disruption was detected by increased intrathecal and serum concentrations of albumin, immunoglobulin (Ig)G, IgA, and IgM. A multivariable analysis was performed with a logistic regression model to identify factors associated with unfavorable outcomes. Receiver operating characteristic curves were calculated to investigate the diagnostic value of biomarkers.

RESULTS

The ages and general health of the PTS and CTRL groups did not differ significantly. QAlb, IGAQ, IGGQ, and IGMQ was significantly higher in PTS patients than in controls ( P =<0.001). The degree of intradural adhesion was significantly higher in the unfavorable outcome group than in the favorable outcome group ( P <0.0001). QAlb, immunoglobulin (Ig)AQ, IGGQ, and IGMQ was significantly correlated with clinical status ( R =-0.38, P <0.01; R =-0.47, P =0.03; R =-0.56, P =0.01; R =-0.43, P =0.05, respectively). Higher QAlb before surgery (odds ratio=2.66; 95% CI: 1.134-6.248) was significantly associated with an unfavorable outcome. The receiver operating characteristic curve analysis demonstrated a cutoff for QAlb higher than 10.62 with a specificity of 100% and sensitivity of 96.3%.

CONCLUSION

This study is the first to detect increased permeability and BSCB disruption in PTS patients. QAlb>10.62 was significantly associated with unfavorable clinical outcomes following intradural decompression.

LEVEL OF EVIDENCE

Level III-prognostic.

Role of Preoperative Albumin Quotient in Surgical Planning for Posttraumatic Syringomyelia: A Comparative Cohort Study

OBJECTIVE

Surgical procedures for patients with posttraumatic syringomyelia (PTS) remain controversial. Until now, there have been no effective quantitative evaluation methods to assist in selecting appropriate surgical plans before surgery.

METHODS

We consecutively enrolled PTS patients (arachnoid lysis group, n = 42; shunting group, n = 14) from 2003 to 2023. Additionally, 19 intrathecal anesthesia patients were included in the control group. All patients with PTS underwent physical and neurological examinations and spinal magnetic resonance imaging preoperatively, 3-12 months postoperatively and during the last follow-up. Preoperative lumbar puncture was performed and blood-spinal cord barrier disruption was detected by quotient of albumin (Qalb, cerebrospinal fluid/serum).

RESULTS

The ages (p = 0.324) and sex (p = 0.065) of the PTS and control groups did not differ significantly. There were also no significant differences in age (p = 0.216), routine blood data and prognosis (p = 0.399) between the arachnoid lysis and shunting groups. But the QAlb level of PTS patients was significantly higher than that of the control group (p < 0.001), and the shunting group had a significantly higher QAlb (p < 0.001) than the arachnoid lysis group. A high preoperative QAlb (odds ratio, 1.091; 95% confidence interval, 1.004-1.187; p = 0.041) was identified as the predictive factor for the shunting procedure, with the receiver operating characteristic curve showing 100% specificity and 80.95% sensitivity for patients with a QAlb > 12.67.

CONCLUSION

Preoperative QAlb is a significant predictive factor for the types of surgery. For PTS patients with a QAlb > 12.67, shunting represents the final recourse, necessitating the exploration and development of novel treatments for these patients.

Long-term outcome of surgical treatment for idiopathic spinal arachnoid web: A case series

OBJECTIVE

Spinal arachnoid web (SAW) is a rare condition of the spine with limited long-term follow-up data in the literature. The longest reported follow-up period was an average 3.2 years. The objective of this study is to report our long-term results of patients who underwent surgical treatment for symptomatic idiopathic SAW.

METHODS

We conducted a retrospective review of cases of idiopathic SAW that were operated between 2005-2020. We collected preoperative and last follow-up (LFU) data on motor force, sensory loss, pain, upper motor neuron (UMN) sign, gait disorder, sphincter dysfunction, syringomyelia, hyperintensity on T2-MRI, appearance of newer symptoms and number of reoperations.

RESULTS

Our study included 9 patients with a mean follow-up period of 3.6years (range 2-9.1years). The surgical intervention involved a standard centered laminectomy, durotomy and arachnoid lysis. At presentation, motor weakness was present in 77.8% of patients, sensory loss in 66.7%, pain in 88.9%, sphincter dysfunction in 33.3%, UMN sign in 22%, gait disorder 55.6%, syringomyelia in 55.6% and MRI T2 hyperintensity in 55.6% of patients. At LFU, there was an improvement in all symptoms and signs to varying degrees. No new neurological symptoms appeared postoperatively, and there was no recurrence during the follow-up period.

CONCLUSION

Our results demonstrate that the reported immediate and short-term favorable outcomes following arachnoid lysis for symptomatic SAW persist over a long-term period and the risk of readhesion-correlated neurological deterioration following conventional surgical intervention is low.

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Does Direct Surgical Decompression After Traumatic Spinal Cord Injury Influence Post-Traumatic Syringomyelia Rates? An 18-Year Single-Center Experience

OBJECTIVE

Risk factors for post-traumatic syringomyelia (PTS) development after traumatic spinal cord injury (tSCI) are incompletely understood. This study aimed to investigate the influence of direct surgical decompression after tSCI, as well as demographic, clinical, and other management-related factors, on rates of PTS development.

METHODS

A single-center case-control study was conducted on patients who presented with tSCI to a tertiary referral center over an 18-year period and received adequate follow-up. Cases were defined by both clinical suspicion and radiologic evidence of PTS. Demographic, clinical, and management-related data were collected and a multivariable logistic regression analysis performed.

RESULTS

A total of 286 patients were analyzed, of whom 33 (11.5%) demonstrated PTS. Direct surgical decompression with or without stabilization was performed in 190 of 286 patients, stabilization alone in 47, and non-surgical management in 49. On multivariable analysis, no significant influence on PTS risk was demonstrated for method of acute management (P > 0.05). A ten-year increase in age at injury was shown to decrease PTS rates by 0.72 (P = 0.01). Neurologically complete injury was associated with an increased rate of PTS, though this association did not achieve significance (P = 0.08). When only surgically managed patients were considered (n = 237), no significant influence on PTS rates was demonstrated for anterior decompression (adjusted odds ratio = 1.13, 95% CI = 0.34-3.74, P = 0.84) and for stabilization alone (adjusted odds ratio = 1.19, 95% CI = 0.39-3.61, P = 0.76) relative to posterior decompression.

CONCLUSIONS

Direct surgical decompression after tSCI was not demonstrated to significantly influence rates of PTS development. Age at injury and severity of injury should be considered as risk factors for PTS on follow-up.

Long-term outcome following surgical treatment of posttraumatic tethered cord syndrome: a retrospective population-based cohort study

STUDY DESIGN

Retrospective population-based cohort study.

OBJECTIVE

To investigate the long-term outcome following surgery for posttraumatic spinal cord tethering (PSCT).

SETTING

Publicly funded tertiary care center.

METHODS

Patients surgically treated for PSCT between 2005-2020 were identified and included. No patients were excluded or lost to follow-up. Medical records and imaging data were retrospectively reviewed.

RESULTS

Seventeen patients were included. Median age was 52 (23-69) years and 7 (41%) were female. PSCT was diagnosed at a median of 5.0 (0.6-27) years after the initial trauma. Motor deficit was the most common neurological manifestation (71%), followed by sensory deficit (53%), spasticity (53%), pain (41%) and gait disturbance (24%). Median follow-up time was 5.1 (0.7-13) years. Fifteen patients (88%) showed satisfactory results following untethering, defined as improvement or halted progression of one or more of the presenting symptoms. Treatment goals were met for motor symptoms in 92%, sensory loss in 100%, spasticity in 100%, gait disturbance in 100% and pain in 86%. Statistically, a significant improvement in motor deficit (p = 0.031) and syrinx decrease (p = 0.004) was also seen. A postoperative complication occurred in four patients: three cases of cerebrospinal fluid leakage and one postoperative hematoma. Two patients showed a negative surgical outcome: 1 with increased neck pain and 1 with left arm weakness following the postoperative hematoma.

CONCLUSION

Surgical treatment of PSCT results in improved neurological function or halted neurological deterioration in the vast majority of patients.

The Management of Idiopathic and Refractory Syringomyelia

Idiopathic syringomyelia (IS) and refractory syringomyelia (RS) are types of syringomyelia that often pose a management challenge and are associated with long-term clinical sequela. They are usually an epiphenomenon reflecting an underlying pathology where the treatment of the primary cause should be the aim for any surgical intervention. In the case of IS, the initial step is agreeing on the definition of the terms idiopathic and syringomyelia. After a rigorous exhaustive clinic-radiological workup, only IS patients with progressive neurology are treated, usually unblocking subarachnoid cerebrospinal fluid (CSF) pathway obstruction somewhere in the thoracic spinal canal and reserving shunting techniques to nonresponsive cases. Similar to IS, also RS is multifactorial, and its management varies based on the initial pathology, strongly supported by radiological and clinical features. We aim to address this topic focusing on the etiopathology, investigation paradigm, and surgical pathway, formulating algorithms of management with available evidence in literature. Surgical techniques are discussed in detail.

Syrinx shunts for syringomyelia: a systematic review and meta-analysis of syringosubarachnoid, syringoperitoneal, and syringopleural shunting

OBJECTIVE

Syringomyelia is a debilitating, progressive disease process that can lead to loss of neurological function in patients already experiencing significant compromise. Syringosubarachnoid, syringoperitoneal, and syringopleural shunts are accepted treatment options for patients with persistent syringomyelia, but direct comparisons have been lacking to date. The authors conducted a systematic review of the literature and meta-analysis to compare clinical outcomes between these three syrinx shunt modalities.

METHODS

Utilizing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews, Ovid Embase, PubMed, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and Database of Abstracts of Review of Effectiveness were searched to identify all potentially relevant studies published from inception until July 2020. Data were extracted and analyzed using meta-analysis of proportions. The primary study outcome was the rate of reoperation based on the initial shunt modality. Secondary outcomes included clinical improvement, clinical deterioration, and complications following shunt placement.

RESULTS

A total of 22 articles describing 27 distinct treatment cohorts published between 1984 and 2019 satisfied the inclusion criteria. This captured 473 syrinx shunt procedures, 193 (41%) by syringosubarachnoid shunt, 153 (32%) by syringoperitoneal shunt, and 127 (27%) by syringopleural shunt, with an overall median clinical follow-up of 44 months. The pooled incidences of revision surgery were estimated as 13% for syringosubarachnoid, 28% for syringoperitoneal, and 10% for syringopleural shunts, respectively (p-interaction = 0.27). The rate of clinical improvement was estimated as 61% for syringosubarachnoid, 64% for syringoperitoneal, and 71% for syringopleural shunts. The rate of clinical deterioration following placement was estimated as 13% for syringosubarachnoid, 13% for syringoperitoneal, and 10% for syringopleural shunts.

CONCLUSIONS

The preferred modality of syrinx shunting remains a controversial topic for symptomatic syringomyelia. This study suggests that while all three modalities offer similar rates of clinical improvement and deterioration after placement, syringoperitoneal shunts have a greater rate of malfunction requiring surgical revision. These data also suggest that syringopleural shunts may offer the best rate of clinical improvement with the lowest rate of reoperation.

Reintervention rate of arachnolysis versus shunting for nonforaminal syringomyelia

OBJECTIVE

Surgical treatment for nonforaminal syringomyelia related to spinal arachnoiditis is still controversial. The authors sought to assess respective outcomes and rates of reintervention for shunting and spinal cord untethering (arachnolysis) in spinal arachnoiditis with syringomyelia.

METHODS

This retrospective cohort study was conducted at a single reference center for syringomyelia. Patients undergoing arachnolysis and/or shunting interventions for nonforaminal syringomyelia were screened.

RESULTS

The study included 75 patients undergoing 130 interventions. Arachnolysis without shunting was performed in 48 patients, while 27 patients underwent shunting. The mean follow-up between the first surgery and the last outpatient visit was 65.0 months (range 12-379 months, median 53 months). At the last follow-up, the modified McCormick score was improved or stabilized in 83.4% of patients after arachnolysis versus 66.7% after shunting. Thirty-one (41.3%) patients underwent reintervention during follow-up, with a mean delay of 33.2 months. The rate of reintervention was 29.2% in the arachnolysis group versus 63.0% in the shunting group (chi-square = 8.1, p = 0.007). However, this difference was largely driven by the extension of the arachnoiditis: in patients with focal arachnoiditis (≤ 2 spinal segments), the reintervention rate was 21.6% for arachnolysis versus 57.1% for shunting; in patients with extensive arachnoiditis, it was 54.5% versus 65.0%, respectively. Survival analysis assessing the time to the first reintervention demonstrated a better outcome in both the arachnolysis (p = 0.03) and the focal arachnoiditis (p = 0.04) groups.

CONCLUSIONS

Arachnolysis led to fewer reinterventions than shunting in patients with nonforaminal syringomyelia. There was a high risk of reintervention for patients with extensive arachnopathies, irrespective of the surgical technique.

Treatment of posttraumatic syringomyelia: evidence from a systematic review

Background

Following spinal cord injury (SCI), the routine use of magnetic resonance imaging (MRI) resulted in an incremental diagnosis of posttraumatic syringomyelia (PTS). However, facing four decades of preferred surgical treatment of PTS, no clear consensus on the recommended treatment exists. We review the literature on PTS regarding therapeutic strategies, outcomes, and complications.

Methods

We performed a systematic bibliographic search on (“spinal cord injuries” [Mesh] AND “syringomyelia” [Mesh]). English language literature published between 1980 and 2020 was gathered, and case reports and articles examining syrinx due to other causes were excluded. The type of study, interval injury to symptoms, severity and level of injury, therapeutic procedure, duration of follow-up, complications, and outcome were recorded.

Results

Forty-three observational studies including 1803 individuals met the eligibility criteria. The time interval from SCI to the diagnosis of PTS varied between 42 and 264 months. Eighty-nine percent of patients were treated surgically (n = 1605) with a complication rate of 26%. Symptoms improved in 43% of patients postoperatively and in 2% treated conservatively. Stable disease was documented in 50% of patients postoperatively and in 88% treated conservatively. The percentage of deterioration was similar (surgery 16%, 0.8% dead; conservative 10%). Detailed analysis of surgical outcome with regard to symptoms revealed that pain, motor, and sensory function could be improved in 43 to 55% of patients while motor function deteriorated in around 25%. The preferred methods of surgery were arachnoid lysis (48%) and syrinx drainage (31%).

Conclusion

Even diagnosing PTS early in its evolution with MRI, to date, no satisfactory standard treatment exists, and the present literature review shows similar outcomes, regardless of the treatment modality. Therefore, PTS remains a neurosurgical challenge. Additional research is required using appropriate study designs for improving treatment options.

Syringomyelia as a delayed complication of lumbar-sacral adhesive arachnoiditis in Pott's disease

Syringomyelia is the development of a fluid-filled cyst (syrinx) within the spinal cord and is an extremely rare chronic manifestation of tuberculosis. The syrinx so formed may expand over time, causing compression or destruction of spinal tracts and surrounding nerve roots. Development of syringomyelia in a patient of Pott's disease is particularly infrequent. We report this rare case of a 31-year-old man with syringomyelia as a prolonged complication of Pott's disease.

Effect of extradural constriction on CSF flow in rat spinal cord

Background

Fluid homeostasis in the central nervous system (CNS) is essential for normal neurological function. Cerebrospinal fluid (CSF) in the subarachnoid space and interstitial fluid circulation in the CNS parenchyma clears metabolites and neurotransmitters and removes pathogens and excess proteins. A thorough understanding of the normal physiology is required in order to understand CNS fluid disorders, including post-traumatic syringomyelia. The aim of this project was to compare fluid transport, using quantitative imaging of tracers, in the spinal cord from animals with normal and obstructed spinal subarachnoid spaces.

Methods

A modified extradural constriction model was used to obstruct CSF flow in the subarachnoid space at the cervicothoracic junction (C7–T1) in Sprague–Dawley rats. Alexa-Fluor 647 Ovalbumin conjugate was injected into the cisterna magna at either 1 or 6 weeks post–surgery. Macroscopic and microscopic fluorescent imaging were performed in animals sacrificed at 10 or 20 min post–injection. Tracer fluorescence intensity was compared at cervical and thoracic spinal cord levels between control and constriction animals at each post-surgery and post-injection time point. The distribution of tracer around arterioles, venules and capillaries was also compared.

Results

Macroscopically, the fluorescence intensity of CSF tracer was significantly greater in spinal cords from animals with a constricted subarachnoid space compared to controls, except at 1 week post-surgery and 10 min post-injection. CSF tracer fluorescence intensity from microscopic images was significantly higher in the white matter of constriction animals 1 week post surgery and 10 min post-injection. At 6 weeks post–constriction surgery, fluorescence intensity in both gray and white matter was significantly increased in animals sacrificed 10 min post-injection. At 20 min post-injection this difference was significant only in the white matter and was less prominent. CSF tracer was found predominantly in the perivascular spaces of arterioles and venules, as well as the basement membrane of capillaries, highlighting the importance of perivascular pathways in the transport of fluid and solutes in the spinal cord.

Conclusions

The presence of a subarachnoid space obstruction may lead to an increase in fluid flow within the spinal cord tissue, presenting as increased flow in the perivascular spaces of arterioles and venules, and the basement membranes of capillaries. Increased fluid retention in the spinal cord in the presence of an obstructed subarachnoid space may be a critical step in the development of post-traumatic syringomyelia.

Electronic supplementary material

The online version of this article (10.1186/s12987-019-0127-8) contains supplementary material, which is available to authorized users.

Spinal Meninges and Their Role in Spinal Cord Injury: A Neuroanatomical Review

Current recommendations support early surgical decompression and blood pressure augmentation after traumatic spinal cord injury (SCI). Elevated intraspinal pressure (ISP), however, has probably been underestimated in the pathophysiology of SCI. Recent studies provide some evidence that ISP measurements and durotomy may be beneficial for individuals suffering from SCI. Compression of the spinal cord against the meninges in SCI patients causes a "compartment-like" syndrome. In such cases, intentional durotomy with augmentative duroplasty to reduce ISP and improve spinal cord perfusion pressure (SCPP) may be indicated. Prior to performing these procedures routinely, profound knowledge of the spinal meninges is essential. Here, we provide an in-depth review of relevant literature along with neuroanatomical illustrations and imaging correlates.

Cell Therapy as a New Approach to the Treatment of Posttraumatic Syringomyelia

BACKGROUND

Cell transplantation with autologous bone marrow-derived mesenchymal stromal cells (MSCs) seems to be a therapeutic promise for patients with established spinal cord injury, achieving improvement in their quality of life, but there is no experience with the application of this type of cell therapy in patients suffering posttraumatic syringomyelia.

OBJECTIVE

To study the possible utility of cell therapy with autologous MSCs in posttraumatic syringomyelia.

METHODS

A 40-year-old man with complete paraplegia since 1991 as a consequence of a Th4 vertebral fracture showed a great posttraumatic syringomyelia that extended up to C2 vertebral level, without signs of recent worsening. Autologous MSCs (150 × 10⁶) were injected into the syrinx, without drainage or aspiration.

RESULTS

One year after cell therapy, syrinx was reduced without collapse of cervical spinal cord. During the course of follow-up, clear clinical improvement was observed, mainly in sphincter dysfunction.

CONCLUSIONS

Injection of MSCs in the syrinx of posttraumatic syringomyelia is safe and is associated with clinical and neuroimaging improvement. The possibility of cell therapy as a new approach to posttraumatic syringomyelia, or even for idiopathic syringomyelia, is an open door that requires further study.

Treatment of Posttubercular Syringomyelia Not Responsive to Antitubercular Therapy: Case Report and Review of Literature

Posttubercular adhesive arachnoiditis is a rare, late complication of tubercular meningitis. Syringomyelia can develop as a consequence of intramedullary cystic lesions and cerebrospinal fluid (CSF) flow disturbance around the spinal cord, even after successful chemotherapy. We reviewed the literature related to posttubercular syringomyelia treatment and suggest a new combined surgical approach. A 25-year-old Nigerian male patient presented with legs numbness, urinary disturbance, and legs weakness. Spinal magnetic resonance revealed a T5-T7 syringomyelia, secondary to adhesive spinal arachnoiditis related to a history of tuberculous meningitis. Adhesiolysis by direct visualization with a flexible endoscope was performed and a handmade S-italic syringe-subdural shunt was placed to restore CSF flow. During the postoperative course, the neurological deficits improved together with the resolution of the syrinx. Long-term magnetic resonance imaging follow-up documented no recurrences or shunt displacements. We suggest that, when antitubercular therapy is not effective to resolve postarachnoiditis syrinx, arachnolysis with a flexible endoscope together with the placement of an S-italic shunt allowed free CSF communication between the syrinx and the subarachnoid space. Furthermore, we support that the use of an s-shaped shunt could prevent displacement or migration of the device and allows an easier revision in case of acute or late complications.

Intracranial hypotension after syringopleural shunting in posttraumatic syringomyelia: Case report and review of the literature

We report a case of a 45-year-old male with a syringopleural shunt who developed intracranial hypotension. The patient presented with 2 weeks history of worsening headache and back pain, on a background of having had a syringopleural shunt inserted for a thoracic posttraumatic syrinx. Computerized tomography imaging of the brain revealed bilateral subdural fluid collections. Magnetic resonance imaging appearances of spinal and intracranial pachymeningeal enhancement confirmed intracranial hypotension. We present a rare case of intracranial hypotension secondary to syringopleural shunting in a patient with posttraumatic syringomyelia.

Arachnolysis or cerebrospinal fluid diversion for adult-onset syringomyelia? A Systematic review of the literature

OBJECTIVE

To identify surgical practice patterns in the literature for nonpediatric syringomyelia by systematic review and to determine the following: 1) What is the best clinical practice of cerebrospinal fluid (CSF) diversion to maximize clinical improvement or to achieve the lowest recurrence rate? 2) Does arachnolysis, rather than CSF diversion, lead to prolonged times to clinical recurrence?

METHODS

A database search comprising PubMed, Cochrane Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Database of Systematic Reviews was conducted to find pertinent articles on postinfectious, posttraumatic, or idiopathic syringomyelia.

RESULTS

An advanced PubMed search in August 2012 yielded 1350 studies, including 12 studies meeting Oxford Centre for Evidence-Based Medicine criteria for level IV evidence as a case series, with a total of 410 patients (mean age, 39 years). Data on 486 surgeries were collected. Mean follow-up data were available for 10 studies, with a mean follow-up time of 62 months. On regression analysis, increased age had a significant correlation with a higher likelihood of having clinically significant recurrence on mean follow-up (P < 0.05). The use of arachnolysis in surgery was associated with a longer duration until clinically symptomatic recurrence (P = 0.02). Data on mortality were unavailable. The mean number of surgeries per patient across all studies was 1.20 (range, 0.95-2.00).

CONCLUSIONS

With postinfectious and posttraumatic etiologies, arachnolysis was the only surgical treatment to have a statistically significant effect on decreasing recurrence rates. More prospective, randomized, controlled studies are required to reach a clear consensus.

Dorsal spinal arachnoid web diagnosed with the quantitative measurement of cerebrospinal fluid flow on magnetic resonance imaging

An arachnoid web is an abnormal formation of the arachnoid membrane in the spinal subarachnoid space that blocks CSF flow and causes syringomyelia. Although the precise mechanism of syrinx formation is unknown, dissection of the arachnoid web shrinks the syrinx and improves symptoms. Precisely determining the location of the arachnoid web is difficult preoperatively, however, because the fine structure generally cannot be visualized in usual MRI sequences. In this report the authors describe 2 cases of arachnoid web in which the web was preoperatively identified using quantitative CSF flow analysis of MRI. By analyzing cardiac-gated phase-contrast cine-mode MRI in multiple axial planes, the authors precisely localized the obstruction of CSF flow on the dorsal side of the spinal cord in both patients. This technique also revealed a 1-way valve-like function of the arachnoid webs. Imaging led to the early diagnosis of myelopathy related to the derangement of CSF flow and allowed the authors to successfully excise the webs through limited surgical exposure.

[Spinal cord injury and syringomyelia]

Spinal cord injuries often occur in cases of multiple trauma, can occur alone or in combination with concomitant injuries and are mostly associated with high morbidity and mortality. They often result in lifelong impairment and need for medical care. Radiologic diagnostics are crucial in the acute setting as well as in the long-term treatment of spinal cord injuries. Besides an overview of diagnostic and therapeutic management, typical magnetic resonance imaging (MRI) findings in the acute and chronic stages of spinal cord injuries are presented in this article. Post-traumatic syringomyelia can even develop years after the initial injury of the spine or spinal cord. As syringomyelia can also occur in association with tumors, developmental anomalies and also idiopathically, a thorough MRI diagnostic is essential especially in any case of newly diagnosed syringomyelia.

Subarachnoid-subarachnoid bypass: a new surgical technique for posttraumatic syringomyelia

OBJECT

The origin of posttraumatic syringomyelia is not completely understood. With respect to posttraumatic syringomyelia, the optimum management strategy for patients with spinal cord injury has also not been established. The authors hypothesized that reconstruction of the subarachnoid channels would reestablish CSF flow, thereby addressing the underlying cause of the syrinx formation. The authors performed a new type of surgery, subarachnoid-subarachnoid bypass (S-S bypass), in which an attempt was made to reestablish normal CSF circulation around the spinal cord. The purpose of this study was to evaluate the effectiveness of S-S bypass for posttraumatic syringomyelia.

METHODS

Twenty consecutive patients with symptomatic posttraumatic syringomyelia who had progressive neurological symptoms and underwent S-S bypass were included in the study. The surgical procedure was as follows: a laminectomy was performed at the level of trauma, and a midline dural opening was made under a microscope. The arachnoid was exposed up to the area of normal arachnoid mater with normal CSF circulation. After dissection of the normal arachnoid mater at the cephalic and caudal sites, 1 or 2 tubes made of medical-grade silicone were inserted into the cephalic and caudal ends of the normal subarachnoid space. Bypass tubes were laid in the subdural space, and a watertight dural closure was accomplished using running sutures. The mean follow-up period was 48.2 months (range 12-93 months). The preoperative status and postoperative clinical course were assessed according to 3 grading systems: the Frankel grading system for global neurological status, the American Spinal Injury Association motor score for motor weakness, and the Klekamp system for bladder function. The major presenting symptoms or signs were assessed in terms of symptom improvement, stabilization, or deterioration. Preoperative and postoperative MRI was used to analyze the size and craniocaudal extension of the cavity.

RESULTS

Twelve patients showed clinical improvement, 4 were stable, and 4 showed deterioration. The mean length of the syrinx observed on preoperative MRI was 9.9 spinal levels, and the mean Vaquero index was 62.3%. The mean length of the syrinx observed on postoperative MRI was 5.3 spinal levels, and the mean Vaquero index was 28.4%. These values were significantly lower than the preoperative values (p = 0.01 and p < 0.01, respectively).

CONCLUSIONS

This study showed that interference with CSF flow was the major cause of syrinx development and that reconstruction of CSF flow is the most important treatment strategy based on the cause of the syrinx. Subarachnoid-subarachnoid bypass, which can be performed without myelotomy, was not only a safe and effective surgical technique, but may also be a more physiological way of treating posttraumatic syringomyelia.

Treatment of Syringomyelia Related to Nontraumatic Arachnoid Pathologies of the Spinal Canal

BACKGROUND:

Disturbances of cerebrospinal fluid (CSF) flow are the commonest cause of syringomyelia. Spinal arachnopathies may lead to CSF flow obstructions but are difficult to diagnose. Consequently, associated syringomyelias are often categorized as idiopathic.

OBJECTIVE:

To present and analyze the diagnosis of and long-term outcomes in an observational study of patients with nontraumatic arachnopathies from 1991 to 2011.

METHODS:

A total of 288 patients (mean age, 47 ± 15 years; follow-up, 54 ± 46 months) were evaluated. Decompression with arachnolysis, untethering, and duraplasty for restoration of CSF flow was recommended to patients with neurological progression. Neurological examinations, magnetic resonance images, and follow-up data were evaluated. Individual symptoms were analyzed during the first postoperative year, and long-term outcomes were analyzed with Kaplan-Meier statistics to determine rates of progression-free survival.

RESULTS:

In total,189 patients either refused an operation or were managed conservatively for lack of progression. Among 79 unoperated patients with follow-up information available for up to 8 years, 2 patients deteriorated. Ninety-nine patients with progressive symptoms underwent 116 operations: 108 decompressions and 8 other surgeries. Three months postoperatively, 53% considered their status improved and 37% were unchanged. In the long term, surgery on arachnopathies limited to 2 spinal segments was followed by progression-free survival for 78% over 10 years, in contrast to 31% with extensive arachnopathies.

CONCLUSION:

Surgery on nontraumatic arachnopathies related to syringomyelia should be reserved for patients with progressive symptoms. Arachnolysis, untethering, and duraplasty provide good long-term results for focal arachnopathies. For extensive pathologies with a history of subarachnoid hemorrhage or meningitis, treatment remains a major challenge.

Syringo-subarachnoid-peritoneal shunt using T-tube for treatment of post-traumatic syringomyelia

Various surgical procedures for the treatment of post-traumatic syringomyelia have been introduced recently, but most surgical strategies have been unreliable. We introduce the concept and technique of a new shunting procedure, syringo-subarachnoid-peritoneal shunt. A 54-year-old patient presented to our hospital with a progressive impairment of motion and position sense on the right side. Sixteen years before this admission, he had been treated by decompressive laminectomy for a burst fracture of L1. On his recent admission, magnetic resonance (MR) imaging studies of the whole spine revealed the presence of a huge syrinx extending from the medulla to the L1 vertebral level. We performed a syringo-subarachnoid-peritoneal shunt, including insertion of a T-tube into the syrinx, subarachnoid space and peritoneal cavity. Clinical manifestations and radiological findings improved after the operation. The syringo-subarachnoid-peritoneal shunt has several advantages. First, fluid can communicate freely between the syrinx, the subarachnoid space, and the peritoneal cavity. Secondly, we can prevent shunt catheter from migrating because dural anchoring of the T-tube is easy. Finally, we can perform shunt revision easily, because only one arm of the T-tube is inserted into the intraspinal syringx cavity. We think that this procedure is the most beneficial method among the various shunting procedures.

Treatment of posttraumatic syringomyelia

Object

This paper presents results of a prospective study for patients undergoing surgery for posttraumatic syringomyelia between 1991 and 2010.

Methods

A group of 137 patients with posttraumatic syringomyelia were evaluated (mean age 45 ± 13 years, mean follow-up 51 ± 51 months) with pre- and postoperative MRI and clinical examinations presenting in this period and followed prospectively by outpatient visits and questionnaires. Surgery was recommended for symptomatic patients with a progressive course. Short-term results were determined within 3 months of surgery, whereas long-term outcomes in terms of clinical recurrences were studied with Kaplan-Meier statistics.

Results

Three groups were distinguished according to the type of trauma: Group A, patients with spinal trauma but without cord injury (ASIA E, n = 37); Group B, patients with an incomplete cord injury (ASIA C or D, n = 55); and Group C, patients with complete loss of motor function or a complete cord injury (ASIA A or B, n = 45). Overall, 61 patients with progressive symptoms underwent 71 operations. Of these operations, 61 consisted of arachnolysis, untethering, and duraplasty at the trauma level (that is, decompression), while 4 ASIA A patients underwent a cordectomy. The remaining procedures consisted of placement of a thecoperitoneal shunt, 2 opiate pump placements, and 2 anterior and 1 posterior cervical decompression and fusion. Seventy-six patients were not treated surgically due to lack of neurological progression or refusal of an operation. Neurological symptoms remained stable for 10 years in 84% of the patients for whom surgery was not recommended due to lack of neurological progression. In contrast, 60% of those who declined recommended surgery had neurological progression within 5 years. For patients presenting with neurological progression, outcome was better with decompression. Postoperatively, 61% demonstrated a reduction of syrinx size. Although neurological symptoms generally remained unchanged after surgery, 47% of affected patients reported a postoperative improvement of their pain syndrome. After 3 months, 51% considered their postoperative status improved and 41% considered it unchanged. In the long-term, favorable results were obtained for Groups A and C with rates for neurological deterioration of 6% and 14% after 5 years, respectively. In Group B, this rate was considerably higher at 39%, because arachnolysis and untethering to preserve residual cord function could not be fully achieved in all patients. Cordectomy led to neurological improvement and syrinx collapse in all 4 patients.

Conclusions

The technique of decompression with arachnolysis, untethering, and duraplasty at the level of the underlying trauma provides good long-term results for patients with progressive neurological symptoms following ASIA A, B and E injuries. Treatment of patients with posttraumatic syringomyelia after spinal cord injuries with preserved motor functions (ASIA C and D) remains a major challenge. Future studies will have to establish whether thecoperitoneal shunts would be a superior alternative for this subgroup.

Syringomyelia associated with arachnoid septum at the craniovertebral junction, contradicting the currently prevailing theory of syringomyelia formation

Despite a number of various hypotheses in the literature, the pathophysiology of syringomyelia is still not well understood. In this article, we report two cases of cervical syringomyelia not associated with Chiari I malformation. Both cases had a septum-like structure in the subarachnoid space on the dorsal side of the cord at the craniovertebral junction. Cardiac-gated phase-contrast cine-mode magnetic resonance imaging (MRI) demonstrated decreased cerebrospinal fluid (CSF) flow on the dorsal side of the spinal cord. Surgical excision of this septum, restoring the CSF flow, resulted in a prompt reduction of the syrinx size in both cases. Findings in these cases contradict the currently prevailing hypothesis of syrinx formation that postulate that the piston-like movement of the cerebellar tonsils enhance the pulsatile CSF flow in the spinal subarachnoid space, driving the CSF into the syrinx through the perivascular space of Virchow and Robin. The authors propose that a mechanism based on the decreased pulsatile CSF flow in the spinal subarachnoid space will be more suitable as a hypothesis in studying the pathophyisiology of syringomyelia. These cases also provide an important lesson in managing the patients with syringomyelia not associated with Chiari I malformation.

Surgical management of post-traumatic syringomyelia

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine the indications for surgical intervention and optimal surgical treatment technique for patients with post-traumatic syringomyelia and spinal cord tethering.

SUMMARY OF BACKGROUND DATA

The proper management strategy for post-traumatic syringomyelia has not been established. Most modern surgical series have documented improvement in symptomatic patients who have an internal decompression of their syrinx. Several options exist and include shunting the syrinx (to the subarachnoid space or to either the pleural or peritoneal cavities) as well as spinal cord untethering (with or without expansile duraplasty).

METHODS

A systematic review of literature followed by expert panel consensus was performed. English language literature published between 1980 and 2010 was gathered to examine articles search was conducted using the search terms syringomyelia, syrinx, spinal cord injury, traumatic syringomyelia, post-traumatic syringomyelia. Case reports and articles examining syrinx due to other cause were excluded. Articles were graded for strength of evidence according to the GRADE approach. The evidentiary tables were reviewed and approved by all 4 authors, and disagreements were resolved by consensus.

RESULTS

The literature search yielded a total of 296 abstracts, and 22 articles were found to fulfill all the criteria specified above. All identified articles were of low or very low evidence levels. The reported incidence of post-traumatic syringomyelia is 0.5% to 4.5%; the incidence is twice as common in complete versus incomplete injuries. The literature consistently demonstrated that surgery post-traumatic syringomyelia is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes. The literature does not support surgical intervention for incidental, asymptomatic syrinx. The literature does not support one surgical technique as superior for the treatment of post-traumatic syringomyelia.

CONCLUSION

The literature supports and the consensus panel recommended that there is no indication for direct decompression at the time of initial injury specifically for the purpose of limiting future risk of syringomyelia. The literature supports and the consensus panel gave a strong recommendation for surgical intervention in the setting of motor neurologic deterioration as a consequence of post-traumatic syrinx/tethered cord. The panel gave a weak recommendation against surgical intervention for patients developing sensory loss/pain syndrome or for asymptomatic but expanding syrinx. Finally, the literature does not provide strong evidence to support the superiority of one surgical technique over the others; however, the consensus panel gave a weak recommendation that spinal cord untethering with expansile duraplasty is the preferred first-line surgical technique.