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Wu J, Ji S, Niu P, Zhang B, Shao D, Li Y, Xie S, Jiang Z. Knowledge mapping of syringomyelia from 2003 to 2022: A bibliometric analysis. J Clin Neurosci 2023; 110:63-70. [PMID: 36822071 DOI: 10.1016/j.jocn.2023.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/26/2022] [Accepted: 01/04/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Syringomyelia is a chronic, progressive disease of the spinal cord. Syringomyelia is an etiologically diverse affliction caused by disturbance of normal cerebrospinal fluid flow dynamics. Lesions are characterized by the formation of tubular cavities in the gray matter of the spinal cord and gliosis; however, the etiology is unknown and treatment methods differ. Many existing studies have focused on the relationship between other diseases and syringomyelia. There is a lack of comprehensive and objective reports on the research status of syringomyelia. Therefore, this study aimed to conduct a bibliometric analysis to quantify studies on Syringomyelia and trending issues in the last 20 years. METHODS Articles were acquired from the Web of Science Core Collection database. We used the Library Metrology online analysis platform, BICOMB, gCLUTO, CiteSpace bibliometrics tools for analysis, VOSviewer 1.6.16 (Nees Jan van Eck and Ludo Waltman, 2010), and Microsoft Excel 2019 to perform bibliometric analysis and visualization. Individual impact and collaborative information were quantified by analyzing annual publications, journals, co-cited journals, countries/regions, institutions, authors, and co-cited authors. We then identified the trending research areas of syringomyelia by analyzing the co-occurrence of keywords and co-cited references. RESULTS From January 2003 to August 2022, 9,556 authors from 66 countries published a total of 1,902 research articles on syringomyelia in 518 academic journals. Most publications come from the United States, China, the United Kingdom, and Japan, with the United States dominating. Nanjing University and the University of Washington are the most active institutions, Dr. Claire Rusbridge has published the most papers, and Miholat has the most co-citations. The Journal of Neurosurgery has the highest number of co-cited articles, which are mainly in the fields of neurology, surgery, and biology. High-frequency keywords included syringomyelia, Chiari-I malformation, children, surgical treatment, and spinal cord. CONCLUSIONS The number of articles on syringomyelia has increased steadily over the past two decades. At present, research on syringomyelia is mainly focused on the age of onset, potential therapeutic interventions, surgical treatment, avoidance of recurrence, and delay of pain. The use of surgical treatment of the disease and the mechanism of further treatment are the current hot research topics. The correlation between trauma and congenital factors, translational application, the effect of surgical treatment, postoperative recurrence, and complications are further hot research areas. These may provide ideas for further research into a radical cure for syringomyelia.
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Affiliation(s)
- Junyong Wu
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Shuxin Ji
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Pengyuan Niu
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Binbin Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Dongqi Shao
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yu Li
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Shan Xie
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhiquan Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China.
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Outcome predictors and clinical presentation of syringomyelia. Asian J Surg 2023; 46:705-711. [PMID: 35868963 DOI: 10.1016/j.asjsur.2022.06.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/30/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The prognosis of syringomyelia is not yet established. Syringomyelia derived from different etiologies contributes to similar symptoms. OBJECTIVE Assess the syringomyelia in our medical institutes and describe the etiologies and clinical appearance of the disorder. And identify the predictors of a good outcome and to find the most suitable timing of surgical intervention according to our results. METHODS This retrospective cohort study used databases in our hospitals to analyze 70 cases of syringomyelia between 1997 and 2014. All available information was obtained from medical records and radiological reports. We used American Spinal Injuries Association disability scores (ASIA scores), the modified Nurick classification system, and recorded the number of days the patient was hospitalized, for neurological and functional assessment. Univariate and multivariate analyses were used to evaluate the relationship between clinical factors and outcomes. RESULTS Non-communicating syringomyelia was the most common type of syringomyelia. In univariate analysis, autonomic dysfunction and motor impairment were strong predictors of poor neurological and functional outcomes. In addition to the above factors, syrinxes at the cervical level predicted better functional outcomes than at any spinal level in multivariate analysis. CONCLUSIONS Motor impairment, which is commonly seen in patients with syringomyelia in Taiwan, is a strong predictor to poor neurological and functional outcomes. Our study indicates that patients without autonomic dysfunction or motor impairment should receive timely surgical intervention to prevent symptomatic deterioration. We also found that cervical syringomyelia in particular has the potential for good functional recovery after adequate intervention.
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Abstract
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.
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Affiliation(s)
- Pasquale Gallo
- Department of Paediatric Neurosurgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
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Massimi L, Peretta P, Erbetta A, Solari A, Farinotti M, Ciaramitaro P, Saletti V, Caldarelli M, Canheu AC, Celada C, Chiapparini L, Chieffo D, Cinalli G, Di Rocco F, Furlanetto M, Giordano F, Jallo G, James S, Lanteri P, Lemarchand C, Messing-Jünger M, Parazzini C, Paternoster G, Piatelli G, Poca MA, Prabahkar P, Ricci F, Righini A, Sala F, Sahuquillo J, Stoodley M, Talamonti G, Thompson D, Triulzi F, Zucchelli M, Valentini L. Diagnosis and treatment of Chiari malformation type 1 in children: the International Consensus Document. Neurol Sci 2022; 43:1311-1326. [PMID: 34097175 PMCID: PMC8789635 DOI: 10.1007/s10072-021-05317-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/08/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chiari malformation type 1 (CM1) is a rare condition where agreed classification and treatment are still missing. The goal of this study is to achieve a consensus on the diagnosis and treatment of CM1 in children. METHODS A multidisciplinary panel formulated 57 provisional statements based on a review of the literature. Thirty-four international experts (IE) participated in a Delphi study by independently rating each statement on a 4-point Likert scale ("strongly disagree," "disagree," "agree," "strongly agree"). Statements that were endorsed ("agree" or "strongly agree") by < 75% of raters were re-formulated, or new statements were added, and another Delphi round followed (up to a maximum of three). RESULTS Thirty-five IE were contacted and 34 agreed to participate. A consensus was reached on 30/57 statements (52.6%) after round 1. Three statements were added, and one removed. After round 2, agreement was reached on 56/59 statements (94.9%). Finally, after round 3, which took place during the 2019 Chiari Consensus Conference (Milan, Italy), agreement was reached on 58/59 statements (98.3%) about four main sections (Definition and Classification, Planning, Surgery, Isolated Syringomyelia). Only one statement did not gain a consensus, which is the "definition of radiological failure 24 month post-surgery." CONCLUSIONS The consensus document consists of 58 statements (24 on diagnosis, 34 on treatment), serving clinicians and researchers following children with CM1. There is a clear need for establishing an international network and registry and to promote collaborative studies to increase the evidence base and optimize the long-term care of this patient population.
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Affiliation(s)
- Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Paola Peretta
- Pediatric Neurosurgery, AOU Citta' della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Erbetta
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Solari
- Neuroepidemiology Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mariangela Farinotti
- Neuroepidemiology Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Palma Ciaramitaro
- Department of Neuroscience, AOU Citta' della Salute e della Scienza di Torino, Torino, Italy
| | - Veronica Saletti
- Department of Pediatric Neurology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Massimo Caldarelli
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | | | - Carlo Celada
- "Associazione Italiana Siringomielia e Arnold Chiari", Garino, Italy
| | - Luisa Chiapparini
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Daniela Chieffo
- Clinical Psychology Unit, Fondazione Policlinico Universitario A Gemelli IRCCS and UCSC, Rome, Italy
| | - Giuseppe Cinalli
- Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Federico Di Rocco
- Pediatric Neurosurgery Department, Université de Lyon, INSERM U1033, Hopital Femme Mère Enfant, Lyon, France
| | - Marika Furlanetto
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Flavio Giordano
- Department of Neurosurgery, Meyer Pediatric Hospital, Florence, Italy
| | - George Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Syril James
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, Paris, France
| | - Paola Lanteri
- Department of Diagnostic and Technology, Neurophysiopathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | | | - Cecilia Parazzini
- Department of Pediatric Radiology and Neuroradiology, Children Hospital V. Buzzi, Milan, Italy
| | - Giovanna Paternoster
- Department of Pediatric Neurosurgery, Necker Enfants Malades Hospital, Paris, France
| | - Gianluca Piatelli
- Department of Neurosurgery, Gaslini Children's Hospital, Genoa, Italy
| | - Maria A Poca
- Neurosurgery and Pediatric Neurosurgery, Vall d'Hebron Hospital Universitari, Neurotrauma and Neurosurgery Research Unit, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Prab Prabahkar
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Federica Ricci
- Pediatric Neuropsychiatric Unit, AOU Citta' della Salute e della Scienza di Torino, Torino, Italy
| | - Andrea Righini
- Department of Pediatric Radiology and Neuroradiology, Children Hospital V. Buzzi, Milan, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Juan Sahuquillo
- Neurosurgery and Pediatric Neurosurgery, Vall d'Hebron Hospital Universitari, Neurotrauma and Neurosurgery Research Unit, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcus Stoodley
- Department of Clinical Medicine, Macquarie University Clinical Associates, Sidney, Australia
| | | | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
| | - Fabio Triulzi
- Department of Pathophysiology and Transplantation, Neuroradiology Unit, University of Milan, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mino Zucchelli
- Neurochirurgia Pediatrica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Laura Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Saletti V, Farinotti M, Peretta P, Massimi L, Ciaramitaro P, Motta S, Solari A, Valentini LG. The management of Chiari malformation type 1 and syringomyelia in children: a review of the literature. Neurol Sci 2021; 42:4965-4995. [PMID: 34591209 DOI: 10.1007/s10072-021-05565-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
In anticipation of the "Chiari and Syringomyelia Consensus Conference" held in Milan in 2019, we performed a systematic literature review on the management of Chiari malformation type 1 (CM1) and syringomyelia (Syr) in children.We aimed to summarize the available evidence and identify areas where consensus has not been reached and further research is needed.In accordance with PRISMA guidelines, we formulated seven questions in Patients-Interventions-Comparators-Outcomes (PICO) format. Six PICOs concerned CM1 children with/without additional structural anomalies (Syr, craniosynostosis, hydrocephalus, tethered cord, and cranio-vertebral junction anomalies), and one PICO Syr without CM1. We searched Medline, Embase, Cochrane, and NICE databases from January 1, 1999, to May 29, 2019. Cohort studies, controlled and randomized clinical trials (CCTs, RCTs), and systematic reviews were included, all pertinent only to patients ≤ 18 years of age.For CM1, 3787 records were found, 460 full texts were assessed and 49 studies (46 cohort studies, one RCT, and two systematic reviews) were finally included. For Syr, 376 records were found, 59 full texts were assessed, and five studies (one RCT and four cohort studies) were included. Data on each PICO were synthetized narratively due to heterogeneity in the inclusion criteria, outcome measures, and length of follow-up of the included studies.Despite decades of experience on CM1 and Syr management in children, the available evidence remains limited. Specifically, there is an urgent need for collaborative initiatives focusing on the adoption of shared inclusion criteria and outcome measures, as well as rigorous prospective designs, particularly RCTs.
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Affiliation(s)
- Veronica Saletti
- Developmental Neurology Unit, Mariani Foundation Center for Complex Disabilities, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria, 11, 20133, Milan, Italy.
| | - Mariangela Farinotti
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paola Peretta
- Pediatric Neurosurgery Unit, Ospedale Infantile Regina Margherita, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Massimi
- Pediatric Neurosurgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Ciaramitaro
- Clinical Neurophysiology, Department of Neuroscience, Presidio CTO, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Grazia Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Abstract
Spondylotic myelopathies are among the most common disorders of the spine, yet the clinical and treatment approach is far from standardized. This article discusses our current understanding of the epidemiology, pathophysiology, clinical assessment, natural history, and treatment options in degenerative myelopathies of the cervical and thoracic spine. We additionally review diagnostic modalities including imaging modalities of the spine and neurophysiological tools such as electromyography/nerve conduction studies, somatosensory-evoked potentials, and motor-evoked potentials. Assessment instruments that can be used for the assessment of myelopathies are reviewed, including the Japanese Orthopedic Association (JOA) score, modified-JOA scale, Nurick scale, nine-hole peg test, and 30-m walking test. We also review common disorders that mimic spondylotic myelopathies, as well as helpful diagnostic clues in differentiating spondylotic and nonspondylotic myelopathies.
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Affiliation(s)
- Ligia V Onofrei
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - A Michael Henrie
- Department of Physical Medicine and Rehabilitation, University of Utah, UT
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Ishisaka E, Usami K, Ogiwara H. Surgical outcomes by sectioning a filum terminale in patients with terminal syringomyelia. Childs Nerv Syst 2020; 36:3035-3039. [PMID: 32318892 DOI: 10.1007/s00381-020-04615-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although terminal syringomyelia suggests a tethered spinal cord, a consensus has still not been established for surgical indications, when there are no associated abnormalities or only minor associated abnormalities. We analyzed surgical outcomes of sectioning a filum terminale in patients with terminal syringomyelia to elucidate the significance of untethering surgery. METHODS Fifty-seven pediatric patients with terminal syringomyelia who underwent untethering via sectioning the filum terminale between 2007 and 2018 were retrospectively analyzed. Postoperative outcomes of symptoms and MRI findings were evaluated. RESULTS Of 57 patients, 40 had other associated abnormalities (25 with filar lipoma and 29 with low conus medullaris) that could be responsible for tethered cord. Nineteen patients had symptoms. The mean age at the time of surgery was 18 months (3-96 months). The mean follow-up period was 3.3 years (1-9 years). Preoperative symptoms improved in 9 patients (47%) after surgery. At 1 year after the surgery, the size of syringomyelia decreased in 19 (33%), increased in 4 (8%), and did not change in 34 (69%) patients. Of 28 patients who were followed up for more than 3 years, the size decreased in 17 (61%), increased in 1 (4%), and did not change in 10 (35%). CONCLUSION When untethering was performed by sectioning a filum terminale, the size of terminal syringomyelia decreased in more than half of patients in the long term. Sectioning the filum terminale demonstrated the possibility of radiological and clinical improvement in patients with terminal syringomyelia.
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Affiliation(s)
- Eitaro Ishisaka
- Division of Neurosurgery, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kenichi Usami
- Division of Neurosurgery, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Hideki Ogiwara
- Division of Neurosurgery, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, 157-8535, Japan.
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Faillot M, Morar S, Delphine S, El-Mendili M, Ducreux D, Parker F, Aghakhani N. Prospective Follow-up of Intramedullary Slitlike Cavities: A Consecutive Series of 48 Patients. Front Neurol 2020; 11:495. [PMID: 32595590 PMCID: PMC7304370 DOI: 10.3389/fneur.2020.00495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/06/2020] [Indexed: 11/13/2022] Open
Abstract
Object: Predicting whether intramedullary slitlike cavity (SC) will worsen over time or remain stable is an outstanding clinical challenge. The aim of this study was to identify early features of SC (clinical and magnetic resonance imaging [MRI] findings). Methods: We prospectively included all patients referred to our institution following the discovery of a SC and divided them in two groups: typical SC (defined as a cavity spanning fewer than three vertebrae, not enlarging the spinal cord, and located at the midline between the anterior third and posterior two-thirds of the spinal cord) or atypical SC (all others). Clinical evolution and changes in MRI features were evaluated during follow-up. In some patients, diffusion tensor imaging was performed and cervical cord cross-sectional area was analyzed. Results: A total of 48 consecutive patients were included in the study. The mean follow-up was 58 months. Of the seven patients presenting with deficits at first consultation, two worsened and five remained stable. Of the 41 patients without deficits, seven worsened and 34 remained stable. None of the patients developed severe motor deficits or experienced enlargement of the cavity; 7% of patients who presented with typical SC worsened compared with 35% with atypical SC. The negative predictive value was 0.93 (P = 0.02). Conclusion: Most patients remained stable and a subset of patients developed minor motor deficits. For clinical management, we propose surveillance of patients with a typical SC and close follow-up of those with an atypical SC and/or presenting with deficits.
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Affiliation(s)
- Matthieu Faillot
- Neurosurgery Department, Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Sud, Le Kremlin-Bicêtre, France
- CRMR C-MAVEM (Centre de reference Maladies Rares Chiari-Syringomyélie et Malformations vertébrales et médullaires rares/Reference Center for Rare Diseases: Chiari-Syringomyelia and Rare Malformations of the Spine and Spinal Cord), Paris, France
| | - Silvia Morar
- Neurosurgery Department, Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Sud, Le Kremlin-Bicêtre, France
- CRMR C-MAVEM (Centre de reference Maladies Rares Chiari-Syringomyélie et Malformations vertébrales et médullaires rares/Reference Center for Rare Diseases: Chiari-Syringomyelia and Rare Malformations of the Spine and Spinal Cord), Paris, France
| | - Sebastien Delphine
- Biomedical imaging laboratory (LIB, Laboratoire d'Imagerie Biomédicale), CNRS, UMR 7371, INSERM, UMR-S 1146, Sorbonne Université, Paris, France
| | - Mounir El-Mendili
- Neurology Department, Icahn School of Medicine at Mount Sinaï, NewYork, NY, United States
| | - Denis Ducreux
- Neuroradiology Department, Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Fabrice Parker
- Neurosurgery Department, Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Sud, Le Kremlin-Bicêtre, France
- CRMR C-MAVEM (Centre de reference Maladies Rares Chiari-Syringomyélie et Malformations vertébrales et médullaires rares/Reference Center for Rare Diseases: Chiari-Syringomyelia and Rare Malformations of the Spine and Spinal Cord), Paris, France
| | - Nozar Aghakhani
- Neurosurgery Department, Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Sud, Le Kremlin-Bicêtre, France
- CRMR C-MAVEM (Centre de reference Maladies Rares Chiari-Syringomyélie et Malformations vertébrales et médullaires rares/Reference Center for Rare Diseases: Chiari-Syringomyelia and Rare Malformations of the Spine and Spinal Cord), Paris, France
- *Correspondence: Nozar Aghakhani
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Bruzek AK, Starr J, Garton HJL, Muraszko KM, Maher CO, Strahle JM. Syringomyelia in children with closed spinal dysraphism: long-term outcomes after surgical intervention. J Neurosurg Pediatr 2019; 25:319-325. [PMID: 31835253 DOI: 10.3171/2019.9.peds1944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The nature of the relationship between spinal cord syrinx and tethered cord is not well known. It is unclear if surgical cord untethering results in resolution or improvement of an associated syrinx. The objective of this study was to report the response of spinal cord syrinx to surgical cord untethering. METHODS The authors retrospectively reviewed all patients with a syrinx and tethered cord who presented to a single institution over an 11-year interval. Patients with open neural tube defects were excluded. Thirty-one patients were identified, 25 of whom had both clinical and imaging follow-up after surgery. Patients were grouped according to etiology of the tethered cord. Clinical outcomes and syrinx characteristics were recorded. RESULTS Of the 25 patients with tethered cord, 68% (n = 17) were male. The average age at presentation was 2.5 years (0-10.1 years) and age at surgery was 3.7 years (range 1 day to 17 years). Etiologies of tethered cord were lipomyelomeningocele (n = 8), thickened/fatty filum (n = 7), intradural lipoma (n = 5), myelocystocele (n = 2), meningocele (n = 2), and diastematomyelia (n = 1). Twenty-three of the patients underwent primary untethering, whereas 2 patients had received untethering previously at another institution. The average syrinx length and width prior to surgery were 4.81 vertebral levels (SD 4.35) and 5.19 mm (SD 2.55 mm), respectively. Conus level ranged from L1 to S3. Patients were followed for an average of 8.4 years (1.35-15.85 years). Overall there was no significant change in syrinx length or width postoperatively; the average syrinx length increased by 0.86 vertebral levels (SD 4.36) and width decreased by 0.72 mm (SD 2.94 mm). Seven of 25 patients had improvement in at least one presenting symptom, including scoliosis, weakness, bowel/bladder dysfunction, and pain. Eight patients had stable presenting symptoms. Six patients were asymptomatic and 5 patients had new or worsening symptoms, which included scoliosis, pain, or sensory changes. CONCLUSIONS Although some syrinxes improved after surgery for tethered cord, radiological improvement was not consistent and did not appear to be associated with change in clinical symptoms. The decision to surgically untether a cord should be focused on the clinical symptoms and not the presence of a syrinx alone. Further studies are needed to confirm this finding.
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Affiliation(s)
- Amy K Bruzek
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Jordan Starr
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Hugh J L Garton
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Karin M Muraszko
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Cormac O Maher
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Jennifer M Strahle
- 2Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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Geljic A, Abdovic S, Stampalija F, Loncar L, Tripalo BA, Cuk M. An Unusual Case of Syringohydromyelia Presenting with Neurogenic Bladder. European J Pediatr Surg Rep 2019; 7:e79-e82. [PMID: 31763129 PMCID: PMC6874505 DOI: 10.1055/s-0039-1697925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 08/19/2019] [Indexed: 11/04/2022] Open
Abstract
We report the case of a 4-year-old boy who first presented with acute pyelonephritis at the age of 6 months. Diagnostic workup revealed high-grade bilateral vesicourethral reflux (VUR). At the age of 18 months, a bulking agent was used to treat bilateral VUR. Since the VUR persisted, an open bilateral Lich-Gregoir procedure was done at the age of 3 years. Immediately after surgery, he developed acute urinary retention with hydronephrosis that resolved with the placement of dwelling urinary catheter. After removal of the catheter urinary retention relapsed so placement of suprapubic urinary catheter was indicated since he did not have sensory loss. He was started with tamsulosin (α − 1-blocker) and prophylactic antibiotics. Urodynamics were performed and suggested bladder outlet obstruction. On the basis of previous urethroscopy and the absence of neurological sequelae, the differential diagnosis of Hinman syndrome was made. After removal of the suprapubic catheter, clean intermittent catheterization was started and α-blocker continued. However, magnetic resonance imaging of the brain and the spinal cord revealed syringohydromyelia extending from thoracic spine (Th5) to conus medullaris with 6 to 7 mm in diameter. Electromyoneurogram was normal. After a follow-up of 3 years, the hydronephrosis has resolved. The patient is on clean intermittent catherization and has no urinary tract infections.
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Affiliation(s)
- Antonella Geljic
- Department of Paediatrics, Klinika za djecje bolesti Zagreb, Zagreb, Croatia
| | - Slaven Abdovic
- Department of Pediatric Nephrology, Klinika za djecje bolesti Zagreb Klinika za pedijatriju, Zagreb, Croatia
| | - Fran Stampalija
- Department of Pediatric Urology, Klinika za djecje bolesti Zagreb, Zagreb, Croatia
| | - Lana Loncar
- Department of Pediatric Neurology, Klinika za djecje bolesti Zagreb Klinika za pedijatriju, Zagreb, Croatia
| | - Batos A Tripalo
- Department of Pediatric Radiology, Klinika za djecje bolesti Zagreb, Zagreb, Croatia
| | - Martin Cuk
- Department of Pediatric Nephrology, Klinika za djecje bolesti Zagreb Klinika za pedijatriju, Zagreb, Croatia
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11
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Giner J, Pérez López C, Hernández B, Gómez de la Riva Á, Isla A, Roda J. Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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12
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Jones JY, Saigal G, Palasis S, Booth TN, Hayes LL, Iyer RS, Kadom N, Kulkarni AV, Milla SS, Myseros JS, Reitman C, Robertson RL, Ryan ME, Schulz J, Soares BP, Tekes A, Trout AT, Karmazyn B. ACR Appropriateness Criteria® Scoliosis-Child. J Am Coll Radiol 2019; 16:S244-S251. [DOI: 10.1016/j.jacr.2019.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/08/2019] [Indexed: 11/25/2022]
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Shetty J, Kandasamy J, Sokol D, Gallo P. Clinical deterioration despite syringomyelia resolution after successful foramen magnum decompression for Chiari malformation - Case series. Eur J Paediatr Neurol 2019; 23:333-337. [PMID: 30683486 DOI: 10.1016/j.ejpn.2019.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/27/2018] [Accepted: 01/08/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Neurosurgical treatment is recommended for symptomatic syringomyelia and the post-operative radiological resolution of the syringomyelia is associated with an improvement or at least stability of the patient's pre-operative symptoms. METHODS We reviewed syringomyelia treatment in our centre over the last five years for clinical outcome, surgical complications, post operative MRI and long term symptom resolution. RESULTS 50 cases of symptomatic syringomyelia underwent foramen magnum decompression and expansile watertight duroplasty. While the outcomes for majority are similar to what published in literature, three of them developed typical syringomyelia symptoms after initial good recovery and radiological resolution of syrinx. CONCLUSION Syringomyelia symptoms may appear or worsen following successful surgical treatment and radiological resolution of syrinx and it is important to counsel young people and their family regarding this.
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Affiliation(s)
- J Shetty
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK; University of Edinburgh, UK.
| | - J Kandasamy
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - D Sokol
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
| | - P Gallo
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
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Qin X, He Z, Qiu Y, Zhu Z. Anterior Spinal Overgrowth of the Thoracic Spine May Not Be Involved in the Initiation of Adolescent Idiopathic Scoliosis. World Neurosurg 2019; 125:e319-e325. [PMID: 30685373 DOI: 10.1016/j.wneu.2019.01.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare vertebral morphology among patients with adolescent idiopathic scoliosis (AIS), patients with Chiari I malformation (CMS)-associated scoliosis, and normal control subjects, with the goal of determining the role of anterior column overgrowth in the development of AIS. METHODS One hundred and forty adolescent girls were enrolled (50 with AIS, 40 with CMS, and 50 control subjects). Thoracic computed tomography images were obtained for all subjects. Anterior height of the vertebral body (VBHa), posterior height of the vertebral body (VBHp), and height of the pedicle (PH) were measured for each level. Finally, the ratios of VBHa and VBHp to PH were calculated and compared among the 3 groups. RESULTS Compared with the control group, both the AIS and CMS groups exhibited consistently longer VBHa and VBHp for most thoracic vertebral bodies, whereas the PH of most vertebral bodies was shorter in both AIS and CMS groups. Moreover, the ratios for differential growth between the anterior and posterior elements of each thoracic vertebra in both the AIS and CMS groups were significantly larger than the ratios in the control group. However, for all mentioned parameters, there were no significant differences between the AIS and CMS groups. CONCLUSIONS Faster growth of the anterior spinal column was confirmed by longer vertebral bodies and shorter pedicles in both patient groups. Relative anterior spinal overgrowth of the thoracic spine is not involved in the initiation of AIS, and the abnormal growth pattern of the vertebral body in AIS might be a secondary change to the spinal curve.
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Affiliation(s)
- Xiaodong Qin
- Spine Surgery, Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhong He
- Spine Surgery, Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Spine Surgery, Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Zezhang Zhu
- Spine Surgery, Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
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Fruergaard S, Ohrt-Nissen S, Dahl B, Kaltoft N, Gehrchen M. Neural Axis Abnormalities in Patients With Adolescent Idiopathic Scoliosis: Is Routine Magnetic Resonance Imaging Indicated Irrespective of Curve Severity? Neurospine 2018; 16:339-346. [PMID: 30653908 PMCID: PMC6603845 DOI: 10.14245/ns.1836154.077] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/06/2018] [Indexed: 12/05/2022] Open
Abstract
Objective Magnetic resonance imaging (MRI)-verified neural axis abnormalities (NAAs) have been described in adolescent idiopathic scoliosis (AIS), and several risk factors have been associated with the presence of NAAs in AIS patients. However, the clinical significance of these findings is unclear. The purpose of the present study was to determine the prevalence of NAAs in a large consecutive cohort of AIS patients and to evaluate the clinical significance of previously proposed risk factors.
Methods We prospectively included AIS patients referred to a tertiary facility for evaluation. Full-spine MRI scans were performed on all included patients irrespective of curve magnitude or proposed treatment modality. MRI scans were prospectively analyzed by a neuroradiologist and the pathologic findings were confirmed by a second independent radiologist.
Results NAA was observed in 34 of the 381 patients (8.9%): 32 patients had a syrinx, 1 patient had an arachnoid cyst, and 1 patient had a Chiari malformation. Four patients were referred for a neurosurgical evaluation but none received any neurosurgical treatment. No statistically significant difference was observed between the NAA and non-NAA groups in terms of sex, major curve size, thoracic kyphosis, left thoracic curve, curve convexity, curve progression, or level of pain (p>0.05).
Conclusion In this prospective study examining the risk factors for NAA in AIS patients, we found that previously proposed risk factors could not predict the MRI outcomes. The finding of an NAA had no clinical implications and we do not support MRI scans as a routine diagnostic modality in all AIS patients.
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Affiliation(s)
- Sidsel Fruergaard
- Department of Orthopedic Surgery, Spine Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- Department of Orthopedic Surgery, Spine Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopaedic Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - Nicolai Kaltoft
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Gehrchen
- Department of Orthopedic Surgery, Spine Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Tan H, Shen J, Feng F, Zhang J, Wang H, Chen C, Li Z. Clinical manifestations and radiological characteristics in patients with idiopathic syringomyelia and scoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2148-2155. [PMID: 29961133 DOI: 10.1007/s00586-018-5679-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/27/2018] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To clarify the clinical manifestation and radiological characteristics of idiopathic syringomyelia (IS) and to investigate the relationship between syrinx and scoliotic curves in IS-related scoliosis patients. METHODS Fifty-five patients with IS and scoliosis were identified and reviewed retrospectively from June 2009 to December 2016. Radiographic features of syrinx, scoliosis and clinical manifestations of neurological deficits were collected. The syrinx/cord (S/C) ratio was defined as the anteroposterior diameter of syrinx divided by the diameter of spinal cord at the same level. Patients were classified into two groups, the thoracic group (T group, apex vertebra located from T2 to intervertebral disk of T11-T12) and the thoracolumbar/lumbar group (TL/L group, apex vertebra located from T12 to L5). RESULTS There was no correlation between the radiological features of idiopathic syrinx and scoliotic curve parameters. The TL/L group had a lower level of most caudal extent (13.7 compared with 10.6, P = 0.029) and lower level of largest S/C ratio (12.0 compared with 8.7, P = 0.016) than that in T group. The deviated side of syrinx was not coincident with major curve convexity (27.2% concordance rate, P = 0.522) or dominant side of neurological deficit (16.3% concordance rate, P = 0.212). CONCLUSIONS Patients with major curves located on the thoracolumbar or lumbar spine had a much lower caudal extent and lower level of greatest S/C ratio compared to patients with major curves located on the thoracic spine. No significant relationships were detected between syrinx features, scoliotic curve parameters and neurological deficits. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Haining Tan
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China
| | - Jianxiong Shen
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China.
| | - Fan Feng
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China
| | - Hai Wang
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China
| | - Chong Chen
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China
| | - Zheng Li
- Department of Orthopedics, Peking Union Medical College Hospital and Graduate School of Peking Union Medical College, Peking Union Medical College, Chinese Academy of Medical Science, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing, 100730, China
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Klekamp J. How Should Syringomyelia be Defined and Diagnosed? World Neurosurg 2018; 111:e729-e745. [DOI: 10.1016/j.wneu.2017.12.156] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 11/29/2022]
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Samdani AF, Hwang SW, Singla A, Bennett JT, Ames RJ, Kimball JS. Outcomes of patients with syringomyelia undergoing spine deformity surgery: do large syrinxes behave differently from small? Spine J 2017; 17:1406-1411. [PMID: 28412564 DOI: 10.1016/j.spinee.2017.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/19/2016] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A paucity of data exists studying outcomes of patients with syringomyelia undergoing spinal deformity correction. The literature does not stratify patients by syrinx size, which is likely a major contributor to outcomes. PURPOSE The study aimed to compare differences in outcomes between patients with large (≥4 mm) and small syrinxes (<4 mm) undergoing spinal deformity correction. DESIGN This is a retrospective review. PATIENT SAMPLE The sample included 28 patients (11 with large syrinx [LS, >4 mm] and 17 with small syrinx [SS, <4 mm]). OUTCOME MEASURES The outcome measures were radiographic, operative, and neurophysiological measures. METHODS We retrospectively reviewed 28 patients with syringomyelia who underwent spine deformity surgery with 2-year follow-up. Demographic, surgical, and radiographic data were collected and compared preoperatively and at 2 years. RESULTS The LS group (11 patients) trended toward more left-sided thoracic curves (36% vs. 18%, p=.38) and was more likely to have had a Chiari decompression (45% vs. 12%, p=.08). The LS patients had larger preoperative major curves (LS=66° vs. SS=57°, p=.05), more thoracic kyphosis (LS=42°, SS=24°, p<.01), and greater rib prominences (LS=16°, SS=13°, p=.04). The LS patients had more levels fused (LS=12.2, SS=11.2, p=.05), higher estimated blood loss (EBL) (LS=1068 cc, SS=832 cc, p=.04), and a trend toward less percent correction of the major curve (LS=57%, SS=65%, p=.18). Four of 11 LS patients (36%) did not have somatosensory evoked potentials, and one of these also did not have motor evoked potentials. Neuromonitoring changes occurred in 3 of 11 (27%) LS patients and in none of the SS patients, with no postoperative deficits. CONCLUSIONS Outcomes of patients with syringomyelia undergoing spine deformity surgery are dependent on the size of the syrinx. Those with large syringomyelia are fused longer with more EBL and less correction. Spine surgeons should be aware that these patients are more likely to have less reliable neuromonitoring, with a higher chance of experiencing a change.
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Affiliation(s)
- Amer F Samdani
- Shriners Hospitals for Children - Philadelphia, 3551 N Broad St, Philadelphia, PA 19140, USA
| | - Steven W Hwang
- Shriners Hospitals for Children - Philadelphia, 3551 N Broad St, Philadelphia, PA 19140, USA.
| | - Anuj Singla
- University of Virginia Health System, Suite 3100, 415 Ray C Hunt Dr. Charlottesville, VA 22908, USA
| | - James T Bennett
- Lewis Katz School of Medicine, Temple University, 3500 N Broad St, Philadelphia, PA, 19140, USA
| | - Robert J Ames
- Lewis Katz School of Medicine, Temple University, 3500 N Broad St, Philadelphia, PA, 19140, USA
| | - Jeff S Kimball
- Drexel University College of Medicine, 2900 W Queen Ln, Philadelphia, PA, 19129, USA
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Kyriacou S, Man Y, Plumb K, Shaw M, Rezajooi K. Is a persistent central canal a risk factor for neurological injury in patients undergoing surgical correction of scoliosis? SCOLIOSIS AND SPINAL DISORDERS 2017; 12:25. [PMID: 28920082 PMCID: PMC5598069 DOI: 10.1186/s13013-017-0133-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 05/02/2017] [Indexed: 12/05/2022]
Abstract
Background Scoliosis patients with associated syringomyelia are at an increased risk of neurological injury during surgical deformity correction. The syrinx is therefore often addressed surgically prior to scoliosis correction to minimize this risk. It remains unclear if the presence of a persistent central canal (PCC) within the spinal cord also poses a similar risk. The aim of this study is to determine whether there is any evidence to suggest that patients with a PCC are also at a higher risk of neurological injury during surgical scoliosis correction. Methods Eleven patients with a PCC identified on pre-operative magnetic resonance imaging who had undergone correction of adolescent idiopathic scoliosis (AIS) over a 7-year study period at our institution were retrospectively identified. The incidence of abnormal intra-operative spinal cord monitoring (SCM) traces in this group was in turn compared against 44 randomly selected age- and sex-matched controls with no PCC who had also undergone surgical correction of AIS during the study period. Fisher’s exact test was applied to determine whether there was a significant difference in the incidence of abnormal intra-operative SCM traces between the two groups. Results Statistical analysis demonstrated no significant difference in the incidence of abnormal intra-operative SCM signal traces between the PCC group and the control group. Conclusions This study demonstrates no evidence to suggest a PCC increases the risk of neurological complications during scoliosis correction. We therefore suggest that surgical correction of scoliosis in patients with a PCC can be carried out safely with routine precautions.
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Affiliation(s)
- Steven Kyriacou
- Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Yuen Man
- The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Karen Plumb
- The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Matthew Shaw
- Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Kia Rezajooi
- Spinal Deformity Unit, Royal National Orthopaedic Hospital, Stanmore, UK
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Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation. Neurologia 2016; 34:318-325. [PMID: 27939111 DOI: 10.1016/j.nrl.2016.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/20/2016] [Accepted: 09/30/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Much has been published on syringomyelia related to Chiari malformation. In contrast, little is known about the condition when it is not associated with this malformation, but this presentation of syringomyelia constitutes a different entity and therefore requires specific management. We conducted a literature review to summarise the most accepted and widespread ideas about the pathophysiology, management and other aspects of syringomyelia unrelated to Chiari malformation. DEVELOPMENT We reviewed the most relevant literature on this condition, focusing on the pathophysiology, clinical presentation, diagnosis, and treatment. CONCLUSIONS Syringomyelia unrelated to Chiari malformation is a distinct entity that must be well understood to guarantee correct diagnosis, monitoring, and management. When the disease is suspected, a thorough study should be conducted to identify its aetiology. Treatment must aim to eliminate the cause of the disease; symptomatic treatment should remain a second-line option.
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Kyrklund K, Pakarinen MP, Taskinen S, Kivisaari R, Rintala RJ. Spinal cord anomalies in patients with anorectal malformations without severe sacral abnormalities or meningomyelocele: outcomes after expectant, conservative management. J Neurosurg Spine 2016; 25:782-789. [PMID: 27448173 DOI: 10.3171/2016.4.spine1641] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The goal of this study was to determine the significance of spinal cord anomalies (SCAs) in patients with anorectal malformations (ARMs) by comparing the outcomes for bowel function, lower urinary tract symptoms (LUTS), and lower-limb neurological abnormalities to these outcomes in patients with similar ARMs and a normal spinal cord. METHODS The spinal cord MRI records of female patients treated for vestibular and perineal fistula (VF/PF) and male patients with rectourethral fistula (RUF) at a single center between 1983 and 2006 were reviewed. Bowel function and LUTS were assessed by questionnaire. Patients with extensive sacral anomalies or meningomyelocele were excluded. RESULTS Of 89 patients (median age 15 years, range 5-29 years), MRI was available in 90% (n = 80; 40 male patients with RUF), and 80% of patients returned the questionnaire (n = 64; 31 male patients with RUF). Spinal cord anomalies were found in 34%, comprising a filum terminale lipoma in 30%, low conus medullaris in 10%, and thoracolumbar syrinx in 6%. Bowel functional outcomes between patients with SCAs (n = 23) and those with a normal spinal cord (n = 41) were not significantly different for soiling (70% vs 63%), fecal accidents (43% vs 34%), and constipation (57% vs 39%; p = not significant for all). The LUTS, including urge (65% vs 54%), urge incontinence (39% vs 24%), stress incontinence (17% vs 22%), and straining (32% vs 29%) were also comparable between groups (p = not significant for all). No patients developed lower-limb neurological abnormalities. CONCLUSIONS The results suggest that the long-term functional outcomes for patients with SCAs who had VF/PF and RUF may not differ significantly from patients with the same type of ARMs and a normal spinal cord. The results favor a conservative approach to their management in the absence of abnormal neurological findings in the lower limbs.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Seppo Taskinen
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Reetta Kivisaari
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
| | - Risto J Rintala
- Department of Pediatric Surgery, University of Helsinki, Hospital for Children and Adolescents, Helsinki, Finland
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Abstract
Syringomyelia is the term given to cystic cavities in the spinal cord, most of which are associated with congenital malformations of the craniocervical junction and represent dilation of the central canal of the cord. As such, syrinxes can be considered analogous to hydrocephalus. The exact etiology of syrinx formation remains a subject of debate, but there is ample evidence that they are the result of obstruction of the normal flow of cerebrospinal fluid between the intracranial and spinal compartments. The chances that a syrinx will progress over time are much greater when they are associated with a causative lesion (Chiari malformation, tumor, infection, and trauma), but asymptomatic central canal dilation may be a stable incidental finding. Although spinal cord neoplasms are a recognized etiology for syrinx formation, especially in adults, it is not always necessary to administer contrast when evaluating a syrinx for the first time with magnetic resonance imaging.
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Affiliation(s)
- Blaise V Jones
- Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH.
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Segal D, Heary RF, Sabharwal S, Barry MT, Ming X. Severe holocord syrinx in a child with megalencephaly-capillary malformation syndrome. J Neurosurg Pediatr 2016; 18:79-82. [PMID: 27035547 DOI: 10.3171/2016.1.peds15482] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present the case of a child with megalencephaly-capillary malformation syndrome who developed a rapidly progressive holocord syringomyelia that was treated surgically. A 3-year-old boy with megalencephaly-capillary malformation-polymicrogyria (MCAP) syndrome presented with several months of right leg weakness, worsening scoliosis, and increased seizures. An MRI study of the brain demonstrated a Chiari I malformation and massively dilated syringomyelia extending from C-2 to the conus medullaris. The patient underwent an urgent suboccipital craniectomy with C1-3 laminectomies to relieve the CSF outflow obstruction with significant clinical improvement. Surgery was complicated by bleeding from intracranial vascular malformations. This report describes a very rapidly developing, massive holocord syringomyelia related to CSF obstruction due to an unusual congenital brain malformation and associated vascular overgrowth at the site. Serial, premorbid MRI studies demonstrated the very rapid progression from no Chiari malformation, to progressively greater cerebellar tonsillar herniation, to holocord syrinx. This complication has never been reported in MCAP syndrome and should be considered in any affected MCAP patient with a progressive neurological decline, even if previous spine imaging findings were normal. Surgical complications due to hemorrhage also need to be considered in this vascular brain malformation.
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Affiliation(s)
| | | | | | - Maureen T Barry
- Radiology, Rutgers New Jersey Medical School, Newark, New Jersey
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Abd-El-Barr MM, Proctor MR. Chiari Malformations and Other Anomalies. HEAD AND NECK INJURIES IN YOUNG ATHLETES 2016:105-118. [DOI: 10.1007/978-3-319-23549-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Abstract
OBJECT Syringohydromyelia is frequently identified on spinal imaging. The literature provides little guidance to decision making regarding the need for follow-up or treatment. The purpose of this study was to review the authors' experience in managing pediatric syringohydromyelia of unknown cause. METHODS A single-institution retrospective review of all cases involving pediatric patients who underwent spinal MRI from 2002 to 2012 was conducted. Patients with idiopathic syringohydromyelia (IS) were identified and categorized into 2 subgroups: uncomplicated idiopathic syrinx and IS associated with scoliosis. Clinical and radiological course were analyzed. RESULTS Ninety-eight patients (50 female, 48 male) met the inclusion criteria. Median age at diagnosis of syrinx was 11.9 years. Median maximum syrinx size was 2 mm (range 0.5-17 mm) and spanned 5 vertebral levels (range 1-20 vertebral levels). Thirty-seven patients had scoliosis. The most common presenting complaint was back pain (26%). Clinical follow-up was available for 78 patients (80%), with a median follow-up of 20.5 months (range 1-143 months). A neurological deficit existed at presentation in 36% of the patients; this was either stable or improved at last follow-up in 64% of cases. Radiological follow-up was available for 38 patients (39%), with a median duration of 13 months (range 2-83 months). There was no change in syrinx size in 76% of patients, while 16% had a decrease and 8% had an increase in syrinx size. Thirty-six patients had both clinical and radiological follow-up. There was concordance between clinical and radiological course in 14 patients (39%), with 11 patients (31%) showing no change and 3 patients (8%) showing clinical and radiological improvement. No patients had concurrent deterioration in clinical and radiological course. One patient with scoliosis and muscular dystrophy underwent direct surgical treatment of the syrinx and subsequently had a deteriorated clinical course and decreased syrinx size. CONCLUSIONS There remains a paucity of data regarding the management of pediatric IS. IS in association with scoliosis can complicate neurosurgical decision making. There was no concordance between radiological syrinx size increase and clinical deterioration in this cohort, indicating that surgical decision making should reflect clinical course as opposed to radiological course.
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Affiliation(s)
- Analiz Rodriguez
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and
| | - Elizabeth N Kuhn
- Department of Neurosurgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Aravind Somasundaram
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and
| | - Daniel E Couture
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and
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Zhu Z, Sha S, Chu WCC, Yan H, Xie D, Liu Z, Sun X, Zhu W, Cheng JCY, Qiu Y. Comparison of the scoliosis curve patterns and MRI syrinx cord characteristics of idiopathic syringomyelia versus Chiari I malformation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:517-25. [DOI: 10.1007/s00586-015-4108-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 11/30/2022]
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Strahle J, Muraszko KM, Garton HJL, Smith BW, Starr J, Kapurch JR, Maher CO. Syrinx location and size according to etiology: identification of Chiari-associated syrinx. J Neurosurg Pediatr 2015; 16:21-9. [PMID: 25837888 DOI: 10.3171/2014.12.peds14463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Syrinx size and location within the spinal cord may differ based on etiology or associated conditions of the brain and spine. These differences have not been clearly defined. METHODS All patients with a syrinx were identified from 14,118 patients undergoing brain or cervical spine imaging at a single institution over an 11-year interval. Syrinx width, length, and location in the spinal cord were recorded. Patients were grouped according to associated brain and spine conditions including Chiari malformation Type I (CM-I), secondary CM (2°CM), Chiari malformation Type 0 (CM-0), tethered cord, other closed dysraphism, and spinal tumors. Syringes not associated with any known brain or spinal cord condition were considered idiopathic. Syrinx characteristics were compared between groups. RESULTS A total of 271 patients with a syrinx were identified. The most common associated condition was CM-I (occurring in 117 patients [43.2%]), followed by spinal dysraphism (20 [7.4%]), tumor (15 [5.5%]), and tethered cord (13 [4.8%]). Eighty-three patients (30.6%) did not have any associated condition of the brain or spinal cord and their syringes were considered idiopathic. Syringes in patients with CM-I were wide (7.8 ± 3.9 mm) compared with idiopathic syringes (3.9 ± 1.0, p < 0.0001) and those associated with tethered cord (4.2 ± 0.9, p < 0.01). When considering CM-I-associated and idiopathic syringes, the authors found that CM-I-associated syringes were more likely to have their cranial extent in the cervical spine (88%), compared with idiopathic syringes (43%; p < 0.0001). The combination of syrinx width greater than 5 mm and cranial extent in the cervical spine had 99% specificity (95% CI 0.92-0.99) for CM-I-associated syrinx. CONCLUSIONS Syrinx morphology differs according to syrinx etiology. The combination of width greater than 5 mm and cranial extent in the cervical spine is highly specific for CM-I-associated syringes. This may have relevance when determining the clinical significance of syringes in patients with low cerebellar tonsil position.
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Affiliation(s)
- Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Jordan Starr
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Joseph R Kapurch
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Abstract
In recent years, the utilization of diagnostic imaging of the brain and spine in children has increased dramatically, leading to a corresponding increase in the detection of incidental findings of the central nervous system. Patients with unexpected findings on imaging are often referred for subspecialty evaluation. Even with rational use of diagnostic imaging and subspecialty consultation, the diagnostic process will always generate unexpected findings that must be explained and managed. Familiarity with the most common findings that are discovered incidentally on diagnostic imaging of the brain and spine will assist the pediatrician in providing counseling to families and in making recommendations in conjunction with a neurosurgeon, when needed, regarding additional treatments and prognosis.
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Adeleye AO, Ogbole GI. Clinical-radiological improvement following low-tech surgical treatment of an extensive cervical-medullary idiopathic syringomyelia in a low-resource African neurosurgical practice. Neurosurg Rev 2015; 38:579-83; discussion 583. [PMID: 25697142 DOI: 10.1007/s10143-015-0618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
Abstract
Surgical intervention is not so commonly deployed for idiopathic syringomyelia, even the symptomatic ones; is only undertaken, in the current era, after thorough clinical evaluation and extensive high-resolution neuroimaging; and is more assuredly performed, high-tech, in health facilities in the developed world with cutting edge logistic supports. In the practice environment of a low-resource African developing country, a 41-year-old young man recently presented in severe clinical-neurological deficit, Nurick grade 5, with an extensive cervical-medullary idiopathic syringomyelia. In spite of severe preoperative and intraoperative resource limitations, he successfully underwent spinal surgical decompression, fenestration of syrinx, and expansile duraplasty. He improved clinically postoperatively and achieved mobility, Nurick grade 3, before hospital discharge. He sustained this improvement, Nurick grade 3 to 2, 20 months post-op. He is now independent, needing only a walking stick to aid ambulation, and an MRI at this time showed only minimal focal post-op changes but total disappearance of the syrinx.
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Affiliation(s)
- Amos O Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, UCH, Ibadan, Nigeria,
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Evolution of syrinx in patients undergoing posterior correction for scoliosis associated with syringomyelia. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:955-62. [DOI: 10.1007/s00586-014-3694-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 11/17/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
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Tsitouras V, Sgouros S. Syringomyelia and tethered cord in children. Childs Nerv Syst 2013; 29:1625-34. [PMID: 24013332 DOI: 10.1007/s00381-013-2180-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The presence of syringomyelia varies in patients with different forms of dysraphism; from 21 % to 67 %. Only around 60 % of patients with syringomyelia is likely to experience symptoms related to it. PATHOPHYSIOLOGY Many theories have been outlined for the creation of syringomyelia. The one most applicable to tethered cord dictates that tensile radial stress may create a syrinx in a previously normal cord tissue and transiently lower pressure may draw in interstitial fluid, causing the syrinx to enlarge if fluid exit is inhibited. In addition, arachnoiditis increases flow resistance in the spinal subarachnoid space, altering temporal CSF pulse pressure dynamics, which promotes entry of CSF in to the spinal cord. CLINICAL PRESENTATION There is a significant overlap between the symptoms that are due to tethered cord and syringomyelia, both in newly presenting patients with coexisting syringomyelia, and in previously treated patients who during follow-up present recurrent symptoms and a new syringomyelia cavity. TREATMENT The treatment of patients with tethered cord and syringomyelia is directed towards untethering the cord from its most caudal region upwards and restoring spinal anatomy with reestablishment of unobstructed CSF flow in the subarachnoid space. Only if complete untethering has been ensured and syringomyelia deteriorates, then surgical treatment can be directed against the syrinx. In patients with spinal dysraphism and coexisting hydrocephalus, radiological presentation of new syringomyelia or deterioration of previously known syringomyelia may signify shunt obstruction "until proven otherwise". CONCLUSION In most occasions, satisfactory cord untethering addresses the development of syringomyelia.
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Affiliation(s)
- Vasilios Tsitouras
- "Mitera" Childrens Hospital, Erythrou Stavrou 6 Marousi, 151 23 Athens, Greece
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Joseph RN, Batty R, Raghavan A, Sinha S, Griffiths PD, Connolly DJA. Management of isolated syringomyelia in the paediatric population--a review of imaging and follow-up in a single centre. Br J Neurosurg 2013; 27:683-6. [PMID: 23472665 DOI: 10.3109/02688697.2013.771728] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the natural history of isolated syringomyelia in children. METHODS MRI reports from February 2007 to August 2011 mentioning syrinx were identified on Sheffield Children's PACS database. Scans with syringes having an AP diameter of > 1 mm and extending over at least two vertebral bodies were reviewed. Patients with an identifiable cause such as a Chiari malformation were then excluded. RESULTS Thirty-nine patients were included with a mean age at diagnosis of 10.6 years. The average syrinx AP diameter was 3.30 mm. The rostrocaudal length of the syringes varied between 2 and 19 vertebral bodies. Twenty-seven out of 39 syringes were thoracic in origin. There were 3 and 6 syringes involving the cervicothoracic and thoracolumbar regions, respectively, with 3 involving the cervical area only. Eleven out of 39 (Group I) patients were found "incidentally" during work-up for adolescent idiopathic scoliosis and these were considered as a separate group. These patients did not have any significant symptoms and were discharged following their scoliosis correction surgery. Syrinx was incidental in 14 further patients (Group II). Of the 14 patients, 11 remained asymptomatic with no change in syrinx morphology throughout follow up. Of the 14 patients, 3 were lost to follow-up. Of the 39 patients, 14 (Group III) presented with progressive back pain without any obvious clinical cause. Of the 14, 10 either improved or remained the same. Of the 14 patients, 3 underwent lumbar puncture, 1/14 having myelography. All 4/14 patients reported significant pain reduction on follow up following intervention. CONCLUSION Idiopathic syrinx is a benign pathology, which can be managed expectantly. Most cases remain stable or improve over time. In a small minority who have progressive back pain, we have found that lumbar puncture may be helpful in reducing symptoms.
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Affiliation(s)
- R N Joseph
- Department of Radiology, Sheffield Children's Hospital, Sheffield, South Yorkshire, UK
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Kulwin CG, Patel NB, Ackerman LL, Smith JL, Boaz JC, Fulkerson DH. Radiographic and clinical outcome of syringomyelia in patients treated for tethered cord syndrome without other significant imaging abnormalities. J Neurosurg Pediatr 2013; 11:307-12. [PMID: 23259548 DOI: 10.3171/2012.11.peds12251] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Charles G Kulwin
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Singhal A, Bowen-Roberts T, Steinbok P, Cochrane D, Byrne AT, Kerr JM. Natural history of untreated syringomyelia in pediatric patients. Neurosurg Focus 2012; 31:E13. [PMID: 22133172 DOI: 10.3171/2011.9.focus11208] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The natural history of syringomyelia in pediatric patients remains uncertain. Although symptomatic and operative cases of syringomyelia are well studied, there are fewer articles in the literature on the nonoperative syrinx and its clinical and radiological course. The purpose of this research was to analyze the natural history of untreated syringomyelia in pediatric patients presenting with minimal neurological symptoms. METHODS A review of the neurosurgery database at British Columbia's Children's Hospital identified all pediatric patients (< 18 years of age) with syringes identified on MR imaging. Patients were included in this study if they had at least 2 MR images of the spine, at least 1 year apart, while receiving nonoperative treatment. Magnetic resonance imaging was used to determine changes in the size of the syrinx over time. Clinic notes were analyzed to establish demographic and clinical features and to determine any clinical changes over time. RESULTS A total of 17 patients were included in the study. Symptoms at presentation were often mild and included limb numbness (3 cases), headaches (2 cases), mild sensory deficits (2 cases), mild motor deficits (3 cases), and intermittent incontinence (7 cases). The consultant neurosurgeon believed that the syrinx was not contributing to the symptoms in these 17 patients. The syrinx either remained unchanged (7 cases) or diminished in size (8 cases) in a total of 15 patients (88%). In the remaining 2 patients the authors noted an increase in syrinx size, in 1 of whom the clinical course also worsened. Both of these patients had a Chiari malformation and subsequently underwent craniocervical decompression. Overall, the mean change was -0.7 mm of maximal axial diameter (range -2.6 to +2.7 mm). Sixteen patients (94%) exhibited no worsening of symptoms over time. CONCLUSIONS Syringomyelia often remains stable in patients receiving nonoperative treatment. However, given that 2 (12%) of 17 syringes in this series enlarged, it is likely appropriate to include periodic imaging in the follow-up of these cases.
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Affiliation(s)
- Ash Singhal
- Department of Surgery, Division of Pediatric Neurosurgery, British Columbia’s Children’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
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Abstract
Many types of spinal abnormalities can have an impact on an athlete’s ability to participate in sports. One of the challenges in the current era is distinguishing the clinically relevant lesions from the incidental. Almost without exception, a Chiarimal formation, significant syringomyelia or other cyst compressing the spinal cord or nerve roots, tethered spinal cord, or spinal tumor should prompt referral to a neurosurgeon. However, tonsillar ectopia (descent of the cerebellum less than 5 mm beyond the foramen magnum) and small dilatations of the central canal, are very commonly seen and appear to represent normal anatomic variants that place athletes at no increased risk of spinal injury, and should not be considered a contraindication to play. The recommendations made in this article are largely based on consensus and experience, but as we gain more clinical experience to correlate with the increasingly sophisticated imaging findings, we hope that these recommendations can be refined further.
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Affiliation(s)
- Mark R Proctor
- Department of Neurosurgery, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
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Roy AK, Slimack NP, Ganju A. Idiopathic syringomyelia: retrospective case series, comprehensive review, and update on management. Neurosurg Focus 2011; 31:E15. [DOI: 10.3171/2011.9.focus11198] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Object
A syrinx is a fluid-filled cavity within the spinal cord that can be an incidental finding or it can be accompanied by symptoms of pain and temperature insensitivity. Although it is most commonly associated with Chiari malformation Type I, the advancement of imaging techniques has resulted in more incidental idiopathic syringes that are not associated with Chiari, tumor, trauma, or postinfectious causes. The authors present a comprehensive review and management strategies for the idiopathic variant of syringomyelia.
Methods
The authors retrospectively identified 8 idiopathic cases of syringomyelia at their institution during the last 6 years. A PubMed/Medline literature review yielded an additional 38 articles.
Results
Two of the authors' patients underwent surgical treatment that included a combination of laminectomy, lysis of adhesions, duraplasty, and syrinx fenestration. The remaining 6 patients were treated conservatively and had neurologically stable outcomes. Review of the literature suggests that an etiology-driven approach is essential in the diagnosis and management of syringomyelia, although conservative management suffices for most cases. In particular, it is important to look at disturbances in CSF flow, as well as structural abnormalities including arachnoid webs, cysts, scars, and a diminutive posterior fossa.
Conclusions
The precise etiology for idiopathic syringomyelia (IS) is still unclear, although conceptual advances have been made toward the overall understanding of the pathophysiology of IS. Various theories include the cerebellar piston theory, intramedullary pulse pressure theory, and increased spinal subarachnoid pressure. For most patients with IS, conservative management works well. Continued progression of symptoms, however, could be approached using decompressive strategies such as laminectomy, lysis of adhesions, and craniocervical decompression, depending on the level of pathology. Management for patients with progressive neurological dysfunction and the lack of flow disturbance is unclear, although syringosubarachnoid shunting can be considered.
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Massey SL, Buland J, Hauber S, Piatt J, Goraya J, Faerber E, Valencia I. Acute VI nerve palsy in a 4 year-old girl with Chiari I malformation and pontomedullary extension of syringomyelia: case report and review of the literature. Eur J Paediatr Neurol 2011; 15:303-9. [PMID: 21561792 DOI: 10.1016/j.ejpn.2011.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 04/08/2011] [Indexed: 10/18/2022]
Abstract
We report the case of a previously healthy 4 year-old African American female who presented to the emergency department with acute onset of unilateral abducens nerve palsy and torticollis. Within 12 h of presentation, the patient's symptoms progressed to include ipsilateral facial nerve palsy and gait ataxia. On exam, the patient demonstrated right cranial nerve VI and VII palsies, ataxic gait with left lateropulsion, spasticity of bilateral lower extremities with clonus, and the presence of bilateral Babinski sign. MRI of the brain and spinal cord revealed severe Chiari I malformation with associated extensive holochord syringomyelia and syringobulbia. The patient underwent successful surgical decompression 72 h after initial presentation. We review the literature on Chiari malformations and syringomyelia, including epidemiology, presentation and neurological manifestations, and treatment recommendations. As our patient had a very acute presentation, we additionally review the previously reported cases of acute and atypical presentation of patients with Chiari I malformation and syringomyelia. The aim of this report is to make practitioners aware of the acuteness with which children with Chiari malformation type I with syringomyelia and syringobulbia can present.
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Affiliation(s)
- Shavonne L Massey
- Department of Pediatrics, St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
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