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

Case report: CSF hypotension secondary to a free syringo-subarachnoid-peritoneal shunt

INTRODUCTION

Syringomyelia is present in 40% of pediatric patients with Chiari malformation. Typically treated with posterior fossa decompression, some cases require further intervention such as syrinx shunting.

CASE REPORT

We report a 16-year-old female with Chiari type 1 malformation and syringomyelia who underwent posterior fossa decompression and subsequent free syringo-subarachnoid-peritoneal shunting. The patient developed symptoms of CSF overdrainage, and imaging indicated CSF hypotension. A distal catheter ligation temporarily improved symptoms, but eventually, a programmable ventricular shunt was necessary due to shunt dependence.

CONCLUSION

This case highlights the rare complication of CSF overdrainage from syrinx shunting and the importance of shunt selection considerations.

Treatment of Terminal Syrinx With a Syringo-Subarachnoid Shunt and the Novel Use of a Titanium Knot Fastener: A Case Report

A syrinx involves cystic dilation of the central canal of the spinal cord due to the accumulation of cerebrospinal fluid and often results in a neurological deficit. While treatment options vary, surgical management is often utilized and requires an open durotomy. A 70-year-old female presented with one year of progressive low back pain with associated leg numbness, urinary incontinence, bilateral foot drop, and imbalance resulting in multiple falls. MRI revealed a terminal syrinx at the level of the conus medullaris. She underwent an uncomplicated T12-L1 laminectomy for syrinx fenestration and syringo-subarachnoid shunt placement, resulting in improved bladder/bowel function, strength, sensation, and ambulation. The necessary midline durotomy was closed with a running 6-0 prolene suture fastened at the start and end of the suture line with the novel use of the COR-KNOT MICROTM device (LSI Solutions, Victor, New York, US). We present the successful surgical management of a progressively symptomatic terminal syrinx using a syringo-subarachnoid shunt and the novel use of the COR-KNOT MICROTM titanium fastener device for dural closure. Earlier shunting should be considered in the disease course of terminal syrinx, and the successful novel use of a titanium fastener on the dura warrants further investigation.

Acute Respiratory Failure Requiring Invasive Ventilation in Adults With Congenital Syringomyelia/Arnold-Chiari Malformations: A Systematic Review

Arnold-Chiari malformations (ACM) and congenital syringomyelia/syrinx are rare neurological phenomenons that can present as acute respiratory failure and contribute to multiple extubation failures despite surgical intervention. A systematic review was conducted to scrutinize the current literature, screening 65 papers and including 12 papers (13 patients). Sixty-one percent of patients had type 1 ACM and 70% had a congenital syringomyelia. Neurosurgical intervention occurred in seven patients, five patients had at least one extubation failure which was due to apnea or reoccurrence of respiratory failure, and eight patients needed tracheostomies. The neurosurgical intervention aims to improve patient symptoms, but our data and current literature suggest that patients with these pathologies still undergo long ventilation weans and are not liberated from the ventilator due to ongoing respiratory failure.

Optimizing Therapeutic Strategies for Syringomyelia Associated with Tethered Cord Syndrome: A Comprehensive Review

This review highlights the need for therapeutic guidelines for syringomyelia associated with tethered cord syndrome (TCS) caused by spinal dysraphism (SD). A comprehensive literature review was conducted, selecting twelve articles to analyze common therapeutic strategies. Surgical cord untethering alone has recently become a preferred treatment, with 45 ± 21.1% of patients experiencing remission or improvement, 47 ± 20.4% unchanged and asymptomatic, and 4 ± 8% worsened. Untethering with direct surgical drainage for the syrinx had better outcomes than untethering alone (78% vs. 45%, p = 0.05). Terminal syringostomy was beneficial for syrinxes extending to the filum terminale but not for asymptomatic small syrinxes with a syrinx index < 0.4. Syrinx shunting was recommended for symptomatic large syrinxes (>2 cm in length and syrinx index > 0.5). Various shunt procedures for syrinxes are still advocated, mainly for refractory syringomyelia in Chiari malformation, posttraumatic cases, SD, or other causes. Personalized surgical methods that address the root cause of syringomyelia, particularly those improving cerebrospinal fluid flow, offer promising results with minimized complications. Ongoing studies are required to enhance management strategies for syringomyelia associated with TCS, optimize patient outcomes, and reduce the risk of recurrent symptoms.

Myelomeningocele: Long-Term Neurosurgical Management

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

Syringopleural shunt for refractory syringomyelia: how I do it

BACKGROUND

Surgical treatment of syringomyelia is directed at the reconstruction of the subarachnoid space and restoration normal cerebrospinal fluid flow. Direct intervention on the syrinx is a rescue procedure and should be offered to patients with refractory syringomyelia.

METHODS

We provide an overview on indications and technique of syringopleural shunt (SPS). The procedure involves the connection of syrinx with the pleural space using a lumboperitoneal shunt. The occurrence of a negative pressure inside the pleural compartment offers an appropriate gradient for drainage from the syrinx.

CONCLUSIONS

The SPS allows for a safe and effective treatment of persistent syringomyelia when management of the underlying cause does not yield substantial improvement.

Spontaneous resolution of syringomyelia following pregnancy and parturition in a patient with type I chiari malformation: A case and systematic review

BACKGROUND

Spontaneous resolution of syringomyelia has rarely been reported in the literature. Rarer still are cases wherein this process is associated with pregnancy and parturition. We review theories on syringomyelia development and spontaneous resolution to better understand the role pregnancy and parturition may play in both processes.

METHODS

We present a 30-year-old female with MRI-confirmed spontaneous syrinx regression following caesarean delivery of a full-term pregnancy. We additionally review the literature to identify previously reported cases of spontaneous syrinx regression both independent of and associated with pregnancy.

RESULTS

Including the present case, 39 cases describing spontaneous regression of syringomyelia have been reported in the literature, of which only four are associated with pregnancy and parturition. 75% of all reported cases were associated with type I Chiari malformation, though several disorders of the craniocervical junction and spinal canal were implicated. Complete syrinx regression was achieved in 33.3% of cases and 5% of cases described recurrence of syringomyelia following the spontaneous resolution.

CONCLUSION

Syringomyelia likely develops due to disturbance of the physiologic flow of cerebrospinal fluid around the craniocervical junction and the obex. Several mechanisms including fissuring of the spinal cord parenchyma and reduction of subarachnoid scarring are likely involved in this process. In the setting of pregnancy, additional mechanisms surrounding the increased intraabdominal forces imparted by a growing fetus, Valsalva-like strain experienced during labor, and hemodynamic changes that occur to accommodate gestation are likely implicated. Nevertheless, patients should continue to be monitored periodically for syrinx recurrence.

Revision Thoracic Syringo-Subarachnoid Shunt for Recurrent Syrinx With Syringobulbia: Technique and Surgical Video

Syringomyelia and syringobulbia continue to remain a diagnosis without widely accepted treatment paradigms. Furthermore, the currently available treatment options can be complicated by delayed symptom recurrence and the need for revision surgery. Revision intradural surgery is challenging, and currently, there is a paucity of literature describing safe techniques for revision syringotomy and shunt placement. In this technical report, we present a surgical video describing the technique of revision syringo-subarachnoid shunt placement in a 61-year-old female with a history of multiple intradural surgeries who presented with progressively symptomatic ascending syringobulbia.