Primary spinal syringomyelia: a personal perspective

Aquaporin-4 expression and modulation in a rat model of post-traumatic syringomyelia

Aquaporin-4 (AQP4) has been implicated in post-traumatic syringomyelia (PTS), a disease characterised by the formation of fluid-filled cysts in the spinal cord. This study investigated the expression of AQP4 around a mature cyst (syrinx) and the effect of pharmacomodulation of AQP4 on syrinx size. PTS was induced in male Sprague-Dawley rats by computerized spinal cord impact and subarachnoid kaolin injection. Immunofluorescence of AQP4 was carried out on mature syrinx tissue 12 weeks post-surgery. Increased AQP4 expression corresponded to larger, multiloculated cysts (R2 = 0.94), yet no localized changes to AQP4 expression in perivascular regions or the glia limitans were present. In a separate cohort of animals, at 6 weeks post-surgery, an AQP4 agonist (AqF026), antagonist (AqB050), or vehicle was administered daily over 4 days, with MRIs performed before and after the completion of treatment. Histological analysis was performed at 12 weeks post-surgery. Syrinx volume and length were not altered with AQP4 modulation. The correlation between increased AQP4 expression with syrinx area suggests that AQP4 or the glia expressing AQP4 are recruited to regulate water movement. Given this, further investigation should examine AQP4 modulation with dose regimens at earlier time-points after PTS induction, as these may alter the course of syrinx development.

Knowledge mapping of syringomyelia from 2003 to 2022: A bibliometric analysis

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.

Surgical Management of Lumbar Adhesive Arachnoiditis Postmeningitis: A Bermuda Triangle?—Case Report and Review of Literature

Spinal arachnoiditis can occur as a delayed sequel of meningitis. Cerebrospinal fluid flow disturbances and adhesive loculations can cause cord compression and traction on roots causing the symptoms. The surgical treatment of this condition is often considered a limited option, because of the high chances of recurrence of symptoms and adhesions, often considered as surgical failure. Here, we report a patient with extensive lumbar–sacral adhesive arachnoiditis successfully treated with limited adhesiolysis under neuromonitoring and cystoperitoneal shunt placement.

Syrinx regression after correction of iatrogenic kyphotic deformity: illustrative case

BACKGROUND

Syringomyelia has a long-established association with pediatric scoliosis, but few data exist on the relationship of syringomyelia to pediatric kyphotic deformities.

OBSERVATIONS

This report reviewed a unique case of rapid and sustained regression of syringomyelia in a 13-year-old girl after surgical correction of iatrogenic kyphotic deformity.

LESSONS

In cases of syringomyelia associated with acquired spinal deformity, treatment of deformity to resolve an associated subarachnoid block should be considered because it may obviate the need for direct treatment of syrinx.

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

Surgical outcomes by sectioning a filum terminale in patients with terminal syringomyelia

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.

Subacute posttraumatic ascending myelopathy (SPAM): A potential complication of subarachnoid shunt for syringomyelia?

Context: Treatment of primary spinal syringomyelia is still controversial. Among others, shunting syrinx fluid to the subarachnoid, peritoneal or pleural space has been utilized with varying success. Shunt obstruction, migration, and infection represent the most common complications of these procedures. Findings: The authors present the case of an 81-year-old woman who developed an unusual neurological deterioration resembling a subacute posttraumatic ascending myelopathy (SPAM) after the insertion of a syringosubarachnoid shunt for the treatment of slow-growing D10 syringomyelia. Conclusion/Clinical Relevance: To date, no cases of SPAM secondary to the insertion of a syringosubarachnoid shunt for the treatment of syringomyelia have been reported. The potential pathogenesis related to this phenomenon is discussed.

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

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

Professional Profiles, Technical Preferences, Surgical Opinions, and Management of Clinical Scenarios from a Panel of 63 International Experts in the Field of Chiari I Malformation

BACKGROUND

Chiari I Malformation (CMI) and the topics concerning it have been the subject of numerous discussions and polarizing controversies over the course of the past 20 years.

METHODS

The opinions of 63 recognized international Neurosurgical CMI experts from 4 continents, with a collective surgical experience of more than 15,000 CMI cases, were gathered through a detailed questionnaire, divided in two parts: diagnostic and therapeutic. The therapeutic part was organized into four sections: Professional Profile, Technical Preferences, Surgical Opinions, and Clinical Scenarios.

RESULTS

The data reflected a wide spectrum of opinions, approaches, and expertise. The second part of the questionnaire dealt with the surgical aspects of CMI care and painted a more complex picture: • 81% of the surgeons preferred the Intradural technique. • 88% of the experts agreed that CMI surgery is not indicated for minimal non-debilitating symptoms alone, or as prophylaxis. • In the face of given clinical scenarios, a wide spectrum of therapeutic approaches was chosen by the whole group, but the 4 Surgeons with the largest case series expressed the same opinion. • Eight out of 63 Surgeons had a surgical experience above 600 cases, were responsible for more than half of the total 15,000 declared CMI cases, and shared a similar profile in terms of technical surgical choices, therapeutic opinions, and low complication rate, with a marked preference for Intradural techniques and tonsillar manipulation. • Once large individual case series were accumulated, we did not see any differences in the opinions and preferences between Adult and Pediatric Neurosurgeons.

CONCLUSION

Surgeons who have focused on CMI have been able to accumulate large surgical series, have chosen in their practices the more aggressive (and intrinsically more effective) CMI surgical techniques, and have achieved a low complication rate which compares favorably with that one of the extradural techniques.

The cystic dilation of ventriculus terminalis with neurological symptoms: Three case reports and a literature review

CONTEXT

The ventriculus terminalis (VT) is a very small ependymal-lined residual lumen in the conus medullaris. It is normally present in all subjects during fetal development. VT in adults appears as an unusual pathology with an uncertain pathogenesis.

FINDINGS

In this paper, we described three case reports of symptomatic fifth ventricle cystic dilations. All of them were female and their mean age was 59 years. We treated them surgically and all three patients were improved based on clinical and imaging assessments.

CONCLUSION

Our cases suggested that surgical decompression was a safe and effective treatment in symptomatic patients and the neurosurgeons should be aware of such rare situations. A complete list of differential diagnosis about other cystic dilations of the conus medullaris should be emphasized to select the correct clinical approach.

Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation

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.

Syringosubarachnoid shunting using a myringotomy tube

BACKGROUND

Syringomyelia results from obstruction of cerebrospinal fluid (CSF) flow due to a multitude of causes. Often symptoms of pain, weakness, and sensory disturbance are progressive and require surgical treatment. We present here a rare technique for syringosubarachnoid shunting.

CASE DESCRIPTION

We present the case of a 38-year-old male who suffered a traumatic cervical spinal cord injury due to a motor vehicle accident. With progressive pain and motor decline, a magnetic resonance imaging was obtained and showed a new syrinx extending cervical multiple segments. A unique surgical procedure using a myringotomy tube to shunt CSF into the subarachnoid space was employed in this case. The patient's examination stabilized postoperatively, and at 2 months and 6 months follow-up visits, his strength and sensation continued to improve.

CONCLUSION

We used a myringotomy tube for syringosubarachnoid shunting for the surgical management of a posttraumatic syrinx with good results. This technique minimizes suturing and may minimize shunt-related complications.

Syringomyelia coexisting with guillain-barre syndrome

Guillain-Barre syndrome (GBS) and syringomyelia are diseases of different entities. GBS is an acute post-infectious autoimmune disease which is mediated by autoantibodies against the myelin of peripheral nerves. Syringomyelia is a chronic disease characterized by a cavity extending longitudinally inside the spinal cord. A 67-year-old man is being hospitalized due to severe numbness and ascending weakness in all limbs. On neurological examination, the motor power of all limbs are decreased and show absence of deep tendon reflexes (DTRs). The patient is being diagnosed with GBS on the basis of the acute clinical course, nerve conduction studies of segmental demyelinating polyneuropathy, and a finding of albuminocytologic dissociation in the cerebrospinal fluid. The patient is presented with a new set of symptoms thereafter, which composes of sensory changes in the upper extremities, the urinary dysfunction including frequency and residual urine, spastic bilateral lower extremities, and increased reflexes of the knee and the biceps at follow-up examinations. The spinal magnetic resonance imaging in the sagittal section revealed a syrinx cavity between the fifth cervical and the first thoracic vertebral segment in the cord. The somatosensory evoked potential show sensory pathway defects between both the brachial plexus and the brain stem. Thus, this patient is being diagnosed with both GBS and syringomyelia. We report a case of symptomatic syringomyelia coexisting with GBS. Since the GBS is presented with a progressive muscle weakness and reduced DTRs, the muscle weakness and stiffness in the extremities suggests a concurrent syringomyelia might be easily overlooked.

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

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Terminal ventriculostomy as an adjuvant treatment of complex syringomyelia: a case report and review of the literature

Complex syringomyelia is multifactorial, and treatment strategies are highly individualized. In refractory cases, sectioning of the filum terminale, also known as terminal ventriculostomy, has been described as a potential adjuvant treatment to alleviate syrinx progression. A 10-year-old boy with a history of arachnoiditis presented with complex syringomyelia, progressive lower extremity motor weakness, and spasticity. Previously, he had failed spinal cord detethering and direct syrinx shunting. Imaging studies demonstrated a holocord syrinx extending to the level of his conus medullaris and into the filum terminale. The patient underwent an uncomplicated lumbar laminectomy and transection of the filum terminale. Operative pathologic specimens demonstrated a dilated central canal within the filum. Postoperative imaging demonstrated significant reduction in the diameter of the syrinx. At follow-up, the patient's motor symptoms had improved. Terminal ventriculostomy may be a useful adjuvant in treating caudally placed syringes refractory to other treatments. This procedure carries low neurological risk and involves no hardware implantation. In select cases, terminal ventriculostomy may help preserve neurological function in the face of otherwise progressive syringomyelia.

Endoscope-assisted surgery of spinal intradural adhesions in the presence of cerebrospinal fluid flow obstruction

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To investigate whether the adjunctive use of endoscopy of the subarachnoid space (arachnoscopy) can improve the success of microsurgery for spinal arachnoid adhesions.

SUMMARY OF BACKGROUND DATA

Intradural adhesions that obstruct pulsatile cerebrospinal fluid (CSF) flow are a typical spinal cause of syringomyelia. Phase-contrast magnetic resonance imaging (MRI) allows CSF flow obstructions to be reliably localized. The treatment of choice is the microsurgical removal of CSF flow obstructions caused by adhesions. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. In this study, we therefore investigated whether endoscopic assistance allows adhesions in the vicinity of the exposed area to be detected.

METHODS

From 2006 to 2009, a single neurosurgeon performed 27 consecutive microsurgical procedures with endoscopic assistance in 25 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. CSF flow was studied before and after surgery in all patients using phase-contrast MRI in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine.

RESULTS

In all 27 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MRI. In 25 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In six cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery.Postoperative MRI scans demonstrated free CSF flow in all patients and a decrease in syrinx size in six patients.

CONCLUSION

Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space, which would remain undetected by microscopy alone.

Arachnoscopy: a special application of spinal intradural endoscopy

Object

The microsurgical removal of obstructions to CSF flow is the treatment of choice in the surgical management of intradural arachnoid cysts. Cardiac-gated phase-contrast MR imaging is an effective tool for the primary diagnosis and localization of arachnoid cysts. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. The use of a thin endoscope allows surgeons to assess intraoperatively whether the exposure is wide enough.

Methods

Between 2006 and 2010, a single neurosurgeon performed 31 consecutive microsurgical procedures with endoscopic assistance in 28 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. The CSF flow was studied before and after surgery in all patients by using phase-contrast MR imaging in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine.

Results

In all 31 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MR imaging. In 29 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In 6 cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space that were not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery.

Conclusions

Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space that would remain undetected by microscopy alone.

Syringopleural shunt as a rescue procedure in patients with syringomyelia refractory to restoration of cerebrospinal fluid flow

OBJECTIVE

Syringomyelia should be treated by reconstruction of the subarachnoid space and restoration of cerebrospinal fluid homeostasis. Direct intervention on the syrinx is a difficult choice and should be considered a rescue procedure. Data in the literature examining the various options are scanty, with generally unsatisfying results. We report our experience with shunting of the syrinx into the pleural space.

METHODS

Twenty patients with syringomyelia refractory to cerebrospinal fluid flow restoration underwent a procedure for placement of a syringopleural shunt between 1998 and 2008. Modified Japanese Orthopaedic Association Scale scores and magnetic resonance imaging were available for each patient preoperatively and at the latest follow-up evaluation. A 2-tailed Wilcoxon signed-rank test was used for statistical analysis. Complications related to the operative procedure and to hardware failure were noted.

RESULTS

Nineteen patients were available for follow-up with a mean duration of 37.5 (standard deviation, 31.1) months. The condition of 1 patient deteriorated, 2 remained stable, and the remainder improved. The overall mean improvement on the Modified Japanese Orthopaedic Association Scale was 19.5% (95% confidence interval, 8.5-30.5). The median improvement was 4 points on the 17-point scale. Results were statistically significant (P < 0.001). Follow-up magnetic resonance imaging showed syrinx collapse in 17 cases and marked shrinkage in 2 cases. Except for 1 case of meningitis followed by fatal pulmonary embolism, no significant complications were noted.

CONCLUSION

A syringopleural shunt should, in our view, be the syrinx diversion procedure of choice. More series of institutional experiences with a homogeneous approach would be helpful to verify this recommendation.

Thecal shunt placement for treatment of obstructive primary syringomyelia

OBJECT

The most commonly reported treatment of primary syringomyelia has been laminectomy with duraplasty or direct shunting from the syrinx cavity. Diversion of cerebrospinal fluid (CSF) from the spinal subarachnoid space to peritoneal, atrial, or pleural cavities has been described previously in only a few case reports. Shunting of the CSF from the subarachnoid space rostral to the level of myelographic blockage may reduce the filling force of the syrinx cavity and avoids myelotomy and manipulation of the spinal cord parenchyma. The authors report on 7 patients who underwent thecal shunt placement for primary spinal syringomyelia.

METHODS

This study is a retrospective review of a consecutive series. The authors reviewed the medical records and neuroimaging studies of 7 adult patients with posttraumatic, postsurgical, or postinflammatory syringomyelia treated with thecoperitoneal, thecopleural, or thecoatrial shunt placement at the University of California Los Angeles Medical Center. Myelographic evidence of partial or complete CSF flow obstruction was confirmed in the majority of patients. The mean duration of follow-up was 33 months (range 6-104 months).

RESULTS

Six (86%) of 7 patients showed signs of clinical improvement, whereas 1 remained with stable clinical symptoms. Of the 6 patients with available postoperative imaging, each demonstrated a reduction in syrinx size. Three patients (43%) had > or = 1 complication, including shunt-induced cerebellar tonsillar descent in 1 patient and infections in 2.

CONCLUSIONS

If laminectomy with duraplasty is not possible for the treatment of primary syringomyelia, placement of a thecoperitoneal shunt (or thecal shunt to another extrathecal cavity) should be considered. Although complications occurred in 3 of 7 patients, the complication rate was outweighed by a relatively high symptomatic and imaging improvement rate.

CARDIAC-GATED PHASE-CONTRAST MAGNETIC RESONANCE IMAGING OF CEREBROSPINAL FLUID FLOW IN THE DIAGNOSIS OF IDIOPATHIC SYRINGOMYELIA

OBJECTIVE

Syringomyelia without an obvious cause, such as a Chiari malformation, a tumor, or a spinal injury, is rare and may be associated with an arachnoid web or cyst. In the literature, conventional myelography is the diagnostic method of choice. In this retrospective study, we evaluated the diagnostic value of magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow studies as compared with conventional myelography in patients with syringomyelia.

METHODS

From early 2003 to late 2006, 320 patients with syringomyelia underwent cardiac-gated phase-contrast MRI of CSF flow in the brain and spine. We assessed the presence of CSF flow blockage as well as syrinx site, shape, and size. Additional myelography was performed in 8 patients. CSF flow blockage and progressive neurological symptoms or progression of syringomyelia were indications for surgery.

RESULTS

Syringomyelia without an obvious cause was found in 125 patients. CSF flow blockage was detected in 33 patients. Seven of these patients underwent cyst wall resection and decompression of the subarachnoid space via a unilateral approach without laminectomy. Myelography revealed CSF flow blockage in only 2 of 8 cases. In the other 6 patients, MRI detected a blockage and surgery revealed arachnoid cysts or webs. Postoperative CSF flow studies revealed free CSF flow in all 10 surgically treated patients. In 6 of these patients, syrinx size was reduced after surgery.

CONCLUSION

Myelography should not be the method of choice for the diagnosis of idiopathic syringomyelia. MRI CSF flow studies were found to be more reliable.

Cystic lesion of the ventriculus terminalis: proposal for a new clinical classification

The ventriculus terminalis is a small cavity inside the conus medullaris that is formed during the embryonic development. Previous reports regarding cystic lesion of the ventriculus terminalis (CLVT) in adults have detailed a broad and diversified distribution in terms of clinical symptoms, clinical evolution, neurological findings, and treatment. Therefore, nonstandardized management has led to unsatisfactory outcomes. Thus, the authors propose a new classification system in which the clinical presentation is taken into account to standardize the cases and facilitate the proper management of these lesions. Two more cases are described. The literature was reviewed, dividing the patients into 3 groups by clinical presentation as follows: CLVT Type I, patients with nonspecific neurological symptoms or nonspecific complaints; CLVT Type II, presence of focal neurological deficit; and CLVT Type III, presence of sphincter disturbances (bowel or bladder dysfunction). Two patients were classified as CLVT Type I, 3 as CLVT Type II, and 12 as CLVT Type III. In Type I, no improvement was observed in clinical evaluation after surgery, and stable symptoms were achieved with clinical management. In Type II, 2 patients had total improvement and 1 had subtotal improvement after surgery. Finally, in Type III, 92% of the patients improved postoperatively; among these 33% presented with total improvement. Only 1 case in this group was handled conservatively and no improvement was documented. This new classification is useful to group the patients into 3 clinical types to provide guidance as to the best management options. Treatment for the Type I lesion seems to be best conducted conservatively, whereas Types II and III seem to be best handled surgically.

Minimally Invasive Insertion of Syringosubarachnoid Shunt for Posttraumatic Syringomyelia: Technical Case Report

Objective:

Symptomatic posttraumatic syringomyelia affects up to 10% of patients with spinal cord injuries and manifests in a delayed manner as progressive sensorimotor changes below the level of the syrinx. Syrinx shunting, and in particular syringosubarachnoid shunting (SSAS), provides neurological improvement or stabilization in at least 50% of these patients. Given the debilitated condition of many of these patients, a minimally invasive approach to the insertion of these devices is desirable. We provide the first report of an SSAS inserted in a minimally invasive fashion through a tubular retractor.

Patients and Methods:

A 27-year-old woman presented 4 years after C6 to C7 fracture dislocation and incomplete spinal cord injury with increasing pain and spasticity below the midthoracic region. Magnetic resonance imaging scan revealed a midthoracic syrinx that had enlarged on serial imaging. SSAS was inserted using a minimally invasive technique via the X-Tube retractor (Medtronic Sofamor Danek, Memphis, TN). Through a 2.5-cm incision, hemilaminotomy was performed, and a midline durotomy and myelotomy were opened for SSAS insertion under microscopic visualization.

Results:

Intraoperative ultrasonography revealed successful syrinx decompression after SSAS insertion. The operative time was 150 minutes and estimated blood loss was less than 100 mL. The patient was mobilized on postoperative Day 1 and was discharged 38.5 hours after surgery with resolution of her preoperative symptoms. Postoperative magnetic resonance imaging scan revealed excellent decompression of the syrinx, and through 1 year of follow-up, the patient has had no recurrence of her syrinx-related symptoms.

Conclusion:

This is the first report of minimal-access insertion of an SSAS. The minimally invasive technique appears to be a safe and effective means of implanting an SSAS. This approach allows for diminished blood loss and early mobilization and transfer to rehabilitation units for these patients.

Primary spinal syringomyelia. Invited submission from the joint section meeting on disorders of the spine and peripheral nerves, March 2005

In the present review the author describes the different types of syringomyelia that originate from abnormalities at the level of the spinal cord rather than at the craniovertebral junction. These include posttraumatic and postinflammatory syringomyelia, as well as syringomyelia associated with arachnoid cysts and spinal cord tumors. The diagnosis and the principles of managing these lesions are discussed, notably resection of the entity restricting cerebrospinal fluid flow. Placement of a shunt into the syrinx cavity is reserved for patients in whom other procedures have failed or who are not candidates for other procedures.

Neurosurgical considerations in posttraumatic syringomyelia

Syringomyelia is a progressive degenerative disorder that results in numerous life-altering symptoms. People with this disorder frequently are misdiagnosed and most likely will experience intractable pain for many years. Surgical procedures may offer some relief from symptoms through spinal decompression or cerebrospinal fluid shunting; however, these procedures often are unsuccessful in altering the course or progression of the disease process. Information on the implications of the disease offers insight that is helpful for nurses providing care to these patients. This article presents relevant clinical information and discusses surgical procedures, as well as a patient's perspective on living with this relatively unknown disorder.