Thecal shunt placement for treatment of obstructive primary syringomyelia

Development of pre-syrinx state and syringomyelia following a minor injury: a case report

Background

A generally accepted rule is that posttraumatic syringomyelia (PTS) results from spinal cord injury (SCI).

Case presentation

Here, we report the development of syringomyelia without SCI in a 54-year-old Caucasian man following a mild motor vehicle accident. The computed tomography on admission excluded an injury of the spine. Because of neck and back pain, magnetic resonance imaging was performed on day 3 post-injury and demonstrated minimal changes from a ligamentous strain at the cervicothoracic transition. Any traumatic affection of the bone, vertebral discs, intraspinal compartment, or spinal cord were excluded. Some limb weakness and neurogenic bladder dysfunction started manifesting within the following weeks. Repeated MRIs following the accident demonstrated arachnoid adhesions at the C1–2 level and spinal cord edema equivalent to a pre-syrinx state at 12 months and syrinx formation at 24 months. Because of further deterioration, decompression was performed at 36 months.

Conclusions

We conclude that even after a minor trauma PTS can occur and that medullary edema (pre-syrinx state) may precede syrinx formation.

Treatment of posttraumatic syringomyelia: evidence from a systematic review

Background

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

Methods

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

Results

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

Conclusion

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

Early Development of Syringomyelia after Spinal Cord Injury: Case Report and Review of the Literature

We report a case of post-traumatic syringomyelia (PTS), which developed 2 months after spinal cord injury (SCI). A 20-year-old man who was involved in a motorcycle accident sustained a complete SCI resulting from a burst fracture of the T5 vertebral body. He underwent posterior fixation with decompression at another hospital 2 days after the injury. Postoperative imaging suggested that spinal stenosis endured at the T4 level and swelling of the spinal cord above that level. Two months later, he felt dysesthetic pain in his forearms and hands, but the cause of the pain was not examined in detail. Four months after the injury, he presented with motor weakness in the upper extremities. Magnetic resonance imaging (MRI) showed syringomyelia ascending from the T3 level to the C1 level, and he was referred to our hospital immediately. The imaging studies suggested that PTS was caused by congestion of the cerebrospinal fluid (CSF) at the T3 level. The patient was treated with syringosubarachnoid (SS) shunt at the T1-T2 level, whereby neurological symptoms of the upper extremities were immediately relieved. Postoperative MRI showed shrinkage of the syrinx. At the latest follow-up 2 years postoperatively, there was no sign of recurrence. It is noteworthy that PTS potentially occurs in the early phase after severe SCI. We discuss relevant pathology and surgical treatment through a review of previous literature.

Syringomyelia and spinal arachnoiditis resulting from aneurysmal subarachnoid hemorrhage: Report of two cases and review of the literature

Syringomyelia resulting from arachnoiditis secondary to aneurysmal subarachnoid hemorrhage (SAH) is an extremely rare clinical entity with few cases reported in the literature. The presentation, management, and pathogenesis of syringomyelia in this setting is poorly understood. We describe the presentation, radiology, management, and outcomes in two patients with syringomyelia resulting from arachnoiditis secondary to aneurysmal SAH and review the literature on this rare condition. Case number 1 was treated successfully with syrinx-subarachnoid shunt after extensive lysis of adhesions. Case number 2 was treated with syringoperitoneal shunt. Both patients had radiographic decreased syrinx size postoperatively. These patients add to the small literature on syringomyelia occurring secondary to SAH-associated arachnoiditis. The radiographic outcomes demonstrate that in the appropriately selected patient, syrinx-subarachnoid or syringoperitoneal shunting are viable options.

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

BACKGROUND:

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

OBJECTIVE:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

Treatment of posttraumatic syringomyelia

Object

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

Methods

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

Results

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

Conclusions

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

A lumped-parameter model of the cerebrospinal system for investigating arterial-driven flow in posttraumatic syringomyelia

Fluid transport in syringomyelia has remained enigmatic ever since the disease was first identified some three centuries ago. However, accumulating evidence in the last decade from animal studies implicates arterial pulsations in syrinx formation. In particular, it has been suggested that a phase difference between the pressure pulse in the spinal subarachnoid space and the perivascular spaces, due to a pathologically disturbed cerebrospinal fluid (CSF) or blood supply, could result in a net influx of CSF into the spinal cord (SC). A lumped-parameter model is developed of the cerebrospinal system to investigate this conjecture. It is found that although this phase-lag mechanism may operate, it requires the SC to have an intrinsic storage capacity due to the collapsibility of the contained venous reservoir. This net flux is associated with a higher mean pressure in the SC than the SSS which is maintained in the periodic steady state. According to our simulations the mechanical perturbations of arachnoiditis exacerbate the phase-lag effect, which may be partially alleviated by the presence of a posttraumatic syrinx and more completely by a syringo-subarachnoid shunt.

The role of lumboperitoneal shunts in the treatment of syringomyelia

OBJECT The role of thecoperitoneal shunts in the management of syringomyelia is not well defined. In this study, the authors analyze the outcome of lumboperitoneal shunt procedures carried out to treat syringomyelia in their institution. METHODS The authors retrospectively reviewed the medical records of 19 patients who underwent lumboperitoneal shunt procedures for syringomyelia. RESULTS The mean follow-up duration was 25 months (range 3-51 months). Of 16 cases followed up, only 5 patients reported clinical improvement in their preoperative symptoms, but of these, 2 had clear radiological evidence of improvement. Three of 6 patients with syringomyelia due to spinal arachnoiditis improved. CONCLUSIONS Lumboperitoneal shunts may lead to useful improvement in the symptoms of a patient with syringomyelia while avoiding the risk of neurological deterioration inherent in myelotomies required for syrinx shunting procedures.