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

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.

A new surgical method for treating syringomyelia secondary to arachnoiditis following cervical spine surgery: the syringo-cisterna magna shunt

PURPOSE

The 5-year postoperative failure rate of conventional shunt treatment for syringomyelia is 50%, with arachnoditis, shunt obstruction, and shunt malfunction being the most common causes. We report a new syringo-cisterna magna (SCM) shunt that allows syrinx cerebrospinal fluid (CSF) drainage normally into the cerebellomedullary cisterns through the subarachnoid space.

METHODS

Between November 2012 and February 2017, six patients (mean age: 57.25 years; sex: four male and two female) received the SCM shunt. They had spinal cord injury, abscess formation after a spine operation, and cerebral meningitis-related syringomyelia (syrinx between C0 and T9), and presented sensory changes and motor weakness. Preoperatively and at 1 year postoperatively, the syrinx length and diameter were assessed using magnetic resonance imaging (MRI). Clinical outcomes were evaluated using the visual analog scale (VAS) and Japanese Orthopedic Association (JOA) scores.

RESULTS

Motor weakness improved, pain subsided, and sensory disturbance resolved in all patients who returned to work within 6 weeks postoperatively. In all cases, the syrinx collapsed (length: 3.3 levels decreased; diameter: decreased from 7.90 to 4.64 mm, p = 0.046) on postoperative MRI. No patient experienced syrinx recurrence and shunt malfunction on MRI or showed spinal instability signs on plain radiography. The VAS (pre- vs post-shunt: 6.50 vs 3.83, p = 0.027) and JOA scores (pre- vs post-shunt: 10.00 vs 11.17, p = 0.167) were improved postoperatively.

CONCLUSION

We developed a new shunting system allowing syrinx CSF drainage to the posterior fossa, with symptomatic improvement, minimal complications, and syrinx decrease on follow-up MRI. The SCM shunt is effective for treating syringomyelia.

Radiographic assessment of surgical treatment of post-traumatic syringomyelia

Context: Symptomatic post-traumatic syringomyelia can affect the quality of life in patients whose neurologic function has already been impacted by a spinal cord injury.Objective: To investigate the radiographic and clinical outcomes following surgery for syringomyelia, we present a literature review along with a case series from a single surgeon's experience.Methods: A retrospective review was conducted on patients with post-traumatic syringomyelia who were treated by a single surgeon. Thirty-four patients who underwent surgical treatment consisting of syrinx fenestration, lysis of adhesions, and duraplasty were identified. In addition, a narrative literature review was conducted with a primary focus on diagnosis and management of post-traumatic syringomyelia.Results: Literature review suggests that regardless of age, sex, vertebral location, or severity of trauma, patients who experience a spinal cord injury should be closely monitored for post-traumatic syringomyelia. Retrospective review of our 34 patients revealed 24 patients for whom pre- and post- operative MRI was available. The predominant location of the injury was cervical (15). The average syrinx length, measured in spinal segments, was similar when comparing pre- and post-operative MRIs; average syrinx length was 5.5 and 5.4 spinal segments, respectively. In contrast, syrinx axial dimension was decreased in 16 of the patients post-operatively and stable or increased in the other eight. The change in syrinx size did not correlate with clinical outcomes.Conclusion: Current surgical treatment of post-traumatic syringomyelia involves restoration of normal CSF flow dynamics; further prospective work is needed to correlate the clinical state, radiographic measures, and efficacy of surgical intervention.

Syringosubarachnoid shunt: insertion technique

Background: Syringomyelia is a rare disorder but its impact on patients' quality of life can be devastating. The exact pathophysiology remains unknown; the syrinx can either be idiopathic or associated with conditions such as Chiari malformation, scoliosis, malignancy, infection and trauma. Several techniques have been described to decompress syringomyelia with distal drainage to the subarachnoid space, pleura or peritoneum.Method: We present a modification of the syringosubarachnoid shunt insertion technique with minimal myelotomy and the use of a T shaped shunt which does not require suturing to the pia matter to prevent shunt migration.Conclusion: This technique for syringosubarachnoid shunt insertion is likely to prevent shunt migration and scarring whilst minimizing suturing and optimising syrinx decompression.

Syringobulbia: A delayed complication following spinal cord injury - case report

CONTEXT

Syringobulbia is a very rare progressive disorder of central nervous system, with several possible underlying conditions. Rarely, it is also encountered as a late complication of syringomyelia.

FINDINGS

In the present manuscript, a case of a paraplegic patient, due to traumatic spinal cord injury (thoracolumbar fracture), presenting after years progressively developing symptoms of the lower cranial nerves and upper extremities, owed to syringomyelia and syringobulbia, the surgical treatment applied and its outcomes are described. We performed a syringo-peritoneal shunting procedure using a T-tube. The patient's symptoms resolved postoperatively and the cavity's size was reduced to a great degree.

CONCLUSION/CLINICAL RELEVANCE

The late appearance of cranial nerve deficits or symptoms-signs of the upper extremities in a patient with traumatic thoracic spinal cord injury should raise suspicion that post-traumatic syringomyelia or syringobulbia has occurred. In such cases, radiologic evaluation and early surgical drainage of the cyst as a means of preventing significant delayed neurologic deficit is advocated.

[Syringosubarachnoid shunting in treatment of syringomyelia: a literature review and a clinical case report]

In the article, we describe a clinical case of syringomyelia associated with an Arnold-Chiari type 1 malformation, evaluate the efficacy of syringosubarachnoid shunting, and analyze the literature data of domestic and international researchers involved in investigation and treatment of the pathology. Application of syringosubarachnoid shunting in the described case resulted in a clinical improvement in the form of regression of paresis and hypoesthesia, which demonstrated the efficacy of the shunting technique for correction of the syringomyelia symptoms.

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

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

Treatment of Syringomyelia due to Chiari Type I Malformation with Syringo-Subarachnoid-Peritoneal Shunt

Chiari type I malformation is a tonsillar herniation more than 3 mm from the level of foramen magnum, with or without concurrent syringomyelia. Different surgical treatments have been developed for syringomyelia secondary to Chiari's malformations: craniovertebral decompression with or without plugging of the obex, syringo-subarachnoid, syringo-peritoneal, and theco-peritoneal shunt placement. Shunt placement procedures are useful for neurologically symptomatic large-sized syrinx. In this paper, authors define the first successful treatment of a patient with syringomyelia due to Chiari type I malformation using a pre-defined new technique of syringo-subarachnoid-peritoneal shunt with T-tube system.