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.     

脊髓内肿瘤伴全长空洞的诊治体会

目的探讨髓内肿瘤伴脊髓全长空洞的诊断、治疗方法及空洞形成机制.方法对6例确诊为髓内肿瘤伴脊髓全长空洞的患者行显微镜下肿瘤摘除术,空洞不予处理.结果经3年的随访,6例均疗效明显,肿瘤摘除完整,空洞自行缩小或消失,症状改善.病程越短,疗效越好.结论脊髓全长空洞发生率可能比文献报道高.空洞是由于肿瘤本身的梗阻引起,显微外科技术能最大限度地保留脊髓功能,空洞不需处理.     

Post-traumatic stress disorder

Developments in the study of psychological trauma are briefly charted, prior to the inclusion of the stressor-generic diagnostic category of ‘post-traumatic stress disorder’ (PTSD) in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Against the context of the assumptions underlying the DSM-III classification system, evidence relating to the general validity of the PTSD diagnostic criteria is examined. Progress in the development of assessment techniques and psychotherapeutic procedures is reviewed. and proposals for refinement and revision of the diagnostic category are considered.     

Pathogenesis and treatment of delayed post-traumatic syringomyelia

Summary The role of trauma in the pathogenesis of syringomyelia has been known for a long time. Repeated microtraumata have been considered to play a role in triggering the classical syringomyelia on the basis of a congenital predisposition. It has been proven that posttraumatic arachnoiditis can cause cavitation in the spinal cord and probably syringomyelia stricto sensu as well. The delayed appearance of syringomyelia after a severe single spinal trauma resulting in contusion of the spinal cord without the complication of arachnoiditis is a more recent issue, but is now well-known. Delayed syringomyelia after a minor single spinal trauma, with at first complete recovery, is extremely rare, and is probably often disregarded as a diagnosis. Having studied such a case, with complete neuroradiological work-up, we want to draw attention to the pathogenetic aspects and the possibilities for treatment, of which the syringoperitoneal shunt seems to be the most efficient one.     

Cystic degeneration following severe spinal trauma. Clinical observations in 30 patients

Secondary, in most cases ascending neurological deterioration following severe spinal trauma has been known since the beginning of this century. The alterations are caused by cystic cord degeneration and probably are due to venous circulatory disturbances. In a review of the literature 680 cases were found. The present paper describes findings in our 30 patients. Modern diagnostic methods provide exact localization and evaluation of the cysts. These can then be drained microsurgically. Short-term success is good in many cases, long-term developments will be observed carefully. The functional loss of only one segment can, depending on the level of the original lesion, result in dramatic consequences for the patient.     

Post-traumatic syringomyelia

Post-traumatic syringomyelia is estimated to develop in more than 20% of individuals with traumatic spinal cord injury (SCI). The development can give rise to clinical symptoms 6 months to 26 years after the injury, and presentation 40 years post-injury has been seen by one of the authors.1234 We present an unusual case for comments and discussion.     

Comparison of different operative modalities in post-traumatic syringomyelia: preliminary report

Post-traumatic syringomyelia (PTS) is a relatively rare, but potentially disastrous, complication of spinal cord injury. Operative treatment by shunting procedures often shows only a short-term improvement, and the rate of recurrence of syringomyelia is high, so different treatment modalities have been used in the last years. The various results are discussed in this analysis. A prospective clinical study was conducted of 30 patients with PTS treated by shunting procedures or with pseudomeningocele over a period of 9 years, and followed with regular clinical and magnetic resonance imaging examinations. Shunting procedures like syringosubarachnoid and syringopleural or -peritoneal shunting showed good results only at the first follow-ups. In our department, we perform an artificial liquor reservoir at the level of the lesion after opening the spinal pathways and arachnoid adhesions at that level. This procedure was performed in 12 patients. Five of these had been previously operated by shunting procedures; all of them had suffered a recurrence of syringomyelia because of internal occlusion. In the group of patients treated by shunting procedures, a neurological improvement was be recorded in five, and a steady state in eight. Five patients showed a further deterioration. The performance of an artificial liquor reservoir to guarantee a free flow of cerebrospinal fluid around the lesion resulted in a neurological improvement in ten patients, with two maintaining a steady state. Our experience is that shunting procedures often show a neurological improvement only in the short term; the rate of recurrence of typical shunting complications is high. The performance of a pseudomeningocele is an encouraging new step in the treatment of PTS. Further long-term follow-up studies are necessary to assess the benefits of this new method.     

Cordectomy for post-traumatic syringomyelia

Summary We performed cordectomy, a surgical technique that is infrequently used at present, for a patient with post-traumatic syringomyelia (following complete paraplegia of both lower limbs due to dislocation fracture of the 9th thoracic vertebra), yielding a favourable result. We recommend cordectomy as a surgical technique to which spinal surgeons should give utmost consideration for patients with post-traumatic syringomyelia demonstrating progressive symptoms assumed to be attributable to the syrinx and with an anatomically transected spinal cord of the mid-to-lower thoracic vertebral level. Correspondence: Yuichi Kasai MD, Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi Tsu-city Mie, 514-8507, Japan.     

Intraoperative ultrasound imaging of the spinal cord: Syringomyelia, cysts, and tumors — A preliminary report

Dynamic intraoperative imaging of the spinal cord was done using a real-time ultrasound scanner. Prior to opening the dura mater the neurosurgeon is able to “explore” the intradural space and with a 7.5 MHz transducer visualize the normal spinal cord, including the central canal and the dentate ligaments. Anterior and posterior spinal arteries may be seen in certain patients. In syringomyelia the fluid-filled cavities may be visualized with ultrasound and drained or shunted with intraoperative ultrasound guidance. Spinal cord cysts or cystic components of tumors can be precisely identified and drained using ultrasound. Intramedullary tumors can be demonstrated sonographically, as can the location and extent of intradural extramedullary tumors and tumors that have both extradural and intradural components. Experience to date with intraoperative imaging of the spinal cord and with the real-time ultrasound scanner is very encouraging, and in the future it should allow for a more precise characterization of and operative approach to lesions of the spinal cord.     

Post-traumatic syringomyelia.

Post-traumatic syringomyelia is uncommon. It is seen predominantly after injury to the thoracic or the lumbar spine and rarely after injury to the cervical spine. In this report, three cases of post-traumatic syringomyelia are presented. The injury was limited to the thoracic spine in one case and to the cervical spine in the rest. The symptoms began after two years in two cases and after fifteen years in the third. The diagnosis was suggested by radiographic examination and was confirmed at operation in each case. Following evacuation and drainage of the cyst, significant improvement occurred in two patients.     

Spinal haemangioblastoma associated with syringomyelia and multiple lung lesions

Haemangioblastomas involving the spinal cord are uncommon but by no means unknown. It is well established that haemangioblastomas of the central nervous system are commonly associated with lesions in the retinae and in various abdominal organs. The simultaneous occurrence of similar tumours in the lung is less common and not well recognized. The case of a man with a haemangioblastoma of the spinal cord with many small haemangioblastomas of the lung is reported here.     

Stabwound of the cervical spinal cord. Two case reports

Two cases of Brown-Sequard syndrome following a stab wound of the cervical spinal cord are reported. Spinal cord hemisection was confirmed by magnetic resonance imaging and surgical exploration. Both patients presented leakage of the cerebrospinal fluid and underwent surgical repair. In the first case, the pia-mater was sutured to close the wound and decrease the risk of post-traumatic syringomyelia. Outcome at ten and two years follow up was good in both patients who were able to walk. One of them returned to work. The contribution of surgical repair of spinal cord stab wounds and mechanisms of recovery are discussed.     

Syringoperitoneal shunt for syringomyelia: A preliminary report

Syringoperitoneal shunting has been used in the treatment of 4 patients with idiopathic syringomyelia. The procedures have been performed without morbidity or mortality. Postoperative observation, ranging from 7 to 23 months, has not revealed progression of symptoms or failure of the shunt. The pathophysiological theories of syringomyelia are discussed, and various surgical procedures for syringomyelia are reviewed and their results compared to the effectiveness of the syringoperitoneal shunt.     

Guillain-Barre syndrome: A possibility in a spinal cord injured patient

A 28-year-old male had paraplegia as a result of fracture dislocation of T12/L1 six years ago. He was functioning independently until four weeks ago, when he started complaining of trunkal paraesthesia which later progressed to include the upper extremities. The initial diagnosis was that of posttraumatic syringomyelia (PTS). While awaiting the MRI scan he developed weakness of upper limbs. The weakness restricted his self-care activities including transfers. The MRI did not show any evidence of syringomyelia. Neurological consultation and assessment yielded provisional diagnosis of Guillain-Barre syndrome (GBS). The patient was treated with immunoglobulins and regained 90% of his previous neurological status. This case is reported to raise awareness among clinicians to include the possibility of the GBS in the differential diagnosis of progressive neurological loss on top of existing neurological deficiency in spinal cord injured patients.     

Electrophysiologic Findings in Post-Traumatic Syringomyelia: Implications for Clinical Management

ABSTRACT

Traumatic spinal cord injured (SCI) patients may develop pain, new weakness and/or sensory loss due to an enlarging fluid-filled cyst in the spinal cord. The clinical history and physical exam are nonspecific and insensitive, particularly for diagnosing and monitoring recurrent or progressive post-traumatic syringomyelia (PTS). We compare the sensitivity and specificity of three electrodiagnostic tests, median and ulnar F waves, electromagnetic motor evoked potentials (MEP), and needle electromyography, with respect to syrinx by imaging (MRI or CT scan) and neurologic progression on serial clinical exams. Central motor conduction time (CMCT) calculated from scalp and spine MEP was the most sensitive diagnostic test. F waves were less sensitive and less specific than the CMCT, and did not provide evidence of syrinxes in the mid or upper cervical cord. Positive sharp wave and fibrillation potentials were the least sensitive and least specific. The CMCT is a useful adjunct to imaging studies for diagnosing and monitoring PTS.     

Post-traumatic syringomyelia following complete neurological recovery

OBJECTIVE: To describe the later neurologic deterioration secondary to the appearance of a post-traumatic syringomyelic cavity, in a patient who, in the initial phase, had an incomplete spinal cord lesion (ASIA C), which improved to ASIA E. METHODS: A 52-year-old male patient who, at the age of 19 (1965), suffered a spinal cord injury. He presented with a fracture of the sixth and seventh cervical neurological segment at the time of the lesion, evolving to ASIA E. Nine years after the traumatism, he began to feel pain accompanied by a sensory and motor deficit. RESULTS: With the aid of myelography and MRI, the existence of a syringomyelic cavity was detected, which extended from the fourth to the seventh cervical segments. The patient was operated on, on various occasions, placing a syringo-subarachnoid shunt. The neurological status of the patient continued to deteriorate and, at present, he has a complete lesion below the fourth neurological cervical segment with a partially preserved sensitive area up to T1. CONCLUSION: The development of the syringomyelic cavity could be one of the causes of later neurologic deterioration in patients with traumatic spinal cord injury with neurological recovery 'ad integrum' in the initial phase of spinal cord injury.     

后路全脊椎截骨术治疗合并脊髓空洞重度僵硬性脊柱侧后凸畸形的安全性及疗效分析

目的探讨后路全脊椎截骨术(Posterior Vertebral Column Resection,PVCR)治疗合并脊髓空洞的重度僵硬性脊柱侧后凸的安全性及临床疗效。方法回顾分析2009-10-2013-03在我院接受PVCR手术治疗的合并脊髓空洞的重度僵硬性脊柱侧后凸畸形患者16例;其中同时伴发Chiari畸形I型患者在脊柱畸形截骨矫行前均先于神经外科进行后颅凹减压术;对于单纯合并脊髓空洞患者,直接进行脊柱截骨畸形矫治;记录手术时间、出血量及围手术期并发症情况。结果手术前、后冠状面及矢状面主弯Cobb角比较,差异具有统计学意义(P0.05);手术后与末次随访时冠状面及矢状面主弯Cobb角比较,差异无统计学意义(P0.05)。结论对于合并脊髓空洞的重度僵硬性脊柱侧后凸畸形,采用PVCR进行治疗,可获得安全、有效的临床结果。     

Unraveling the riddle of syringomyelia

The pathophysiology of syringomyelia development is not fully understood. Current prevailing theories suggest that increased pulse pressure in the subarachnoid space forces cerebrospinal fluid (CSF) through the spinal cord into the syrinx. It is generally accepted that the syrinx consists of CSF. The here-proposed intramedullary pulse pressure theory instead suggests that syringomyelia is caused by increased pulse pressure in the spinal cord and that the syrinx consists of extracellular fluid. A new principle is introduced implying that the distending force in the production of syringomyelia is a relative increase in pulse pressure in the spinal cord compared to that in the nearby subarachnoid space. The formation of a syrinx then occurs by the accumulation of extracellular fluid in the distended cord. A previously unrecognized mechanism for syrinx formation, the Bernoulli theorem, is also described. The Bernoulli theorem or the Venturi effect states that the regional increase in fluid velocity in a narrowed flow channel decreases fluid pressure. In Chiari I malformations, the systolic CSF pulse pressure and downward motion of the cerebellar tonsils are significantly increased. This leads to increased spinal CSF velocities and, as a consequence of the Bernoulli theorem, decreased fluid pressure in narrow regions of the spinal CSF pathways. The resulting relatively low CSF pressure in the narrowed CSF pathway causes a suction effect on the spinal cord that distends the cord during each systole. Syringomyelia develops by the accumulation of extracellular fluid in the distended cord. In posttraumatic syringomyelia, the downwards directed systolic CSF pulse pressure is transmitted and reflected into the spinal cord below and above the traumatic subarachnoid blockage, respectively. The ensuing increase in intramedullary pulse pressure distends the spinal cord and causes syringomyelia on both sides of the blockage. The here-proposed concept has the potential to unravel the riddle of syringomyelia and affords explanations to previously unanswered clinical and theoretical problems with syringomyelia. It also explains why syringomyelia associated with Chiari I malformations may develop in any part of the spinal cord including the medullary conus. Syringomyelia thus preferentially develops where the systolic CSF flow causes a suction effect on the spinal cord, i.e., at or immediately caudal to physiological or pathological encroachments of the spinal subarachnoid space.