Treatment of syringomyelia associated with arachnoid scarring caused by arachnoiditis or trauma

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✓ The authors conducted a retrospective study of 107 patients treated for syringomyelia associated with arachnoid scarring between 1976 and 1995 at the Departments of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, and the University of California in Los Angeles, California. Twenty-nine patients have not been surgically treated to date because of their stable neurological status. Seventy-eight patients with progressive neurological deficits underwent a total of 121 surgical procedures and were followed for a mean period of 32 (±37) months. All patients demonstrated arachnoid scarring at a level close to the syrinx. In 52 patients the arachnoid scarring was related to spinal trauma, whereas 55 had no history of trauma and developed arachnoid scarring as a result of an inflammatory reaction. Of these, 15 patients had undergone intradural surgery, eight had suffered from spinal meningitis, three had undergone peridural anesthesia, and one each presented with a history of osteomyelitis, spondylodiscitis, and subarachnoid hemorrhage. No obvious cause for the inflammatory reaction resulting in arachnoid scarring could be ascertained for the remaining 26 patients.

The postoperative neurological outcome correlated with the severity of arachnoid pathology and the type of surgery performed. Shunting of the syrinx to the subarachnoid, pleural, or peritoneal cavity was associated with recurrence rates of 92% and 100% for focal and extensive scarring, respectively. Successful long-term management of the syrinx required microsurgical dissection of the arachnoid scar and decompression of the subarachnoid space with a fascia lata graft. This operation stabilized the preoperative progressive neurological course in 83% of patients with a focal arachnoid scar. For patients with extensive arachnoid scarring over multiple spinal levels or after previous surgery, clinical stabilization was achieved in only 17% with this technique.

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Address reprint requests to: Jörg Klekamp, M.D., Neurosurgical Clinic, Nordstadt Hospital, Haltenhoffstraße 41, 30167 Hannover, Germany.

© AANS, except where prohibited by US copyright law.

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    Left: Preoperative T1-weighted MR image showing a C1—T3 syrinx in a 54-year-old man presenting with burning dysesthesias and hypesthesia of his left arm. There was no history of spinal trauma. Center: Intraoperative photograph showing an arachnoid scar at T-7, which was classified as Grade I at dissection; a decompression was achieved by leaving the dura open. Right: A T1-weighted MR image obtained 6 months postoperatively showing total disappearance of the syrinx. Symptoms remained unchanged without further progression for 4 years.

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    Left: Preoperative MR image obtained in a 51-year-old man showing a posttraumatic syrinx at T4–5 that developed 4 years after a car accident that caused trauma at T-5. Six years prior to admission, this patient underwent arachnoid dissection and syringosubarachnoid shunting at T-5 at another hospital. The patient presented at our institution with progressive gait ataxia, motor weakness, sphincter dysfunction, and hypesthesia on the left side. Center: Intraoperative photograph showing the dura opened at T-4 and T-5. Dense arachnoid scarring (Grade III) is evident. The shunt is displaced and floating inside the syrinx cavity with the myelotomy still patent. Right: Postoperative MR image showing syrinx collapse 2 weeks after arachnoid dissection and decompression with a fascia lata graft. The paraparesis was aggravated but gradually recovered to the preoperative level after 6 months.

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    Graphs showing Kaplan—Meier analysis for patients with posttraumatic (upper) and postinflammatory (lower) arachnoid scarring and syringomyelia. No significant differences in recurrence rates could be demonstrated between these groups if the same surgical procedure had been performed. p = probability that patients would remain free of a clinical recurrence.

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    Upper: Graph showing Kaplan—Meier analysis for patients with spinal arachnoid scarring (Grades I and II) and syringomyelia. The log-rank test revealed a significant difference between shunting and decompression with a graft 10 months postoperatively (p = 0.04 at 10 months). Lower: Graph showing Kaplan—Meier analysis for patients with spinal arachnoid scarring (Grades III and IV) and syringomyelia. The log-rank test revealed no significant difference between shunting and decompression with a graft. p = probability that patients would remain free of a clinical recurrence.

References

  • 1.

    Adelstein LJ: The surgical treatment of syringomyelia. Am J Surg 40:3843951938Adelstein LJ: The surgical treatment of syringomyelia. Am J Surg 40:384–395 1938

  • 2.

    Alvisi CCerisoli M: Long-term results of the surgical treatment of syringohydromyelia. Acta Neurochir 71:1331401984Alvisi C Cerisoli M: Long-term results of the surgical treatment of syringohydromyelia. Acta Neurochir 71:133–140 1984

  • 3.

    Assenmacher DRDucker TB: Experimental traumatic paraplegia. The vascular and pathological changes seen in reversible and irreversible spinal-cord lesions. J Bone Joint Surg (Am) 53:6716801971Assenmacher DR Ducker TB: Experimental traumatic paraplegia. The vascular and pathological changes seen in reversible and irreversible spinal-cord lesions. J Bone Joint Surg (Am) 53:671–680 1971

  • 4.

    Aubin MLBaleriaux DCosnard Get al: MRI in syringomyelia of congenital, infectious, traumatic or idiopathic origin. A study of 142 cases. J Neuroradiol 14:3133361987Aubin ML Baleriaux D Cosnard G et al: MRI in syringomyelia of congenital infectious traumatic or idiopathic origin. A study of 142 cases. J Neuroradiol 14:313–336 1987

  • 5.

    Barnett HJM: The pathogenesis of syringomyelic cavitation associated with arachnoiditis localised to the spinal cord in Barnett HJMFoster JBHudgson P (eds): Syringomyelia. Major Problems in Neurology. London: WB Saunders1973 Vol 1 pp 245260Barnett HJM: The pathogenesis of syringomyelic cavitation associated with arachnoiditis localised to the spinal cord in Barnett HJM Foster JB Hudgson P (eds): Syringomyelia. Major Problems in Neurology. London: WB Saunders 1973 Vol 1 pp 245–260

  • 6.

    Barnett HJMJousse ATBall MJ: Pathology and pathogenesis of progressive cystic myelopathy as a late sequel to spinal cord injury in Barnett HJMFoster JBHudgson P (eds): Syringomyelia. Major Problems in Neurology. London: WB Saunders1973 Vol 1 pp 179219Barnett HJM Jousse AT Ball MJ: Pathology and pathogenesis of progressive cystic myelopathy as a late sequel to spinal cord injury in Barnett HJM Foster JB Hudgson P (eds): Syringomyelia. Major Problems in Neurology. London: WB Saunders 1973 Vol 1 pp 179–219

  • 7.

    Caplan LRNorohna ABAmico LL: Syringomyelia and arachnoiditis. J Neurol Neurosurg Psychiatry 53:1061131990Caplan LR Norohna AB Amico LL: Syringomyelia and arachnoiditis. J Neurol Neurosurg Psychiatry 53:106–113 1990

  • 8.

    Cho KHIwasaki YImamura Het al: Experimental model of posttraumatic syringomyelia: the role of adhesive arachnoiditis in syrinx formation. J Neurosurg 80:1331391994Cho KH Iwasaki Y Imamura H et al: Experimental model of posttraumatic syringomyelia: the role of adhesive arachnoiditis in syrinx formation. J Neurosurg 80:133–139 1994

  • 9.

    Dolan RA: Spinal adhesive arachnoiditis. Surg Neurol 39:4794841993Dolan RA: Spinal adhesive arachnoiditis. Surg Neurol 39:479–484 1993

  • 10.

    Edgar RQuail P: Progressive post-traumatic cystic and noncystic myelopathy. Br J Neurosurg 8:7221994Edgar R Quail P: Progressive post-traumatic cystic and noncystic myelopathy. Br J Neurosurg 8:7–22 1994

  • 11.

    Fehlings MGBernstein M: Syringomyelia as a complication of tuberculous meningitis. Can J Neurol Sci 19:84871992Fehlings MG Bernstein M: Syringomyelia as a complication of tuberculous meningitis. Can J Neurol Sci 19:84–87 1992

  • 12.

    Feigin IOgata JBudzilovich G: Syringomyelia: the role of edema in its pathogenesis. J Neuropathol Exp Neurol 30:2162321971Feigin I Ogata J Budzilovich G: Syringomyelia: the role of edema in its pathogenesis. J Neuropathol Exp Neurol 30:216–232 1971

  • 13.

    Guyer DWWiltse LLEskay MLet al: The long-range prognosis of arachnoiditis. Spine 14:133213411989Guyer DW Wiltse LL Eskay ML et al: The long-range prognosis of arachnoiditis. Spine 14:1332–1341 1989

  • 14.

    Hackney DBAsato RJoseph PMet al: Hemorrhage and edema in acute spinal cord compression: demonstration by MR imaging. Radiology 161:3873901986Hackney DB Asato R Joseph PM et al: Hemorrhage and edema in acute spinal cord compression: demonstration by MR imaging. Radiology 161:387–390 1986

  • 15.

    Holmes GKennedy RF: Two anomalous cases of syringomyelia. Proc R Soc Med 2 (Neurological Section):171909Holmes G Kennedy RF: Two anomalous cases of syringomyelia. Proc R Soc Med 2 (Neurological Section):1–7 1909

  • 16.

    Jenik FTekle-Haimanot RHamory BH: Non-traumatic adhesive arachnoiditis as a cause of spinal cord syndromes. Investigation of 507 patients. Paraplegia 19:1401541981Jenik F Tekle-Haimanot R Hamory BH: Non-traumatic adhesive arachnoiditis as a cause of spinal cord syndromes. Investigation of 507 patients. Paraplegia 19:140–154 1981

  • 17.

    Kaplan ELMeier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:4574811958Kaplan EL Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457–481 1958

  • 18.

    Karnofsky DABurchenal JH: The clinical evaluation of chemotherapeutic agents in cancer in MacLeod CM (ed): Evaluation of Chemotherapeutic Agents. New York: Columbia University Press1949 pp 191205Karnofsky DA Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer in MacLeod CM (ed): Evaluation of Chemotherapeutic Agents. New York: Columbia University Press 1949 pp 191–205

  • 19.

    Klekamp JSamii M: Introduction of a score system for the clinical evaluation of patients with spinal processes. Acta Neurochir 123:2212231993Klekamp J Samii M: Introduction of a score system for the clinical evaluation of patients with spinal processes. Acta Neurochir 123:221–223 1993

  • 20.

    La Haye PABatzdorf U: Posttraumatic syringomyelia. West J Med 148:6576631988La Haye PA Batzdorf U: Posttraumatic syringomyelia. West J Med 148:657–663 1988

  • 21.

    Li KCChui MC: Conventional and CT metrizamide myelography in Arnold-Chiari I malformation and syringomyelia. AJNR 8:11171987Li KC Chui MC: Conventional and CT metrizamide myelography in Arnold-Chiari I malformation and syringomyelia. AJNR 8:11–17 1987

  • 22.

    Lombardi GPasserini AMigliavacca F: Spinal arachnoiditis. Br J Radiol 35:3143201962Lombardi G Passerini A Migliavacca F: Spinal arachnoiditis. Br J Radiol 35:314–320 1962

  • 23.

    McLean DRMiller JDRAllen PBRet al: Posttraumatic syringomyelia. J Neurosurg 39:4854921973McLean DR Miller JDR Allen PBR et al: Posttraumatic syringomyelia. J Neurosurg 39:485–492 1973

  • 24.

    Nagahiro SMatsukado YHirata Yet al: [Pathogenesis and treatment of secondary syringomyelia.] No To Shinkei 39:1431491987 (Jpn)Nagahiro S Matsukado Y Hirata Y et al: [Pathogenesis and treatment of secondary syringomyelia.] No To Shinkei 39:143–149 1987 (Jpn)

  • 25.

    Padilla CR: Syringomyelia after spinal cord injury. Am Fam Phys 26:1451511982Padilla CR: Syringomyelia after spinal cord injury. Am Fam Phys 26:145–151 1982

  • 26.

    Peerless SJDurward QJ: Management of syringomyelia: a pathophysiological approach. Clin Neurosurg 30:5315761983Peerless SJ Durward QJ: Management of syringomyelia: a pathophysiological approach. Clin Neurosurg 30:531–576 1983

  • 27.

    Quencer RMPost MJDHinks RS: Cine MRI in the evaluation of normal and abnormal CSF flow: intracranial and intraspinal studies. Neuroradiology 32:3713911990Quencer RM Post MJD Hinks RS: Cine MRI in the evaluation of normal and abnormal CSF flow: intracranial and intraspinal studies. Neuroradiology 32:371–391 1990

  • 28.

    Rossier ABFoo DShillito Jet al: Posttraumatic cervical syringomyelia. Incidence, clinical presentation, electrophysiological studies, syrinx protein and results of conservative and operative treatment. Brain 108:4394611985Rossier AB Foo D Shillito J et al: Posttraumatic cervical syringomyelia. Incidence clinical presentation electrophysiological studies syrinx protein and results of conservative and operative treatment. Brain 108:439–461 1985

  • 29.

    Rossier ABWerner AWildi Eet al: Contribution to the study of late cervical syringomyelic syndromes after dorsal or lumbar traumatic paraplegia. J Neurol Neurosurg Psychiatry 31:91051968Rossier AB Werner A Wildi E et al: Contribution to the study of late cervical syringomyelic syndromes after dorsal or lumbar traumatic paraplegia. J Neurol Neurosurg Psychiatry 31:9–105 1968

  • 30.

    Schliep GRitter U: Klinik der Syringomyelie. Fortschr Neurol Psychiatr 39:53821971Schliep G Ritter U: Klinik der Syringomyelie. Fortschr Neurol Psychiatr 39:53–82 1971

  • 31.

    Schon FBowler JV: Syringomyelia and syringobulbia following tuberculous meningitis. J Neurol 237:1221231990Schon F Bowler JV: Syringomyelia and syringobulbia following tuberculous meningitis. J Neurol 237:122–123 1990

  • 32.

    Schwarz E: Präparate von einem Falle syphilitischer Myelomeningitis mit Höhlenbildung im Rückenmark und besonderen degenerativen Veränderungen der Neuroglia. Wiener Klin Wochenschr 7:1771781897Schwarz E: Präparate von einem Falle syphilitischer Myelomeningitis mit Höhlenbildung im Rückenmark und besonderen degenerativen Veränderungen der Neuroglia. Wiener Klin Wochenschr 7:177–178 1897

  • 33.

    Seibert CEDreisbach JNSwanson WBet al: Progressive posttraumatic cystic myelopathy: neuroradiologic evaluation. AJR 136:116111661981Seibert CE Dreisbach JN Swanson WB et al: Progressive posttraumatic cystic myelopathy: neuroradiologic evaluation. AJR 136:1161–1166 1981

  • 34.

    Sgouros SWilliams B: A critical appraisal of drainage in syringomyelia. J Neurosurg 82:1101995Sgouros S Williams B: A critical appraisal of drainage in syringomyelia. J Neurosurg 82:1–10 1995

  • 35.

    Shaw MDMRussell JAGrossart KW: The changing pattern of spinal arachnoiditis. J Neurol Neurosurg Psychiatry 41:971071978Shaw MDM Russell JA Grossart KW: The changing pattern of spinal arachnoiditis. J Neurol Neurosurg Psychiatry 41:97–107 1978

  • 36.

    Sherman JLCitrin CMGangarosa REet al: The MR appearance of CSF pulsations in the spinal canal. AJNR 7:8798841986Sherman JL Citrin CM Gangarosa RE et al: The MR appearance of CSF pulsations in the spinal canal. AJNR 7:879–884 1986

  • 37.

    Shikata JYamamuro TIida Het al: Surgical treatment for symptomatic spinal adhesive arachnoiditis. Spine 14:8708751989Shikata J Yamamuro T Iida H et al: Surgical treatment for symptomatic spinal adhesive arachnoiditis. Spine 14:870–875 1989

  • 38.

    Tatara N: [Experimental syringomyelia in rabbits and rats after localized spinal arachnoiditis.] No To Shinkei 44:111511251992 (Jpn)Tatara N: [Experimental syringomyelia in rabbits and rats after localized spinal arachnoiditis.] No To Shinkei 44:1115–1125 1992 (Jpn)

  • 39.

    Tator CHMeguro KRowed DW: Favorable results with syringosubarachnoid shunts for treatment of syringomyelia. J Neurosurg 56:5175231982Tator CH Meguro K Rowed DW: Favorable results with syringosubarachnoid shunts for treatment of syringomyelia. J Neurosurg 56:517–523 1982

  • 40.

    Tobimatsu YNihei RKimura Tet al: [A quantitative analysis of cerebrospinal fluid flow in posttraumatic syringomyelia.] Nippon Seikeigeka Gakkai Zasshi 65:5055161991 (Jpn)Tobimatsu Y Nihei R Kimura T et al: [A quantitative analysis of cerebrospinal fluid flow in posttraumatic syringomyelia.] Nippon Seikeigeka Gakkai Zasshi 65:505–516 1991 (Jpn)

  • 41.

    Vernon JDSilver JRSymon L: Post-traumatic syringomyelia: the results of surgery. Paraplegia 21:37461983Vernon JD Silver JR Symon L: Post-traumatic syringomyelia: the results of surgery. Paraplegia 21:37–46 1983

  • 42.

    Wagner FC JrVan Gilder JCDohrmann GJ: The development of intramedullary cavitation following spinal cord injury: an experimental pathological study. Paraplegia 14:2452501977Wagner FC Jr Van Gilder JC Dohrmann GJ: The development of intramedullary cavitation following spinal cord injury: an experimental pathological study. Paraplegia 14:245–250 1977

  • 43.

    Williams B: On the pathogenesis of syringomyelia: a review. J R Soc Med 73:7988061980Williams B: On the pathogenesis of syringomyelia: a review. J R Soc Med 73:798–806 1980

  • 44.

    Williams BPage N: Surgical treatment of syringomyelia with syringopleural shunting. Br J Neurosurg 1:63801987Williams B Page N: Surgical treatment of syringomyelia with syringopleural shunting. Br J Neurosurg 1:63–80 1987

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