Treatment of posttraumatic syringomyelia

Clinical article

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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.

Article Information

Address correspondence to: Jörg Klekamp, M.D., Department of Neurosurgery, Christliches Krankenhaus, Danziger Strasse 2, 49610 Quakenbrück, Germany. email: j.klekamp@ckq-gmbh.de.

Please include this information when citing this paper: published online July 13, 2012; DOI: 10.3171/2012.5.SPINE11904.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Sagittal T2-weighted MR image obtained in a 49-year-old male patient 30 years after a conservatively managed fracture at T-6 that was not associated with any neurological symptoms. It shows a syrinx from the T-1 to the T-10 level and a profound kyphosis. Ten years after the accident the patient started to notice weakness in his left leg. A syrinx was found between T-4 and T-10, which subsequently ascended to T-1. B: Axial T2-weighted image demonstrating an area of posterior tethering on the right side. At presentation 20 years after the onset of new symptoms, the patient had to use a walker due to a spastic paraparesis. A correction of the kyphosis was discussed but refused by the patient. He underwent T-6 and T-7 laminotomy with arachnolysis and duraplasty. C: Postoperative MR image obtained 7 months after surgery showing a reduction of the syrinx. As of this writing, the patient's neurological situation has remained stable for 3 years.

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    A: Sagittal T2-weighted MR image obtained in a 46-year-old male patient 17 months after a motor vehicle accident that caused a spinal cord concussion with a persistent sensory level at T7–8, showing a small syrinx from T-2 to T-4. B: Sagittal MR image obtained 1 year later showing a slight expansion of the syrinx now crossing the level of the T1–2 disc space. C and D: Axial T2-weighted images, adjacent slices. The first image (C) poorly demonstrates the surface contour of the cord at the lower end of the syrinx due to pulsation artifact from the arachnoid pouch that compresses the cord posteriorly on the next axial image below that level (D). E: Axial MR image showing that the demarcation and form of the spinal cord returned to normal below the arachnopathy at T-5. The abrupt change of syrinx caliber at T-4, the cranial ascent of the syrinx, the slight posterior compression at T-4, and the motion artifacts at that level are indirect signs of the posttraumatic arachnopathy causing the syrinx. A decompression at T-4 was undertaken. F: Postoperative MR image obtained 3 months after decompression showing complete resolution of the syrinx. The patient's clinical condition was unchanged.

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    Left: Sagittal T2-weighted MR image obtained in a 38-year-old male patient 20 years after a burst fracture at T6–7 that resulted in complete paraplegia. Within 3 years before presentation the patient underwent 7 attempts at syrinx shunting at other institutions (to control the syrinx) without any success. Due to the postsurgical arachnoid scarring and the kyphosis at the injury level, a decompression was considered unlikely to stabilize the ascending neurological symptoms. Right: After cordectomy, the syrinx completely collapsed and the patient noticed recovery of his hand function mainly due to improved sensory function. As of this writing the improvement has lasted for 2 years.

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    Kaplan-Meier analysis demonstrating progression-free survival (lack of clinical recurrence) after decompression in Groups A, B, and C (p = 0.07, log-rank test).

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