Syrinx shunts for syringomyelia: a systematic review and meta-analysis of syringosubarachnoid, syringoperitoneal, and syringopleural shunting

Robert J. Rothrock MD1, Victor M. Lu MD, PhD1, and Allan D. Levi MD, PhD1
View More View Less
  • 1 Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

Syringomyelia is a debilitating, progressive disease process that can lead to loss of neurological function in patients already experiencing significant compromise. Syringosubarachnoid, syringoperitoneal, and syringopleural shunts are accepted treatment options for patients with persistent syringomyelia, but direct comparisons have been lacking to date. The authors conducted a systematic review of the literature and meta-analysis to compare clinical outcomes between these three syrinx shunt modalities.

METHODS

Utilizing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews, Ovid Embase, PubMed, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and Database of Abstracts of Review of Effectiveness were searched to identify all potentially relevant studies published from inception until July 2020. Data were extracted and analyzed using meta-analysis of proportions. The primary study outcome was the rate of reoperation based on the initial shunt modality. Secondary outcomes included clinical improvement, clinical deterioration, and complications following shunt placement.

RESULTS

A total of 22 articles describing 27 distinct treatment cohorts published between 1984 and 2019 satisfied the inclusion criteria. This captured 473 syrinx shunt procedures, 193 (41%) by syringosubarachnoid shunt, 153 (32%) by syringoperitoneal shunt, and 127 (27%) by syringopleural shunt, with an overall median clinical follow-up of 44 months. The pooled incidences of revision surgery were estimated as 13% for syringosubarachnoid, 28% for syringoperitoneal, and 10% for syringopleural shunts, respectively (p-interaction = 0.27). The rate of clinical improvement was estimated as 61% for syringosubarachnoid, 64% for syringoperitoneal, and 71% for syringopleural shunts. The rate of clinical deterioration following placement was estimated as 13% for syringosubarachnoid, 13% for syringoperitoneal, and 10% for syringopleural shunts.

CONCLUSIONS

The preferred modality of syrinx shunting remains a controversial topic for symptomatic syringomyelia. This study suggests that while all three modalities offer similar rates of clinical improvement and deterioration after placement, syringoperitoneal shunts have a greater rate of malfunction requiring surgical revision. These data also suggest that syringopleural shunts may offer the best rate of clinical improvement with the lowest rate of reoperation.

ABBREVIATIONS

ES = effect size; CI = confidence interval; GRADE = Grading of Recommendations, Assessment, Development and Evaluations; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SQAT = Study Quality Assessment Tool.

Supplementary Materials

    • Supplementary Table 1 (PDF 407 KB)

Illustration from Rothrock et al. (pp 535–545). Copyright Roberto Suazo. Published with permission.

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Wetjen NM, Heiss JD, Oldfield EH. Time course of syringomyelia resolution following decompression of Chiari malformation Type I. J Neurosurg Pediatr. 2008;1(2):118123.

    • Search Google Scholar
    • Export Citation
  • 2

    Groves ML, Zadnik PL, Recinos PF, et al. Intramedullary spinal cord tumor resection. Neurosurg Focus. 2012;33(1)(suppl 1):1.

  • 3

    Lee TT, Alameda GJ, Camilo E, Green BA. Surgical treatment of post-traumatic myelopathy associated with syringomyelia. Spine (Phila Pa 1976).2001;26(24)(suppl):S119S127.

    • Search Google Scholar
    • Export Citation
  • 4

    Batzdorf U, Klekamp J, Johnson JP. A critical appraisal of syrinx cavity shunting procedures. J Neurosurg. 1998;89(3):382388.

  • 5

    Frazier CH, Rowe SN. The surgical treatment of syringomyelia. Ann Surg. 1936;103(4):481497.

  • 6

    Swartz MK. The PRISMA statement: a guideline for systematic reviews and meta-analyses. J Pediatr Health Care. 2011;25(1):12.

  • 7

    Freeman MF, Tukey JW. Transformations related to the angular and the square root. Ann Math Stat. 1950;21(4):607611.

  • 8

    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177188.

  • 9

    Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557560.

  • 10

    Study quality assessment tools. National Heart, Lung, and Blood Institute. Accessed January 22, 2021. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

    • Search Google Scholar
    • Export Citation
  • 11

    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):10881101.

  • 12

    Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629634.

    • Search Google Scholar
    • Export Citation
  • 13

    Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455463.

    • Search Google Scholar
    • Export Citation
  • 14

    Atkins D, Eccles M, Flottorp S, et al. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group. BMC Health Serv Res. 2004;4(1):38.

    • Search Google Scholar
    • Export Citation
  • 15

    Asano M, Fujiwara K, Yonenobu K, Hiroshima K. Post-traumatic syringomyelia. Spine (Phila Pa 1976).1996;21(12):14461453.

  • 16

    Barbaro NM, Wilson CB, Gutin PH, Edwards MS. Surgical treatment of syringomyelia. Favorable results with syringoperitoneal shunting. J Neurosurg. 1984;61(3):531538.

    • Search Google Scholar
    • Export Citation
  • 17

    Davidson KA, Rogers JM, Stoodley MA. Syrinx to subarachnoid shunting for syringomyelia. World Neurosurg. 2018;110:e53e59.

  • 18

    Hess MJ, Foo D. Shunting for syringomyelia in patients with spinal cord injuries: self-reported, long-term effects in 8 patients. Arch Phys Med Rehabil. 2001;82(11):16331636.

    • Search Google Scholar
    • Export Citation
  • 19

    Hida K, Iwasaki Y, Imamura H, Abe H. Posttraumatic syringomyelia: its characteristic magnetic resonance imaging findings and surgical management. Neurosurgery. 1994;35(5):886891.

    • Search Google Scholar
    • Export Citation
  • 20

    Iwasaki Y, Koyanagi I, Hida K, Abe H. Syringo-subarachnoid shunt for syringomyelia using partial hemilaminectomy. Br J Neurosurg. 1999;13(1):4145.

    • Search Google Scholar
    • Export Citation
  • 21

    Karam Y, Hitchon PW, Mhanna NE, et al. Post-traumatic syringomyelia: outcome predictors. Clin Neurol Neurosurg. 2014;124:4450.

  • 22

    Sgouros S, Williams B. A critical appraisal of drainage in syringomyelia. J Neurosurg. 1995;82(1):110.

  • 23

    Tassigny D, Abu-Serieh B, Fofe DT, et al. Shunting of syringomyelic cavities by using a myringotomy tube: technical note and long-term results. World Neurosurg. 2017;98:15.

    • Search Google Scholar
    • Export Citation
  • 24

    Vaquero J, Martínez R, Salazar J, Santos H. Syringosubarachnoid shunt for treatment of syringomyelia. Acta Neurochir (Wien). 1987;84(3-4):105109.

    • Search Google Scholar
    • Export Citation
  • 25

    Wiedemayer H, Nau HE, Rauhut F, et al. Operative treatment and prognosis of syringomyelia. Neurosurg Rev. 1994;17(1):3741.

  • 26

    Aghakhani N, Baussart B, David P, et al. Surgical treatment of posttraumatic syringomyelia. Neurosurgery. 2010;66(6):11201127.

  • 27

    Lesoin F, Petit H, Thomas CE III, et al. Use of the syringoperitoneal shunt in the treatment of syringomyelia. Surg Neurol. 1986;25(2):131136.

    • Search Google Scholar
    • Export Citation
  • 28

    Lund-Johansen M, Wester K. Syringomyelia treated with a nonvalved syringoperitoneal shunt: a follow-up study. Neurosurgery. 1997;41(4):858865.

    • Search Google Scholar
    • Export Citation
  • 29

    Naito K, Yamagata T, Ohata K, Takami T. Safety and efficacy of syringoperitoneal shunting with a programmable shunt valve for syringomyelia associated with extensive spinal adhesive arachnoiditis: technical note. World Neurosurg. 2019;132:1420.

    • Search Google Scholar
    • Export Citation
  • 30

    Suzuki M, Davis C, Symon L, Gentili F. Syringoperitoneal shunt for treatment of cord cavitation. J Neurol Neurosurg Psychiatry. 1985;48(7):620627.

    • Search Google Scholar
    • Export Citation
  • 31

    Wiart L, Dautheribes M, Pointillart V, et al. Mean term follow-up of a series of post-traumatic syringomyelia patients after syringo-peritoneal shunting. Paraplegia. 1995;33(5):241245.

    • Search Google Scholar
    • Export Citation
  • 32

    Fan T, Zhao X, Zhao H, et al. Treatment of selected syringomyelias with syringo-pleural shunt: the experience with a consecutive 26 cases. Clin Neurol Neurosurg. 2015;137:5056.

    • Search Google Scholar
    • Export Citation
  • 33

    Cacciola F, Capozza M, Perrini P, et al. Syringopleural shunt as a rescue procedure in patients with syringomyelia refractory to restoration of cerebrospinal fluid flow. Neurosurgery. 2009;65(3):471476.

    • Search Google Scholar
    • Export Citation
  • 34

    Williams B, Page N. Surgical treatment of syringomyelia with syringopleural shunting. Br J Neurosurg. 1987;1(1):6380.

  • 35

    Heiss JD, Patronas N, DeVroom HL, et al. Elucidating the pathophysiology of syringomyelia. J Neurosurg. 1999;91(4):553562.

  • 36

    Hussain I, Greenfield JP. Ultrasound-guided syringosubarachnoid shunt insertion for cervicothoracic syringomyelia. Clin Spine Surg. 2020;33(5):185191.

    • Search Google Scholar
    • Export Citation
  • 37

    Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal fluid shunting complications in children. Pediatr Neurosurg. 2017;52(6):381400.

    • Search Google Scholar
    • Export Citation
  • 38

    Summers JC, Vellore Y, Chan PCH, Rosenfeld JV. Intracranial hypotension after syringopleural shunting in posttraumatic syringomyelia: case report and review of the literature. Asian J Neurosurg. 2015;10(2):158161.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 88 88 88
Full Text Views 73 73 73
PDF Downloads 78 78 78
EPUB Downloads 0 0 0