Management and outcome of posttraumatic syringomyelia

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✓ Traumatic paraplegia is the most common cause of nonhindbrain—related syringomyelia. Fifty-seven patients with a mean age of 34.3 years at presentation were treated at the Midland Centre for Neurosurgery and Neurology between 1973 and 1993. A variety of treatment strategies have been used over the years, including syringosubarachnoid and syringopleural shunts, spinal cord transection, and pedicled omental graft transposition. More recently decompressive laminectomy, subarachnoid space reconstruction and formation of surgical meningocele have been used. A total of 81 operations were performed in these patients, 69 of them at the Syringomyelia Clinic. Combinations of strategies were often chosen; the use of one strategy such as drainage did not preclude another such as transection or augmentation of the cerebrospinal fluid pathways.

The overall postoperative complication rate was 12%. Problems specific to the operation type included dislodged, blocked, and infected drains (10 patients). Acute gastric dilation was seen following pedicled omental graft (one patient). At 6 years only 49% of the drains inserted still functioned. A higher than expected rate of cervical spondylotic myelopathy has been noted. Two patients developed Charcot's joints. Thirty-six patients were asked to score themselves with regard to limb function and performance of daily living activities and 30% reported improvement, particularly in arm function.

Since the use of magnetic resonance imaging has become widespread, it has become apparent that decompressive laminectomy with subarachnoid space reconstruction is effective in controlling the syrinx cavity. In complete paraplegia, spinal cord transection is an effective alternative. Pedicled omental grafting was associated with poor outcome and an increased complication rate and has been abandoned.

Article Information

Address reprint requests to: Spiros Sgouros, F.R.C.S., Birmingham Neuroscience Centre, Queen Elizabeth Hospital, Birmingham B15 2TH, England.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schematic diagram showing the technique of the subarachnoid space reconstruction. A wide laminectomy is performed at the injury site. The dura is opened and an extensive dissection of the subarachnoid adhesions is performed, preferably on both sides of the spinal cord, until cerebrospinal fluid (CSF) emerges both cranially and caudally. The flaps of the dissected arachnoid are sutured to the dura to try to lessen formation of recurrent adhesions. At the end of the procedure the dura is left open. The arrows indicate the flow of CSF following reconstruction of the subarachnoid space at the injury site.

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    Upper: Bar graph showing treatment trends in the Syringomyelia Clinic for the last three decades. A move away from drainage procedures in favor of subarachnoid space reconstruction should be noted. Lower: Graph comparing the effectiveness of drainage procedures with subarachnoid space reconstruction. The Kaplan—Meier product limit method was used to produce cumulative proportion curves. At 6 years postsurgery only 50% of the drains still functioned, compared to an 80% success rate for subarachnoid space reconstruction. DRA = syringopleural or syringosubarachnoid drains; MYE = myelotomy; OME = pedunculated omental graft transposition; SSR = subarachnoid space reconstruction; TRA = cord transection; TVE = terminal ventriculostomy.

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    Left: Preoperative magnetic resonance (MR) image showing the cervical spine in a patient who developed syringomyelia following fracture of the C-5 vertebra. A sizable syrinx occupied the central part of the cord, extending to the upper cervical spine. Right: Postoperative MR image following laminectomy and subarachnoid space reconstruction, showing collapse of the syrinx. The surgical meningocele is clearly seen as a collection of cerebrospinal fluid at the site of the laminectomy. The presence of a primary spinal cord cyst is clearly appreciated at the injury site. This is an example of a primary spinal cord cyst that does not merit any treatment.

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    Upper: Bar graph showing the effect of surgery on the overall performance as well as on activities of daily living in 36 patients with posttraumatic syringomyelia who responded to our questionnaire. Patients who reported no change have been omitted. Almost half of the responding patients (17 of 36) reported an overall continuing deterioration despite successful surgical treatment. Lower: Bar graph showing the effect of surgery on limb sensation and function and on bladder function. Patients who reported no change have been omitted. With the exception of arm sensation, a general trend of deterioration was reported in most other treatment modalities. fun. = function; IMP = improved; sen. = sensation; WOR = worse.

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    Left: Magnetic resonance (MR) image showing T3–4 fracture with paraplegia. The primary cyst is clearly seen. The cavity extends above the arch of C-1. Right: An MR image showing postoperative result in the same case. The top syrinx is empty but the primary cyst remains full. Note the artificial meningocele filling the inner layers of the laminectomy wound. No drain was used in this case.

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    Magnetic resonance (MR) images obtained in a patient with syringomyelia treated with two drainage operations. a: An MR image revealing severe morphology with irregularly spaced septations. Although the patient had no motor deficits the cavity is bigger than before either of the drain placements and is obviously dangerous. b: An MR image showing the fracture site with a suggestion of a primary cyst formation. As is commonly seen, the state of filling of the two syringes is different, which indicates that the two cavities are not in communication. c: An MR image showing collapse of the syrinx after creation of a three-segment artificial meningocele. The primary cyst remains full. The success of the opening of the subarachnoid spaces to the meningocele can be well appreciated at the top of the primary cysts. One of the drains that was inserted at another center can be seen three segments above the fracture. d: Axial cervical MR image showing collapsed, concave morphology of the treated cavity.

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    Magnetic resonance (MR) images obtained in a patient with a T11–12 fracture showing the effects of a previous drainage operation performed at the widest part of the syrinx. Upper Left: The drain is seen on the left-hand image with a recurrent syrinx below and a shape that looks like a primary cyst, perhaps caused by the effect of upward sloshing abutting against the zone of gliosis provoked by the myelotomy and the drain. The right-hand image depicts the adjacent sagittal slice with the tip of the drain at the level of the inferior aspect of C-2. It should be noted that the new syrinx is located away from the drain. The symptoms had changed sides from right to left. Upper Right: Low cervical axial MR image showing the tense circular syrinx in the same patient. Compare with the typical postoperative appearance of Fig. 6d. Lower Left: Postoperative axial MR image showing collapsed syrinx and the tube of the syringopleural shunt that was inserted previously. Compare with upper right. Lower Right: An MR image showing that the entire syrinx has collapsed. The T2-weighted image shows persistent excess fluid in the cord in relation to the drain, which would have been avoided by prompt and drainless surgery. Compare with upper left.

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    Intraoperative photograph obtained in the same case as Fig. 7 showing meningeal fibrosis associated with the cord damage (between the arrows). On the left of the picture is the suture used to hold the right dentate ligament to the left. This opens up the anterior subarachnoid space so that it can accept the stent. The lower stent was easily placed in the lumbar sac between the left-sided nerve roots.

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