Post Traumatic Syringomyelia
Post Traumatic Syringomyelia
Post Traumatic Syringomyelia
Neurochirurgien et chirurgien de la colonne, Hpital de Hull, CSSSG 116, Boulevard Lionel-mond, Gatineau (Qubec) J8Y 1W7, Canada
Department of Neurosurgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242, USA
c
Department of Neurology and Neurosciences, RutgersNew Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
b
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 21 May 2014
Accepted 9 June 2014
Available online 17 June 2014
Objective: To identify risk factors that predispose to post-traumatic syringomyelia (PTS) and describe the
outcome of surgical management.
Methods: Retrospective cohort study of 27 patients with post-traumatic syringomyelia. Spinal cord injury
of these patients spanned the period from 1963 to 2008. All data were collected retrospectively using
available medical records and radiological images.
Results: There were 24 males and 3 females. The level of initial spine injury was thoracic in 21, cervical in
4, and lumbar in 2. The average age (SD) at diagnosis of PTS was 40 13 years. The mean follow-up SD
from injury was 18 11 years. On admission after injury, there were 14 patients with American Spinal
Injuries Association (ASIA) disability scores of A, 3 with ASIA C, and 10 with ASIA score of D. At the time of
diagnosis of PTS, local kyphosis at the site of injury measured 28 12 , and the residual canal was
67 19% compared to the average rostral and caudal anteroposterior diameter. Fourteen patients
underwent a single operation for PTS, and 13 needed two or more procedures. In the 11 patients in whom
the initial surgery included a duraplasty, 3 required reoperation for unsuccessful reduction in the size of
the syrinx and failure to improve symptoms. In the 16 patients in whom the initial procedure was that of a
shunt alone, 10 required revision (p = 0.0718 rate of revision between shunting and duraplasty). As a
result of treatment for PTS, improvement in symptoms of PTS occurred in 14, symptoms were unchanged
in 10, and progressed in 3. In the 11 patients with sequential MRI scans, a signicant correlation was
shown between the reduction in the size of the syrinx and clinical improvement (p < 0.001).
Conclusion: PTS is often the result of severe spinal cord injuries, with over half of patients having an ASIA
disability score of A. Our review corroborates other published reports showing that PTS is associated with
signicant deformity and stenosis. Irrespective of treatment, over half of the patients required
reoperation for their PTS. Duraplasty and arachnolysis are the preferred treatment for PTS over shunting
alone. Treatment was associated with cessation of symptoms or improvement in nearly 90% of the
patients.
2014 Elsevier B.V. All rights reserved.
Keywords:
Duraplasty
Posttraumatic syringomyelia
Spinal cord injury
Spinal trauma
Syrinx
1. Introduction
Syrinx is a Greek name that means cavity of tubular shape.
Ollivier introduced this term in 1827, dening it as a pure dilatation
of the central canal [1]. The rst to describe post-traumatic
syringomyelia (PTS) was Bastian [2], in 1867, followed by Strumpell
[3], in 1880, and subsequently many other others [46]. Barnett
and Jousse [7] reviewed the literature in 1973 and described 5
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of arachnoidal adhesions, syringo-subarachnoid shunt, and duraplasty. The suture line was reinforced with a dural sealant
(DuraSealTM, Covidien, Crystal Lake, IL). His condition improved
for a short period of time. However, two months later he presented
with intractable pain involving both sides of the chest cavity and
arms, worse on the left side. He occasionally experienced difculty
swallowing his pills. An MRI was obtained (Fig. 5C), showing a
large extradural mass compressing the cord and associated with a
larger-than-before syrinx. At surgery, a sterile xanthochromic
epidural uid collection was drained, and the arachnolysis,
syringo-subarachnoid shunt, and duraplasty were revised. Three
months later his pain was improved, and sensory perception on the
chest wall had returned to baseline. MRI (Fig. 5D) showed
reduction in the syrinx cavity.
4. Discussion
As a general rule, myelomalacia is the localized destruction of
the cord resulting from injury, with syringomyelia being the
progressive chronic cavitation of the cord extending rostrally and
caudally from the site of injury. Post-traumatic syringomyelia most
commonly presents with pain, ascending sensory loss, increased
Fig. 1. At 18 years of age, this 32-year-old man was involved in a car accident with a T1112 fracture dislocation and paraplegia. He was treated with Harrington rods, which
were removed one year later. He presents on 12/24/2003 with pain and numbness in the neck, shoulder, and left arm. Symptoms are worse with exertion, sneezing, and
coughing. MRI scans of the cervical (A) and thoracic (B) spine show a holocord syrinx extending from T12 to C2. On 1/16/2004 the patient underwent T11-L1 laminectomy,
duraplasty, lysis of adhesions, and syringo-subarachnoid shunt. He was last seen on 12/15/2011. His preoperative numbness and pain have long disappeared, but his ASIA score
of A is unchanged. Postoperative MRI scans (C, D) show collapse of the syrinx without need of revision.
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Fig. 2. Sixty-ve-year-old man presents with increasing stiffness of neck and upper extremities with pain for the past 1.5 years. Forty-three years earlier he had been involved
in a car accident with a T3 spinal fracture that left him with paraplegia. The fracture was treated with immobilization and bracing. Preoperative MRI (A) shows a holocord
syrinx extending from C1 past the fracture and constriction to the conus. The patient was treated with T23 laminectomy, duraplasty, lysis of adhesions, and with C7-T4
instrumentation. On follow-up two months later, he is back to baseline and still complains of neck stiffness. Postoperative MRI (B) shows the syrinx unchanged in spite of the
decompression and duraplasty.
Fig. 3. Clinical improvement using the Odom score from 1 to 4, correlated closely and signicantly with the reduction in the size of the syrinx (correlation coefcient r = 0.912,
p < 0.001).
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Fig. 4. This 58-year-old paraparetic gentleman presented with burning sensation of the lower back and left leg for the past year. While driving, he experiences numbness in
his legs. He has experienced recent onset of urinary incontinence as noted by dribbling of urine and occasional episodes where he cannot make it to the bathroom in time. He
complains of erectile dysfunction for the past ve years. At the age of 19 he was involved in a snowmobile accident with an L1 fracture and ASIA of D. MRI (A) reveals kyphosis
at L1 with myelomalacia and a syrinx from T11 to L1. He underwent laminectomy, an attempt at lysis of adhesions, syringo-subarachnoid shunt, and duraplasty. Four months
postoperatively, he has noted improvement in his bowel and bladder control as well as pain. His gait is stable, and he still experiences erectile dysfunction. Postoperative MRI
(B) shows reduction in the size of the syrinx, but not total disappearance. Intraoperative ndings (C, D) show the severe intradural scarring and adhesions and the expected
difculty of arachnolysis and shunting.
higher, and possibly 20% [17,26,28]. Wang [29] identied the MRI
characteristics of syrinx as follows: hypo-signal on T1, hyper-signal
on T2, extending above or below the traumatic injury site (more
than two levels), tapered at one or both ends, and may appear with
loculations with well-dened borders. In the presence of pacemakers or stimulators, where MRI cannot be obtained, myelography and post-myelographic CT scan are indicated. In our study,
MRI images available for review allowed not only diagnosis but an
assessment of deformity and stenosis. In our patients, kyphosis and
the residual canal at the site of injury measured 28 12 and
67 19%, respectively. This degree of kyphosis in the thoracic spine
is signicantly greater than the normal estimate of 5 and 0
kyphosis in the thoracic and thoracolumbar spine [30,31]. These
data support the relationship between deformity and the
development of PTS. Signicant correlation of PTS with spinal
canal stenosis and spine deformity has been demonstrated in the
literature [12,17,28,29,32,33]. As in our own series, many patients
who ultimately developed PTS had been treated nonoperatively
[28], or had undergone procedures for their initial injuries without
correcting deformity. These results favor the correction of
deformity and the management of stenosis in the avoidance of
PTS [34].
Several theories have been proposed to explain the pathophysiology of PTS. A syrinx may develop after spinal cord trauma, either
soon after resorption of an intramedullary hematoma or as a delayed
phenomenon after cord contusion or compression with microcystic
cavitations [35]. Deformity and scarring from trauma results in
obstruction of CSF circulation. This can result in an increase in
intramedullary uid pressure with cyst formation [36]. Another
mechanism is the Venturi effect occurring at the site of constriction,
with a differential of pressure between the subarachnoid and
intraspinal space [36]. This difference in pressure results in the
expansion of intraparenchymal CSF accumulation and the formation
of PTS. Hence, restoring normal ow of CSF at the site of injury or
obliterating the pressure differential contributes to syrinx collapse.
With the extent of post-traumatic subdural and subarachnoid
scarring, and syrinx septation, shunting procedures have frequently not achieved the desired outcomes [37,38]. Thus, treatment
described herein, and by others [26,27], is directed more to the
release of adhesions and attempted normalization of CSF circulation and the elimination of differences in pressure in and around
the cord at the site of injury. The rate of revision surgery for
syringomyelia was 10/16 patients treated with shunt alone,
compared to 3/11 of those treated with duraplasty and lysis of
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Fig. 5. Ten years earlier, this 57-year-old man had suffered a T67 fracture dislocation with paraplegia. He now presents with pain and dysesthesia involving the left shoulder.
MRI shows stenosis at the site of injury with a cervicothoracic syrinx (A, B). At surgery, he underwent lysis of adhesions and duraplasty, and the suture line was secured with
the tissue adhesive (DuraSealTM, Covidien, Manseld, MA). Post-operatively, he experienced short-lived improvement. Two months later he presented with intractable pain
involving the chest and arms. An MRI was obtained, showing an extradural mass compressing the cord associated with a larger cervicothoracic syrinx (C). At surgery, a sterile
xanthochromic uid collection was drained, and the arachnolysis, syringo-subarachnoid shunt, and duraplasty were revised. Three months later his pain was improved, and
the MRI (D) shows reduction of the syrinx.
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