Syringomyelia presenting as shoulder instability

Neuropathic arthropathy of the shoulder secondary to operated syringomyelia: a case-based review

Neuropathic arthropathy (NA) is a long-term progressive disorder that causes joint destruction in the existence of a neurologic deficit. Minor injuries and fractures are commonly overlooked until the visible joint deterioration becomes persistent. Syringomyelia is one of the important causes of NA. The appearance of clinical signs in syringomyelia is caused by longitudinal cysts formed in the cervical and cervicothoracic regions of the spinal cord. Depending on the existence of the underlying disorder, the number and localization of the syrinxes, a range of symptoms, involving pain, sensation deficit, loss of motor function, and deep tendon reflex abnormality, emerge. The case is here described of a 68-year-old female patient with shoulder NA following syringomyelia, who partially responded to the rehabilitation program. Furthermore, the available case reports were comprehensively reviewed on Web of Science, Scopus, and PubMed/Medline. Furthermore, the available case reports were comprehensively evaluated on Web of Science, Scopus, and PubMed/Medline. Thus, we aimed to present the demographic characteristics, symptoms, physical examination signs, treatment, and follow-up parameters of syringomyelia-related shoulder NA cases.

Neuropathic arthropathy of the shoulder as a presenting feature of Chiari malformation with syringomyelia: a case report with a systematic literature review

BACKGROUND

Neuropathic arthropathy (NA) of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Syringomyelia, a spinal cord disease, is the leading cause of NA in the upper extremity.

OBJECTIVE

We present a systematic review of NA with syringomyelia cases alongside a case report of an adult with NA of the shoulder that occurs a few 4 years after a revelation and surgical management of a Chiari malformation with syringomyelia.

METHODS

A systematic review was conducted following PRISMA guidelines. A PubMed, Scopus, Isiknowledge, and manual search through references of relevant publications were used to identify all published case reports of NA. Data were collected from each case report on patient characteristics.

RESULTS

The systematic review identified 56 publications and 85 patients (including ours): nearly the same number of males (n = 41) and females (n = 44). The mean age was 50,69. Presentations included reduction of mobility (n = 66), swelling (n = 61) and sensory disorder (n = 63). The pain was absent in 41 cases. In the majority of reported cases 56 (65.1%), syringomyelia was revealed by neuropathic arthropathy, and eleven patients (12.9%) had a history of syringomyelia. Treatment was categorized into non-operative management (37[43.5%]), operative management (27[31.7%]). Following-up was non-reported in 31 (36%) cases. Improvement was reported more with patients who underwent a surgical approach than medical one 28.5% versus 8.1%.

CONCLUSION

Physicians need to be more aware of this destructive joint disease, rare, and often misdiagnosed. Also, it is imperative to integrate clinical, pathological, and imaging findings for accurate diagnosis and for delivering appropriate therapy.

Neuropathic Arthropathy of the Shoulder: A Systematic Review of Classifications and Treatments

BACKGROUND

Neuropathic arthropathy of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Causes include syringomyelia, syphilis, diabetes, chronic alcoholism, and leprosy, with syringomyelia accounting for the vast majority of upper-extremity Charcot joints. Early presentation of this rare condition includes nonspecific symptoms such as swelling, erythema, sensory symptoms, and decreased functionality, making diagnosis challenging.

METHODS

We systematically reviewed 32 case reports published between 1924 and 2016. A total of 59 shoulders from 56 patients are included in this analysis. Variables include patient demographic characteristics, presentation, etiology, diagnostic techniques, treatment, outcome, and follow-up of Charcot shoulder.

RESULTS

We compiled a total of 25 right shoulders (42%), 24 left shoulders (41%), and 10 shoulders (17%) with unspecified laterality. The mean patient age (and standard deviation) was 49 ± 11 years, and the median age was 47 years. There was a higher prevalence in men (37 shoulders [63%]) compared with women (22 shoulders [37%]). Presenting symptoms included reduced range of motion (53 shoulders [90%]), paresthesia or hypoesthesia (45 [76%]), swelling (44 [75%]), weakness (40 [68%]), pain (31 [53%]), and reduction in deep tendon reflexes (22 [37%]). Shoulder radiographs were made in all cases. The presence of a syrinx was detected in 45 shoulders (76%) with magnetic resonance imaging, myelography, or clinical diagnosis. Sixteen shoulders (27%) reported exposure to trauma, with a 69% decrease in time from presentation to diagnosis compared with non-traumatic cases. Treatment was categorized as solely nonoperative management (14 [24%]), operative management (13 [22%]), combined therapy (20 [34%]), and no treatment listed (10 [17%]). Two surgical cases (3%) were excluded from our treatment group analysis as they were treated for unrelated or misdiagnosed conditions.

CONCLUSIONS

Our study increases awareness and understanding of this complex, progressive disease to reduce delay and misdiagnosis and to contribute to the standard-of-care recommendations.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spontaneous Ruptures of the Distal Biceps and Rotator Cuff Tendons Secondary to Syringomyelia: A Case Report

CASE

We present a case of ipsilateral spontaneous ruptures of the distal biceps and rotator cuff tendons secondary to syringomyelia of the cervical spine. The distal biceps tendon ruptured first and underwent successful repair. Six months postoperatively, the patient was found to have an ipsilateral massive acute-on-chronic rotator cuff tear following minimal trauma, with a well-maintained glenohumeral joint space. He was subsequently diagnosed with a syrinx and underwent neurosurgical decompression. Five months later, a successful lower trapezius transfer was performed.

CONCLUSION

Orthopaedic surgeons should maintain a high index of suspicion for a neurologic etiology in the setting of relatively atraumatic tendon ruptures in otherwise healthy young patients.

Neuropathic arthropathy of the shoulder

We retrospectively reviewed the records of six men (seven shoulders) with neuropathic arthropathy of the shoulder who were referred to our shoulder service during a twenty-eight-year period (from 1969 through 1997). The etiology of the neuropathic condition was syringomyelia in five patients (six shoulders) and chronic alcoholism in one patient. Five patients (six shoulders) were initially misdiagnosed, and seven operative procedures that were unrelated to the etiology of the neuropathic condition were performed in four of these patients. Radiographs revealed destruction of the shoulder joint and marked resorption of the humeral head in all patients. Magnetic resonance images revealed a syrinx of the central cord in all of the patients except for the one who had chronic alcoholism.

Proprioceptive function of the shoulder girdle in healthy volunteers

In 27 healthy volunteers (9 females, 18 males) we evaluated the proprioceptive function of the glenohumeral joint. The volunteers were asked to place the arm in different positions with and without visual control. The test was performed for the dominant and for the nondominant extremity. The following joint positions were measured: 50 degrees, 100 degrees, 150 degrees abduction; 50 degrees, 100 degrees, 150 degrees flexion; +45 degrees, 0 degrees, -45 degrees rotation in 90 degrees abduction. Joint position was documented with a motion-analyzing system with passive reflecting markers. The results showed significant differences between the measurements with and without visual control. Proprioception was worse below the shoulder level (50 degrees abduction, flexion). Two volunteers with generally good coordinative capabilities showed better results than the rest of the group. We observed no differences between dominant and nondominant extremities nor between males and females. Our results demonstrated low variance of the proprioceptive function of the glenohumeral joint in healthy volunteers. Our findings serve as a base for further evaluations in different patients' populations.