Chiari malformation, cervical disc prolapse and syringomyelia--always think twice

Neurological deterioration after posterior fossa decompression for adult syringomyelia: Proposal for a summarized treatment algorithm

Background

Patients with syringomyelia who present with new neurological symptoms after posterior fossa decompression (PFD) are not uncommon. However, systematic reports on different pathologies are few in the literature.

Objective

The purpose of this study was to summarize our experience for failed PFD.

Methods

Between January 2015 and December 2019, 85 consecutive failed PFD patients were identified. The neurological courses were summarized with Klekamp J (KJ) or mJOA score system for all patients. Long-term results were summarized with Kaplan-Meier method.

Results

Twenty-eight consecutive patients underwent FMDD (Foramen magnum and foramen of Magendie dredging) (Group I), extradural PFD and manipulation of tonsil was significantly associated with lower failure rates. Twenty patients underwent craniocervical fixation (Group II), nine underwent local spinal segment decompression (Group III), six underwent CSF diversion procedures, and one were treated for persistent pain by radiofrequency. Neuropathic pain was most significantly improved in Group I while swallowing improved in Group II within 1 year after the surgery. In the long term, late postoperative deterioration-free possibility in Group II was better than in Group I. All patients in Group III improved (P = 0.0088). Six cases of CSF diversion procedures were relieved in a short time. Pain in one patient persisted after PFD, and trial of radiofrequency failed.

Conclusion

Not only does the recurrent cerebrospinal fluid flow obstruct the foramen magnum, but also spinal pathologies and craniocervical instabilities may occur. This study provides the largest summarized clinical experience that may assist surgeons with different therapeutic decisions for failed PFD.

Syringomyelia resolution after anterior cervical discectomy: A case report and literature review

Background:

Syringomyelia is rarely associated with cervical disc herniations and/or spinal stenosis.

Case Description:

A 62-year-old male presented with a 4-month history of right brachial pain and hyposensitivity in the C5 distribution. The cervical magnetic resonance (MR) imaging scan revealed a C5–C6 right anterolateral disc herniation with syringomyelia extending from C5–C6 to T1. Following a C5–C6 anterior cervical discectomy and fusion (ACDF), the patient’s symptoms resolved. The 3-month postoperative MR documented total resolution of the syrinx. Notably, due to residual neuropathic pain, the patient required a subdural spinal cord stimulator which was placed without any complications.

Conclusion:

Syringomyelia rarely occurs in conjunction with cervical disc disease and stenosis, and even more infrequently resolves following an ACDF. Future research should focus on the etiology of syrinx formation in these patients and should explore their response to various treatment modalities.

Interval Recovery of Syringomyelia in Chiari I Malformation Patient with Acute Cervical Trauma After Anterior Decompression: Case Report and Review of Literature

BACKGROUND

Syringomyelia in the cervical spinal cord is a complex pathology that is commonly associated with Chiari I malformation or spinal cord trauma. In both cases the development of syringomyelia has been linked to multiple anatomic and molecular elements including epidural compression. Literature has mainly reported posterior cervical decompressive procedures or shunting of the cyst as options to address this pathology. Anterior decompression is rarely recommended.

CASE DESCRIPTION

We present the case of a 19-year-old female who suffered a motor vehicle accident causing a cervical subluxation with mild new-onset neurologic deficits. Preoperative workup showed a large incidental cervical syringomyelia associated with a Chiari I malformation. Anterior cervical decompression at the subluxated cervical segment with a concomitant anterior and posterior fusion was performed. Postoperative workup revealed a significant interval reduction in the size of the syrinx cavity with concomitant neurologic improvement.

CONCLUSIONS

Anterior decompression may be considered as an option in select cases of syringomyelia. The findings of this case support the theory of epidural compression as one of the inciting events for the development of syringomyelia.

Magnetic resonance 4D flow characteristics of cerebrospinal fluid at the craniocervical junction and the cervical spinal canal

OBJECTIVES

To evaluate the applicability of 4D phase contrast (4D PC) MR imaging in the assessment of cerebrospinal fluid dynamics in healthy volunteers and patients with lesions at the craniocervical junction or the cervical spinal canal.

METHODS

Ten healthy volunteers and four patients with lesions including Chiari I malformation and cervical canal stenoses were examined by a cardiac-gated 4D PC imaging sequence on 1.5T MRI. Phase contrast images were postprocessed allowing for flow quantification and flow pathline visualisation. Velocity data were compared with conventional axial 2D phase contrast images.

RESULTS

The 4D PC sequence allowed for flow quantification and visualisation in all individuals. Bland-Altman analysis showed good agreement of 2D and 4D PC velocity data. In healthy volunteers, CSF flow was homogeneously distributed in the anterior and anterolateral subarachnoid space with the flow directed caudally during systole and cranially during diastole. Flow velocities were closely related to the width of the subarachnoid space. Patients showed grossly altered CSF flow patterns with formation of flow jets with increased flow velocities.

CONCLUSIONS

4D PC MR imaging allows for a detailed assessment of CSF flow dynamics helping to distinguish physiological from complex pathological flow patterns at the craniocervical junction and the cervical spine.

Syringomyelia due to thoracic spinal stenosis with ossified ligamentum flavum--case report

A 50-year-old male presented with back pain and numbness of the lower extremities persisting for 10 years. He had played volleyball for a long period until recently. He had no history of meningitis or traumatic injury. Magnetic resonance imaging revealed a syringomyelia located in the region from T8 to T9 without contrast enhancement or Chiari malformations. Computed tomography showed T9-10 spinal stenosis caused by the right enlarged ossified yellow ligament. Decompressive laminectomy was performed and the ossified ligament removed. Due to the finding of arachnoid thickening and adhesions during the intradural operation, shunting was also performed. Postoperatively, the neuroimaging and clinical findings improved. Syringomyelia is often associated with Chiari malformations, trauma, spinal tumor, hemorrhaging, and meningitis. We suggest that repeated minor mechanical damage caused by physical exercise in addition to long-standing compression of the spinal cord due to spinal spondylosis could induce severe arachnoid fibrotic change similar to adhesive arachnoiditis, which may be one of the main triggers of syringomyelia. Extradural decompressive surgery is considered to be the initial treatment for syringomyelia associated with spinal spondylosis.