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Berliner JA, Lam MA, Najafi E, Hemley SJ, Bilston LE, Stoodley MA. Aquaporin-4 expression and modulation in a rat model of post-traumatic syringomyelia. Sci Rep 2023; 13:9662. [PMID: 37316571 PMCID: PMC10267129 DOI: 10.1038/s41598-023-36538-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
Aquaporin-4 (AQP4) has been implicated in post-traumatic syringomyelia (PTS), a disease characterised by the formation of fluid-filled cysts in the spinal cord. This study investigated the expression of AQP4 around a mature cyst (syrinx) and the effect of pharmacomodulation of AQP4 on syrinx size. PTS was induced in male Sprague-Dawley rats by computerized spinal cord impact and subarachnoid kaolin injection. Immunofluorescence of AQP4 was carried out on mature syrinx tissue 12 weeks post-surgery. Increased AQP4 expression corresponded to larger, multiloculated cysts (R2 = 0.94), yet no localized changes to AQP4 expression in perivascular regions or the glia limitans were present. In a separate cohort of animals, at 6 weeks post-surgery, an AQP4 agonist (AqF026), antagonist (AqB050), or vehicle was administered daily over 4 days, with MRIs performed before and after the completion of treatment. Histological analysis was performed at 12 weeks post-surgery. Syrinx volume and length were not altered with AQP4 modulation. The correlation between increased AQP4 expression with syrinx area suggests that AQP4 or the glia expressing AQP4 are recruited to regulate water movement. Given this, further investigation should examine AQP4 modulation with dose regimens at earlier time-points after PTS induction, as these may alter the course of syrinx development.
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Affiliation(s)
- Joel A Berliner
- Faculty of Medicine, Health and Human Sciences, Macquarie University, 2 Technology Place, Sydney, NSW, 2109, Australia.
| | - Magdalena A Lam
- The ANZAC Research Institute, Concord Repatriation General Hospital, Gate 3, Hospital Road, Sydney, NSW, 2139, Australia
| | - Elmira Najafi
- Faculty of Medicine, Health and Human Sciences, Macquarie University, 2 Technology Place, Sydney, NSW, 2109, Australia
| | - Sarah J Hemley
- Faculty of Medicine, Health and Human Sciences, Macquarie University, 2 Technology Place, Sydney, NSW, 2109, Australia
| | - Lynne E Bilston
- Neuroscience Research Australia, Margarete Ainsworth Building, 139 Barker Street, Sydney, NSW, 2031, Australia
- Faculty of Medicine, School of Clinical Medicine, University of New South Wales, Sydney, NSW, 2031, Australia
| | - Marcus A Stoodley
- Faculty of Medicine, Health and Human Sciences, Macquarie University, 2 Technology Place, Sydney, NSW, 2109, Australia
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Azad TD, Materi J, Hwang BY, Mathios D, Lehner KR, Hansen L, Bernhardt LJ, Xia Y, Shah PP, Kannapadi NV, Theodore N. Spinal cord untethering and midline myelotomy for delayed, symptomatic post-traumatic syringomyelia due to retained ballistic fragments: case report. Spinal Cord Ser Cases 2022; 8:66. [DOI: 10.1038/s41394-022-00533-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/05/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022] Open
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Perrouin-Verbe B, Lefevre C, Kieny P, Gross R, Reiss B, Le Fort M. Spinal cord injury: A multisystem physiological impairment/dysfunction. Rev Neurol (Paris) 2021; 177:594-605. [PMID: 33931244 DOI: 10.1016/j.neurol.2021.02.385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/24/2022]
Abstract
Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.
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Affiliation(s)
- B Perrouin-Verbe
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France.
| | - C Lefevre
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - P Kieny
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - R Gross
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - B Reiss
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - M Le Fort
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
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Kleindienst A, Laut FM, Roeckelein V, Buchfelder M, Dodoo-Schittko F. Treatment of posttraumatic syringomyelia: evidence from a systematic review. Acta Neurochir (Wien) 2020; 162:2541-2556. [PMID: 32820376 PMCID: PMC7496040 DOI: 10.1007/s00701-020-04529-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/04/2020] [Indexed: 01/29/2023]
Abstract
Background Following spinal cord injury (SCI), the routine use of magnetic resonance imaging (MRI) resulted in an incremental diagnosis of posttraumatic syringomyelia (PTS). However, facing four decades of preferred surgical treatment of PTS, no clear consensus on the recommended treatment exists. We review the literature on PTS regarding therapeutic strategies, outcomes, and complications. Methods We performed a systematic bibliographic search on (“spinal cord injuries” [Mesh] AND “syringomyelia” [Mesh]). English language literature published between 1980 and 2020 was gathered, and case reports and articles examining syrinx due to other causes were excluded. The type of study, interval injury to symptoms, severity and level of injury, therapeutic procedure, duration of follow-up, complications, and outcome were recorded. Results Forty-three observational studies including 1803 individuals met the eligibility criteria. The time interval from SCI to the diagnosis of PTS varied between 42 and 264 months. Eighty-nine percent of patients were treated surgically (n = 1605) with a complication rate of 26%. Symptoms improved in 43% of patients postoperatively and in 2% treated conservatively. Stable disease was documented in 50% of patients postoperatively and in 88% treated conservatively. The percentage of deterioration was similar (surgery 16%, 0.8% dead; conservative 10%). Detailed analysis of surgical outcome with regard to symptoms revealed that pain, motor, and sensory function could be improved in 43 to 55% of patients while motor function deteriorated in around 25%. The preferred methods of surgery were arachnoid lysis (48%) and syrinx drainage (31%). Conclusion Even diagnosing PTS early in its evolution with MRI, to date, no satisfactory standard treatment exists, and the present literature review shows similar outcomes, regardless of the treatment modality. Therefore, PTS remains a neurosurgical challenge. Additional research is required using appropriate study designs for improving treatment options.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | | | - Verena Roeckelein
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | - Michael Buchfelder
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | - Frank Dodoo-Schittko
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
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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; 132:14-20. [PMID: 31465850 DOI: 10.1016/j.wneu.2019.08.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/10/2019] [Accepted: 08/14/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Although syringomyelia associated with extensive spinal adhesive arachnoiditis (SAA) can be a progressive disease that has potentially devastating clinical consequences, its surgical resolution has remained poorly defined. The aim of the present study was to verify the safety and efficacy of syringoperitoneal shunting for syringomyelia associated with extensive SAA. METHODS The present retrospective study included 15 patients who had undergone syringoperitoneal shunting with a programmable shunt valve for the diagnosis of syringomyelia associated with extensive SAA from October 2012 to June 2018. The shunt pressure was appropriately adjusted according to the postoperative sequential clinical condition and change in syringomyelia evaluated using magnetic resonance imaging. The average postoperative follow-up duration was 32.7 months. RESULTS No surgery-related complications such as shunt dysfunction or infection occurred during the follow-up period, except for 2 patients with minor issues with the shunt tube. The average shunt pressure at the last follow-up examination was 4.5 cm H2O. The findings from the clinical assessment suggested that the average grade on the sensory pain scale was 2.9 before surgery and had improved significantly to 2.5 at the most recent follow-up examination. Radiological analysis suggested that improvement of syringomyelia was noted in 14 of the 15 patients (93.3%), with no cases of radiological aggravation. No recurrence of syringomyelia developed during the follow-up period in the present study. CONCLUSION Syringoperitoneal shunting with a programmable shunt valve was safe and effective for clinical control of syringomyelia associated with extensive SAA. Long-term follow-up is mandatory to monitor for shunt dysfunction and mechanical trouble.
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Affiliation(s)
- Kentaro Naito
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toru Yamagata
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
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Syringomyelia in an Adult American Paint Horse. Vet Sci 2018; 5:vetsci5020039. [PMID: 29621191 PMCID: PMC6024669 DOI: 10.3390/vetsci5020039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 11/22/2022] Open
Abstract
Syringomyelia is a form of myelodysplasia defined by the formation of one or more fluid-filled cavities within the spinal cord that do not communicate with the central canal. The defect may be congenital or acquired. Clinical signs correlate to the segment of spinal cord affected and include pain, paresis, proprioceptive deficits, alterations in sensation, scoliosis, and autonomic dysfunction. This report describes the clinical and pathologic changes in a case of acquired syringomyelia in a 10-year-old American Paint Horse mare. The horse had a six-week history of progressive proprioceptive deficits in all four limbs, bilateral pelvic limb ataxia, and muscle fasciculations that were unresponsive to treatment with stall rest, phenylbutazone, and dexamethasone. Syringomyelia was diagnosed postmortem within cervical, thoracic, and lumbar spinal cord segments. Acquired syringomyelia should be considered among differential diagnoses in adult horses displaying progressive neurologic deficits.
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Neurosurgical untethering with or without syrinx drainage results in high patient satisfaction and favorable clinical outcome in post-traumatic myelopathy patients. Spinal Cord 2018; 56:873-882. [DOI: 10.1038/s41393-018-0094-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 12/16/2022]
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Hechler AC, Moore SA. Understanding and Treating Chiari-like Malformation and Syringomyelia in Dogs. Top Companion Anim Med 2018; 33:1-11. [DOI: 10.1053/j.tcam.2018.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 11/11/2022]
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Spontaneous regression of post-traumatic syringomyelia: A case report and literature review. J Clin Neurosci 2017; 44:249-253. [DOI: 10.1016/j.jocn.2017.06.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/21/2017] [Indexed: 11/22/2022]
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Yildiz S, Thyagaraj S, Jin N, Zhong X, Heidari Pahlavian S, Martin BA, Loth F, Oshinski J, Sabra KG. Quantifying the influence of respiration and cardiac pulsations on cerebrospinal fluid dynamics using real-time phase-contrast MRI. J Magn Reson Imaging 2017; 46:431-439. [DOI: 10.1002/jmri.25591] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/28/2016] [Indexed: 02/05/2023] Open
Affiliation(s)
- Selda Yildiz
- Woodruff School of Mechanical Engineering; Georgia Institute of Technology; Atlanta Georgia USA
| | - Suraj Thyagaraj
- Department of Mechanical Engineering, Conquer Chiari Research Center; University of Akron; Akron Ohio USA
| | - Ning Jin
- MR R&D Collaborations; Siemens Healthcare; Columbus Ohio USA
| | - Xiaodong Zhong
- MR R&D Collaborations; Siemens Healthcare; Atlanta Georgia USA
- Department of Radiology; Emory University; Atlanta Georgia USA
| | - Soroush Heidari Pahlavian
- Department of Mechanical Engineering, Conquer Chiari Research Center; University of Akron; Akron Ohio USA
| | - Bryn A. Martin
- Department of Biological Engineering; University of Idaho; Moscow Idaho USA
| | - Francis Loth
- Department of Mechanical Engineering, Conquer Chiari Research Center; University of Akron; Akron Ohio USA
| | - John Oshinski
- Department of Radiology & Imaging Sciences and Biomedical Engineering; Emory University; Atlanta Georgia USA
| | - Karim G. Sabra
- Woodruff School of Mechanical Engineering; Georgia Institute of Technology; Atlanta Georgia USA
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Konar SK, Maiti TK, Bir SC, Nanda A. Spinal cordectomy: A new hope for morbid spinal conditions. Clin Neurol Neurosurg 2017; 152:5-11. [DOI: 10.1016/j.clineuro.2016.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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Frisbie JH, Aguilera EJ, Foo D. Flexed Neck Posture Due to Cervical Posttraumatic Syringomyelia. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/01952307.1989.11735797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Wong JHY, Song X, Hemley SJ, Bilston LE, Cheng S, Stoodley MA. Direct-trauma model of posttraumatic syringomyelia with a computer-controlled motorized spinal cord impactor. J Neurosurg Spine 2016; 24:797-805. [PMID: 26824588 DOI: 10.3171/2015.10.spine15742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The pathogenesis of posttraumatic syringomyelia remains enigmatic and is not adequately explained by current theories. Experimental investigations require a reproducible animal model that replicates the human condition. Current animal models are imperfect because of their low reliability, severe neurological deficits, or dissimilar mechanism of injury. The objective of this study was to develop a reproducible rodent model of posttraumatic syringomyelia using a spinal cord impactor that produces an injury that more closely mimics the human condition and does not produce severe neurological deficits. METHODS The study consisted of 2 parts. Seventy animals were studied overall: 20 in Experiment 1 and 48 in Experiment 2 after two rats with severe deficits were killed early. Experiment 1 aimed to determine the optimal force setting for inducing a cystic cavity without neurological deficits using a computer-controlled motorized spinal cord impactor. Twenty animals received an impact that ranged from 50 to 150 kDyn. Using the optimal force for producing an initial cyst determined from Experiment 1, Experiment 2 aimed to compare the progression of cavities in animals with and those without arachnoiditis induced by kaolin. Forty-eight animals were killed at 1, 3, 6, or 12 weeks after syrinx induction. Measurements of cavity size and maximum anteroposterior and lateral diameters were evaluated using light microscopy. RESULTS In Experiment 1, cavities were present in 95% of the animals. The duration of limb weakness and spinal cord cavity size correlated with the delivered force. The optimal force chosen for Experiment 2 was 75 kDyn. In Experiment 2, cavities occurred in 92% of the animals. Animals in the kaolin groups developed larger cavities and more vacuolations and enlarged perivascular spaces than those in the nonkaolin groups. CONCLUSIONS This impact model reliably produces cavities that resemble human posttraumatic syringomyelia and is suitable for further study of posttraumatic syringomyelia pathophysiology.
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Affiliation(s)
- Johnny H Y Wong
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Xin Song
- Centre for Advanced Imaging, University of Queensland, St. Lucia, Queensland, Australia
| | | | - Lynne E Bilston
- Neuroscience Research Australia;,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales; and
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Krebs J, Koch HG, Hartmann K, Frotzler A. The characteristics of posttraumatic syringomyelia. Spinal Cord 2015; 54:463-6. [DOI: 10.1038/sc.2015.218] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/05/2015] [Accepted: 11/11/2015] [Indexed: 11/09/2022]
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Garcia-Ovejero D, Arevalo-Martin A, Paniagua-Torija B, Florensa-Vila J, Ferrer I, Grassner L, Molina-Holgado E. The ependymal region of the adult human spinal cord differs from other species and shows ependymoma-like features. Brain 2015; 138:1583-97. [PMID: 25882650 DOI: 10.1093/brain/awv089] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/30/2015] [Indexed: 12/20/2022] Open
Abstract
Several laboratories have described the existence of undifferentiated precursor cells that may act like stem cells in the ependyma of the rodent spinal cord. However, there are reports showing that this region is occluded and disassembled in humans after the second decade of life, although this has been largely ignored or interpreted as a post-mortem artefact. To gain insight into the patency, actual structure, and molecular properties of the adult human spinal cord ependymal region, we followed three approaches: (i) with MRI, we estimated the central canal patency in 59 control subjects, 99 patients with traumatic spinal cord injury, and 26 patients with non-traumatic spinal cord injuries. We observed that the central canal is absent from the vast majority of individuals beyond the age of 18 years, gender-independently, throughout the entire length of the spinal cord, both in healthy controls and after injury; (ii) with histology and immunohistochemistry, we describe morphological properties of the non-lesioned ependymal region, which showed the presence of perivascular pseudorosettes, a common feature of ependymoma; and (iii) with laser capture microdissection, followed by TaqMan® low density arrays, we studied the gene expression profile of the ependymal region and found that it is mainly enriched in genes compatible with a low grade or quiescent ependymoma (53 genes); this region is enriched only in 14 genes related to neurogenic niches. In summary, we demonstrate here that the central canal is mainly absent in the adult human spinal cord and is replaced by a structure morphologically and molecularly different from that described for rodents and other primates. The presented data suggest that the ependymal region is more likely to be reminiscent of a low-grade ependymoma. Therefore, a direct translation to adult human patients of an eventual therapeutic potential of this region based on animal models should be approached with caution.
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Affiliation(s)
- Daniel Garcia-Ovejero
- 1 Laboratory of Neuroinflammation, Hospital Nacional de Paraplejicos (SESCAM), Toledo, Spain
| | - Angel Arevalo-Martin
- 1 Laboratory of Neuroinflammation, Hospital Nacional de Paraplejicos (SESCAM), Toledo, Spain
| | - Beatriz Paniagua-Torija
- 1 Laboratory of Neuroinflammation, Hospital Nacional de Paraplejicos (SESCAM), Toledo, Spain
| | - José Florensa-Vila
- 2 Radiology Unit, Hospital Nacional de Paraplejicos (SESCAM), Toledo, Spain
| | - Isidro Ferrer
- 3 Institut de Neuropatologia, Servei d'Anatomia Patolo`gica, IDIBELL-Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Lukas Grassner
- 4 Center for Spinal Cord Injuries, Trauma Center Murnau, Germany 5 Institute of Molecular Regenerative Medicine, SCI-TReCS (Spinal Cord Injury and Tissue Regeneration Center Salzburg), Paracelsus Medical University, Salzburg, Austria
| | - Eduardo Molina-Holgado
- 1 Laboratory of Neuroinflammation, Hospital Nacional de Paraplejicos (SESCAM), Toledo, Spain
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Post-traumatic syringomyelia: outcome predictors. Clin Neurol Neurosurg 2014; 124:44-50. [PMID: 25016238 DOI: 10.1016/j.clineuro.2014.06.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/09/2014] [Indexed: 11/22/2022]
Abstract
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 significant 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 significant 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.
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Cecchinato R, Berjano P, Damilano M, Lamartina C. Spinal osteotomies to treat post-traumatic thoracolumbar deformity. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24 Suppl 1:S31-7. [DOI: 10.1007/s00590-014-1464-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/10/2014] [Indexed: 10/25/2022]
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Shields CB, Zhang YP, Shields LBE. Post-traumatic syringomyelia: CSF hydrodynamic changes following spinal cord injury are the driving force in the development of PTSM. HANDBOOK OF CLINICAL NEUROLOGY 2013; 109:355-67. [PMID: 23098724 DOI: 10.1016/b978-0-444-52137-8.00022-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Post-traumatic syringomyelia (PTSM) is a disorder that occurs infrequently following spinal cord injury (SCI), characterized by progressive neurological deterioration resulting from syrinx expansion originating in proximity to the traumatic epicenter. Several pathogenetic factors are associated with this disorder, however, the precise mechanism of the development of PTSM is controversial. Combined anatomical alterations and molecular changes following trauma to the spinal cord and arachnoid participate in the development of this condition. These factors include narrowing or obstruction of the subarachnoid space (SAS), central canal occlusion, myelomalacia, and alterations in intramedullary water permeability. If a patient sustains a SCI with delayed progressive deterioration in neurological function, in association with the MRI appearance of syringomyelia (SM), the diagnosis of PTSM is straightforward. The treatment of PTSM has not undergone any significant changes recently. The surgical treatment of PTSM consists of reconstructing the SAS or shunting fluid away from the syrinx to other locations. The advantages and disadvantages of each procedure will be discussed. With greater understanding of the mechanisms contributing to the development of SM, including advanced diagnostic methods and further advances in the development of artificial dural and shunting tubing, future therapies of PTSM will be more effective and long-lasting. Incorporation of alterations of AQP4 expression provides an intriguing possibility for future treatment of PTSM.
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Abstract
Spinal cord injuries often occur in cases of multiple trauma, can occur alone or in combination with concomitant injuries and are mostly associated with high morbidity and mortality. They often result in lifelong impairment and need for medical care. Radiologic diagnostics are crucial in the acute setting as well as in the long-term treatment of spinal cord injuries. Besides an overview of diagnostic and therapeutic management, typical magnetic resonance imaging (MRI) findings in the acute and chronic stages of spinal cord injuries are presented in this article. Post-traumatic syringomyelia can even develop years after the initial injury of the spine or spinal cord. As syringomyelia can also occur in association with tumors, developmental anomalies and also idiopathically, a thorough MRI diagnostic is essential especially in any case of newly diagnosed syringomyelia.
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Hemley SJ, Bilston LE, Cheng S, Stoodley MA. Aquaporin-4 expression and blood–spinal cord barrier permeability in canalicular syringomyelia. J Neurosurg Spine 2012; 17:602-12. [DOI: 10.3171/2012.9.spine1265] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Noncommunicating canalicular syringomyelia occurs in up to 65% of patients with Chiari malformation Type I. The pathogenesis of this type of syringomyelia is poorly understood and treatment is not always effective. Although it is generally thought that syringomyelia is simply an accumulation of CSF from the subarachnoid space, the pathogenesis is likely to be more complex and may involve cellular and molecular processes. Aquaporin-4 (AQP4) has been implicated in numerous CNS pathological conditions involving fluid accumulation, including spinal cord edema. There is evidence that AQP4 facilitates the removal of extracellular water following vasogenic edema. The aim of this study was to investigate AQP4 expression and the structural and functional integrity of the blood–spinal cord barrier (BSCB) in a model of noncommunicating canalicular syringomyelia.
Methods
A kaolin-induced model of canalicular syringomyelia was used to investigate BSCB permeability and AQP4 expression in 27 adult male Sprague-Dawley rats. Control groups consisted of nonoperated, laminectomy-only, and saline-injected animals. The structural integrity of the BSCB was assessed using immunoreactivity to endothelial barrier antigen. Functional integrity of the BSCB was assessed by extravasation of systemically injected horseradish peroxidase (HRP) at 1, 3, 6, or 12 weeks after surgery. Immunofluorescence was used to assess AQP4 and glial fibrillary acidic protein (GFAP) expression at 12 weeks following syrinx induction.
Results
Extravasation of HRP was evident surrounding the central canal in 11 of 15 animals injected with kaolin, and in 2 of the 5 sham-injected animals. No disruption of the BSCB was observed in laminectomy-only controls. At 12 weeks the tracer leakage was widespread, occurring at every level rostral to the kaolin injection. At this time point there was a decrease in EBA expression in the gray matter surrounding the central canal from C-5 to C-7. Aquaporin-4 was expressed in gray- and white-matter astrocytes, predominantly at the glia limitans interna and externa, and to a lesser extent around neurons and blood vessels, in both control and syrinx animals. Expression of GFAP and APQ4 directly surrounding the central canal in kaolin-injected animals was variable and not significantly different from expression in controls.
Conclusions
This study demonstrated a prolonged disruption of the BSCB directly surrounding the central canal in the experimental model of noncommunicating canalicular syringomyelia. The disruption was widespread at 12 weeks, when central canal dilation was most marked. Loss of integrity of the barrier with fluid entering the interstitial space of the spinal parenchyma may contribute to enlargement of the canal and progression of syringomyelia. Significant changes in AQP4 expression were not observed in this model of canalicular syringomyelia. Further investigation is needed to elucidate whether subtle changes in AQP4 expression occur in canalicular syringomyelia.
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Affiliation(s)
- Sarah J. Hemley
- 1The Australian School of Advanced Medicine, Macquarie University
| | - Lynne E. Bilston
- 2Neuroscience Research Australia
- 3Prince of Wales Clinical School, University of New South Wales; and
| | - Shaokoon Cheng
- 2Neuroscience Research Australia
- 4School of Medical Science, University of New South Wales, Sydney, New South Wales, Australia
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Heiss JD, Snyder K, Peterson MM, Patronas NJ, Butman JA, Smith RK, Devroom HL, Sansur CA, Eskioglu E, Kammerer WA, Oldfield EH. Pathophysiology of primary spinal syringomyelia. J Neurosurg Spine 2012; 17:367-80. [PMID: 22958075 PMCID: PMC3787878 DOI: 10.3171/2012.8.spine111059] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECT The pathogenesis of syringomyelia in patients with an associated spinal lesion is incompletely understood. The authors hypothesized that in primary spinal syringomyelia, a subarachnoid block effectively shortens the length of the spinal subarachnoid space (SAS), reducing compliance and the ability of the spinal theca to dampen the subarachnoid CSF pressure waves produced by brain expansion during cardiac systole. This creates exaggerated spinal subarachnoid pressure waves during every heartbeat that act on the spinal cord above the block to drive CSF into the spinal cord and create a syrinx. After a syrinx is formed, enlarged subarachnoid pressure waves compress the external surface of the spinal cord, propel the syrinx fluid, and promote syrinx progression. METHODS To elucidate the pathophysiology, the authors prospectively studied 36 adult patients with spinal lesions obstructing the spinal SAS. Testing before surgery included clinical examination; evaluation of anatomy on T1-weighted MRI; measurement of lumbar and cervical subarachnoid mean and pulse pressures at rest, during Valsalva maneuver, during jugular compression, and after removal of CSF (CSF compliance measurement); and evaluation with CT myelography. During surgery, pressure measurements from the SAS above the level of the lesion and the lumbar intrathecal space below the lesion were obtained, and cardiac-gated ultrasonography was performed. One week after surgery, CT myelography was repeated. Three months after surgery, clinical examination, T1-weighted MRI, and CSF pressure recordings (cervical and lumbar) were repeated. Clinical examination and MRI studies were repeated annually thereafter. Findings in patients were compared with those obtained in a group of 18 healthy individuals who had already undergone T1-weighted MRI, cine MRI, and cervical and lumbar subarachnoid pressure testing. RESULTS In syringomyelia patients compared with healthy volunteers, cervical subarachnoid pulse pressure was increased (2.7 ± 1.2 vs 1.6 ± 0.6 mm Hg, respectively; p = 0.004), pressure transmission to the thecal sac below the block was reduced, and spinal CSF compliance was decreased. Intraoperative ultrasonography confirmed that pulse pressure waves compressed the outer surface of the spinal cord superior to regions of obstruction of the subarachnoid space. CONCLUSIONS These findings are consistent with the theory that a spinal subarachnoid block increases spinal subarachnoid pulse pressure above the block, producing a pressure differential across the obstructed segment of the SAS, which results in syrinx formation and progression. These findings are similar to the results of the authors' previous studies that examined the pathophysiology of syringomyelia associated with obstruction of the SAS at the foramen magnum in the Chiari Type I malformation and indicate that a common mechanism, rather than different, separate mechanisms, underlies syrinx formation in these two entities. Clinical trial registration no.: NCT00011245.
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Affiliation(s)
- John D Heiss
- National Institute of Neurological Disorders and Stroke, Surgical Neurology Branch, National Institute of Health, Bethesda, Maryland, USA.
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Caremel R, Hamel O, Gerardin E, Lenormand L, Parker F, Lefort M, Grise P, Perrouin-Verbe B. [Post-traumatic syringomyelia: What should know the urologist?]. Prog Urol 2012; 23:8-14. [PMID: 23287478 DOI: 10.1016/j.purol.2012.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 08/27/2012] [Accepted: 09/08/2012] [Indexed: 11/26/2022]
Abstract
The incidence of post-traumatic syringomyelia (PTS) is estimated according to recent studies at 25 to 30% of patients with traumatic spinal cord injuries in magnetic resonance imaging (MRI), which remains the gold standard exam for syringomyelia diagnosis and monitoring. Syringomyelia is translated by an increased cord signal (similar to CSF) with low-density T1-weighted image and high-density T2-weighted image, which extends beyond site of initial lesion at least to two vertebral segments. Two conditions are required for development of PTS: traumatic spinal cord injury and blocked the flow of CSF epidural. The mean interval from spinal cord injury to diagnosis SPT was 2.8years (range, 3months to 34years). The commonest symptoms are pain and sensory loss. PTS should be suspected if the patient has new neurological symptoms above level of injury, such as dissociated sensory injuries, reflexes abolition, and motor deficit, after the neural function becomes stable for certain time. In urologic practice, new neurological symptoms could be bladder and/or erectile dysfunction. The medical management based on prevention efforts with closed-glottis pushing, which could aggravate the syrinx cavity. In urology, extracorporeal shockwave lithotripsy, and laparoscopic or robotic surgery could extend the syrinx cavity for the same reason (increase abdominal pressure). The indications for surgical intervention and optimal surgical treatment technique for patients with PTS are not consensual. The literature demonstrated that surgery PTS is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes.
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Affiliation(s)
- R Caremel
- Service d'urologie, hôpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France.
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Wong J, Hemley S, Jones N, Cheng S, Bilston L, Stoodley M. Fluid Outflow in a Large-Animal Model of Posttraumatic Syringomyelia. Neurosurgery 2012; 71:474-80; discussion 480. [DOI: 10.1227/neu.0b013e31825927d6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ko HY, Kim W, Kim SY, Shin MJ, Cha YS, Chang JH, Shin YB. Factors associated with early onset post-traumatic syringomyelia. Spinal Cord 2012; 50:695-8. [PMID: 22487955 DOI: 10.1038/sc.2012.35] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES To identify factors associated with the development of early onset post-traumatic syringomyelia within 5 years of spinal cord injury. SETTING Department of Rehabilitation Medicine, Pusan National University School of Medicine, Korea. METHODS We retrospectively examined the records of 502 patients with traumatic cervical or thoracic spinal cord injury who underwent follow-up magnetic resonance imaging (MRI) examinations more than once a year for at least 5 years. Patients were assessed in terms of the neurological level of injury, the severity of initial spinal cord injury, the use of surgery and the extent of spinal canal involvement. The latter was evaluated by calculating the shortest antero-posterior diameter of the injured vertebral canal and the spinal reserve capacity as shown on MRI at the time of trauma onset and at the time of diagnosis of syringomyelia. RESULTS Syringomyelia developed within 5 years in 37 (7.3%) of the 502 patients. The mean age of these 37 patients was 44.6 years (range, 17-67 years) and the mean interval from spinal cord injury to onset of syringomyelia was 38.8 months (range, 2-54 months). The development of post-traumatic syringomyelia within 5 years was not significantly related to the severity or level of injury, the use of spinal surgery or the extent of spinal canal encroachment (P≥0.05 for each comparison). CONCLUSION Early onset syringomyelia occurring within 5 years after spinal cord injury was not associated with neurological injury level, severity of injury, the use of spinal surgery or canal encroachment.
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Affiliation(s)
- H-Y Ko
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Beomeo, Mulgeum, Yangsan, Korea.
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Abstract
Study Design Prospective, randomized, controlled human study. Purpose We checked the proportion of missed syrinx diagnoses among the examinees of the Korean military conscription. Overview of Literature A syrinx is a fluid-filled cavity within the spinal cord or brain stem and causes various neurological symptoms. A syrinx could easily be diagnosed by magnetic resonance image (MRI), but missed diagnoses seldom occur. Methods In this study, we reviewed 103 cases using cervical images, cervical MRI, or whole spine sagittal MRI, and syrinxes was observed in 18 of these cases. A review of medical certificates or interviews was conducted, and the proportion of syrinx diagnoses was calculated. Results The proportion of syrinx diagnoses was about 66.7% (12 cases among 18). Missed diagnoses were not the result of the length of the syrinx, but due to the type of image used for the initial diagnosis. Conclusions The missed diagnosis proportion of the syrinx is relatively high, therefore, a more careful imaging review is recommended.
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Chandra J, Sheerin F, Lopez de Heredia L, Meagher T, King D, Belci M, Hughes RJ. MRI in acute and subacute post-traumatic spinal cord injury: pictorial review. Spinal Cord 2011; 50:2-7. [PMID: 22064660 DOI: 10.1038/sc.2011.107] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Pictorial review. OBJECTIVES To illustrate MRI signs of acute and subacute injury with emphasis on evidence-based links to clinical outcome and implications for treatment. METHODS Description of important aspects of MRI techniques and illustration of critical MRI signs important in the assessment of spinal cord injury following trauma, in the acute and subacute stages. CONCLUSIONS Familiarity with cord MRI appearances has an important impact on planning the management of the acutely spinal cord injured patient and also identifying complications in the subacute phase particularly in the presence of neurological deterioration.
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Affiliation(s)
- J Chandra
- Department of Neuroradiology, John Radcliffe Hospital, Oxford, UK
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Morisako H, Takami T, Yamagata T, Chokyu I, Tsuyuguchi N, Ohata K. Focal adhesive arachnoiditis of the spinal cord: Imaging diagnosis and surgical resolution. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2011; 1:100-6. [PMID: 21572630 PMCID: PMC3075825 DOI: 10.4103/0974-8237.77673] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Although adhesive arachnoiditis of the spinal cord can cause progressive symptoms associated with syringomyelia or myelomalacia, its surgical resolution based on the imaging diagnosis is not well characterized. This study aims to describe the use of imaging for the diagnosis of focal adhesive arachnoiditis of the spinal cord and its surgical resolution using microsurgical arachnoidolysis. Materials and Methods: Four consecutive patients with symptomatic syringomyelia or myelomalacia caused by focal adhesive arachnoiditis underwent microsurgical arachnoidolysis. Comprehensive imaging evaluation using constructive interference in steady-state (CISS) magnetic resonance imaging (MRI) or myelographic MR imaging using true fast imaging with steady-state precession (TrueFISP) sequences was included before surgery to determine the surgical indication. Results: In all four patients a focal adhesion was identified at the cervical or thoracic level of the spinal cord, a consequence of infection or trauma. Three patients showed modest or minor improvement in neurological function, and one patient was unchanged after surgery. The syringomyelia or myelomalacia resolved after surgery and no recurrence was noted within the follow-up period, which ranged from 5 months to 30 months. Conclusions: MRI diagnosis of focal adhesive arachnoiditis is critical to determine the surgical indication. Microsurgical arachnoidolysis appears to be a straightforward method for stabilizing the progressive symptoms, though the procedure is technically demanding.
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Affiliation(s)
- Hiroki Morisako
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Buchowski JM, Bridwell KH, Lenke LG. Management of Posttraumatic Kyphosis After Thoracolumbar Injuries. ACTA ACUST UNITED AC 2010. [DOI: 10.1053/j.semss.2009.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Byun MS, Shin JJ, Hwang YS, Park SK. Decompressive surgery in a patient with posttraumatic syringomyelia. J Korean Neurosurg Soc 2010; 47:228-31. [PMID: 20379479 DOI: 10.3340/jkns.2010.47.3.228] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 07/03/2009] [Accepted: 01/12/2010] [Indexed: 11/27/2022] Open
Abstract
Posttraumatic syringomyelia may result from a variety of inherent conditions and traumatic events, or from some combination of these. Many hypotheses have arisen to explain this complex disorder, but no consensus has emerged. A 28-year-old man presented with progressive lower extremity weakness, spasticity, and decreased sensation below the T4 dermatome five years after an initial trauma. Magnetic resonance imaging (MRI) revealed a large, multi-septate syrinx cavity extending from C5 to L1, with a retropulsed bony fragment of L2. We performed an L2 corpectomy, L1-L3 interbody fusion using a mesh cage and screw fixation, and a wide decompression and release of the ventral portion of the spinal cord with an operating microscope. The patient showed complete resolution of his neurological symptoms, including the bilateral leg weakness and dysesthesia. Postoperative MRI confirmed the collapse of the syrinx and restoration of subarachnoid cerebrospinal fluid (CSF) flow. These findings indicate a good correlation between syrinx collapse and symptomatic improvement. This case showed that syringomyelia may develop through obstruction of the subarachnoid CSF space by a bony fracture and kyphotic deformity. Ventral decompression of the obstructed subarachnoid space, with restoration of spinal alignment, effectively treated the spinal canal encroachment and post-traumatic syringomyelia.
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Affiliation(s)
- Min Seok Byun
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Putz C, Wiedenhöfer B, Gerner HJ, Hüttinger K, Fürstenberg CH. Spinal Fusion of an Unstable Atlantoaxial Fracture in a Completely Tetraplegic Patient Using Silicate-Substituted Calcium Phosphate. Eur J Trauma Emerg Surg 2010; 36:169-75. [PMID: 26815693 DOI: 10.1007/s00068-009-8068-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 12/27/2008] [Indexed: 11/24/2022]
Abstract
Bone graft harvesting from the iliac crest constitutes the gold standard in spinal surgery due to its osteogenic, osteoconductive and osteoinductive properties. Large amounts of autograft can provoke complications like donor site morbidity, pain and the need for a second operation. Therefore, research into bone graft substitutes is of great interest. Silicate-substituted calcium phosphate (Actifuse(TM) Synthetic Bone Graft, ApaTech Ltd, London) was used in combination with morselized corticocancellous graft in a transarticular stabilization (modified Magerl) of a completely tetraplegic patient with an unstable atlantoaxial fracture. Computed tomography showed bone bridging between the segment C1/C2, the surface of the implant and the remodeled bone at follow-up at 8 months. The use of silicate-substituted calcium phosphate as a bone graft extender in spinal surgery could be an alternative to autografting from the iliac crest. Vegetative symptoms are often underestimated but can be triggered by donor site morbidity or pain in patients after spinal cord injury.
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Affiliation(s)
- Cornelia Putz
- Orthopedic University Hospital Heidelberg, Heidelberg, Germany. .,Orthopedic University Hospital Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany.
| | | | - Hans J Gerner
- Orthopedic University Hospital Heidelberg, Heidelberg, Germany
| | - Karl Hüttinger
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, USA
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Martin BA, Loth F. The influence of coughing on cerebrospinal fluid pressure in an in vitro syringomyelia model with spinal subarachnoid space stenosis. Cerebrospinal Fluid Res 2009; 6:17. [PMID: 20043856 PMCID: PMC2806373 DOI: 10.1186/1743-8454-6-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 12/31/2009] [Indexed: 01/30/2023] Open
Abstract
Background The influence of coughing, on the biomechanical environment in the spinal subarachnoid space (SAS) in the presence of a cerebrospinal fluid flow stenosis, is thought to be an important etiological factor in craniospinal disorders, including syringomyelia (SM), Chiari I malformation, and hydrocephalus. The aim of this study was to investigate SAS and syrinx pressures during simulated coughing using in vitro models and to provide information for the understanding of the craniospinal fluid system dynamics to help develop better computational models. Methods Four in vitro models were constructed to be simplified representations of: 1) non-communicating SM with spinal SAS stenosis; 2) non-communicating SM due to spinal SAS stenosis with a distensible spinal column; 3) non-communicating SM post surgical removal of a spinal SAS stenosis; and 4) a spinal SAS stenosis due to spinal trauma. All of the models had a flexible spinal cord. To simulate coughing conditions, an abrupt CSF pressure pulse (~ 5 ms) was imposed at the caudal end of the spinal SAS by a computer-controlled pump. Pressure measurements were obtained at 4 cm intervals along the spinal SAS and syrinx using catheter tip transducers. Results Pressure measurements during a simulated cough, showed that removal of the stenosis was a key factor in reducing pressure gradients in the spinal SAS. The presence of a stenosis resulted in a caudocranial pressure drop in the SAS, whereas pressure within the syrinx cavity varied little caudocranially. A stenosis in the SAS caused the syrinx to balloon outward at the rostral end and be compressed at the caudal end. A >90% SAS stenosis did not result in a significant Venturi effect. Increasing compliance of the spinal column reduced forces acting on the spinal cord. The presence of a syrinx in the cord when there was a stenosis in the SAS, reduced pressure forces in the SAS. Longitudinal pressure dissociation acted to suck fluid and tissue caudocranially in the SAS with a stenosis. Conclusions Pressures in the spinal SAS during a simulated cough in vitro had similar peak, transmural, and longitudinal pressures to in vivo measurements reported in the literature. The pressure wave velocities and pressure gradients during coughing (longitudinal pressure dissociation and transmural pressure) were impacted by alterations in geometry, compliance, and the presence of a syrinx and/or stenosis.
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Affiliation(s)
- Bryn A Martin
- Ecole Polytechnique Fédérale de Lausanne, Integrative Bioscience Institute, Laboratory of Hemodynamics and Cardiovascular Technology, Lausanne, Switzerland
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Chronic neuropathic pain in spinal cord injured patients: What is the effectiveness of surgical treatments excluding central neurostimulations? Ann Phys Rehabil Med 2009; 52:194-202. [PMID: 19909710 DOI: 10.1016/j.rehab.2008.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 12/17/2008] [Indexed: 11/23/2022]
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Post-traumatic syringomyelia producing paraplegia in an infant. Childs Nerv Syst 2008; 24:357-60; discussion 361-4. [PMID: 18026959 DOI: 10.1007/s00381-007-0531-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Post-traumatic syringomyelia is described in adults after spinal trauma but extremely rarely seen in children, especially in the first year of life. MATERIALS AND METHODS We describe a boy who, at the age of 7 months, suffered spinal trauma during a car accident when he was held at his mother's lap and suffered extreme flexion of his torso. He suffered a mid-shaft fracture of his right femur, treated with hip spica for 6 weeks. After removal of the spica, it was noticed that he was not moving his legs, but he had preserved pain sensation in the lower half of his trunk and legs. A spine magnetic resonance scan performed 2 months after the injury showed a compressed wedge fracture of the body of T5 vertebra, kyphosis and a large syringomyelia cavity extending from T4 to T8. He had two operations to control the syringomyelia with laminotomy-laminoplasty, dissection of the arachnoid adhesions initially and drainage of the cavity on the second operation, with only modest success. He remains paraplegic 7 years after the injury. He has received thoracic brace immediately after the first spinal operation, which avoided kyphosis. DISCUSSION Spinal trauma is rare in the first year of life; hence, post-traumatic syringomyelia is very rarely seen in infants. Nevertheless, it should be suspected after a major trauma, in the presence of paraplegia. Surgical treatment of post-traumatic syringomyelia in young children has the additional consideration of post-laminotomy kyphosis; hence, thoracic brace should be used early.
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Lewis PB, Rue JP, Byrne R, Capiola D, Steiner M, Bach BR. Cervical syrinx as a cause of shoulder pain in 2 athletes. Am J Sports Med 2008; 36:169-72. [PMID: 17873154 DOI: 10.1177/0363546507307401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Paul B Lewis
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
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Radojicic M, Nistor G, Keirstead HS. Ascending central canal dilation and progressive ependymal disruption in a contusion model of rodent chronic spinal cord injury. BMC Neurol 2007; 7:30. [PMID: 17822568 PMCID: PMC2018707 DOI: 10.1186/1471-2377-7-30] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 09/07/2007] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Chronic spinal cord injury (SCI) can lead to an insidious decline in motor and sensory function in individuals even years after the initial injury and is accompanied by a slow and progressive cytoarchitectural destruction. At present, no pathological mechanisms satisfactorily explain the ongoing degeneration. METHODS Adult female Sprague-Dawley rats were anesthetized laminectomized at T10 and received spinal cord contusion injuries with a force of 250 kilodynes using an Infinite Horizon Impactor. Animals were randomly distributed into 5 groups and killed 1 (n = 4), 28 (n = 4), 120 (n = 4), 450 (n = 5), or 540 (n = 5) days after injury. Morphometric and immunohistochemical studies were then performed on 1 mm block sections, 6 mm cranial and 6 mm caudal to the lesion epicenter. The SPSS 11.5 t test was used to determine differences between quantitative measures. RESULTS Here, we document the first report of an ascending central canal dilation and progressive ependymal disruption cranial to the epicenter of injury in a contusion model of chronic SCI, which was characterized by extensive dural fibrosis and intraparenchymal cystic cavitation. Expansion of the central canal lumen beyond a critical diameter corresponded with ependymal cell ciliary loss, an empirically predictable thinning of the ependymal region, and a decrease in cell proliferation in the ependymal region. Large, aneurysmal dilations of the central canal were accompanied by disruptions in the ependymal layer, periependymal edema and gliosis, and destruction of the adjacent neuropil. CONCLUSION Cells of the ependymal region play an important role in CSF homeostasis, cellular signaling and wound repair in the spinal cord. The possible effects of this ascending pathology on ependymal function are discussed. Our studies suggest central canal dilation and ependymal region disruption as steps in the pathogenesis of chronic SCI, identify central canal dilation as a marker of chronic SCI and provide novel targets for therapeutic intervention.
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Affiliation(s)
- Milan Radojicic
- Reeve-Irvine Research Center, Department of Anatomy and Neurobiology, University of California at Irvine, 2111 Gillespie Neuroscience Research Facility, Irvine, CA, 92697-4292, USA
- 4000 Civic Center Drive, Suite 206, San Rafael, CA 94903, USA
| | - Gabriel Nistor
- Reeve-Irvine Research Center, Department of Anatomy and Neurobiology, University of California at Irvine, 2111 Gillespie Neuroscience Research Facility, Irvine, CA, 92697-4292, USA
| | - Hans S Keirstead
- Reeve-Irvine Research Center, Department of Anatomy and Neurobiology, University of California at Irvine, 2111 Gillespie Neuroscience Research Facility, Irvine, CA, 92697-4292, USA
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Abstract
BACKGROUND/OBJECTIVE Syringomyelia is characterized by a fluid-filled cavity within the spinal cord. While its pathogenesis is currently debated, the relationship of syringomyelia with other conditions, such as Chiari I malformation and cord/column trauma, is well accepted. Despite these common associations, a nidus for syrinx formation has not been identified in a subset of patients. We report 2 patients with idiopathic cervicothoracic syringomyelia who presented with progressive neurologic dysfunction. Diagnostic and treatment algorithms used in the care of these patients are presented. METHODS Retrospective review, including preoperative and postoperative studies, intraoperative findings, and the patients' surgical outcomes. RESULTS Patients underwent laminectomy, lysis of adhesions, untethering of spinal cord, fenestration of syrinx, and duraplasty after preoperative studies demonstrated evidence of focal cerebrospinal fluid flow block at the level of the syrinx. One patient's neurologic condition improved after surgery, whereas the other's remained unchanged without further deterioration; both showed radiographic decrease in the syrinx on immediate postoperative magnetic resonance imaging. CONCLUSIONS These 2 cases illustrate patients who develop a cervicothoracic syrinx in the absence of any trauma, infection, previous manipulation of the neuraxis, or malformations known to be associated with a syringomyelia. Whereas there is no consensus on the optimal management of these patients, the patients reported here experienced arrest in deterioration or improvement of their neurologic examination, making the identification of this condition important as a potentially reversible cause of neurologic deficits. Long-term follow-up is required to determine the efficacy, durability, and lifestyle impact of the procedure.
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Affiliation(s)
- Paul Porensky
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, 675 N. Clair Street, Suite 20-250, Chicago, IL 60611, USA.
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Attal N, Bouhassira D. Chapter 47 Pain in syringomyelia/bulbia. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:705-713. [PMID: 18808869 DOI: 10.1016/s0072-9752(06)80051-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Schmidt BJ. Subacute delayed ascending myelopathy after low spine injury: case report and evidence of a vascular mechanism. Spinal Cord 2005; 44:322-5. [PMID: 16172631 DOI: 10.1038/sj.sc.3101801] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Case report of a patient with subacute delayed myelopathy after an acute low thoracic spine injury. OBJECTIVES To draw awareness to a rarely described complication with potential to add devastating neurological insult to the original spinal cord injury, and to discuss evidence supporting a vascular mechanism. SETTING Health Science Centre, Winnipeg, Manitoba, Canada. CASE REPORT A 35-year-old woman developed clinical and MRI evidence of ascending myelopathy, extending up to C5, 16 days after a T11/12 fracture dislocation. The distribution of MRI signal abnormality, MRI evidence of prominent venous markings, and association with upright mobilization and the wearing of a thoraco-lumbo-sacral orthosis, suggest that elevated spinal venous pressure in conjunction with low arterial pressure may have induced impaired spinal cord vascular perfusion. CONCLUSION After recent spinal cord injury, factors exacerbating spinal venous hypertension and/or arterial hypotension may in some patients lead to impaired spinal cord perfusion. These factors should be considered and corrected if symptoms or signs of progressive myelopathy emerge in the first few days or weeks after injury.
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Affiliation(s)
- B J Schmidt
- Section of Neurology, Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Carroll AM, Brackenridge P. Post-traumatic syringomyelia: a review of the cases presenting in a regional spinal injuries unit in the north east of England over a 5-year period. Spine (Phila Pa 1976) 2005; 30:1206-10. [PMID: 15897837 DOI: 10.1097/01.brs.0000162277.76012.0b] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of the management of patients with a confirmed diagnosis of post-traumatic syringomyelia (PTS) in a regional spinal injuries unit. OBJECTIVES To investigate the incidence of PTS in a regional spinal injuries unit, and to assess mode of presentation, management, and subsequent outcome. SUMMARY OF BACKGROUND DATA Majority of patients male, mean age 44 years (range 33-60 years), with thoracic spinal cord injury (SCI). Most PTS developed within 5 years after injury (range 6 months to 25 years) and presented with reduced sensation. Fifty percent had surgical intervention at the time of SCI, and 50% managed conservatively. Four patients had additional spinal injury pathology not corrected at time of surgery. METHODS Retrospective analysis of the case notes of all patients with a confirmed diagnosis of PTS (n = 16). Demographic details obtained and details of the original injury and subsequent clinical course and management noted. RESULTS Incidence of PTS = 0.02%. Magnetic resonance imaging scanning performed in 56% with PTS. The majority of PTS developed around the site of the original lesion. The most common method of management was insertion of a syringoperitoneal shunt (44%). Thirty-one percent improved after surgery, 31% remain stable. One patient died. The symptoms of 3 patients continue to deteriorate slowly despite surgical intervention. CONCLUSIONS Incidence of PTS are lower in our study than that quoted in the literature. Benefits of initial surgical management of SCI in reducing development of PTS are unclear. Benefits of surgical management of PTS are unclear. Additional studies are required as this may influence future management of spinal cord injured patients.
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Affiliation(s)
- Aine M Carroll
- Hexham Spinal Injuries Unit, Hexham General Hospital, Hexham, Northumberland, United Kingdom.
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Mesrati F, Vecchierini MF. F-waves: neurophysiology and clinical value. Neurophysiol Clin 2004; 34:217-43. [PMID: 15639131 DOI: 10.1016/j.neucli.2004.09.005] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Accepted: 09/06/2004] [Indexed: 10/26/2022] Open
Abstract
This review deals with F responses, which are late responses obtained by supramaximal stimulation of virtually all the motor and mixed peripheral nerves. They are recorded over a muscle innervated by the stimulated nerve. The first description of F-waves was published in the fifties. Their neurophysiological mechanisms have been abundantly discussed in the literature leading to a current consensus, whereby F-waves are considered as antidromic responses produced by a pool of motoneurons activated by peripheral nerve stimulation. In the first part of this review, the neurophysiological mechanisms of F-waves as well as the distinction between these and H reflexes are described from a historical point of view. Other late responses are intentionally not reported; nevertheless A-waves are discussed since they are frequently ill-described in a number of conditions. Stimulation and recording procedures as well as F-wave parameters analysis are detailed, with emphasis on measures most useful for clinical purposes. A rigorous F-wave recording method is mandatory for reliable and meaningful analyses. Physiological factors, which influence F-waves such as ageing, drugs and sleep, must be known and their effects discussed. Also, as maturation is an important factor in clinical neurophysiology, data on F-wave ontogenesis are reviewed and discussed. Finally, the different F-wave alterations described so far in the literature, in either peripheral or central disorders, are listed and commented. It is emphasised that F-waves are particularly useful for the diagnosis of polyneuropathies at a very early stage and for the diagnosis of proximal nerve lesions. F-wave recording is indeed one of the rare methods in routine examination allowing at the same time the functional assessment of motor fibres on their proximal segment, and contributing to the evaluation of motoneuronal excitability.
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Affiliation(s)
- F Mesrati
- Service de physiologie, Laboratoire d'explorations fonctionnelles, Groupe hospitalier Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France
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Yamazaki T, Yanaka K, Uemura K, Tsukada A. Subdural Hematoma Caused by Intracranial Hypotension After Syringosubarachnoid Shunting-Case Report-. Neurol Med Chir (Tokyo) 2004; 44:475-8. [PMID: 15600282 DOI: 10.2176/nmc.44.475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 32-year-old man developed an extremely rare subdural hematoma after syringosubarachnoid shunting for syringomyelia. He presented with a 4-year history of neck pain and spastic paraparesis resulting from T-7 and T-8 vertebral body fracture suffered in a traffic accident at age 22 years. Magnetic resonance imaging revealed syringomyelia between the craniocervical junction and the T-10 level. The symptoms were slowly progressive, and a syringosubarachnoid shunting was performed. His spasticity improved after surgery, but he developed orthostatic headache 7 days after surgery. Magnetic resonance imaging of the brain demonstrated a thin subdural hematoma over the right cerebral convexity. The subdural hematoma resolved spontaneously within a week with conservative treatment. Vigorous cerebrospinal fluid outflow observed during surgery presumably lowered the pressure in the syrinx cavity, leading to significant but transient intracranial hypotension and consequently the formation of subdural hematoma.
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Affiliation(s)
- Tomosato Yamazaki
- Department of Neurosurgery, Kennan Hospital, Tsuchiura, Ibaraki, Japan.
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Abstract
More than a quarter of spinal cord injured patients develop syringes and many of these patients suffer progressive neurological deficits as a result of cyst enlargement. The mechanism of initial cyst formation and progressive enlargement are unknown, although arachnoiditis and persisting cord compression with disturbance of cerebrospinal fluid flow appear to be important aetiological factors. Current treatment options include correction of bony deformity, decompression of the spinal cord, division of adhesions, and shunting. Long-term improvement occurs in fewer than half of patients treated. Imaging evidence of a reduction in syrinx size following treatment does not guarantee symptomatic resolution or even prevention of further neurological loss. A better understanding of the causal mechanisms of syringomyelia is required to develop more effective therapy.
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Affiliation(s)
- A R Brodbelt
- Prince of Wales Medical Research Institute, University of New South Wales, NSW, Randwick, Australia
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Lee TT, Alameda GJ, Camilo E, Green BA. Surgical treatment of post-traumatic myelopathy associated with syringomyelia. Spine (Phila Pa 1976) 2001; 26:S119-27. [PMID: 11805618 DOI: 10.1097/00007632-200112151-00020] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Evaluate the clinical outcome of surgical intervention for post-traumatic syringomyelia. INTRODUCTION Progressive post-traumatic cystic myelopathy (PPCM), or syringomyelia, can occur after spinal cord injury. The authors present their surgical treatment protocol and treatment outcome of a series of patients with post-traumatic syringomyelia. METHODS The medical records of 53 patients with PPCM undergoing surgical treatment were reviewed. Laminectomies and intraoperative ultrasonography were performed. For patients with no focal tethering and only a confluent cyst on ultrasonography, a syringosubarachnoid shunt (stent) was inserted. For patients with both tethering and a confluent cord cyst, an untethering procedure was performed first. When a cyst showed significant size reduction (>50%) after untethering, no shunt was placed. When the cyst size persisted on ultrasonographic images, a short syringosubarachnoid shunt was used. The mean follow-up was 23.9 months for the 45 patients available for follow-up (range 12-102 months). RESULTS The interval between the causative event and the operation was from 5 months to 37 years (mean 6.5 years). Pain was the most frequent manifestation, followed by motor deterioration and spasticity. Postoperative improvements in >50% of the patients were noted in those presenting with worsening motor function or spasticity. In 19 of 28 patients with associated tethered spinal cord, untethering alone caused significant collapse of the cyst. Postoperative MRI demonstrated cyst collapse in 95% of the patients with untethering alone and 93% of the patients with a syringosubarachnoid shunt. CONCLUSION Post-traumatic syringomyelia can occur with or without cord tethering. Untethering alone for patients with cord tethering and cyst formation can reduce cyst size and alleviate the symptoms and signs of syringomyelia in the majority of these cases. Untethering with expansion of subarachnoid space with an expansile duraplasty may be a more physiologic way of treating a tethered cord with associated syringomyelia, i.e., treating the cause rather than the result.
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Affiliation(s)
- T T Lee
- Department of Neurological Surgery, University of Miami School of Medicine, 1095 NW 14th Terrace, D4-6, Miami, Florida 33136, USA.
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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; 82:1633-6. [PMID: 11689987 DOI: 10.1053/apmr.2001.25075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To investigate the long-term effects of shunting on neurologic outcome of syringomyelia, a complication of spinal cord injury (SCI). DESIGN Retrospective data collection using telephonic survey. SETTING University based medical center. PARTICIPANTS Eight of 15 patients who had shunts placed between 1976 and 1999. INTERVENTIONS Review of clinical records and self-reported telephone interview. MAIN OUTCOMES MEASURES Initial clinical presentation, recovery after shunt placement, and subsequent neurologic status were recorded. Patients were asked to rate symptomatic improvement after surgery on a 100-point analog scale; they were also asked whether they would have the surgery again. RESULTS Presenting symptoms were weakness in all 8 patients, pain in 5 patients, and numbness in 5 patients. After shunting, 6 patients had improved strength, all had less pain, and 2 had less numbness. Six patients experienced neurologic decline an average of 2 years after shunt placement, 3 because of shunt failure, 2 from a new syrinx, and 1 from both shunt failure and new syrinx. Two of the 3 patients who underwent second shunt placements for a new syrinx had full neurologic recovery. Six patients said they would repeat the shunting procedure if necessary, 1 was uncertain, and 1 would not. CONCLUSION Initial improvements noted after shunting provide long-lasting effects, even though many patients may need a second procedure. Less pain and improved strength are more significant than decreased numbness.
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Affiliation(s)
- M J Hess
- Department of Spinal Cord Injury, Boston Healthcare VA Medical Center, West Roxbury, MA 02132, USA
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Wirth ED, Reier PJ, Fessler RG, Thompson FJ, Uthman B, Behrman A, Beard J, Vierck CJ, Anderson DK. Feasibility and safety of neural tissue transplantation in patients with syringomyelia. J Neurotrauma 2001; 18:911-29. [PMID: 11565603 DOI: 10.1089/089771501750451839] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Transplantation of fetal spinal cord (FSC) tissue has demonstrated significant potential in animal models for achieving partial anatomical and functional restoration following spinal cord injury (SCI). To determine whether this strategy can eventually be translated to humans with SCI, a pilot safety and feasibility study was initiated in patients with progressive posttraumatic syringomyelia (PPTS). A total of eight patients with PPTS have been enrolled to date, and this report presents findings for the first two patients through 18 months postoperative. The study design included detailed assessments of each subject at multiple pre- and postoperative time points. Outcome data were then compared with each subject's own baseline. The surgical protocol included detethering, cyst drainage, and implantation of 6-9-week postconception human FSC tissue. Immunosuppression with cyclosporine was initiated a few days prior to surgery and continued for 6 months postoperatively. Key outcome measures included: serial magnetic resonance imaging (MRI) exams, standardized measures of neurological impairment and functional disability, detailed pain assessment, and extensive neurophysiological testing. Through 18 months, the first two patients have been stable neurologically and the MRIs have shown evidence of solid tissue at the graft sites, without evidence of donor tissue overgrowth. Although it is still too soon to draw any firm conclusions, the findings from the initial two patients in this study suggest that intraspinal grafting of human FSC tissue is both feasible and safe.
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Affiliation(s)
- E D Wirth
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, USA.
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Abstract
OBJECTIVES Syringomyelia may present with confusing, unilateral patterns of segmental muscle involvement and dissociated sensory loss. The objective of this study was to report a patient with Chiari malformation type 1 (CM1) and syringomyelia who had an unusual presentation suggesting ulnar neuropathy at the elbow. RESULTS A 24-year-old woman presented with clinical evidence of ulnar neuropathy at the elbow except that there was disproportionate abductor digiti mini (ADM) atrophy and weakness, equivocal ipsilateral abductor pollicis brevis weakness and hyporeflexia in both arms. Nerve conduction studies revealed marked amplitude reduction of the left ulnar ADM-compound muscle action potential (ADM-CMAP) with a normal first dorsal interosseous-CMAP amplitude, no focal slowing or conduction block, and a normal ulnar sensory response amplitude. Electromyography (EMG) showed multi-segmental, left C7-T1 fibrillations and chronic reinnervation changes. Magnetic resonance imaging (MRI) of the cervical spine demonstrated CM1 and syringomyelia. CONCLUSIONS Syringomyelia may clinically mimic ulnar neuropathy at the elbow.
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Affiliation(s)
- S N Scelsa
- Department of Neurology, Beth Israel Medical Center, NY, New York, USA.
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Nagai M, Sakuma R, Aoki M, Abe K, Itoyama Y. Familial spinal arachnoiditis with secondary syringomyelia: clinical studies and MRI findings. J Neurol Sci 2000; 177:60-4. [PMID: 10967183 DOI: 10.1016/s0022-510x(00)00338-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We report the clinical and MRI findings of two patients with familial spinal arachnoiditis. Although their initial symptoms were various, they both showed spastic paraparesis and sensory disturbance below the thoracic level. Cytokines and WBC in the CSF were studied, but they were not elevated at all. The spinal magnetic resonance images of each showed extensive arachnoiditis and a cystic structure. The other impressive features included: (i) an enhancement within the thickened arachnoid and an adhesion between the spinal cord and the dura mater, (ii) deformation of the thoracic cord where the arachnoid adhered, and (iii) secondary syrinx formation. Laminectomy may have an adverse outcome for such patients.
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Affiliation(s)
- M Nagai
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, 980-8574, Sendai, Japan.
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Affiliation(s)
- E Belanger
- Department of Neurosurgery and the Miami Project to Cure Paralysis, University of Miami, FL 33136, USA
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