Treatment of syringomyelia associated with arachnoid scarring caused by arachnoiditis or trauma

Abstract

The authors conducted a retrospective study of 107 patients treated for syringomyelia associated with arachnoid scarring between 1976 and 1995 at the Departments of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, and the University of California in Los Angeles, California. Twenty-nine patients have not been surgically treated to date because of their stable neurological status. Seventy-eight patients with progressive neurological deficits underwent a total of 121 surgical procedures and were followed for a mean period of 32 (+/- 37) months. All patients demonstrated arachnoid scarring at a level close to the syrinx. In 52 patients the arachnoid scarring was related to spinal trauma, whereas 55 had no history of trauma and developed arachnoid scarring was a result of an inflammatory reaction. Of these, 15 patients had undergone intradural surgery, eight had suffered from spinal meningitis, three had undergone peridural anesthesia, and one each presented with a history of osteomyelitis, spondylodiscitis, and subarachnoid hemorrhage. No obvious cause for the inflammatory reaction resulting in arachnoid scarring could be ascertained for the remaining 26 patients. The postoperative neurological outcome correlated with the severity of arachnoid pathology and the type of surgery performed. Shunting of the syrinx to the subarachnoid, pleural, or peritoneal cavity was associated with recurrence rates of 92% and 100% for focal and extensive scarring, respectively. Successful long-term management of the syrinx required microsurgical dissection of the arachnoid scar and decompression of the subarachnoid space with a fascia lata graft. This operation stabilized the preoperative progressive neurological course in 83% of patients with a focal arachnoid scar. For patients with extensive arachnoid scarring over multiple spinal levels or after previous surgery, clinical stabilization was achieved in only 17% with this technique.

Decompression of the spinal subarachnoid space as a solution for syringomyelia without Chiari malformation

“…7 Where a constricted, adhered subarachnoid space around the cord parenchyma is the main problem, as in most of our cases, then the subarachnoid space decompression is su cient for recovery of the altered CSF¯ow, release of the cord parenchyma and reversal of the symptoms and signs. 5 The cord parenchyma is su ciently decompressed even though its central canal is still dilated, as in case 5 of this study. The syrinx itself or the extent of the syrinx might be the next process which can or cannot be reversed after initial management but has only a secondary e ect on the patient's clinical status.…”

“…(d) T1-weighted sagittal view of thoraco-lumbar MRI after shunt revision on lower lumbar level syrinx shows an almost collapsed syrinx at both upper and lower levels scarring, at the lesion site, either of which is the cause of the syringomyelia. 5 Therefore when the anatomical distortion or the pathological process has been reversed, as in the case of subarachnoid space decompression, it may be anticipated that there will be normalization of the CSF¯ow dynamics, decrease in syrinx size and then symptomatic relief for the patient in sequence. 5,6 Experimental results showed only minimal changes in the size of the syrinx despite clinical improvement in most of the patients.…”

“…5 Therefore when the anatomical distortion or the pathological process has been reversed, as in the case of subarachnoid space decompression, it may be anticipated that there will be normalization of the CSF¯ow dynamics, decrease in syrinx size and then symptomatic relief for the patient in sequence. 5,6 Experimental results showed only minimal changes in the size of the syrinx despite clinical improvement in most of the patients. 7 Where a constricted, adhered subarachnoid space around the cord parenchyma is the main problem, as in most of our cases, then the subarachnoid space decompression is su cient for recovery of the altered CSF¯ow, release of the cord parenchyma and reversal of the symptoms and signs.…”

Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review

“…In occasional cases complicated by space-occupying cystic inclusions, surgical management of the cysts has a recognised role [6,26,29]. For associated syringomyelia, various shunting procedures are possible, although case series have shown benefit rates of only 31% [14], and complications [23] and long-term patency problems are well recognised. In light of this, we chose a less invasive trial of an external drain, which was unfortunately not helpful.…”

“…These can result from direct trauma to neural elements or, more rarely, through introduction of infection, hypoxic cord injury, expanding epidural haematomas or injection of anaesthetic into or adjacent to a canal already critically stenosed by osteophytes, disc protusion or less common abnormalities, such as arteriovenous fistulae [22]. Adhesive arachnoiditis is a rare, but recognised cause of neurological deficit following central neuraxial anaesthesia [5,12,17,[22][23][24][25][26][27][28][29].…”