Posttraumatic Cystic Myelopathy Research Articles

Surgical treatment of post-traumatic myelopathy associated with syringomyelia.

Retrospective review. Evaluate the clinical outcome of surgical intervention for post-traumatic syringomyelia. 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. 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). 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. 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.

Outcome after surgical treatment of progressive posttraumatic cystic myelopathy.

Progressive posttraumatic cystic myelopathy (PPCM) can occur after an injury to the spinal cord. Traditional treatment of PPCM consists of inserting a shunt into the cyst. However, some authors have advocated a more pathophysiological approach to this problem. The authors of the present study describe their surgical treatment protocol and outcome in a series of patients with syringomyelia. Medical records of 34 patients undergoing surgical treatment for PPCM were reviewed. Laminectomies and intraoperative ultrasonography were performed. In patients without focal tethering of the spinal cord and in whom only a confluent cyst had been revealed on ultrasonography, a syringosubarachnoid shunt was inserted; in those with both tethering and a confluent cord cyst, an untethering procedure was performed first. When a significant reduction (>50%) in the size of the cyst was shown after the untethering procedure, no shunt was inserted. When no changes in cyst size were demonstrated on ultrasonography, a short syringosubarachnoid shunt was used. The mean follow-up period was 28.7 months (range 12-102 months). The interval between the mechanism of injury and the operation ranged from 5 months to 37 years (mean 11 years). Pain was the most frequent symptom, which was followed by motor deterioration and spasticity. Postoperative improvement was noted in 55% of patients who experienced motor function deterioration and in 53% of those who demonstrated worsening spasticity. In 14 of 18 patients with an associated tethered spinal cord, tethering alone caused significant collapse of the cyst. Postoperative magnetic resonance imaging demonstrated cyst collapse in 92% of patients who had undergone untethering alone and in 93% of those who underwent syringosubarachnoid shunt placement. Treatment failure was observed in 7% of the former group and in 13% of the latter. Posttraumatic cystic myelopathy can occur with or without the presence of tethered cord syndrome. Intraoperative ultrasonography can readily demonstrate this distinction to aid in surgical decision making. Untethering alone in patients with tethered cord syndrome and cyst formation can reduce the cyst size and alleviate symptoms and signs of posttraumatic cystic myelopathy in the majority of these cases. Untethering procedures in which duraplasty is performed to expand the subarachnoid space may be a more physiologically effective way of treating tethered cord with associated syringomyelia.

Surgical Treatment Outcome of Posttraumatic Cystic Myelopathy (PPCM)

Surgical Treatment Outcome of Posttraumatic Cystic Myelopathy (PPCM)

Posttraumatic syringomyelia: pathogenesis, imaging, and treatment.

P osttraumatic syringomyelia, or progressive posttraumatic cystic myelopathy, is a complication of spinal cord injury that affects as many as 3.2% of spinal cord patients overall but as many as 8% of patients suffering from complete quadriplegia [11. Time of onset after injusy ranges from 2 months to 30 years, and the most common mitial complaint is pain [1-3]. Other symptoms indude sensoty loss, motor weakness, increased or decreased spasticity, autonomic dysreflexia, hyperhidrosis (above level of injury), sphincter loss or sexual dysfunction, Homer’s syndrome, respiratory insufficiency, and death [3]. The sen5OI3P dysfunction is classically described as dista.l loss of pain and temperature sensation with preservation of proprioceptive sensation and light touch [1, 3, 4].

Early onset posttraumatic cystic myelopathy complicating spinal cord injury

Three cases of posttraumatic cystic myelopathy occurring early in the postinjury period are reported. A patient with C5 tetraplegia developed bilateral upper extremity paresthesias and right upper extremity weakness 2 and a half months postinjury necessitating immediate syringo-subdural shunting. A patient with C6 tetraplegia complained of left upper extremity paresthesias 2 months postinjury. A syringoperitoneal shunt was placed 19 months postinjury due to new onset intermittent weakness of the right upper extremity. A patient with C4 tetraplegia developed right upper extremity paresthesias, sensory loss, and weakness 56 days postinjury; it was treated conservatively. Two years postinjury he required surgery because of progression of symptoms. A review of the literature reveals that posttraumatic cystic myelopathy has been found to be an incidental pathologic finding at autopsy within 2 months postinjury. However, sensory and motor loss have not been clinically described as an early complication of spinal cord injury. We conclude that posttraumatic cystic myelopathy should be considered in the differential diagnosis of motor or sensory loss occurring early in the postinjury period.

Syringoperitoneal shunt for treatment of cord cavitation.

A series of twenty-nine patients with cord cavitation were treated by syringoperitoneal shunt. Twenty-two of them showed improvement after operation, five were unchanged and two worsened. Operation was performed in patients with post-traumatic cystic myelopathy, idiopathic syringomyelia, intramedullary tumours associated with cysts, and patients who had developed cystic myelopathy in association with spinal arachnoiditis. Pain improved in twenty patients, sensory symptoms and signs in eleven and weakness in ten.

Spinal cord injury: optimization of computerized tomography image factors for accuracy

Computerised tomography (CT) scanning has become an accepted diagnostic method in evaluation of patients with spinal cord injury and has become increasingly important in the assessment of the vertebral column, spinal cord, and brain. Since CT images are graphic representations of generated computer mathematical data viewed with variable window and level selections (display factors), various image representatations are possible and potentially erroneous objective and subjective conclusions from viewing and measuring anatomical findings can result if an appreciation of this potential variability is not understood. Additionally, the CT image can be reconstructed from a variety of mathematical algorithm selections, which can enhance or diminish aspects of tissue contrast (smoothing or edge enhancement). Optimization of these factors, (window and level selection for viewing, and image generation algorithm), is especially important if detection and measurement of objective structures are to be reliable.The authors studied otpimization of algorithm selection and display factors (window and level selection), with a phantom designed to mimic spinal column, spinal cord and subarachnoid space. Varying concentrations of metrizamide in the phantom were scanned.With the G.E. 8800 Scanner, the bone algorithm was found to be the optimum algorithm for optimum spinal cord images if the measured metrizamide CT attenuation number was greater than 150-200. With a metrizamide CT attentua-tion number less than 150 the soft tissue algorithm was optimum. Window centre (level) selection greatly influenced the measurement of cord size, whereas window width did not. The appropriate window centre (level) selection is the mean between the metrizamide CT attenuation number and the cord CT attenuation number.The clinical application of these findings is summarized, and includes: Patients with metrizamide CT studies that require accurate measurement of spinal cord size or measurement of spinal cord cyst size (post-traumatic cystic myelopathy). Significant errors are possible if the formula for appropriate window centre selection is not followed. Additionally, the use of the bone algorithm requires higher contrast for accuracy, thus if metrizamide concentrations are weak, erroneous interpretations are possible. The authors also found that in the presence of metal (rods, screws or plates) the bone algorithm increased artifacts in CT, thus should not be used in this situation but rather the soft tissue algorithm must be used when metal is present to minimize artifacts.

Progressive posttraumatic cystic myelopathy: neuroradiologic evaluation.

The neuroradiologic evaluation and findings in 25 symptomatic patients with surgically proven progressive posttraumatic cystic myelopathy are reviewed. To follow patients with spinal cord injury, neuroradiologic algorithms were developed to confirm and define cystic myelopathy. The algorithm used in the early and mid 1970s relied on the myelographic demonstration of a large cord for suspicion of a cyst. Review of this material found that in progressively symptomatic patients 14 of 25 proven cysts were in large cords. A more recent algorithm used computed tomographic metrizamide myelography. In nine of 11 patients studied in this fashion, the cyst filled with contrast material 2--4 hr after injection, yet it did not communicate with the subarachnoid space at subsequent surgery. The origin of the cyst fluid and mechanism of cyst demonstration with metrizamide may be associated with transneural migration of fluid. This condition must be clinically suspected and radiologically confirmed for surgical treatment (cyst-shunt procedure) if neurologic preservation of function is to be maintained.

Neuroradiological evaluation in progressive post-traumatic cystic myelopathy (PPCM)

Neuroradiological evaluation in progressive post-traumatic cystic myelopathy (PPCM)