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Introduction:
Post-traumatic syringomyelia is a major cause of delayed neurological deterioration , in patients with spinal trauma.[1] Two syndromes have been described: the Progressive Post-traumatic Cystic Myelopathy (PPCM) and the Progressive Post traumatic Myelomalacic Myelopathy (PPMM). The PPCM is a progressive pathological process that triggers the formation of a syrinx. The PPMM is due to microcystic degeneration of the spinal cord rather than to formation of a syrinx. [2,3,4,5] Traditionally, syringomyelia has been treated by cysto-peritoneal or cysto-subarachnoidal shunting, with limited effectiveness and with a 50% rate of clinical improvement. [6,7,8] Alternative treatments like lysis of subdural adhesions at the site of the trauma, opening of the syrinx and expansive duroplasty have been described. However, the results obtained with these techniques are similar to those obtained with shunts.[9]There is a need to improve the treatment of post-traumatic syringomyelia using a combined surgical approach which takes into account all the different pathogenic mechanisms.We present the case of a PPCM characterized by a holocord syrinx, treated by combined surgical techniques.

Patient and methods:

A 29 year old male presented a burst fracture of L2 following a motorcycle accident. The patient was treated at another hospital with screw fixation extending fromL1 to L3 with posterolateral arthrodesis, without decompressive laminectomy.The patient underwent physiokinesitherapy, until autonomous deambulation was achieved, with the persistence of a right lower limb motor deficit. The patient initially improved, but at 12 month follow-up the motor disorder has gradually worsened, interfering with deambulation. Other disorders like urgent incontinence, loss of sensitivity in the upper limbs, thermic and pain anesthesia, spasticity and numbness in the legs, sphincter dysfunction and hyperhydrosis also appeared. The patient underwent a L/S CT, which showed the correct positioning of the fixation system. An MRI of the whole spinal cord, showed the presence of a large and deep syrinx with several compartiments , extending from C2 to the conus medullaris, without any emerging points (Figure 1). The patient underwent neurosurgical operation via decompressive laminectomy of L2. Surgery consisted of  removal of arachnoidal intradural adhesions between the roots of the cauda equina, resection of the filum terminale and opening of the syrinx, that included the filum terminale (Figure 2).The patient made a rapid improvement in the immediate post-operative period. Post-operative MRI ,1 and 6 months follow-up showed a reduction of more than 50% of the volume of the syrinx (Figure 3).
Clinical evaluation at 24 month follow-up confirmed the progressive neurological improvement, with remission of hyperhydrosis, restoration of sphincter function, remission of numbness in the limbs and recovery of autonomous deambulation with a unilateral support. MRI scan 14 months later showed a further reduction of the syrinx, whose volume had diminished by more than 90% of its pre-operative size (Figure 4).

Results:

Post-traumatic syringomyelia is an uncommon condition, but it is the most common form of syringomyelia after that due to malformative diseases.[2,4,8]. The incidence is 10% (of all  spinal trauma)[2], but recent MRI and autoptic series have shown that this incidence may reach 20% [10,11] an higher incidence between 22.5% to 53% is associated with a tethered cord mechanism. [7,12,13,14] Trauma is the major driving cause of syringomyelia; it produces: hematomyelia, direct damage to the spinal cord and primary or secondary ischemic events, as inducing an inflammatory reaction, which promotes the formation of a syrinx. The products of bleeding and hemoglobin degradation induce inflammation, that leads to fibrosis within 
the spinal subarachnoid space. The adhesions obstruct the normal flow of cerebrospinal fluid (from the ependymal canal toward the subarachnoid space), causing an inverse pressure gradient. So consequently,increased resistance, creates transmural flow of CSF through the spinal cord.[15,16] Variations in pressure that occur daily within the CSF system, are the primary mechanisms responsible for augmenting and maintaining syringomyelia, because they increase the latency necessary to achieve a physiological balance of pressure gradients between the various CSF compartments. The siringomyelia grows in size after its formation. In our case the extension of the syrinx to the entire cord was probably attributable to late diagnosis and treatment.
The traction exerted on the cauda equina and filum terminale by the subdural fibrosis, caused the 
extension of syringomyelia below the level of the fracture. Post-traumatic syringomyelia is generally extracanalar, does not communicate with the central canal of the spinal cord and is not covered by ependyma, but by reactive gliosis. [6] Furthermore, flexion-extension of the neck, causing traction on the spinal cord, could generate additional forces that complicate tensive damage to  the spinal cord. In these kind of patients the worsening of symptoms is due to spinal cord damage from pressure and tension determined by growth of the syrinx , as well as to local microvascular damage.[7,8,17,18,19] Hence et all, in cases of post-traumatic tethered cord, they suggest that traction exerted by the filum terminale in the spinal cord may play a role in the development and maintenance of syringomyelia. [20] According to Williams [21]the deformations resulting from fractures may be also involved  in the genesis of syringomyelia [14,22,23]
At present, neither the level of trauma nor other clinical and radiological evidence can predict which patients will develop syringomyelia and which will not. [9]
The symptoms caused by syringomyelia can manifest  over a period of 3 months to 41 years after trauma with an average of 5-7 years [10,13,14,17,19,23,24,25,26,27]. Symptoms include root pain, neurological deficits, spasticity, and autonomic dysfunction. [7,8,14,25,26].
Owing to the many underlying mechanisms, syringomyelia requires a complex therapeutic approach.[24] Outcome is not always favorable, even when the results of radiological imaging are good. [2,14] Currently, the main goal of treatment of syringomyelia is removal of the underlying cause: if this cannot be identified, shunting of the syrinx should be carried out [4,8,27,28]. In the series described by Batzdorf [29] 36% of patients required more than one operation for resolution of syringomyelia. Historically, the treatment of syringomyelia was based on a volume reduction of the syrinx in order to restore the flow of cerebrospinal fluid inside. The rationale behind this treatment is based on the evidence that correlates a volume reduction of syringomyelia to a better neurological outcome.[17,22,27,30,31] Surgical treatment consists of making a cyst-subarachnoidal or cyst-peritoneal shunt [27], using the minimally invasive technique recently proposed by O Toole [32]. However the effectiveness of such treatment does not exceed 50% [9,26,33]. Instead in all cases of posttraumatic syringomielia the surgeon has to consider the surgical option of cisto-peritoneal shunting, but it�s low effectiveness means that it�s considered a second-choice treatment strategy[7,28,29]. The cyst-subaracnoid or peritoneal 
shunting do not interrupt the pathogenetic mechanism of patology, it would be the cause of low 
effectiveness. The same authors underline the high incidence of shunt occlusion or dysfunction at long term follow-up. Possible complications of shunting are arachnoiditis and infections, in addition to the presence of pre-existing spinal cord damage due to the trauma or tension exerted by syringomyelia. The clinical response to these treatments mainly concerns the painful symptoms and only marginally motor disturbances [25,34] Another therapeutic approach is to perform decompressive laminectomy or revision of fixation systems, especially in cases where syringomyelia is caused by deformation or post-traumatic stenosis of the spinal canal, with consequent mechanical traction on the spinal cord. [2,9,21,28,35,36] In cases of post-traumatic syringomyelia secondary to an alteration of CSF dynamics in the sub-arachnoidal and subdural spaces, lysis of subdural adhesions with opening of the cyst and expansive  duroplasty, represent the best approach, to restore a proper CSF flow with reduction of syringomyelia. Furthermore 
resection of the filum terminale in post-traumatic tethered-cord has proved to be a useful technique in association with these treatments. [13,36]. These treatments have proven effective both individually and in combination with techniques such as shunting, as shown in the literature [18,26,30,37], and the results obtained were the same as those observed after shunting alone. Combined treatment  can act on multiple pathogenic mechanisms: resection of arachnoidal adhesions, elimination of the barrier impeding flow of cerebrospinal fluid, at the same time the shunt diverts CSF from the syrinx reducing its volume.[13] In our case, several mechanisms  contributed to the maintenance and progression of syringomyelia. The presence of fibrosis at the level of the cauda equine, caused a tethered cord mechanism and impeded the CSF flow from the subarachnoid space through external spaces. Nonsurgical decompression of the spinal canal during the first surgery resulted in a canal stenosis. This condition made it necessary to perform 
multiple combined surgical techniques: a decompressive laminectomy in the region involved, removal of any arachnoidal adhesions and resection of the filum terminale.The dura mater provoked fibrous adherences only with filum terminale, but wasn�t involved in epidural adhesions or interferences with the roots of cauda equine and didn�t cause any dural stenosis as it 
usually do in trauma. The roots and filum terminale were involved thereselves in arachnoidal adhesions, so dura mater didn�t cause any CSF flow interferences. Therefore , we did not perform expansive duroplasty, due to the increased risk of pseudomeningocele and dural fistula. Single resection of filum terminale and root debridement was considered sufficient. In particular, during the section maneuvers of the filum terminale simultaneous opening of the cyst has been observed, because it involved this portion of  spinal cord too. In fact, we may assume that a single treatment would not have been sufficient for resolution of the syringomyelia as suggested by Batzdorf.[9,28,29] The combination of multiple methods is, more effective: such methods include shunt techniques, because they make it possible not only to divert the fluid contained in the syrinx, but also to interrupt the mechanisms involved in the training and enhancing the syringomyelia.

Conclusions:

The traditional approach to post-traumatic syringomyelia, not only causes a variety of complications, but it is also ineffective in terms of clinical results in the long term.
Expansive duroplasty with resection of the arachnoidal adhesion particularly in association with resection of the filumterminale, represents a valid and effective treatment strategy for post-traumatic syringomyelia, to reduce pressure in the syrinx and to remove any dural fibrosis. 
The decrease in tension stops further clinical progression or bring about an improvement in patient's neurological status. Combined surgical management represents an appropriate approach for effective treatment of posttraumatic syringomyelia, although the results obtained so far need to be supported by long-term follow-up studies. Taking into consideration the possibility of recurrence, surely the patient under examination will be subjected to a long-term follow-up.


References:
1. Rossier AB, Foo D, Shillito J, et al. Post-traumatic cervical syringomyelia: incidence, clinical presentation, electrophysiological studies, syrinx protein and results of conservative and operative treatment. Brain 1985;108:439�61.
http://dx.doi.org/10.1093/brain/108.2.439
PMid:4005531
 
2. Edgar R, Quail P. Progressive post-traumatic cystic and non-cystic myelopathy.Br J Neurosurg 1994;8:7�22.
http://dx.doi.org/10.3109/02688699409002388
PMid:8011197	
 
3. Falcone S, Quencer RM, Green BA, et al. Progressive post-traumatic myelomalacic myelopathy: imaging and clinical features. AJNR Am J Neuroradiol 1994;15:747�54.
PMid:8010278	
 
4. Gebarski JS, Maynard FW, Gabrielsen TO, et al. Post-traumatic progressive myelopathy. Radiology 1985;1157:379�85.	
 
5. Stevens JM, Olney JS, Kendall BE. Post-traumatic cystic and non-cystic myelopathy. Neuroradiology 1985;27:48�56.11. Sklar E, Quencer RM, Green BA, et al. Acquired spinal subarachnoid cysts: evaluation with MR, CT myelography, and intraoperative sonography.AJNR Am J Neuroradiol 1989;10:1097�104.	
 
6. Asano M, Fujiwara K, Yonenobu K, et al. Post-traumatic syringomyelia. Spine 1996;12:1446�53.
http://dx.doi.org/10.1097/00007632-199606150-00009

 
7. Barnett HJM, Jousse AT. Syringomyelia as a late sequel to traumatic paraplegia and quadriplegia. In Barnett HMJ, Foster JB, Hudgson P, eds. Syringomyelia: Major Problems in Neurology, vol. 1. London: Saunders, 1973:129�53.	
 
8. Barnett HJM, Jousse AT. Nature, prognosis and management of posttraumatic syringomyelia. In: Barnett HJM, Foster JB, Hudgson P, eds. Syringomyelia: Major Problems in Neurology, vol. 1. London: Saunders, 1973:154�64.	
 
9. Batzdorf U, Klekamp J, Johnson JP. A critical appraisal of syrinx cavity shunting procedures. J Neurosurg 1998;89:382�8.
http://dx.doi.org/10.3171/jns.1998.89.3.0382
PMid:9724111	
 
10. Quencer RM, Green BA, Eismont FJ. Post traumatic spinal cord cysts (PTSCC): clinical features and characterization with metrizamide computed tomography. Radiology 1983;146:415�23.
PMid:6849087	
 
11. Sklar E, Quencer RM, Green BA, et al. Acquired spinal subarachnoid cysts: evaluation with MR, CT myelography, and intraoperative sonography.AJNR Am J Neuroradiol 1989;10:1097�104.
PMid:2505526	
 
12. Donaldson I, Gibson R. Spinal cord atrophy associated with arachnoiditis as demonstrated by computed tomography. Neuroradiology 1982;24:101�5.
http://dx.doi.org/10.1007/BF00339199
PMid:7177369	
 
13. Lee TT, Alameda GJ, Gromelski EB, et al. Outcome after surgical treatment of progressive post-traumatic cystic myelopathy. J Neurosurg Spine 2000;92:149�54.
http://dx.doi.org/10.3171/spi.2000.92.2.0149

 
14. Perrouin-Verbe B, Lenne-Aurier K, Robert R, et al. Post-traumatic syringomyelia and post-traumatic spinal canal stenosis: a direct relationship. Review of 75 patients with a spinal cord injury. Spinal Cord 1998;36:137 �43.
http://dx.doi.org/10.1038/sj.sc.3100625
PMid:9495005	
 
15. Andrew R. BrodbeltMBChB, et al. Altered Subarachnoid Space Compliance and Fluid Flow in an Animal Model of Posttraumatic SyringomyeliaSPINE Volume 28, Number 20, pp E413�E419				
				
 
16. Shaw MDM, Russell JA, Grossart KW. The changing pattern of spinal arachnoiditis. J NeurolNeurosurg Psychiatry 1978;41:97�107.
http://dx.doi.org/10.1136/jnnp.41.2.97
PMid:632824 PMCid:492975	
 
17. Hoffman HJ, Hendrick EB, Humphreys RP. The tethered spinal cord: its protean manifestations, diagnosis and surgical correction. Childs Brain 1976;2:145�55.
PMid:786565	
 
18. Lee TT, Arias JA, Andrus HL, et al. Progressive post-traumatic myelopathy:treatment with untethering and duraplasty. J Neurosurg 1997;86:624�8.
http://dx.doi.org/10.3171/jns.1997.86.4.0624
PMid:9120625	
 
19. Quencer RM, Green BA, Eismont FJ. The clinical and radiographic features of post-traumatic spinal cord cysts. In: Post MDJ, ed. Computed Tomography of the Spine. Baltimore: Williams & Wilkins, 1984:809 �15.	
 
20. Milhorat TH, Kotzen RM, Mu HTM, et al. Dysesthetic pain in patients with syringomyelia. Neurosurgery 1996;38:940�7.
http://dx.doi.org/10.1097/00006123-199605000-00017
PMid:8727819	
 
21. Williams B. Post-traumatic syringomyelia, an update. Paraplegia 1990;28: 296�313.
http://dx.doi.org/10.1038/sc.1990.39
PMid:2235038	
 
22. MacDonald RL, Findlay JM, Tator CH. Microcystic spinal cord degeneration causing post-traumatic myelopathy: report of two cases. J Neurosurg 1988;68:466�71.
http://dx.doi.org/10.3171/jns.1988.68.3.0466
PMid:3343618	
 
23. Ragnarsson TS, Durward QJ, Nordgren RE. Spinal cord tethering after traumatic paraplegia with late neurological deterioration. J Neurosurg 1986;64: 379�401.
http://dx.doi.org/10.3171/jns.1986.64.3.0397
PMid:3950719	
 
24. Holly LT, Johnson JP, Masciopinto JE, Batzdorf U: treatment of posttraumatic syringomyelia with extradural decompressive surgery. Neurosurg Focus 8:E1�E6, 2000
http://dx.doi.org/10.3171/foc.2000.8.3.8

 
25. Levi ADO, Sonntag VKH. Management of post-traumatic syringomyelia using an expansileduraplasty. Spine 1998;23:128�32.
http://dx.doi.org/10.1097/00007632-199801010-00026
PMid:9460162	
 
26. Schaller B, Mindermann T, Gratzl O. Treatment of syringomyelia after posttraumatic paraparesis or tetraparesis. J Spinal Disord 1999;12:485�8.
http://dx.doi.org/10.1097/00002517-199912000-00007
PMid:10598990	
 
27. Tator CH, Briceno C. Treatment of syringomyelia with a syringosubarachnoid shunt. Can J NeurolSci 1988;15:48�57.
PMid:3345462	
 
28. L. T. Holly, et al. Treatment of posttraumatic syringomyelia with extradural decompressive surgery. Neurosurg. Focus / Volume 8 / March, 2000
PMid:16676931	
 
29. Batzdorf U: Primary spinal syringomyelia. Invited submission from the joint section meeting on disorders of the spine and peripheral nerves, March 2005. J Neurosurg 3:429 �435, 2005.	
 
30. Abel R, Gerner HJ, Smit C, et al: Residual deformity of the spinal canal in patients with traumatic paraplegia and secondary changes of the spinal cord. Spinal Cord 37:14�19, 1999
http://dx.doi.org/10.1038/sj.sc.3100740
PMid:10025689	
 
31. Sgouros S, Williams B. Management and outcome of post-traumatic syringomyelia. J Neurosurg 1996;85:197�205.
http://dx.doi.org/10.3171/jns.1996.85.2.0197
PMid:8755746	
 
32. John E. O'toole, M.D. Et Al. Minimally Invasive Insertion Of Syringo Subarachnoid Shunt For Posttraumatic Syringomyelia:Technical Case Report Volume 61 | Operative Neurosurgery 2 | November 2007				
				
 
33. Schneider RC, Knighton R. Chronic neurological sequelae of acute trauma to the spine and spinal cord: III. The syndrome of chronic injury to the cervical spinal cord in the region of the central canal. J Bone Joint Surg Am 1959;41:905�19.
PMid:13664724	
 
34. Smith KA, Rekate HL. Delayed postoperative tethering of the cervical spinal cord. J Neurosurg 1994;81:196�201
http://dx.doi.org/10.3171/jns.1994.81.2.0196
PMid:8027801	
 
35. Andrews BT, Weinstein PR, Rosenblum ML, BarbaroNM:Intradural arachnoid cysts of the spinal anal associated with intramedullary cysts. J Neurosurg 68:544�549, 198825.
http://dx.doi.org/10.3171/jns.1988.68.4.0544
PMid:3280748	
 
36. Thomas T. Lee, MD, Gustavo J. Alameda, BA, Elizabeth Camilo, BS, BA, and Barth A. Green, MD Surgicaltreatment of Post-traumatic Myelopathy Associated With Syringomyelia Volume 26 Number 24S 2001				
				
 
37. Green BA, Lee TT, Madsen PW, et al. Management of post-traumatic cystic myelopathy. Top Spinal Cord Inj Rehabil 1997;2:36�46.	
Figures� legend:
Figure 1:Sagittal T2W MRI images showing the presence of a large and deep syrinx with several 
compartiments , extending from C2 to the conusmedullaris.

Figure 2:Intraoperative image, that shows the opening of the cyst at the level of filumterminale

Figure 3:Sagittal T2W MRI image showing the reduction of the volume of the syrinx at 1 month follow-up

Figure 4:Sagittal T2W MRI image showing the further reduction of the volume of the syrinx at 14 months follow-up 










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