Elsevier

World Neurosurgery

Volume 98, February 2017, Pages 1-5
World Neurosurgery

Technical Note
Shunting of Syringomyelic Cavities by Using a Myringotomy Tube: Technical Note and Long-Term Results

https://doi.org/10.1016/j.wneu.2016.10.067Get rights and content

Background

Syringomyelia is a progressive cerebrospinal fluid disorder that can lead to irreversible spinal cord injury. To date, the optimal management of syringomyelic cavities remains controversial. Multiple studies have emphasized the importance of the craniocervical decompression or shunting procedures; however, except for syrinx related to Chiari malformation, nearly one-half of patients need to undergo reoperation. The purpose of the present study was to describe a simple and efficient surgical technique and to report the long-term radioclinical outcomes.

Material and Methods

We report a series of 17 consecutive patients (10 male, 7 female) with symptomatic syringomyelia treated by myringotomy tube between January 1999 and January 2014. The mean follow-up was 43.6 months (5–118). For each case, a laminectomy was carried out at the level of the most expanded part of the syrinx. The myringotomy tube was then placed through a puncture myelotomy.

Results

Clinical examination showed disappearance of symptoms in 3 cases, a significant improvement in 8 cases, stabilization in 5 patients, and continuation of neurologic deterioration in 1 case. Thus, favorable long-term outcomes were observed in two-thirds of patients. No permanent postoperative complication was reported. The postoperative imaging showed complete or almost complete disappearance of the syrinx in 11 cases and a reduction over 80% in 4 cases. In 2 cases, the cavity remained stable. Moreover, just 2 patients had to undergo reoperation with the placement of a syringoperitoneal shunt.

Conclusion

A myringotomy tube is a simple surgical technique that seems to be an efficient and safe treatment for syringomyelic cavities.

Introduction

Syrinx is a fluid-filled longitudinal cavity located within the spinal cord that can increase over time and lead to irreversible neurologic lesions.1 The most common etiology of syringomyelic cavity is a congenital deformity of the craniocervical junction. Other common acquired causes are localized meningeal fibrosis due to spinal cord trauma, tumor, or infection.2 Finally, when no etiology is found, a primary syringomyelia is present.3 Syringomyelia can be an incidental finding or be accompanied by symptoms, such as pain or temperature insensitivity.

For symptomatic patients, the assumption was made that the suppression of the underlying cause or drainage of the cyst would result in neurologic improvement or stabilization of symptoms. To this end, since the 19th century, several procedures were suggested: aspiration, myelotomy, and shunt diversion. For acquired and primary syrinxes, cavity shunting is the main surgical option. Three continuous fluid diversion systems were proposed: subarachnoid, peritoneal, and pleural shunts4, 5, 6; however, peritoneal and pleural shunts are associated with a high rate of hardware failure as the result of shunt blockage, migration, or infection. Indeed, for these procedures nearly one-half of patients need to undergo reoperation.7, 8

Our purpose in the present study was to describe our surgical technique, to report the long-term radioclinical outcomes, to compare with other procedures described in the literature, and to propose a “decision process” for the surgical management of syringomyelic cavities.

Section snippets

Population and Methods

Seventeen patients with symptomatic syringomyelia treated by myringotomy tube between January 1999 and January 2014 were included in this study. All patients reported disabling or progressing symptoms related to an acquired or primary syringomyelic cavity or failed posterior fossa decompression for syrinx related to Chiari malformation. Data were collected from 2 institutions: Centre Hospitalier Régional, Namur, Belgium, and Centre Hospitalier Régional Citadelle, Liège, Belgium. Two types of

Results

Seventeen consecutive patients were included in this study. The mean age was 43.3 years (range, 9–71 years) and the female/male ratio was 1:1.4. The most frequently mean reported symptoms were motor disturbance in 11 patients and temperature insensitivity in 10 patients. Only 5 patients reported pain. The syrinx cavity was related to unknown etiology in 7 cases; posttraumatic in 5 cases, to arachnoid cyst in 2 cases, and to tumor in 1 case. In 4 patients, the syrinx was associated with Chiari

Discussion

Syringomyelia was described for the first time about 150 years ago; however, to this day, the physiopathologic mechanisms of syringomyelic cavity formation are not fully elucidated.9 Myringotomy tube does not impede the formation mechanisms; however, it allows the emptying of the cavity and prevents its reformation. Indeed, the myringotomy tube, introduced by a short myelotomy, keeps open a communication between the intramedullar cavity and the subarachnoid space. This permanent opening does

Conclusions

The management of syringomyelic cavities is based on their formation mechanisms and on the subarachnoid obstruction. For syrinxes related to congenital deformity of the craniocervical junction, craniovertebral decompression remains the first option. For acquired and primary syrinxes or after failure of craniovertebral decompression, the treatment depends of the extent of the subarachnoid obstruction. For diffuse obstructions, the best results were reported with syrinx derivation that can shunt

References (19)

  • T. Fan et al.

    Treatment of selected syringomyelias with syringo-pleural shunt: the experience with a consecutive 26 cases

    Clin Neurol Neurosurg

    (2015)
  • R. Abbe et al.

    Syringomyelia. Operation-exploration of cord, withdrawal of fluid, exhibition of patient

    J Nerv Ment Dis

    (1892)
  • J. Klekamp

    The pathophysiology of syringomyelia—historical overview and current concept

    Acta Neurochir (Wien)

    (2002)
  • J.D. Heiss et al.

    Pathophysiology of primary spinal syringomyelia

    J Neurosurg Spine

    (2012)
  • J. Vaquero et al.

    Syringosubarachnoid shunt for treatment of syringomyelia

    Acta Neurochir (Wien)

    (1987)
  • P. Kunert et al.

    Syringoperitoneal shunt in the treatment of syringomyelia

    Neurol Neurochir Pol

    (2009)
  • V. Logue et al.

    Syringomyelia and its surgical treatment—an analysis of 75 patients

    J Neurol Neurosurg Psychiatry

    (1981)
  • U. Batzdorf

    Primary spinal syringomyelia

    J Neurosurg Spine

    (2005)
  • D. Greitz

    Unraveling the riddle of syringomyelia

    Neurosurg Rev

    (2006)
There are more references available in the full text version of this article.

Cited by (8)

  • Safety and Efficacy of Syringoperitoneal Shunting with a Programmable Shunt Valve for Syringomyelia Associated with Extensive Spinal Adhesive Arachnoiditis: Technical Note

    2019, World Neurosurgery
    Citation Excerpt :

    They suggested that spinal tissue scarring at the injury site could cause a tethering effect on the spinal cord, which could lead to significant alterations of the spinal cord parenchyma.12 The treatment strategy for syringomyelia associated with extensive SAA should include direct drainage of the syringomyelia, dissection of the adhesive arachnoid with expansive duroplasty, and a CSF shunt, as demonstrated in the present study (Table 4).16-31 Adhesive arachnoid dissection appears to be a straightforward method for stabilizing the progressive symptoms, although its use might be limited, and the procedure is technically demanding.

  • Syrinx to Subarachnoid Shunting for Syringomyelia

    2018, World Neurosurgery
    Citation Excerpt :

    In such cases, where obstruction of the subarachnoid space extends over many spinal levels, decompression and duraplasty alone are unlikely to be able to relieve extensive scarring,24,28 and direct drainage of the syrinx has been recommended.12,29 Although syrinx to subarachnoid shunting may not prevent entry of fluid into a syrinx cavity, it provides a direct outflow pathway.30 Microsurgical techniques and shunt materials have changed since the time of previous reviews (1970 to 1995); contemporary methods involve a minimally invasive surgical procedure, with no reported operative mortality and very low morbidity in more recent case studies and small case series.16,20,31-34

  • Syringostomy Using Myringostomy Tube

    2017, World Neurosurgery
  • Syringosubarachnoid shunt: insertion technique

    2023, British Journal of Neurosurgery
View all citing articles on Scopus

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text