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Clinical evaluation of the outcome and the method of surgical decompression for syringomyelia associated with Chiari type I malformation
Spine - Syringomyelia, Vascular Lesions and Tumours
Thursday, 10 July 1997
this disease,as well as associated factors such as treatmentmodality, seizure, recurrence, and outcome. Methods: We retrospectively reviewed 274 consecutive operated cases of suspected subacute or chronic subdural hematomas in a six-year period and followedfor a mean of 12 months. Results: An incorrectdiagnosiswas madein 4.4% olthe cases. Thesecases were not used for the final analysis. The mean age of the adult patients was 68 years. Pediatricpopulation was found in 2.7% of the cases, associated with ventriculo-peritoneal shunts in 86% of the cases. Two-thirds of the cases were chronic and one-third was subacute. History of head trauma was identified in 72% of the cases, being morecommon in the subacutegroup.The hematomas were bilateral in 16% of the cases Recurrence was found in 7.84% of the adult cases at an average of 53 days post-drainage. There was no difference in the incidencebetweenthe subacuteand chroniccases. Postoperative seizures occur in 6.2% of the cases. Recurrence rate was not affected by the type of operationperformed. The principalcomplication wasan intracerebral hematoma (2.7%), whichwas associated with a pooroutcomein mostof thecases.Mortality was 0.9% and morbidity8.8%. Conclusions: Chronic subdural hematomas are more commonthan subacute subdural hematomas. Treatment modality will not change the recurrence rate.Pre-operative seizuresare not associatedwith postoperative seizures. The use of prophyiacticantiepilepticdrugs did not decreasethe incidenceof postoperativeseizures, even not in the alcoholic patients. Prophylactic anticonvulsant is not indicated. Outcome of these patients is good or excellentin 96% of the cases.
Thursday, 10 July 1997
0-26
14:00-16:30
Spine - Syringomyelia, Vascular Lesions and Tumours
I0-26-3771
The treatment of syringomyelia associated with postinflammatory and posttraumatic arachnoid scarring
J. Klekamp1 , U. Batzdorf2, M. Samii 1. 1 NordstadtKrankenhaus, Dept. of Neurosurgery, Hannover, Germany, 2 Universityof California, Div. of Neurosurgery, Los Angeies, USA Introduction: We have performeda retrospective study on patients with posttraumaticand postinflammatory syringomyeliatreatedbetween 19n and 1995. Methods: Sixty-sevenpatients underwent 93 operations and were followed for a mean periodof 39 ± 38 months (meanclinical history43 ± 72 months, average age 45 ± 14 years). Most patientscomplained about pain, dysesthesias, motor weakness, and gait ataxia. Only patients with a progressive neurological course were operated. Fifty-six syrinx shunts (36 syringoperitoneal, 13 syringosubarachnoid, and 7 syringopleural shunts) were implanted. Thirty-seven operations intended to treat the associated arachnoid scarring by arachnoid dissection and decompression with a dural graft (25), leaving the dura open (10), or by arachnoiddissectiononly (3). Follow-upinformation was obtainedby neurological examinations, questionnaires, or telephone calls. Results: Every patient demonstrated arachnoid scarringeither at the lower end (40), upper end (17), or along the syrinx cavity (37). Neurological outcome depended only on the type of surgery and the extent of arachnoid scarring. Shunting procedures were followed by a clinical recurrence in 93%, whereas arachnoid dissection and decompression with a dural graft led to a sustained decrease in syrinx size and stabilizedor improvedthe neurological status in up to 78% of patients. Discussion: Syringomyelia is a syndromeof impairedCSF flow. We recommend to establisha free CSF pathwayby arachnoid dissectionand decompression with a dural graft as the treatment of choice.
I0-26-3781
Management of syringomyelia and Chiari malformation
Ferruh Gezen, Serdar Kahraman, Zafer Canakci, MehmetDaneyemez, Naci Seber. Dept. of Neurosurgery, GOlhane Medical Faculty. Ankara, Turkey Up to now various techniques have been describedin diagnosisand treatment of syringomyelia with or without Chiari type I malformation (Ch 1M). MRI has facilitatedthe diagnosis, treatmentandfollow-upof syringomyelia anditsassociated pathologies. The pathophysiological mechanism and treatmentmethods of
S203
syringomyelia are still contraversial, although advances in neuro-microsurgical techniques and diagnosticmethods. The aim of this study is to analyse the role of SEP and MRI in diagnosis, surgicalmanagement and follow-upof syringomyelia with or withoutCh I M. We reviewed 34 cases of syringomyelia with surgicallytreated during 1992 to 1996 at the GOlhane medicalschool.Thirteen of these also have Ch I M. The age of patients ranged from 19 to 53 years. The most common complaints were loss of sensation (75%), following extremity weakness (60%), neck and shoulder pain, dysphonia, and dysphagia. SEP and MRI were applied in all cases pre and postoperatively. Syringosubarachnoid shunt (SSS) was performed through our modifiedtechnique unilateral partial hemilaminectomy (UPHL) in 19 cases with non-communicate syringomyelia. SSS not only used in all cases, but also craniovertebral decompression (CVD) plus duraplastywas performed in cases of Ch I M. All caseswere followedby SEP and MRI for 6 monthsto 4 years. The early postoperative MRI showed a clear collaps of syrinx in 31 cases. Diameterof syrinx was not decreased in three cases with Ch I M treated only CVD at first operation. These cases were operated for SSS at second step and control MRI showed collaps of syrinx. MRI findings were showed improvement in all cases, while have shown electrophysiological improvement in 18 cases (54%), although 21 (63%) cases improved clinically. The findings of cerebellar and lower cranial nerves compression were resolved in most cases at early postoperative period. In spite of, electrophysiological, radiological and clinical improvement of spinal cord pathologywere observedat different degrees in the late postoperative period. There was no significantcorrelation between the syrinx/canal indexand spinalsymptomatology, althoughclose correlation between posteriorfossa compression and tonsillary herniationdegree and electrophysiologicalfindings. MRI provideconsiderable information to correlates well with the clinical and electrophysiological findings in case of syringomyelia with or without Ch I M. Combination of SEP and MRI not only proved clinicopathological correlation, but also predict surgicaloutcome. Early surgery could be optimal the treatment for syringomyelia. Pluggingof the obex is not necessaryfor obtaining medullary collapse. The application of SSSthroughUPHLis a practicaland useful surgical method, because of a small risk of surgical trauma, infection, granulation and stabilization,
I0-26-3791
Clinical evaluation of the outcome and the method of surgical decompression for syringomyelia associated with Chiari type I malformation
Shinji Imae, FuminoriOzaki, Kunio Nakai, Toru ltakura. Department of NeurologicalSurgery, Wakayama Medical College, Wakayama 640, Japan Introduction: The technique of foramen magnum decompression for syringomyelia associated with Chiari type I malformation has not been standardized yet. No one procedure has been always successful, leading to many alternativeprocedures. The purpose of the current study is to decide the best procedureat present. Patients and Methods: 42 patients with syringomyeliaassociated with the Chiari type I malformation, diagnosed by magnetic resonance imaging (MRI), underwent surgical treatment. In all patients anomalies of the craniocervical junction,cervicaldisc herniation and other spinal disease were ruled out. There were 26 men and 16 women, ranging from 6 to 72 (mean: 42.3) years in age. All patients were treated by foramen magnumdecompression and divided into 4 groups according to the degree of decompression: 1) tonsillectomy group: 12 patients underwent suboccipital craniectomy (SOC) with patchy-graft dural plastyusinglyophilized duramaterandtonsillectomy. 2) lysisgroup:7 underwent SOC,dural plastyand microsurgical lysis of arachnoidal trabeculaand fibrinoid filament application around the herniated tonsil. 3) plasty group: 17 underwent SOCand dural plasty. 4) duralgroup:6 underwentSOC and removalof the outer layer of the dura mater. The mean follow-up period of the tonsillectomy group was 3.7 years, lysis group: 3.6 years, plasty group; 2.3 years, dural group; 1.8 years, respectively. Evaluation of the effects following the four types of surgical treatment was performed on the basis of clinical symptoms and the volume of the syrinx cavity on sagittal MRI. The ratio of the area of the syrinx to the spinal cord on preoperative and postoperative sagittal MRIwas measured by personalcomputer. Results: There was no significantdifference among the 4 groups as to the degree of reduction of the syrinx in the sagittal plane as evaluated on MRI, whereaswith regards to improvement of the clinicalsymptoms, dural group was significantly worsethan the other three groups. Discussion and Conclusion: The surgical procedure of plasty was manifestly less invasivethanthat of tonsillectomy and lysis.These resultssuggested that we should firstly choose dural plasty for syringomyelia associatedwith the Chiari type I malformation.
Thursday, 10 July 1997
this disease,as well as associated factors such as treatmentmodality, seizure, recurrence, and outcome. Methods: We retrospectively reviewed 274 consecutive operated cases of suspected subacute or chronic subdural hematomas in a six-year period and followedfor a mean of 12 months. Results: An incorrectdiagnosiswas madein 4.4% olthe cases. Thesecases were not used for the final analysis. The mean age of the adult patients was 68 years. Pediatricpopulation was found in 2.7% of the cases, associated with ventriculo-peritoneal shunts in 86% of the cases. Two-thirds of the cases were chronic and one-third was subacute. History of head trauma was identified in 72% of the cases, being morecommon in the subacutegroup.The hematomas were bilateral in 16% of the cases Recurrence was found in 7.84% of the adult cases at an average of 53 days post-drainage. There was no difference in the incidencebetweenthe subacuteand chroniccases. Postoperative seizures occur in 6.2% of the cases. Recurrence rate was not affected by the type of operationperformed. The principalcomplication wasan intracerebral hematoma (2.7%), whichwas associated with a pooroutcomein mostof thecases.Mortality was 0.9% and morbidity8.8%. Conclusions: Chronic subdural hematomas are more commonthan subacute subdural hematomas. Treatment modality will not change the recurrence rate.Pre-operative seizuresare not associatedwith postoperative seizures. The use of prophyiacticantiepilepticdrugs did not decreasethe incidenceof postoperativeseizures, even not in the alcoholic patients. Prophylactic anticonvulsant is not indicated. Outcome of these patients is good or excellentin 96% of the cases.
Thursday, 10 July 1997
0-26
14:00-16:30
Spine - Syringomyelia, Vascular Lesions and Tumours
I0-26-3771
The treatment of syringomyelia associated with postinflammatory and posttraumatic arachnoid scarring
J. Klekamp1 , U. Batzdorf2, M. Samii 1. 1 NordstadtKrankenhaus, Dept. of Neurosurgery, Hannover, Germany, 2 Universityof California, Div. of Neurosurgery, Los Angeies, USA Introduction: We have performeda retrospective study on patients with posttraumaticand postinflammatory syringomyeliatreatedbetween 19n and 1995. Methods: Sixty-sevenpatients underwent 93 operations and were followed for a mean periodof 39 ± 38 months (meanclinical history43 ± 72 months, average age 45 ± 14 years). Most patientscomplained about pain, dysesthesias, motor weakness, and gait ataxia. Only patients with a progressive neurological course were operated. Fifty-six syrinx shunts (36 syringoperitoneal, 13 syringosubarachnoid, and 7 syringopleural shunts) were implanted. Thirty-seven operations intended to treat the associated arachnoid scarring by arachnoid dissection and decompression with a dural graft (25), leaving the dura open (10), or by arachnoiddissectiononly (3). Follow-upinformation was obtainedby neurological examinations, questionnaires, or telephone calls. Results: Every patient demonstrated arachnoid scarringeither at the lower end (40), upper end (17), or along the syrinx cavity (37). Neurological outcome depended only on the type of surgery and the extent of arachnoid scarring. Shunting procedures were followed by a clinical recurrence in 93%, whereas arachnoid dissection and decompression with a dural graft led to a sustained decrease in syrinx size and stabilizedor improvedthe neurological status in up to 78% of patients. Discussion: Syringomyelia is a syndromeof impairedCSF flow. We recommend to establisha free CSF pathwayby arachnoid dissectionand decompression with a dural graft as the treatment of choice.
I0-26-3781
Management of syringomyelia and Chiari malformation
Ferruh Gezen, Serdar Kahraman, Zafer Canakci, MehmetDaneyemez, Naci Seber. Dept. of Neurosurgery, GOlhane Medical Faculty. Ankara, Turkey Up to now various techniques have been describedin diagnosisand treatment of syringomyelia with or without Chiari type I malformation (Ch 1M). MRI has facilitatedthe diagnosis, treatmentandfollow-upof syringomyelia anditsassociated pathologies. The pathophysiological mechanism and treatmentmethods of
S203
syringomyelia are still contraversial, although advances in neuro-microsurgical techniques and diagnosticmethods. The aim of this study is to analyse the role of SEP and MRI in diagnosis, surgicalmanagement and follow-upof syringomyelia with or withoutCh I M. We reviewed 34 cases of syringomyelia with surgicallytreated during 1992 to 1996 at the GOlhane medicalschool.Thirteen of these also have Ch I M. The age of patients ranged from 19 to 53 years. The most common complaints were loss of sensation (75%), following extremity weakness (60%), neck and shoulder pain, dysphonia, and dysphagia. SEP and MRI were applied in all cases pre and postoperatively. Syringosubarachnoid shunt (SSS) was performed through our modifiedtechnique unilateral partial hemilaminectomy (UPHL) in 19 cases with non-communicate syringomyelia. SSS not only used in all cases, but also craniovertebral decompression (CVD) plus duraplastywas performed in cases of Ch I M. All caseswere followedby SEP and MRI for 6 monthsto 4 years. The early postoperative MRI showed a clear collaps of syrinx in 31 cases. Diameterof syrinx was not decreased in three cases with Ch I M treated only CVD at first operation. These cases were operated for SSS at second step and control MRI showed collaps of syrinx. MRI findings were showed improvement in all cases, while have shown electrophysiological improvement in 18 cases (54%), although 21 (63%) cases improved clinically. The findings of cerebellar and lower cranial nerves compression were resolved in most cases at early postoperative period. In spite of, electrophysiological, radiological and clinical improvement of spinal cord pathologywere observedat different degrees in the late postoperative period. There was no significantcorrelation between the syrinx/canal indexand spinalsymptomatology, althoughclose correlation between posteriorfossa compression and tonsillary herniationdegree and electrophysiologicalfindings. MRI provideconsiderable information to correlates well with the clinical and electrophysiological findings in case of syringomyelia with or without Ch I M. Combination of SEP and MRI not only proved clinicopathological correlation, but also predict surgicaloutcome. Early surgery could be optimal the treatment for syringomyelia. Pluggingof the obex is not necessaryfor obtaining medullary collapse. The application of SSSthroughUPHLis a practicaland useful surgical method, because of a small risk of surgical trauma, infection, granulation and stabilization,
I0-26-3791
Clinical evaluation of the outcome and the method of surgical decompression for syringomyelia associated with Chiari type I malformation
Shinji Imae, FuminoriOzaki, Kunio Nakai, Toru ltakura. Department of NeurologicalSurgery, Wakayama Medical College, Wakayama 640, Japan Introduction: The technique of foramen magnum decompression for syringomyelia associated with Chiari type I malformation has not been standardized yet. No one procedure has been always successful, leading to many alternativeprocedures. The purpose of the current study is to decide the best procedureat present. Patients and Methods: 42 patients with syringomyeliaassociated with the Chiari type I malformation, diagnosed by magnetic resonance imaging (MRI), underwent surgical treatment. In all patients anomalies of the craniocervical junction,cervicaldisc herniation and other spinal disease were ruled out. There were 26 men and 16 women, ranging from 6 to 72 (mean: 42.3) years in age. All patients were treated by foramen magnumdecompression and divided into 4 groups according to the degree of decompression: 1) tonsillectomy group: 12 patients underwent suboccipital craniectomy (SOC) with patchy-graft dural plastyusinglyophilized duramaterandtonsillectomy. 2) lysisgroup:7 underwent SOC,dural plastyand microsurgical lysis of arachnoidal trabeculaand fibrinoid filament application around the herniated tonsil. 3) plasty group: 17 underwent SOCand dural plasty. 4) duralgroup:6 underwentSOC and removalof the outer layer of the dura mater. The mean follow-up period of the tonsillectomy group was 3.7 years, lysis group: 3.6 years, plasty group; 2.3 years, dural group; 1.8 years, respectively. Evaluation of the effects following the four types of surgical treatment was performed on the basis of clinical symptoms and the volume of the syrinx cavity on sagittal MRI. The ratio of the area of the syrinx to the spinal cord on preoperative and postoperative sagittal MRIwas measured by personalcomputer. Results: There was no significantdifference among the 4 groups as to the degree of reduction of the syrinx in the sagittal plane as evaluated on MRI, whereaswith regards to improvement of the clinicalsymptoms, dural group was significantly worsethan the other three groups. Discussion and Conclusion: The surgical procedure of plasty was manifestly less invasivethanthat of tonsillectomy and lysis.These resultssuggested that we should firstly choose dural plasty for syringomyelia associatedwith the Chiari type I malformation.