Surgical management of post-traumatic syringomyelia.
METHODS
Systematic review.


OBJECTIVE
To determine the indications for surgical intervention and optimal surgical treatment technique for patients with post-traumatic syringomyelia and spinal cord tethering.


BACKGROUND
The proper management strategy for post-traumatic syringomyelia has not been established. Most modern surgical series have documented improvement in symptomatic patients who have an internal decompression of their syrinx. Several options exist and include shunting the syrinx (to the subarachnoid space or to either the pleural or peritoneal cavities) as well as spinal cord untethering (with or without expansile duraplasty).


METHODS
A systematic review of literature followed by expert panel consensus was performed. English language literature published between 1980 and 2010 was gathered to examine articles search was conducted using the search terms syringomyelia, syrinx, spinal cord injury, traumatic syringomyelia, post-traumatic syringomyelia. Case reports and articles examining syrinx due to other cause were excluded. Articles were graded for strength of evidence according to the GRADE approach. The evidentiary tables were reviewed and approved by all 4 authors, and disagreements were resolved by consensus.


RESULTS
The literature search yielded a total of 296 abstracts, and 22 articles were found to fulfill all the criteria specified above. All identified articles were of low or very low evidence levels. The reported incidence of post-traumatic syringomyelia is 0.5% to 4.5%; the incidence is twice as common in complete versus incomplete injuries. The literature consistently demonstrated that surgery post-traumatic syringomyelia is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes. The literature does not support surgical intervention for incidental, asymptomatic syrinx. The literature does not support one surgical technique as superior for the treatment of post-traumatic syringomyelia.


CONCLUSIONS
The literature supports and the consensus panel recommended that there is no indication for direct decompression at the time of initial injury specifically for the purpose of limiting future risk of syringomyelia. The literature supports and the consensus panel gave a strong recommendation for surgical intervention in the setting of motor neurologic deterioration as a consequence of post-traumatic syrinx/tethered cord. The panel gave a weak recommendation against surgical intervention for patients developing sensory loss/pain syndrome or for asymptomatic but expanding syrinx. Finally, the literature does not provide strong evidence to support the superiority of one surgical technique over the others; however, the consensus panel gave a weak recommendation that spinal cord untethering with expansile duraplasty is the preferred first-line surgical technique.
Bonfield
Christopher M
CM
Department of Neurological Surgery, UPMC Presbyterian, Pittsburgh, PA, USA.
Levi
Allan D
AD
Arnold
Paul M
PM
Okonkwo
David O
DO
D019299:Decompression, Surgical; D003697:Delphi Technique; D019317:Evidence-Based Medicine; D006801:Humans; D009043:Motor Activity; D019637:Orthopedic Procedures / Q000009:adverse effects; D010146:Pain / Q000209:etiology / Q000517:prevention & control; D020127:Recovery of Function; D012307:Risk Factors; D012677:Sensation; D013119:Spinal Cord Injuries / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D013595:Syringomyelia / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome