What are the pre-surgical treatments for syringomyelia?

From the Guidelines

The treatment of syringomyelia before surgery should focus on managing symptoms, preventing progression, and preparing for definitive surgical intervention, with a primary focus on pain management and regular neurological monitoring, as suggested by the most recent study 1.

Pre-Surgical Management

The goal of pre-surgical management is to stabilize the patient's condition while preparing for definitive treatment. This approach helps minimize neurological deterioration while optimizing the patient's condition for surgery.

• Pain management is crucial, using medications such as gabapentin (300-1200 mg three times daily), pregabalin (75-300 mg twice daily), or amitriptyline (10-50 mg at bedtime) 1.
• Neuropathic pain may require opioids in severe cases, though these should be used cautiously.
• Physical therapy helps maintain function and prevent contractures, while occupational therapy assists with adaptive techniques for daily activities.
• Patients should avoid activities that increase intracranial pressure, such as heavy lifting or straining, as these can worsen symptoms by altering CSF dynamics.

Diagnostic Imaging

Regular neurological monitoring is essential to track disease progression, with MRI imaging recommended every 6-12 months depending on symptom stability, as suggested by 1.

• Steroids may occasionally be prescribed for inflammatory symptoms.
• The diagnosis of underlying neural axis anomalies, such as hydrosyringomyelia, changes long-term management and outcomes in only selected patients 1.

Surgical Intervention

The goal of pre-surgical management is to stabilize the patient's condition while preparing for definitive treatment, which typically addresses the underlying cause such as Chiari malformation, spinal cord tethering, or tumor removal.

• Early intervention is important, and MRI is recommended in patients with scoliosis and risk factors, as suggested by 1.
• The treatment approach should be individualized based on the patient's specific condition and symptoms.

From the Research

Pre-Surgical Treatment of Syringomyelia

• The treatment of syringomyelia before surgery is a complex issue, and there is no clear consensus on the recommended approach 2.
• A systematic review of 43 observational studies found that 89% of patients were treated surgically, with a complication rate of 26% 2.
• The review also found that symptoms improved in 43% of patients postoperatively and in 2% treated conservatively, while stable disease was documented in 50% of patients postoperatively and in 88% treated conservatively 2.

Surgical Approaches

• A prospective study of 137 patients with posttraumatic syringomyelia found that decompression with arachnolysis, untethering, and duraplasty at the level of the underlying trauma provided good long-term results for patients with progressive neurological symptoms 3.
• The study also found that cordectomy led to neurological improvement and syrinx collapse in all 4 patients who underwent the procedure 3.
• Another study found that syringoperitoneal shunting was effective in reversing or arresting neurological deterioration in patients with syringomyelia, with a higher percentage of patients experiencing neurological improvement compared to other procedures 4.

Conservative Management

• A review of idiopathic syringomyelia found that conservative management was sufficient for most cases, with continued progression of symptoms potentially being approached using decompressive strategies such as laminectomy, lysis of adhesions, and craniocervical decompression 5.
• A study on the diagnosis and management of syringomyelia noted that most cases are now diagnosed earlier, with less pronounced deficits, and that understanding the significance of various presenting symptoms and knowing when surgery might help are new challenges in the management of the condition 6.

Outcome and Complications

• A systematic review found that the percentage of deterioration was similar between surgical and conservative treatment, with 16% of patients experiencing deterioration after surgery and 10% after conservative treatment 2.
• The review also found that the complication rate for surgical treatment was 26%, with detailed analysis of surgical outcome revealing that pain, motor, and sensory function could be improved in 43 to 55% of patients, while motor function deteriorated in around 25% 2.