From the Guidelines
Surgical intervention is the primary approach for treating symptomatic thoracic spinal syrinx, with decompression surgery being the most common procedure, as it can help alleviate symptoms and prevent further neurological damage. When considering the management of thoracic spinal syrinx, it's essential to identify the underlying cause, as this will guide the treatment approach 1. The goal of imaging, such as MRI of the thoracic spine, is to identify potential actionable pain generators that could be targeted for medical treatment, intervention, or surgery 1.
Key Considerations
- Thoracic myelopathy is most commonly due to compressive etiologies, including structural causes resulting in spinal canal stenosis, cord compression/deformity, or other inflammatory, infectious, vascular, or neoplastic etiologies 1.
- Symptomatic thoracic disc herniations are more common in patients in their third to fifth decades of life and, in more than one-third of patients, are associated with a history of trauma 1.
- Indication for surgery is usually severe, intractable pain, or progressive/severe myelopathy 1.
Treatment Approach
- Decompression surgery is the primary approach for symptomatic cases, particularly if the syrinx is associated with conditions that require surgical intervention, such as Chiari malformation or tethered cord 1.
- Medication alone typically cannot resolve a syrinx, though pain management with medications like gabapentin, pregabalin, or amitriptyline may help control symptoms.
- Regular monitoring with MRI is essential for all patients, even after treatment, to assess the syrinx and prevent further neurological damage.
From the Research
Definition and Causes of Thoracic Spinal Syrinx
- A thoracic spinal syrinx is a fluid-filled cavity or cyst that forms within the spinal cord in the thoracic region [ 2 ].
- It can be secondary to various etiologies, including tumor, Chiari malformation, tethered cord, or sequelae of infection or trauma [ 2 ].
- Posttraumatic syringomyelia is a potential complication of spinal injury and can present years after the initial event [ 2 ].
Symptoms and Treatment
- Expansion of the cerebrospinal fluid-filled cyst can lead to pain, sensorimotor deficits, and myelopathy [ 2 ].
- Simple fenestration is often unsuccessful, and permanent shunting of cerebrospinal fluid from the syrinx to the subarachnoid, pleura, or peritoneum can prevent recurrence [ 2 ].
- Surgical management options include shunting the syrinx, spinal cord untethering, and expansile duraplasty [ 3 ].
- The choice of surgical technique depends on the individual case, and there is no single superior technique [ 3 ].
Management of Post-Traumatic Syringomyelia
- The literature consistently demonstrates that surgery for post-traumatic syringomyelia is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes [ 3 ].
- The literature does not support surgical intervention for incidental, asymptomatic syrinx [ 3 ].
- Gabapentin can be used to treat neuropathic pain associated with spinal cord injury, including thoracic spinal syrinx [ 4 ].
Decompression and Shunting
- Decompression of the spinal subarachnoid space can be an effective solution for syringomyelia without Chiari malformation [ 5 ].
- Restoration of cerebrospinal fluid flow dynamics between the syrinx and the subarachnoid space is more effective than simple drainage of the syrinx cavity [ 5 ].
- Outcomes of patients with syringomyelia undergoing spine deformity surgery can vary depending on the size of the syrinx [ 6 ].