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24-MARCH-2010  GHADA ISMAEEL AL-ARYAN  50 YEARS  PROGRESSING SYRINGOMYELIA OF THE UPPER DORSAL SPINAL CORD.

Anamnesis

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The patient came to the clinic 10-February-2010 complaining of LBP for 27 years after RTA. The last 2 months exacerbation of LBP with left sciatica and weak both feet. MRI lumbar spine done 14-March-2009 showing old wedged fracture L1 and Th 7 and 8 with syringomyelia starting at D2 down to D9. MRI dorsal spine performed 19-October-2009 showing progression of the syrinx. The patient is claiming that her condition is deteriorating.

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On examination: the patient is dragging her left lower limb. There is weak grip and extension right hand and triceps muscle  right upper limb 4/5 with hypalgesia medial side of the right arm. There is hypalgesia of the right lower side of the body below D5 with weak muscles left lower limb 3/5. SLRS was 60 degrees in the left due to weakness. There is Babinski sign both sides. The patient was sent for new investigations.

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MRI of the cervical spine performed 16-March-2010  was normal, but MRI of the dorsal spine showed progression of the syrinx to reach the D1 level.

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Laminectomy at D6 level and opening of the dural sac revealed relatively healthy spinal cord, for what the laminectomy was extended up one level and the dural opening was extended also and the spinal cord was seen pathologic in the right side of the posterior surface. At the most affected part of the spinal cord, using blade No 11 0.1 mm incision was made vertically. Using the proximal part of lumboperitoneal tube about 15 cm length the proximal part of the tube was inserted inside the syrinx cavity running down and the distal part running up with small pores created nearby. The distal part was left in the subdural space and fixed by nylon 6 zero to the arachnoid to prevent future slipping of the tube. Applying pressure to the spinal cord showed good outflow of the CSF from inside the syrinx. The spinal cord collapsed. The dura was water-tightly closed.

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Routine closure of the wound.

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Smooth postoperative recovery, and the power of left lower limb improved.


Comments

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Intervention to the static post-traumatic syringomyelia usually cause deterioration of the neurological status. But, when the patient is deteriorating and the syrinx is increasing in size, surgical intervention is the only solution to at least halt the deteriorating course.

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Shunting of the syrinx is preferable to perform at the most caudal part of the syrinx, but this is not always possible. The surface of the spinal cord govern the most appropriate point of insertion of the shunt, as in this case.

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