Posttraumatic Syringomyelia with Holocord Involvement: A Case Report

Abstract

Case Description: 57-year-old man evaluated in the emergency department due to progressive pain in his left neck over 4 months and worsening weakness, over 1 month, in his left hand. History pertinent for a motorcycle accident 30 years prior with residual bilateral foot drop, and baseline ambulation utilizing bilateral Lofstrand crutches. The patient was referred to neurology who ordered an MRI of the cervical and thoracic spine, EMG/NCS and PM&R evaluation. Setting: Outpatient rehabilitation clinic. Results or Clinical Course: Patient evaluated in PM&R clinic after MRI was performed, with results noting T2 hyperintense signal from C1 until at least T12, conistent with spinal cord syrinx. Physical examination notable for atrophy of the FDI, thenar, and hypothenar eminences and weakness at the elbow, wrist and hand; lower extremity examination with trace contraction of the dorsi/plantarflexors. MRI L spine was ordered to evaluate extent of syrinx, which was found as caudal as the conus (L1-L2). Neurosurgical plan was to proceed with placement of a syringosubarachnoid shunt. Further rehabilitation needs would be addressed postoperatively. Discussion: Syringomyelia is a serious condition in which the usual cerebrospinal fluid (CSF) mechanics are disturbed, and can be seen in as many as 3-4% of patients after traumatic spinal cord injury, with an interval of occurrence from several months to many years. Normally, this is a benign prognosis, likely representing an area of liquefaction necrosis of cord tissue, but may progress to worsened or new neurological symptoms, as seen in this case. Holocord involvement had been noted in 1 recent case report, and other studies identified patients with as many as 19 segments involved, though this was in the significant minority (1-3). This study noted that patients appeared to have more desirable outcomes when opting for duraplasty and arachnolysis vs shunting. Conclusion: Spinal cord injury can cause a myriad of consequential conditions that affect a patient's functional mobility and ADLs. Syringomyelia can be a potentially serious sequela in SCI patients and it is important to be aware of in that patient population as the dysfunctional CSF mechanics may continue to expand the syrinx, both proximally and distally, to a level distant from the original injury.