Ultrasound-guided Syringosubarachnoid Shunt Insertion for Cervicothoracic Syringomyelia

Syrinx can be secondary to many etiologies, including tumor, Chiari malformation, tethered cord, or sequelae of infection or trauma. Posttraumatic syringomyelia, a potential complication of spinal injury, can insidiously present years after the initial event. Expansion of the cerebrospinal fluid-filled cyst can lead to pain, sensorimotor deficits, and myelopathy. Simple fenestration is often unsuccessful, therefore permanent shunting of cerebrospinal fluid from the syrinx to the subarachnoid, pleura, or peritoneum can prevent recurrence. In this report, we present a patient with a complex L3 burst fracture from a remote trauma s/p stabilization. Thirty-two years later, he developed progressive neck pain, upper extremity radiculopathy, dysesthesias, and clinical myelopathy (dropping objects, gait imbalance). An MRI demonstrated an expansile syrinx from C2-conus medullaris which previously had been unsuccessfully treated by fenestration. We offered a T1-2 laminectomy and placement of synringosubarachnoid shunt. In the associated video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A107), we demonstrate the step-by-step approach for this procedure, including microsurgical intradural intramedullary exploration and insertion of a T-tube shunt catheter. We additionally demonstrate nuances of ultrasonography that guide medullary entry localization and confirmation of successful shunt placement. Finally, we review preoperative planning pearls pertinent to revision surgeries, pitfalls of the operation, and postoperative management strategies germane to successful outcomes.