Syringo-subarachnoid shunt: how I do it

Abstract

Background

Syringo-subarachnoid shunt (SSS) is a valid method for the treatment of syringomyelia persisting after foramen magnum decompression (FMD) for Chiari I malformation.

Method

We give a brief overview on indication and outcome of SSS, followed by a detailed description of the surgical anatomy, and of the microsurgical technique. In particular, we highlight some key points for complication avoidance.

Conclusion

SSS is a valid option to treat syringomyelia, since in experienced hands, the outcome is good in most patients, including those with holocord syringomyelia. Careful understanding of anatomy and spinal cord physiology is required to minimize complications.

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Authors

Corresponding author

Correspondence to Jehuda Soleman.

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The authors declare that they have no conflict of interest.

Additional information

Key points

- The main indication of SSS is persistent, progressing, recurrent, or newly developed syringomyelia after FMD decompression for Chiari I malformation.

- Before indicating SSS surgery, hydrocephalus, regrowth of the posterior fossa bone (especially in young children), scoliosis, tethered cord syndrome, spinal cord tumors, and spinal instability should be ruled out.

- Microsurgical technique, accompanied by neuromonitoring are imperative as they help preserve neurological function.

- The identification of the posterior midline (posterior median sulcus) of the SC is essential, in order to avoid damage to the ascending columns of the posterior SC.

- Small pial arteries fold medially towards the posterior median sulcus, aiding the surgeon in identifying the midline.

- The syrinx is best reached through a blunt dissection of the SC posterior midline using a plated bayonet, so that the surrounding neuronal structures are minimally affected.

- As an alternative, if the syringomyelia is bulging laterally, it can be approached through the DREZ.

- The shunt catheter is inserted 2–3 cm into the syrinx cavity and subarachnoid space rostrally and cranially, respectively.

- The shunt catheter has to be long enough (at least 4 cm) and must be sutured to the arachnoid, to lower the risk of shunt dislocation.

- The goal of surgery is to release pressure from the SC and prevent further neurological deterioration.

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This article is part of the Topical Collection on Pediatric Neurosurgery

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Video showing the surgical technique of syringo-subarachnoid shunt insertion. (MP4 256145 kb)

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Soleman, J., Roth, J. & Constantini, S. Syringo-subarachnoid shunt: how I do it. Acta Neurochir 161, 367–370 (2019). https://doi.org/10.1007/s00701-019-03810-x

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Keywords

  • Syringo-subarachnoid shunt
  • Syringomyelia
  • Chiari I malformation
  • Spinal cord
  • Microsurgery
  • Pediatric neurosurgery
  • Spinal electrophysiological monitoring