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Spinal cord untethering and midline myelotomy for delayed, symptomatic post-traumatic syringomyelia due to retained ballistic fragments: case report

Abstract

Introduction

Post-traumatic syringomyelia is an uncommon complication after traumatic spinal cord injury. This case study details our decision-making and surgical approach for a patient with symptomatic post-traumatic syringomyelia after sustaining a gunshot wound.

Case presentation

A 24-year-old man with past medical history of distant American Spinal Injury Association Impairment Grade B spinal cord injury due to ballistic injury developed delayed post-traumatic syringomyelia, resulting in unilateral sensory loss and left upper extremity weakness. CT and MR imaging revealed a syrinx spanning his cervical and thoracic spine causing significant spinal cord compression. To relieve achieve decompression and restore CSF flow dynamics, we performed a bony extradural decompression, bullet fragment extraction, spinal cord untethering, and midline myelotomy. Postoperatively, the patient demonstrated clinical and radiographical improvement.

Discussion

Post-traumatic syringomyelia is potentially morbid sequalae of spinal cord injuries. Suspicion for post-traumatic syringomyelia should be maintained in patients with delayed, progressive neurologic deficits. In this setting, surgical intervention may require extradural and intradural procedures to mitigate neural compression along the dilated central canal by the syrinx.

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Fig. 1: Preoperative computed tomography.
Fig. 2: Serial CT myelography.
Fig. 3: Preoperative and postoperative MRI of syrinx.
Fig. 4: Preoperative and postoperative MRI of cervical spine.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

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Acknowledgements

The authors thank Eleanor Buckle who provided valuable assistance with technical aspects of this project.

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Contributions

TDA and NT conceived of the presented idea. TDA and JM wrote the manuscript with support from BYH, DM, KRL, LH, LJB, YX, PPS, NVK, and NT. NT supervised the project.

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Correspondence to Tej D. Azad.

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Ethical approval was not required by the Johns Hopkins Medicine Institutional Review Board, as the presented work is a medical/educational activity that does not meet the Department of Health and Human Services definition of “research”, which is: “a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.”

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Azad, T.D., Materi, J., Hwang, B.Y. et al. Spinal cord untethering and midline myelotomy for delayed, symptomatic post-traumatic syringomyelia due to retained ballistic fragments: case report. Spinal Cord Ser Cases 8, 66 (2022). https://doi.org/10.1038/s41394-022-00533-7

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