presented was: Motor 20.6%, Touch 15.6% and Pinprick 14.4%. The Wilcoxon signed ranks test [Additional file 1] confirms P < 0.001 for all modalities.
There are surgical solutions for the various pathologies, that may appear (with some delay) after a SCI, and they are published with results in many series for each pathology. However, some percentage of relapses is normal and these are intimately linked to obstructions and dislocations of the CSF drainage system. Some authors have performed laminectomies in the area of the injury to effect neurological improvement. However, the results have not been statistically significant so this technique is rarely
used. Nevertheless, some patients showed a measure of recovery, probably due to decompression of the intradural structures and some alteration in CSF dynamics [21,22]. It becomes evident, experimentally and in a series of operated patients, that removal of the arachnoiditis may lead to some neurological recovery at the level of the injury and below it; this was confirmed in all the patients in this study [23,25]. Falci , discussing surgical treatment of posttraumatic cystic and tethered spinal cords, described a group of patients operated for untethering, with one year follow up. The results achieved were: light touch – 2.38 points, pinprick – 3.88 points and motor score – 1.47 points. They were good results at the time, but completely different from the new alternative surgical procedure described here. Imaging techniques such as MRI and CT, which are available for the study of SCI patients, are insufficient to reveal the complete area of the medullar injury and especially the relationship established between the arachnoid, the pia and the dura after the accident and its subsequent consolidation. It is not
possible to see either the fibrotic adhesions or the cysts that have formed, and it is often necessary to carry out a
conventional myelographic tomography to achieve a more accurate diagnosis . However, complete medullar
release at the level of the injury, rostral, and caudal to it permits the extensive arachnoiditis existing in many
patients to be removed and precludes the appearance of more attachments. The operation described has some
advantages, because the responsible factors for obstructing the shunts and stents are eliminated. It is important to
mention that completeness or incompleteness of injuries, the time between the acute traumatic event and this procedure,
or the level and type of injury, were not used as selection criteria for this operation. In short, it is also important to note that this procedure has proved safe and without immediate or delayed adverse effects in 100% of the patients.
This surgical alternative, with complete removal of the arachnoiditis at the level of the injury and of the altered arachnoid on at least two rostral and caudal levels, allows the CSF to circulate as normally as possible, avoiding the relapses that are the reasons for many further surgical operations. Myelotomies and the use of materials such as shunts and stents are avoided. In the three patients with syringomyelia, the symptoms disappeared post surgery and the control MRI scans showed regression of the cysts after one year and three years. In this particular pathology, with a follow up average of 56 months, there were no repeated relapses. In all patients who in the T2 MRI scans showed signs of intra medullar hyper intensity, these images disappeared during the first year, and medullar expansion was visible at the end of the third year. Any medullar atrophy makes this surgical procedure easier, and in no case were there temporary neurological deficits or other post-operative or delayed neurological deterioration. Finally, a particularly significant conclusion is that all the patients with different levels and types of injuries showed motor and sensory recovery, with greatly improved qualities of life.
The author(s) declare that they have no competing interests.
A special thanks to Dr João Lemos Gomes and Dr Pedro Barradas. A special thanks to Rita Vasconcelos, PhD in Countability and Statistics at the University of Madeira for all the analysis and statistical treatment of all data related to all patients.
A special thanks to Dr. Angela Panther of the University of Aberdeen (Biomedes Department), U.K., for the correction of the manuscript.
1. Chang HS, Joko M, Matsuo N, Kim SD, Nakagawa H: Subarachnoid pressure-dependent change in syrinx size in a patient with
adhesive arachnoiditis. Case report J neurosurg Spine 2005, 2(2):209-14.
2. Chang HS, Nakagawa H: Theoretical analysis of the pathophysiology of syringomyelia associated with adhesive arachnoiditis.
J neurol Neurosurg Psychiatry 2004, 75(5):754-7.
3. Koyanagi I, Iwasaki Y, Hida K, Houkin K: Clinical features and pathomechanisms of syringomyelia associated with spinal
arachnoiditis. Surg Neurol 63(4):350-5.
4. Brodbelt AR, Stoodley MA, Watling AM, Tu J, Burke S, Jones NR: Altered subarachnoid space compliance and fluid flow in an
animal model of posttraumatic syringomyelia. Spine 28(20):E413-419. 2003 Oct 15;
5. Brodbelt AR, Stoodley MA, Watling AM, Tu J, Jones NR: Fluid flow in an animal model of post-traumatic syringomyelia. Eur
Spine 2003, 12(3):300-306.
6. Stoodley Ma, Gutschmidt B, Jones NR: Cerebrospinal fluid flow in an animal model of noncommunicating syringomyelia. Neurosurgery 1999, 44(5):1065-1075.
7. Cho KH, Iwasaki Y, Imamura H, Hida K, Abe H: Experimental model of posttraumatic syringomyelia: the role of adhesive
arachnoiditis in syrinx formation. J Neurosurg 1994, 80(1):133-139.
8. Stoodley MA, Jones NR, Brown CJ: Evidence for rapid fluid flow from the subarachnoid space into the spinal cord central
canal in rat. Brain Res 707(2):155-164. 1996 Jan 29;
9. Cosan TE, Tel E, Durmaz R, Gulec S, Baycu C: Non-hinbrainrelated syringomyelia. Obstruction of the subarachnoid
space and the central canal in rats. An experimental study. J Neurosurg Sci 2000, 44(3):123-127.
10. Caplan LR, Norohna AB, Amico LL: Syringomyelia and arachnoiditis. J Neurol Neurosurg Psychiatry 1990, 53(2):106-113.
11. Tatara N: [Experimental syringomyelia in rabbits and rats after localized spinal arachnoiditis]. No To Shinkei 1992,
12. Williams B, Sgouros S, Nenji E: Cerebrospinal fluid drainage for syringomyelia. Eur J Pediatr Surg 1995, 5(suppl 1):27-30.
13. Lee TT, Alameda GJ, Camillo E, Green Ba: Surgical treatment of post-traumatic myelopathy associated with syringomyelia.
Spine 26(24 Suppl):128. 2001 Dec 15;
14. Wang MY, Levi AD, Green BA: Intradural spinal arachnoid cysts in adults. Surg Neurol 2003, 60(1):49-55.
15. Bassiouni H, Hunold A, Asgari S, Hubschen U, Konig HJ, Stolke D: Spinal intradural justmedullary cysts in the adult: surgical
management and outcome. Neurosurgery 2004, 55(6):1352-1359.
16. Perrouin-Verbe B, Lenne-Aurier K, Robert R, Auffray-Calvier E, Richard I, Mauduyt de la Greve I, Mathe JF: Post-traumatic syringomyelia and pos-traumatic spinal canal stenosis: a direct relationship: review of 75 patients with a spinal cord injury.
Spinal Cord 1998, 36(2):137-143.
17. Schaller B, Mindermann T, Gratzl O: Treatment of syringomyelia after posttraumatic paraparesis or tetraparesis. J Spinal Disord 1999, 12(6):485-488.
18. Bains RS, Althausen PL, Gitlin GN, Gupta MC, Benson DR: The role of acute decompression and restoration of spinal canal alignment in the prevention of post-traumatic syringomyelia: case report and review of recent literature. Spine
26(17):E399-402. 2001 Sep 1;
19. Little JW, Ditunno JF Jr, Stiens SA, Harris RM: Incomplete spinal cord injury: neuronal mechanisms of recovery and hyperreflexia. Arch Phys Med Rehabil 1999, 80(5):587-599.
20. von Wild KR: New development of functional neurorehabilitation in neurosurgery. Acta Neurochir Suppl 2003, 87:43-47.
21. Bollman HH, Anderson PA: Anterior decompression and arthrodesis of the cervical spine: long-term improvement in
incomplete traumatic quadriparesis. J Joint Surg (Am) 1992, 74:671-682.
22. Maiman DJ, Larson SJ, Benzel EC: Neurological improvement associated with late decompression of the thoracolumbar
spinal cord. Neurosurgery 1984, 14:302-307.
23. Falcone S, Quencer RM, Green BA, Patchen SJ, Post MJ: Progressive posttraumatic myelomalacic myelopathy: imaging and clinical features. AJNR Am J Neuroradiol 1994, 15(4):747-754.
24. Falci SP, Lammertse DP, Best L, Starnes CA, Prenger EC, Stavros AT, Mellick D: surgical treatment of posttraumatic cystic and tethered spinal cords. J Spinal cord Med Fall 1999, 22(#):173-181.
25. Lee JH, Chung CK, Kim HJ: Decompression of the spinal subarachnoid space as a solution for syringomyelia without Chiari
malformation. Spinal Cord 2002, 40(10):501-506.
26. Brodbelt AR, Stoodley MA: Syringomyelia and the arachnoid web. Acta Neurochir 2003, 145(8):70.
The pre-publication history for this paper can be accessed here: