Rehabilitation medicine has a clear but complex mission As the 13th century physician-philosopher Maimonides once remarked, "To sustain and nurture a man alive in the throes of disease and disability is as great a miracle as to create him" This credo, emblematic of physiatry's calling, is well represented in the pages of Dr Randall L Braddom's new rehabilitation textbook, Physical Medicine and Rehabilitation  Intended as a revitalized rendition of an earlier classical rehabilitation text, Krusen's Handbook of Physical Medicine and Rehabilitation , this volume aims to expand and modernize its coverage of PM&R The goal of Physical Medicine and Rehabilitation , according to its editor, is to "meet the needs of the modern practitioner" By providing state-of-the art information, this volume is a nice complement to its legendary predecessor As one of several formidable physiatry textbooks that have become available in recent years, Braddom's Physical Medicine and Rehabilitation is likely to appeal

Physical medicine and rehabilitation

BACKGROUND AND PURPOSE: Alteration of CSF flow has been proposed to be an important mechanism leading to the development of syringomyelia. We hypothesize that a “presyrinx” condition attributable to a potentially reversible alteration in normal CSF flow exists and that its appearance may be caused by variations in the competence of the central canal of the spinal cord. METHODS: Five patients with clinical evidence of myelopathy, no history of spinal cord trauma, enlargement of the cervical spinal cord with T1 and T2 prolongation but no cavitation, evidence of altered or obstructed CSF flow, and no evidence of intramedullary tumor or a spinal vascular event underwent MR imaging before and after intervention that alleviated obstruction to CSF flow. RESULTS: Preoperatively, all patients had enlarged spinal cords and parenchymal T1 and T2 prolongation without cavitation. Results of MR examinations after intervention showed resolution of cord enlargement and normalization or improvement of cord signal abnormalities. In one patient with severe arachnoid adhesions who initially improved after decompression, late evolution into syringomyelia occurred in association with continued CSF obstruction. CONCLUSION: Nontraumatic obstruction of the CSF pathways in the spine may result in spinal cord parenchymal T2 prolongation that is reversible after restoration of patency of CSF pathways. We refer to this MR appearance as the “presyrinx” state and stress the importance of timely intervention to limit progression to syringomyelia.

http://www.ajnr.org/content/ajnr/20/1/7.full.pdf

The"presyrinx" state : a reversible myelopathic condition that may precede syringomyelia

Object Alteration of cerebrospinal fluid (CSF) flow has been proposed as an important mechanism leading to the development of syringomyelia. We hypothesize that a “presyrinx” condition due to potentially reversible alteration in normal CSF flow exists and that its appearance may be due to variations in the competence of the central canal of the spinal cord. Methods Five patients with clinical evidence of myelopathy, no history of spinal cord trauma, enlargement of the cervical spinal cord with T1 and T2 prolongation but no cavitation, evidence for altered or obstructed CSF flow, and no evidence of intramedullary tumor or a spinal vascular event underwent MR imaging before and after intervention that alleviated obstruction to CSF flow. Results Preoperatively, all patients demonstrated enlarged spinal cords and parenchymal T1 and T2 prolongation without cavitation. Results of magnetic resonance (MR) imaging examinations following intervention in all patients showed resolution of cord enlargement and normali...

/pdf/the-presyrinx-state-is-there-a-reversible-myelopathic-1pmzo3ekmw.pdf

The "presyrinx" state: is there a reversible myelopathic condition that may precede syringomyelia?

Magnetic resonance images of 128 patients with compressive lesions of the cervical spinal canal were reviewed to determine whether a high signal intensity lesion within the spinal cord was present on T2 and proton density weighted spin echo images Such high signal intensity was observed in 24 cases or 188% The incidence was higher in herniated disk (324%), atlanto-axial dislocation (286%), and ossification of the posterior longitudinal ligament (227%), whereas the abnormality was found sporadically in cervical spondylosis and vertebral body tumors The high intensity lesion on T2 weighted images was generally observed in patients with constriction or narrowing of the spinal cord The lesion was not demonstrated on T1 weighted spin echo images Spinal cord constriction or localized narrowing seemed to be the most important predisposing factor in producing such a high signal intensity The pathophysiologic basis of such an abnormality was presumed to be myelomalacia or cord gliosis secondary to a long-standing compressive effect of the spinal cord

Increased MR signal intensity secondary to chronic cervical cord compression

This study aims to demonstrate predictive factors for post traumatic syringomyelia (PTS), and in particular to correlate the role of insufficiency of reduction of a spinal fracture with the occurrence of syringomyelia. One hundred and twenty-eight spinal cord injured patients (SCI) were studied during the years 1992 and 1993. Among them, 75 underwent a complete and reliable evaluation including: review of the initial vertebral lesion, and of the surgery report, and a radiological study of the lesion site with standard X-rays, a CT scan, and an MRI. The CT Scan included slices in sagittal reconstructions and in the axial plane at the site of injury with the calculation of a percentage of canal stenosis in the two planes of the space. An MRI was carried out with T1 and T2 weighted images, including sagittal entire cord images in addition to sagittal and axial slices centred on the site of injury. A syrinx was diagnosed in 28% of the patients. The occurrence of a syrinx is significantly correlated with spinal canal stenosis in the sagittal plane (delta D) with a P < 0.001 and in the axial plane (delta S) (P < 0.05). This present study demonstrates the major role of the insufficiency of reduction of the vertebral lesion in the genesis of a syrinx. The quality of the initial treatment of the vertebral injury is the first step in the prevention of a syrinx. The treatment of a syrinx, besides techniques of drainage, must also take into account the spinal realignment.

/pdf/post-traumatic-syringomyelia-and-post-traumatic-spinal-canal-f3c00ftd5v.pdf

Post-traumatic syringomyelia and post-traumatic spinal canal stenosis: a direct relationship: review of 75 patients with a spinal cord injury.

A description is given of the syndrome of post-traumatic syringomyelia amongst patients with traumatic spinal injuries seen at the National Spinal Injuries Centre. The diagnosis was made on clinical grounds. It was confirmed wherever possible by neuroradiology prior to surgery; one case was confirmed only at post-mortem. The incidence of the condition was found to be in keeping with other large series but, in contrast, no difference was found between the time of onset after injury between complete and incomplete lesions of the spinal cord. The commonest manifestation was pain, followed by sensory loss and rarely motor weakness. In the majority of patients the condition eventually became bilateral and in a significant number the lesion ascended to involve the trigeminal territory. The natural history of the condition was followed, and in all cases the condition gradually progressed. The pathogenesis of the condition is briefly discussed in view of the findings.

/pdf/post-traumatic-syringomyelia-3ss7u836w3.pdf

Post-traumatic syringomyelia.

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Post-traumatic syringomyelia.