Anaesthetic Management of a Patient with Syringomyelia for Modified
Radical Mastectomy and a Review of Literature
Bhagyalakshmi Ramesh1* and Vinoth Kumar Elumalai2 1,2Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram, India
Received date: April 05, 2018; Accepted date: May 01, 2018; Published date:
May 09, 2018
*Corresponding author: Dr Bhagyalakshmi Ramesh, Assistant Professor,
Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram,
India, Tel.: 9847125645; E-mail: : firstname.lastname@example.org
Syringomyelia is a neurological condition in which a cavity develops in
the spinal canal (syrinx). It may be a cause for the development of Arnold
Chiari malformation Type 1 in which there is herniation of the cerebellar
tonsils. It has a prevalence of 8.4 per 100,000 and occurs more frequently
in men than women in the third or fourth decade of life. Rarely, it may
develop in childhood or late adulthood. Here we report the anesthetic
management of a patient who presented with syringomyelia scheduled to
undergo a modified radical mastectomy.
Keywords: Syringomyelia; Arnold Chiari malformation; Anaesthetic
A 78 year old female weighing 56 kg presented with carcinoma of
the breast and was scheduled for modified radical mastectomy. On
preanaesthetic evaluation she was found to be a hypertensive and diabetic.
She had undergone a thyroidectomy surgery 2 years back and was on
thyroid medications. She also complained of weakness on both upper
limbs for last 10years. On neurological evaluation she was diagnosed to
have syrinx at C2-T1 levels on MRI scan. She had grade 3-4 power on
both upper limbs. There was no other associated neurological dysfunction
like slurred speech, swallowing difficulty or loss of temperature or
pain sensation on face, chest or upper limbs. She was detected to have
lower motor neuron weakness of upper limb with wasting .Her blood
investigations were normal. Other consultations done included a cardiac
consultation and a pulmonology evaluation. Her Pulmonary function test
was normal. Her room air saturation was 98%. Her ECHO findings were
normal. Airway examination was normal.
The patient was premedicated with Alprazolam 0.25mg on the night
before the surgery. She also received her routine antihypertensive
medication on the day of the surgery. Blood sugar was controlled with
Insulin. She received Pantoprazole 40mg on the morning of surgery.
Routine monitors were connected. Anintra-arterial line was used to
monitor her blood pressure(invasive monitoring) BIS monitoring was
used intraoperatively.She received Midazolam 1mg and Fentanyl citrate
80mcg as premedication As she did not have any features of raised
intracranial tension she was intubated using IGel (4size) after receiving
Intravenous Propofol (80mg) and Atracurium (15mg) Surgery lasted for
90minutes.Procedure was uneventful and patient was extubated (after
checking Train of four response at the conclusion of the surgery) using
neostigmine 2.5mg and glycopyrrolate 0.4mg. She received Paracetamol
IV postoperatively for pain and fentanyl bolusesas rescue analgesic. She
was discharged after 2 days.
Syringomyelia is an unusual condition which may be associated with
Arnold Chiari malformation in which there is a cavity within the spinal
cord. It has a prevalence of 8.4 per100000 and is more common in males
. It may develop in childhood or late adult age group rarely. It poses
significant challenge to the anaesthetist In a classic case of syringomyelia,
patient shows asymmetric loss of pain and temperature sensation in the
upper limb (lateral spinothalamic tract), lower motor neuron signs in the
hands (anterior horn cells), and upper motor neuron signs in the lower
limbs (corticospinal tracts). Advanced disease is usually characterized
by presence of posterior column signs.Trophic changes may be striking
particularly with gross osteoarthropathy (Charcot’s joints) development.
Autonomic neuropathy can be there in a coexisting syringomyelia .
The patient may be symptomatic if there is neural compression when
they will have signs of raised intracranial pressure. They can present
with difficult airway due to the bony abnormalities in the cervical spine.
They require careful intubation with cervical stabilization. They may
pose difficulties with positioning. They may have altered response to
nondepolarising muscle relaxants [1,2]. They may also have fluctuating
blood pressure due to autonomic dysfunction. The patients who are
symptomatic may require decompression craniectomy .
In our patient we had used the supraglottic device for intubation which
is considered as an adjunct in the difficult airway algorithm. Igel has been
found to be associated with less gastric insufflation and hence chance of
aspiration [3,4]. Studies in obstetric patients have demonstrated the use
of epidural analgesia in these patients with few complications  Reports
of parturients developing respiratory complications in the postoperative
period have also been reported [5,6].
The patients with syringomyelia require careful preoperative workup
including proper neurological evaluation, careful anesthetic planning and
intraoperative vigilance and anticipation of probable complications to
- Anand LK, Malhotra A, Saroa R, Kazal S, Sarna R. Anesthetic management of a patient with syringomyelia and Arnold-Chiari malformation type I with autonomic dysfunction. Anaesth Pain & Intensive Care. 2015;19(3):408-411.
- Kim TY, Lee C, Kim JN. Anesthetic management of a patient with Arnold-Chiari malformation type I with associated syringomyelia: A case report. Anesthesia and Pain Medicine. 2012;7(2):166-169.
- Helmy AM, Atef HM, El-Taher EM, Henidak AM. Comparative study between I-gel, a new supraglottic airway device, and classical laryngeal mask airway in anesthetized spontaneously ventilated patients. Saudi journal of anaesthesia. 2010;4(3):131-136.
- Ghaly RF, Candido KD, Sauer R, Knezevic NN. Anesthetic management during Cesarean section in a woman with residual Arnold–Chiari malformation Type I, cervical kyphosis, and syringomyelia. Surgical Neurology International. 2012;3:26. doi:10.4103/2152-7806.92940.
- Mustapha B, Chkoura K, Elhassani M, Ahtil R, Azendour H, Kamili ND. Difficult intubation in a parturient with syringomyelia and Arnold–Chiari malformation: Use of Airtraq™ laryngoscope. Saudi journal of anaesthesia. 2011;5(4):419-422. doi: 10.4103/1658-354X.87274
- Garvey GP, Wasade VS, Murphy KE, Balki M. Anesthetic and Obstetric Management of Syringomyelia during Labor and Delivery: A Case Series and Systematic Review. Anesthesia & Analgesia. 2017;125(3):913-924. doi: 10.1213/ANE.0000000000001987