Progressive Thoracic Syrinx with Stable Neurological Examination: A Case Report

Case Diagnosis: Expansile Thoracic Syrinx from T1-T4

Case Description or Program Description: A 51-year-old female with a history of expansile thoracic syrinx (T1-T4), presented with worsening mid thoracic back pain radiating to the bilateral hips and numbness and tingling in the bilateral legs, functionally limiting her ability to work as a nurse. Despite the syrinx demonstrating slow progression on imaging since 2015, her neurological examination remained stable without myelopathic signs. Conservative management, including physical therapy and analgesic medications, provided limited relief. Multiple neurosurgeons recommended surgical decompression due to the expanding syrinx and cord displacement, but the patient deferred intervention, prioritizing functional status and avoidance of surgery. MRI findings revealed a large 6 cm x 1 cm syrinx, anterior spinal cord displacement, and decreased anterior CSF flow.

Setting: Spine rehabilitation clinic in a tertiary care center

Assessment/Results: Despite worsening pain and functional limitations, neurological examination consistently showed bilateral lower extremity hyporeflexia, preserved motor function, and no signs of myelopathy. The patient was counseled on the potential for sudden neurological deterioration. Conservative treatment was continued with ongoing monitoring of repeat imaging and neurosurgical reassessment.

Discussion (relevance): This case is unique in its discrepancy between progressive radiographic changes and the lack of clinical neurological decline. It raises important considerations regarding the timing of surgical intervention in patients with slowly enlarging syrinxes who remain functionally intact.

Conclusions: The discordance between imaging progression and stable neurological function, despite clinical symptoms presents a clinical dilemma in syringomyelia management. This case highlights the importance of individualized treatment decisions, longitudinal monitoring, collaboration between rehabilitation medicine and neurosurgery, and further research into factors influencing symptom development.