Syrinx or black hole?

[pokey]

I have had symptoms since 1998, such as  R arm/leg numbness, tingling, bladder spasms, blurred vision. Recently had a few episodes of vertigo. All intermittent. Needless to say, I have had a few MRI's to rule out MS. One T2 hyperintensity near left frontal horn. 1 Cervical MRI normal.

Recent MRI of brain and throacic spine read as small mid-thoracic cord syrinx. Exact borders are difficult to define, but it appears to extend from appx lower T7 to mid T9. Measures appx 2mm in diameter. The abnormaility is centrally located and follows cerebral spinal fluid on T1/T2 sequences. No abnormal enhancement. No fracture. There is a T8 superior endplate Schmorl's node. No paraspinal abnormailty is detected. Impression: Very small T7-9 cord syrinx. No definite etiology is demonstrated. The cerebellar tonsils are boderline low, but DO NOT have the classic configuration of a Chiari I malformation.

Questions:

Could the syrinx actually represent a "black hole" rather than a syrinx? What would be the MRI differences between the 2?

After having several prior MRI's, this is the first time it has been mentioned about the cerebellar tonsils which decend appx 5mm below the foramen magnum. My guess, because its not significant?

I understand the T7-9 thing be responsible for the leg and bladder problems, but really don't explain the arm and vision problems. Any ideas?

I know without seeing the actual films it is difficult to say much but any suggestions as to next steps that sould be taken will be greatly appreciated.

Thank you in advance.
Pokey

[Annika]

Dear Pokey,

Everything Justy has said in his past two posts is right on target with what I have learned about this problem.  I wrote a longer note to you yesterday, but it was lost when my computer crashed.  Thankfully, Justy said all the main things I wanted to point out.  

In particular, the issue of confusion with MS is critical.  Without saying that someone does or does not have MS, it is very common for the comparatively rare spinal disorders (such as syringomyelia, tethered cord and Chiari) to be misdiagnosed as MS.  First, misdiagnosis happens frequently before the spinal anomalies are found

[justy]

Your welcome Pokey,
There have been many Chiarians who have previously been misdiagnosed with fibromyalgia, MS, and Chronic Fatigue. The ctiteria for which most neurologists and radiologists diagnose Chiari is a 3-5mm herniation of the cerebellar tonsils. Dr. Milhorat's 1999 clinical study "Chiari 1 Redefined" which can be read at www.wacma.com in the "on site info" states that this criteria may be too restrictive. You can also talk with other Chiarians many who have gone through what you are going through right now at http://groups.yahoo.com/group/chiari/ I'm sorry if I seem persistant but I know of many who have gone through this. Good Luck.........

[To CCF Neuro MD From Pokey]

Thanks again Justy. I do meet one of the criteria for Chiari and that is the 5mm measurement. But they also stated in the report that the cerebellar tonsils maintain a rounded configuration. When I know that my family Doctor has all the reports, the MRI the consultation with the neuro; then I will make an appointment with him to go over everything. I am going to check out that website. I also did read that article about diagnosing Chiari. Very interesting. I have an x-ray backround, so I do like to look at the pictures on the net, especially the cases that don't give you what it is. I came across info on what they term "Gibbs artifact" which can represent a syrinx on MRI, but since mine showed up in the sagittal plane and the axial plane it makes that unlikely. Anyways, I just have to wait until my Doc has the reports so he can make his decision. I think there will be another opinion in the future. I'll keep ya posted. I'm sure that I'll be posting again. This is the best website!

[To CCF Neuro MD From Pokey]

Hi Everyone,

Just to let you all know what my Doctor said. He says I do not have Chiari. He also said that the syrinx is not causing my symptoms since some of them are related to the brain, and cervial region. So were back onto the MS probablity....again. We did talk about treatment, but without the MRI confirmation of more than 1 spot, he didn't feel we should. I am going to follow up with my PCP and see how he feels. Justy, I feel the same way you do, the fact that it was even mentioned may be important. I'm starting to feel like an airplane in a holding pattern and it's running out of fuel. These past couple of days have been very trying to say the least. I have seen an MS specialist before, maybe I should try to see him again. Maybe he would be able to lead my PCP to the right connections to find out if this is a Chiari or not. One good thing though, atleast a Chiari is fixable!

Pokey

[justy]

Hi Pokey,
Just as Annika said the criteria has changed for Chiari 1 Malformation but the fact that they mentioned it at all in your report is reason for further investigation with a Chiari Expert. The average neurologist and even most neurosurgeons are not usually aware of the changing criteria and the very fact that you have a syrinx and the symtptoms you mentioned is suspect. I have a syrinx and have been told I do not have Chiari. I am seeing a well known Chiari expert in January to get his opinion. I will also be given a Cine MRI which is a special MRI that shows the flow of CSF to see if there is a blockage. I do know of many who were told they did not have Chiari and were given the Cine MRI which proved otherwise.

[To CCF Neuro MD From Pokey]

Thanks for the info CCF Neuro, Justy and Annika. My MRI report was read as "not a classic configuration of a Chiari I malformation". So, I really don't know what to think of this yet. I did have a pretty bad car wreck in 1994, and didn't have any symptoms until 98. Guess there is a possiblity that this came from the car wreck. The differnetial diagnosis is "prominent central cord, but would be unusual". Another thought by the neuroradiologist was possibly an old lesion, but that again would be unusual. Never claimed to be normal! Follow up appt today and hopefully more information today. It would be interesting to see if MS and Chiari can co-exsist. One lesion, and clinical ON....very fustrating.... If this is truly a Chiari, I wonder after all these MRI's is it just now being mentioned....again, fustrating. Well again, thanks to everyone that has taken the time to read my post and respond.

Pokey

[Annika]

Dear Pokey,

I agree with Justy.  There is a lot of new research now on how to diagnose a Chiari.  Dr. Milhorat has published some excellent papers on this

[justy]

Please see a Chiari expert. One of the best is Dr. Thomas Milhorat In Manhasset New York.

[CCF-Neuro-M.D.-JT]

I don't think there is such a thing as a black hole in the spinal cord. If there is indeed a small fluid filled space in the center of the cord visualized on the MRI, it is likely to be a syrinx. You're right about the arm and vision problems not explained by the syrinx in the middle of the back, as these symptoms represent higher regions of the spinal cord and brain. Also, I'm not quite sure as to whether or not the thoracic syrinx is really causing your other symptoms as the size (2mm) is very small. Can't comment on the possibility of Chiari as I would have to see the films for myself. If MS is really a consideration, further evaluation such as visual and somatosensory evoked potentials can be of help which can assess the vision as well as numbness/tingling symptoms. Also, a spinal tap can be considered. This of course all needs to be taken into clinical context and discussed with your neurologist so that unnecessary testing is not ordered.Good luck.