When and why should you consider surgery?

We will be addressing some recurring questions among our patients in today's post. 

 

What should you do when your doctor indicates a surgery?

Surgical indication must be the result of a detailed study of the case, which takes into consideration all factors, like possible diagnosis and treatments, age, quality of life, expectations, etc.

When is the application of Filum System® (FS^®) surgical protocol indicated for the Filum Disease?

As soon as possible after the disease has been diagnosed, to eliminate its cause and prevent the pathology from developing further. The diagnosis Filum Disease means that there is a progressive physical and especially a neurological deterioration ongoing.

Are there asymptomatic cases with an anatomical expression of the disease (detectable on MRI and X-rays)?

In over 3000 diagnostic consultations at our centre, we have never encountered asymptomatic patients: we have always detected signs or symptoms of the disease in the physical examination or medical history that the patient and health professionals may not have realized before that they existed.

According to our clinical experience, we can find different types of condition in patients with Filum Disease:

Patients with many symptoms/signs and little anatomical disease expression

Without a specialized study of the MRI and X-ray images, many of these patients have trouble getting diagnosed (for example: minimum descent of cerebellar tonsils; spinal cord ischemia-oedema as a sign of pre-syringomyelia; less than 10º deviation of the alignment of the spine in scoliosis). This usually delays the diagnosis and the application of the treatment, with the risk of further neurological deterioration.

Patients with few symptoms/signs and strong anatomical disease expression

Some patients find out that they have the disease by chance, through a MRI. Nonetheless, if they consider that they do not have symptoms and their quality of life is satisfying (they are not aware how their life would be without the disease), they decide not to undergo surgery. The FS^® is applied also in these cases as soon as possible, because there is always a physical deterioration, besides risking that some unperceived symptoms (frequently the loss of strength and sensibility in limbs and head) or injuries get worse. Once the damage has started, it can be irreversible. Furthermore, the Descent of the Cerebellar Tonsils (DCT) or the Intramedullary Cyst (IMC) can cause brainstem compression within the foramen magnum. This, due to the traction force producing tension and impaction, can threaten not only the quality of life, but also life itself (sudden death).

Patients with symptoms/signs but no anatomical disease expression

Some cases with no anatomical cause for a clinical picture that was very similar to the Filum Disease’s one, have been diagnosed with it: for example with an impaction of the Cerebellar Tonsils, Arnold-Chiari 0 malformation, clinical Neuro-Cranio-Vertebral Syndrome. Thanks to an accurate examination of brain, brainstem and spinal cord and after excluding other comorbidities, our specialists indicated the FS^® application with excellent results.

Patients with serious anatomical disease expression and apparently without symptoms

Many neurosurgeons, who do not agree with the FS^®, suggest waiting for symptoms to appear before undergoing a surgery, sometimes even in cases with a significant descent of cerebellar tonsils or extensive syringomyelic cavities. This approach is explained by the surgical treatment they choose, Decompression surgery or Suboccipital Craniectomy, with a higher risk than the severe anatomical expressions themselves and potentially worsening the patient’s clinical picture. On the other hand, the FS^® neurosurgeons indicate the application of the surgical treatment despite the apparent absence of symptoms, because through our method it has been proven that there are no asymptomatic cases, at least as far as signs, reflexes or dysfunctions are concerned. The disease is already active, therefore they recommend intervening as soon as possible in order to prevent apparently asymptomatic existing injuries from getting worse and further anatomical deteriorations from affecting the patient’s clinical condition.

Why do many neurosurgeons suggest waiting before applying the surgical treatment?

When the chosen treatment for Arnold-Chiari I Malformation is decompression or suboccipital craniectomy and for Idiopathic Syringomyelia it is syringostomy, in some cases they suggest a period of observation rather than surgery. These are major procedures, with high risks and frequent complications, compared with those of the disease itself. When the disease is not affecting the patient’s quality of life excessively and symptoms are not too serious, they consider that intervening is not necessary.

Are there any cases where it is recommended to wait before applying the Filum System^®?

The FS^® surgical protocol of the sectioning of Filum Terminale for the Filum Disease has in general a minimum risk – a remote possibility of infection or hematoma of the surgical wound, as in any other surgical intervention. Therefore, once the disease is diagnosed, its application is recommended as soon as possible, to halt the progression of tissue injuries, with a minimum surgical risk, almost none if compared to the one of the disease itself.

What are the effects of FS^® and suboccipital decompression and syringostomy on the disease?

The FS^® eliminates the cause of the disease, not its consequences, with the purpose of halting the disease progression. In many cases, even if there is no direct action on the effects of the pathology, we can observe a cerebellar tonsils ascent, a syringomyelic cavity decrease, or a straightening of the spine. By intervening as soon as possible, the worsening of the symptoms can be stopped, while promoting the improvement of the symptoms that are reversible at the moment of the surgery.

On the other hand, suboccipital decompression and syringostomy do not eliminate the cause of the disease (“Siringomielia, escoliosis y malformación de Arnold-Chiari idiopática. Etiología común”, Rev Neurol. 1996 Aug; Vol. 24, Nº 132; 937 – 959, Royo-Salvador MB – “Platibasia, impresión basilar, retroceso odontoideo y kinking del tronco cerebral, etiología común con la siringomielia, escoliosis y malformación de Arnold-Chiari idiopáticas”, Rev Neurol. 1996 Oct; 24 (134):1241-50, Royo-Salvador MB) – the abnormal traction produced by an overly tense filum terminale – and leave it active. This explains why symptoms reappear a few years after suboccipital decompression (“Hindbrain decompression for Chiari – syringomyelia complex: an outcome analysis comparing surgical techniques”, C. Hayhurst, O. Richards, H. Zaki, G. Findlay & T. J. D. Pigott, Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK).

 

What does the post-operative clinical course depend on?

It depends on the speedy application of the FS^®, from the surgical protocol, to the rehab protocol, to the follow-up across the years. We know that, even if in the majority of patients we observed several improvements, the clinical course depends on the reversibility or irreversibility of the injuries at the moment of the sectioning of filum terminale. We therefore recommend its application before any irreversible lesion is produced by the abnormal traction of an overly tight Filum terminale.