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Syringomyelia is one of the many challenging conditions that neurosurgeons encounter and I was very pleased to be given this neurosurgical topic from the American Association of Neurological Surgeons to review. I was further pleased to see that the book has been dedicated to Bernard Williams whom I was privileged to know. He was kind enough to allow me to spend a day with him in his operating theatre shortly before he died. He concentrated his powerful and original intellect on syringomyelia and made an outstanding contribution to the understanding and management of this condition. He began with some well designed and conducted physiological studies on patients and then recorded his clinical data both prospectively and with complete honesty. The best chapter in this volume has been written by Bernard and one needs to read no further than this to gain a working understanding of the condition and a pragmatic approach to its treatment. However, Bernard would be the first to admit that he did not have all the answers and I enjoyed reading contributions from other eminent surgeons, many of whom have published extensively about syringomyelia. This book reinforces my opinion that authors who contribute chapters to books should have a wide personal experience of the conditions that they write about, which goes far beyond a review of the literature.
There are two particularly challenging situations which arise in the management of syringomyelia. One is patients with an associated hind brain hernia who do not improve after adequate craniovertebral decompression in whom postoperative MRI shows adequate CSF at the cervicomedullary junction and no hydrocephalus. Many of the contributors (including Bernard) advocate shunting the syrinx but it seems to me no more logical to shunt the syrinx cavity in this situation than to shunt it initially. There is no rationale for the use of a shunt and the effect of shunting is unpredictable and may be associated with deterioration. Equally, patients with an idiopathic syrinx are by no means uncommon and attempts to demonstrate meningeal fibrosis are often unsuccessful. Sadly the book has not contributed to my understanding of the pathophysiology of either of these problems; nor has it helped me to treat this group of patients.
Readers familiar with these neurosurgical topics will know that there is a list of CME questions at the end. These are a very useful exercise as it is all too easy to read, and merely remember those tracts of the text which reinforce one’s pre-existing prejudices.
Overall I thought that this was an excellent contribution and I am sure all surgeons who treat syringomyelia will wish to buy a copy for themselves and all departmental libraries should have one on their shelves.
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