Syringomyelia

Document the baseline exam - Write down what is already lost before you touch them: the dissociated sensory level (pinprick and temperature versus light touch and vibration), hand intrinsic strength and atrophy, lower-limb tone and reflexes. Every postoperative change gets measured against that, and MRI is what defines syrinx level, extent, and degree of tonsillar ectopia.

Bulbar and airway function - When the syrinx extends into the brainstem or sits with a CM-1, lower cranial nerve involvement shows up as hoarseness, dysphagia, and an absent gag. Ask about voice change and swallowing, and treat these patients as aspiration risks at induction and again at emergence.

Respiratory reserve - Cervical syrinx erodes vital capacity, and progressive scoliosis adds a restrictive component. Get a baseline vital capacity in anyone with cervical disease or a significant curve. Sleep apnea from pharyngeal muscle weakness is common with Chiari and should make you cautious with opioids and with early extubation.

Succinylcholine - Avoid it. The motor deficit and spasticity of a syrinx is an upper motor neuron lesion with denervated muscle, and succinylcholine there risks life-threatening hyperkalemia and the arrhythmias that follow. Rocuronium with sugammadex reversal is the cleaner path.

Nondepolarizing blockade - Upper motor neuron lesions come with increased sensitivity to nondepolarizers and a higher rate of perioperative respiratory complications. Titrate to TOF rather than to a weight-based dose, and confirm full reversal before you pull the tube.

Keep CSF pressure quiet - Coughing, straining, and Valsalva worsen tonsillar descent. Blunt the airway response at induction, do not let them buck on the tube, and plan a smooth emergence rather than letting them cough themselves out.

Neck positioning - The pathology sits at the craniocervical junction. Keep the head neutral, avoid extremes of flexion and extension during transfer and positioning, and reach for the video laryngoscope so you are not levering the neck to get a view.

Positioning and padding - They cannot feel pain or temperature in the affected dermatomes, so they will not tell you a pressure point or a warming device is hurting them. Pad and check the points yourself and document skin condition at the end of the case.

Neuraxial - CSF flow is already obstructed, so a dural puncture is not a neutral act here. Review the MRI for syrinx level and tonsillar descent and take the decision jointly with neurosurgery; the Obstetric Anesthetists' Association consensus statement covers the obstetric version of this problem.

Autonomic instability - Post-traumatic syrinx brings hyperhidrosis and labile heart rate and blood pressure. Have vasoactive drugs drawn up and do not assume every swing is light anesthesia.

Syringomyelia is a fluid-filled cavity — a syrinx — inside the spinal cord parenchyma or central canal, and at its core it is a disorder of CSF circulation. Most cases sit with a Chiari type 1 malformation (CM-1) obstructing flow at the foramen magnum; the rest follow spinal cord tumor, trauma, or post-traumatic or infectious adhesive arachnoiditis. The expanding cavity compresses spinothalamic fibers decussating in the anterior white commissure while the posterior columns are spared, giving dissociated sensory loss — pain and temperature gone, touch and vibration intact — classically in a cape-like distribution over the shoulders and arms. Hand weakness and atrophy, lower-limb spasticity, and progressive scoliosis follow. Coughing, straining, or a sudden jolt of the head increases tonsillar descent and can tip a previously quiet patient into symptoms, which is exactly what a general anesthetic threatens to do.