What To Do for a Patient With Headaches and a Small Syrinx?
My patient is a 27-year-old woman who has been suffering severe headaches for the last year. Her headaches are aggravated by cough and mild sneezing, and have not responded to treatment with analgesics, carbamazepine, or antidepressants. Results of laboratory investigations are within normal ranges. Brain CT scan is normal. MRI of the cervical spine shows very small syrinx that did not increase in size on follow-up MRI 6 months later. Do you have any suggestions?
Ali M. Abdulaziz, MD
The finding of a syrinx, even a very small syrinx, with accompanying headaches that are aggravated by sneezing and coughing is significant. This constellation of symptoms might represent a response to Chiari malformation that would require decompression of the foramen magnum. A CT of the posterior fossa of the brain is often difficult to interpret, and therefore, I would obtain an MRI of the craniocervical junction with CSF flow studies. This would demonstrate both the anatomical and functional relationship of the cerebral tonsils to the foramen magnum and brain stem. Occasionally, even a small amount of tonsillar herniation can be symptomatic, and the CSF flow studies will aid in making the diagnosis in this situation.