Physiotherapy Assessment for Syringomyelia

Background

• Goldman-Cecil Medicine, p. 531
• Rosen's Emergency Medicine, p. 2075

1. Subjective Assessment (History)

Chief Complaints

• Neck and shoulder pain (most common - often deep, aching, dysesthetic)
• Sensory disturbances: numbness, tingling, burning in arms/hands
• Weakness - typically upper limbs first
• Gait unsteadiness
• Headache, exacerbated by cough/sneeze/Valsalva (CSF pressure increase)

Symptom Behaviour

• Note if symptoms worsen with: Valsalva, Valsalva-equivalent activities (straining, lifting), upper-limb elevation, carrying bags - these increase CSF pressure and syrinx tension
• Onset and progression - typically slow and insidious, with intermittent plateaus; acute deterioration warrants urgent neurosurgical review

Functional History

• ADL limitations: dressing, hygiene, overhead tasks, writing
• Prior surgical history (Chiari decompression, syrinx shunting)
• Falls history - gait and balance impairment is common

Red Flags

• Acute neurological deterioration - refer urgently
• Bowel/bladder dysfunction (autonomic pathway involvement)
• Lower cranial nerve symptoms: dysphagia, hoarseness, dysarthria (syringobulbia)

2. Postural and Observation Assessment

• Forward head posture - commonly observed; contributes to increased tensional stress on spinal tissue
• Scoliosis - important in pediatric and adolescent patients; syringomyelia-associated scoliosis tends to be left-sided and may be the presenting sign; atypical curves require MRI
• Shoulder height asymmetry
• Thoracic kyphosis
• Muscle wasting - hands and intrinsic muscles, forearm musculature; may be visible as early atrophy of the thenar/hypothenar eminences
• Skin changes - painless ulcers or calluses on hands (from analgesia)
• Charcot joint - look for swollen shoulder, elbow, or wrist with disproportionately little pain (neurogenic arthropathy)
• Gait observation - spastic gait, footdrop, wide-based gait

3. Neurological Assessment

Sensory Examination

• The classic "dissociative anesthesia" - pain and temperature lost with preservation of light touch and proprioception - is pathognomonic of a central cord/spinothalamic lesion.
• Document the dermatomal level of sensory change bilaterally.
• Rosen's Emergency Medicine, p. 2077

Motor Assessment

• Prioritise MMT of shoulder flexors/extensors/abductors, elbow flexors/extensors, wrist, and hand intrinsics - these are commonly affected early.
• Bradley and Daroff's Neurology, p. 2888-2892

Reflex Testing

• Upper limbs: hyporeflexia or areflexia at the lesion level (anterior horn cell / root damage)
• Lower limbs: hyperreflexia, clonus, extensor plantar response (Babinski positive)
• Biceps, brachioradialis, triceps, knee, ankle reflexes - grade and compare bilaterally

Coordination and Cerebellar Screening

4. Balance Assessment

5. Gait Assessment

• Observe for: spastic gait, scissoring, wide-based gait, foot drop, circumduction
• Observe walking aids used
• Timed Up and Go (TUG) - functional mobility and fall risk

6. Cervical and Thoracic Spine Assessment

• Cervical ROM - assess flexion, extension, rotation, lateral flexion; important baseline as cervical is the most common syrinx level
• Neural tension testing - caution: upper limb tension tests (ULTT) should be performed carefully; excessive tensioning of neural tissue may worsen symptoms
• Valsalva and provocation tests - if symptoms are aggravated by these, document carefully (suggests CSF pressure sensitivity)

7. Respiratory Assessment

• Thoraco-abdominal breathing pattern
• Respiratory rate
• Diaphragm and accessory muscle use (relevant in high cervical syringes)
• Breath sounds bilaterally

8. Pain Assessment

• Numeric Pain Rating Scale (NPRS) or VAS
• Location mapping - cervical, shoulder, radicular, dysesthetic
• Behaviour - constant vs. activity-related
• Pain type characterisation - neuropathic pain (burning, shooting, allodynia) vs. musculoskeletal

9. Functional and Participation Assessment

10. Autonomic and Skin Assessment

• Check for edema and hyperhidrosis (interruption of central autonomic pathways)
• Skin integrity check on hands/feet for painless ulcers (due to analgesia)
• Bladder/bowel history (can indicate autonomic or sacral segment involvement)

Summary: Key Assessment Domains at a Glance

Clinical Notes for PT Practice

1. Symptom aggravation position-testing - assess symptoms in standing, sitting, supine, with cervical loading and UE elevation to identify postures that alter CSF dynamics. This guides exercise prescription.
2. Activity-provocation analysis - map ADL tasks that worsen symptoms (overhead work, heavy lifting, sustained postures); these involve CSF pressure elevation.
3. Scoliosis vigilance - in children/adolescents, scoliosis may be the first presenting sign of an underlying syrinx. Left-sided curves and atypical progression warrant MRI before any spinal bracing.
4. Post-surgical patients - after Chiari decompression or shunting, the syrinx may reduce in size but neurological deficits may persist; reassess baseline at each stage.
5. Conservative management - according to the scoping review on conservative management, physiotherapy (postural correction, spinal stabilisation, hydrotherapy) can reduce symptoms and improve QoL, although it does not reduce syrinx size. Clear and regular reassessment is essential to detect neurological deterioration early.