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Chiari Malformation and Syringomyelia in Dogs and the Cavalier King Charles Spaniel

A Practical Guide for Living and Treatment for CM and SM in Dogs

My best friend, Dexter The Dog, was diagnosed with Chiari Malformation and Syringomyelia in 2012, just before his third birthday. His diagnosis was a big blow to my heart. Over the last 6 years, I’ve written a lot on Dexter’s diagnosis, his care and treatments.

I’ve been asked by my Cavalier community to make a bit of a list for easy reference. I hope you find this article on Chiari malformation and syringomyelia in dogs helpful. My request is that you share this information so that others dealing with this heartbreaking diagnosis can also learn that there are many helpful and natural treatments for dogs with Chiari malformation and syringomyelia.

What is Chiari Malformation (CM)?

Chiari malformation (CM) is when the skull is too small to hold the brain. Because of the brain growth in such a small cavity, the cerebellum and medulla are pushed out and obstruct the normal flow of cerebrospinal fluid.

What is Syringomyelia (SM)?

Because of the obstruction of normal cerebrospinal fluid, there is a buildup of pressure. This pressure can be compared to holding your finger over half of the opening of a lawn hose, preventing the water from flowing freely. That pressure then can cause fluid-filled cavities within the spinal cord known as syringomyelia (SM).

What are Chiari Malformation and Syringomyelia Symptoms in Dogs?

Symptoms of CM and SM in cavaliers and other breeds vary. In fact, they vary a LOT! About a year prior to Dexter’s diagnosis, he started to do a few odd behaviors. First, he seemed to gaze out and get focused on dust particles floating in the sun. Second, he would get focused on his rear end and start fidgeting and biting at his bottom. I took him in to his veterinarian; they checked his anal glands. His diagnosis was that they were slightly full, and maybe he was just more sensitive to when they emptied. Third, he would get really weird after a random fly, gnat, or another flying insect would pass by him or happened to land on him. He would, spin around, growl, and become very “strange.” The fourth symptom, the one that put us over the top, was when he started to growl at his back end and almost get into a trance.

I talked to a Cavalier friend and vet, Dr. Lynette Cole at The Ohio State University. She advised me to record the next episode. I did, and three veterinarian neurologists suspected Chiari malformation and syringomyelia.

Dexter’s CM/SM Video

This is how Dexter presented with his disease. However, other common symptoms of CM/SM can include one or more of the below.

  • Air scratching, particularly on walks or when excited.
  • Head scratching or rubbing.
  • Air snapping or licking.
  • Random yelps out in pain.
  • Sensitive to touch and being picked up.
  • Hind end weakness.
  • Head or body wobbles, bobbles, stumbling, eye flickers, or squinting.
  • Head pressing.
  • Seeking darkness or wanting to be left alone.
  • Inactivity or depression.
  • Restlessness.

Diagnosing Chiari Malformation and Syringomyelia

The only way to truly diagnose this disease is an MRI. If a dog is presenting some of the common symptoms of CM/SM and is a breed prone to this disease (Cavalier King Charles Spaniels, Chihuahua Brussels Griffons, Yorkshire Terriers, Maltese, and other small toy breeds), a vet may start treatment without an MRI confirmation.

For me, I’m a person who always wants to know all that I can and treat accordingly. If I’d just started to treat Dexter for CM/SM without really knowing, I would always be doubting myself and worried that I may be missing another disease. Because Dexter was so focused on his lower lumbar area, the neurologists also performed a spinal tap to ensure we had all the facts.

CM and SM in Dogs and Cavaliers

Chiari Malformation and Syringomyelia Treatment Options

Chiari Malformation and Syringomyelia Surgery

There is a surgical option aimed at restoring the normal flow of spinal fluid. This usually involves decompression, removing pieces of bone, and adding a shunt. The results are varied, with most dogs still feeling pain and needing medications.

Pharmaceuticals to Treat Chiari Malformation and Syringomyelia

The disease is progressive and varies in severity from dog to dog. There is no cure, only various treatments to aid in comfort and lessen pain. Just like the wide variety of symptoms a dog may exhibit for CM/SM, treatment options are just as varied. Pharmaceuticals are likely going to play a role in treating your dog’s symptoms. Dr. Clare Rusbridge, has been the leading specialist in treating dogs with this disease. She offers a wealth of information on her website, along with a pharmaceutical treatment protocol.

When you find that your dog needs to be on regular pharmaceuticals, it is important to play a proactive role in evaluating his organ functions and supporting his organs. Read this article for more information.

Natural Treatment Options for Chiari Malformation and Syringomyelia

Luckily, there are a lot of other ways to help support a dog with CM/SM, to help him stay strong and as pain-free as possible. Here are some common natural treatments that you may consider for your dog. I will link to specific articles on how I’m using the treatment with Dexter when available.

Natural Treatment Samples. Don’t forget to subscribe!

Acupuncture to Treat Chiari Malformation and Syringomyelia

One of the first natural treatments Dexter received was acupuncture. We started our treatment once a week, then tapered off over the first year after his diagnosis. I spoke to Dexter’s acupuncturist, Dr. Mary Cardeccia and she explained the basic principles. Energy is continuity flowing through our bodies through specific pathways. When a pathway is disrupted or blocked, acupuncture helps restore the normal flow of energy. For dogs with CM/SM, their qi (energy) is stagnant along the spinal cord. Through the proper acupuncture points, this energy can be restored.

Dexter’s Acupuncture Treatment

Cold Laser Treatment

The other natural treatment I provided Dexter, was cold laser therapy. Cold laser therapy works by stimulating the cells, enabling them to heal themselves more efficiently. Cold laser treatments also help reduce inflammation, relieve pain, repair tissue damage, and increase blood circulation. This is still a treatment I use regularly for Dexter, and I also take Dexter to his vet for a treatment if he’s having a bad or painful day. It seems to help him feel better right after treatment. We now have added at-home laser treatment too!

Laser Therapy for Dogs

Food Therapy

Shortly after Dexter’s diagnosis, I was introduced the healing powers of food by Dr. Judy Morgan. She taught me how to use food for healing through a Traditional Chinese Veterinary Medicine (TCVM) perspective. There are foods and herbs such as sardines, shiitake mushrooms, celery, radishes, lemon, parsley, and marjoram that can help reduce fluid production. With less fluid production, Dexter has less spinal swelling and pain.

Chiari malformation and syringomyelia is a disease with inflammation. The other part of Dexter’s food therapy includes adding foods that reduce inflammation and avoiding foods that increase inflammation. Dexter is fed a species-appropriate diet of home-cooked or raw dog food. Processed, dry dog food is high in carbohydrates, which increases inflammation. Foods and supplements that I rotate into Dexter’s diet to help decrease inflammation can include blueberries, cruciferous vegetables (broccoli, cabbage), leafy greens, green-lipped mussels, CoQ10, bone broth, CBD oil, probiotics, and omega-3 fatty acids.

Conscious Proprioception, Awareness

One of the things I’ve noticed about Dexter is that he “shuffles” his feet when walking. During one of his veterinary exams, Dexter’s vet flipped his foot over so the top of his toes were touching the ground. By flipping a dog’s foot over, the vet is testing his conscious proprioception. In other words, the dog’s awareness that his foot is upside down. Most dogs will immediately flip their feet back to the normal position, Dexter did not fix his foot. Instead, he left it flipped upside down. He was not getting the signal to his brain that his foot was in the wrong position.

Dr. Cardeccia explains, “Because with the SM there is pressure on his spinal cord (from the pockets cerebrospinal fluid that form within the spinal cord near the brain), it is interfering with the nerves of proprioception, which are on the outer portion of the spinal cord. Proprioception is the internal sense that tells you where your body parts are without your having to look at them, so he is not actually fully aware of where his feet are, and that is why he drags them.

Two treatments I’ve implemented for Dexter are the use of Dr. Buzby’s ToeGrips for Dogs and regular footwork exercises. Using the ToeGrips has brought Dexter an awareness about his feet through proprioceptive stimulus and help Dexter to pick up his feet. A week after wearing his first pair of ToeGrips, Dr. Cardeccia flipped his foot over, and he immediately flipped his foot back to position!

Dexter’s proprioception footwork includes things like walking over objects, walking on a variety of textures, walking sideways and back. This is all to help him be more aware of his feet.

Dog Core Strength Exercises

Next on Dexter’s dog rehabilitation agenda is to build up his core strength and back end strength. Strengthening Dexter’s core muscles and overall strength will help him with his balance issues. When he does lose his balance or starts to stumble, he will hopefully have the strength to catch himself. We do a variety of exercises on a variety of equipment to target Dexter’s abdominal, back, hind legs, etc.

Clip of Dexter’s Exercises

Canine Water or Hydrotherapy

Dog water therapy is a great way to help strengthen a dog’s body, while having a low impact on his joints. Because one of Dexter’s rehabilitation goals is to bring awareness to his hind feet, Dexter does regular water treadmill therapy. This provides not only strength and core strength, but also helps improve his proprioception. During the warm months, I also take Dexter to outdoor ponds and streams to allow him to walk in the water to continue with his therapy.

Dexter’s Water Therapy Session. Don’t forget to subscribe!

Exercise, Walking and Dog Play Limitations

This is a heartbreaker for me. Dexter has always been a spunky, playful, and active dog. Unfortunately, his disease has other things in mind. Each dog will be different on what they can and cannot tolerate. In the beginning, or as the disease progresses, these activities may change.

I’ve learned with Dexter, it’s about short spurts then rest. I also do a lot of training games and exercises, which include his at-home rehab work, that he finds fun and entertaining. This can take the place of rough or physical activities.

Possible Comforts

  • Dog Harness. No Dog Collars, Please. One of the first things a newly diagnosed CM/SM dog parent should do is dump the dog collar and exchange it for a dog harness. Because the disease starts with a malformation of the skull, a dog collar can be quite painful. I’m never a fan of collars in the first place. Even finding a suitable dog harness can be a challenge. Each dog is different in where a pocket-filled cavity may be, so a harness that might work for one dog, may cause pain for another.
  • Dog Strollers. Dog strollers are a great option for dogs with a neurological disorder, such as Chiari malformation and syringomyelia. This allows the dog to be comfortable and safe, while still being able to join in on the adventure. I always have Dexter’s stroller in my car, and I always bring it on long adventures. When he’s in need, I just pop him inside. Sometimes he rests up and then walks after his rest.
  • Cooling Mats and/or Warming Blankets. I’m not sure why, but these dogs tend to run hot or cold. When Dexter was first diagnosed, and we were trying to find our groove, he always seemed cold. I made him a warming blanket, and he loved it! In a pinch, you can toss a fleece dog blanket in the dryer. It’s important to note that your dog should be able to remove himself if he feels too hot. Now, Dexter actually loves his cooling mat! He always gravitates to it, even in the winter. He doesn’t otherwise seem hot or uncomfortable in any way, but he will sleep more on it vs. a warm bed.
  • Snuggle jackets or tight-fitting jackets, such as the ThunderShirt. This seems to be a 50/50 in the community. Some dogs immediately calm down from a painful episode, and others are in too much pain to wear clothing. Take your dog’s cue.
  • Natural Calming Aids. I find this very helpful when Dexter seems to be having a rough day. I put in his favorite calming CD and will use a natural calming spray. I’m sure it has to do with the stress involved with the pain, and Dexter is not sure why he feels the way he does.

Support for Dogs with Chiari Malformation and Syringomyelia

Unfortunately, you are not alone. I say unfortunately because I wish this stupid diseases didn’t exist. It can be so heart-wrenching knowing our beloved dogs can suffer from such great pain. Quality of life issues always are at the forefront of our minds. My personal favorite support system came from a Facebook Group for dogs with CM/SM. This group is amazing, to say the least. They are so helpful, supportive, and very knowledgeable. Next, Dexter’s amazing team of specialists, and he has many. Finally, my family. They are my rock, so I can be Dexter’s rock.

I urge you to reach out to your veterinarians, specialists, and join the Facebook group if you think your dog may have Chiari malformation and syringomyelia. And, please share this article, so that others know of all the possible noninvasive treatments we can provide our beloved dogs with CM/SM and the support system in place.


Does your dog have Chiari Malformation? How are you helping him? Tell me in the comments.

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Syringomyelia

Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in pain, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. The disorder generally leads to a cape-like loss of pain and temperature sensation along the back and arms. Each patient experiences a different combination of symptoms. These symptoms typically vary depending on the extent and, often more critically, to the location of the syrinx within the spinal cord.

Syringomyelia has a prevalence estimated at 8.4 cases per 100,000 people, with symptoms usually beginning in young adulthood. Signs of the disorder tend to develop slowly, although sudden onset may occur with coughing, straining.

What causes Syringomyelia?

Trauma to the spinal cord or congenital developmental problems of the brain and/or spinal cord may result in SM.
Spinal cord trauma such as a car accident or serious fall may manifest years later as SM.

Congenital developmental problems, sometimes undetectable may result in syringomyelia.

In either case, the condition may lie dormant and undetected for months or years until a symptom or variety of symptoms become bothersome enough to warrant medical attention. Many people with SM are not diagnosed until mid-life.

A number of medical conditions can cause an obstruction in the normal flow of cerebrospinal fluid (CSF), redirecting it to the spinal cord itself. This results in the formation of a syrinx (cyst that fills with CSF). Pressure differences along the spine cause the fluid to move within the cyst. It is believed that this continual movement of fluid results in cyst growth and further damage to the spinal cord and connecting nerves.

Different Origins

Generally, there are two forms of syringomyelia: congenital and acquired. (In addition, one form of the disorder involves a part of the brain called the brainstem. The brainstem controls many of our vital functions, such as respiration and heartbeat. When syrinxes affect the brainstem, the condition is called syringobulbia.)

The first major form relates to an abnormality of the brain called an Chiari malformation, named after the physician who first characterized it. This is the most common cause of syringomyelia, where the anatomic abnormality causes the lower part of the cerebellum to protrude from its normal location in the back of the head into the cervical or neck portion of the spinal canal. A syrinx may then develop in the cervical region of the spinal cord. Because of the relationship that was once thought to exist between the brain and spinal cord in this type of syringomyelia, physicians sometimes refer to it as communicating syringomyelia. Here, symptoms usually begin between the ages of 25 and 40 and may worsen with straining or any activity that causes cerebrospinal fluid pressure to fluctuate suddenly. Some patients, however, may have long periods of stability. Some patients with this form of the disorder also have hydrocephalus, in which cerebrospinal fluid accumulates in the skull, or a condition called arachnoiditis, in which a covering of the spinal cord—the arachnoid membrane—is inflamed.

Some cases of syringomyelia are familial, although this is rare.

Acquired

The second major form of syringomyelia occurs as a complication of trauma, meningitis, hemorrhage, a tumor, or arachnoiditis. Here, the syrinx or cyst develops in a segment of the spinal cord damaged by one of these conditions. The syrinx then starts to expand. This is sometimes referred to as noncommunicating syringomyelia. Symptoms may appear months or even years after the initial injury, starting with pain, weakness, and sensory impairment originating at the site of trauma.

The primary symptom of post-traumatic syringomyelia (often referred to using the abbreviation of PTS) is pain, which may spread upward from the site of injury. Symptoms, such as pain, numbness, weakness, and disruption in temperature sensation, may be limited to one side of the body. Syringomyelia can also adversely affect sweating, sexual function, and, later, bladder and bowel control. A typical cause of PTS would be a car accident or similar trauma involving a whip-lash injury.

What can make PTS difficult to diagnose is the fact that symptoms can often first appear long after the actual cause of the syrinx occurred, e.g. a car accident occurring and then the patient first experiencing PTS symptoms such as pain, loss of sensation, reduced ability on the skin to feel varying degrees of hot and cold, a number of months after car accident.

Signs and tests

A neurologic examination may show loss of sensation or movement caused by compression of the spinal cord.

An MRI of the spine confirms syringomyelia and determines the exact location and extent. Often, an MRI of the head will be done to look for associated conditions including hydrocephalus (water on the brain).

Rarely, a spinal CT with myelogram may be done.

Symptoms

Syringomyelia causes a wide variety of neuropathic symptoms due to damage of the spinal cord. Patients may experience chronic pain, abnormal sensations and loss of sensation particularly in the hands. Some patients experience paralysis or paresis temporarily or permanently. A syrinx may also cause disruptions in the parasympathetic and sympathetic nervous systems, leading to abnormal body temperature or sweating, bowel control issues, or other problems. If the syrinx is higher up in the spinal cord or affecting the brainstem as in syringobulbia, vocal cord paralysis, ipsilateral tongue wasting, trigeminal nerve sensory loss, and other signs may occur. Rarely, bladder stones can occur in the onset of weakness in the lower extremities. Classically, syringomyelia spares the dorsal column/medial lemniscus of the spinal cord, leaving pressure, vibration, touch andproprioception intact in the upper extremities. Neuropathic arthropathy, also known as a Charcot joint, can occur, particularly in the shoulders, in patients with syringomyelia. The loss of sensory fibers to the joint is theorized to lead to damage of the joint over time.

Back pain; headaches; stiffness, weakness or pain in the back, shoulders, arms or legs; loss of the ability to feel extremes of hot or cold, especially in the hands?

Treatment

The goals of treatment are to stop the spinal cord damage from getting worse and to maximize functioning. Surgery to relieve pressure in the spinal cord may be appropriate. Physical therapy may be needed to maximize muscular function.

It may be necessary to drain the fluid build up.
Surgery
The first step after diagnosis is finding a neurosurgeon who is experienced in the treatment of syringomyelia. Surgery is the only viable treatment for syringomyelia. Not all patients will advance to the stage where surgery is needed. Evaluation of the condition is often difficult because syringomyelia can remain stationary for long periods of time, and in some cases progress rapidly.

Surgery of the spinal cord has certain, characteristic risks associated with it and the benefits of a surgical procedure on the spine have to be weighed against the possible complications associated with any procedure. Surgical treatment is aimed at correcting the condition that allowed the syrinx to form. It is vital to bear in mind that the drainage of a syrinx does not necessarily mean the elimination of the syrinx-related symptoms, but rather is aimed at stopping progression. In cases involving an Arnold-Chiari malformation, the main goal of surgery is to provide more space for the cerebellum at the base of the skull and upper cervical spine without entering the brain or spinal cord. This often results in flattening or disappearance of the primary syrinx or cavity, over time, as the normal flow of cerebrospinal fluid is restored. If a tumor is causing syringomyelia, removal of the tumor is the treatment of choice and almost always eliminates the syrinx.

Surgery results in stabilization or modest improvement in symptoms for most patients. Delay in treatment may result in irreversible spinal cord injury. Recurrence of syringomyelia after surgery may make additional operations necessary; these may not be completely successful over the long term.

In some patients it may also be necessary to drain the syrinx, which can be accomplished using a catheter, drainage tubes, and valves. This system is also known as a shunt. Shunts are used in both the communicating and noncommunicating forms of the disorder. First, the surgeon must locate the syrinx. Then, the shunt is placed into it with the other end draining cerebrospinal fluid (CSF) into a cavity, usually the abdomen. This type of shunt is called a ventriculoperitoneal shunt and is particularly useful in cases involving hydrocephalus. By draining syrinx fluid, a shunt can arrest the progression of symptoms and relieve pain, headache, and tightness. Without correction, symptoms generally continue.

The decision to use a shunt requires extensive discussion between doctor and patient, as this procedure carries with it greater risk of injury to the spinal cord, infection, blockage, or hemorrhage and may not necessarily work for all patients. Draining the syrinx more quickly does not produce better outcomes, but a shunt may be required if the fluid in the syrinx is otherwise unable to drain.

In the case of trauma-related syringomyelia, the surgeon operates at the level of the initial injury. The syrinx collapses at surgery but a tube or shunt is usually necessary to prevent re-expansion.

Other

Surgery is not always recommended for syringomyelia patients. For many patients, the main treatment is analgesia. A typical treatment of syringomyelia involving severe chronic pain would involve two or more medications. One medication for “classical” back pain such as a weak or strong opioid(e.g. tramadol and Oxycontin respectively) combined with a medication to combat any neuropathic pain symptoms such as shooting and stabbing pains (e.g. Neurontin or Lyrica). In addition, paracetamol (called acetaminophen in the United States) can be used to combat headaches. Such long term treatment of chronic pain should be monitored with blood tests to assess any adverse effects of the medication on the liver, with the dosages being then changed accordingly, depending on the outcome of such blood tests.

Drugs have no curative value as a treatment for syringomyelia. Radiation is used rarely and is of little benefit except in the presence of a tumor. In these cases, it can halt the extension of a cavity and may help to alleviate pain.

In the absence of symptoms, syringomyelia is usually not treated. In addition, a physician may recommend not treating the condition in patients of advanced age or in cases where there is no progression of symptoms. Whether treated or not, many patients will be told to avoid activities that involve straining.

Since the natural history of syringomyelia is poorly understood, a conservative approach may be recommended. When surgery is not yet advised, patients should be carefully monitored by a neurologist or neurosurgeon. Periodic MRI’s and physical evaluations should be scheduled at the recommendation of a qualified physician.

Prevention

There is no known prevention, other than avoiding trauma to the spinal cord. Prompt treatment reduces progression of the disorder.

Expectations (prognosis)

Untreated, the disorder gets worse very slowly, but it eventually causes severe disability. Surgical decompression usually stops the progression of the disorder, with about fifty percent of people showing significant improvement in neurologic function after surgical decompression.

Complications

Without treatment, the condition will lead to:

  • Continued or progressive loss of neurologic function
  • Permanent disability

Possible complications of surgery include:

  • Postoperative infection and other complications common to all surgeries

Testimonials:

Pain – Marijuana acts as an analgesic or natural pain killer in the bodies basic operational system. There is a role for the cannaboids found in marijuana for the body ‘s pain and movement receptors. A number of areas in the brain that produce sensing and processing receptors respond to the analgesic effects of cannabis.

Cannaboids are often successful in treating pain and used as adjunct treatments to opiads.. Acting as pain killers and anti-inflammatories, medical marijuana is far less addictive than many other pain killing medications.

Sleep Aid – A common side effect of marijuana is drowsiness. It is thought to be used for patients who have difficulty sleeping due to their condition or treatment method. Patients experience a more restful sleep and wake up feeling more refreshed.

Medical marijuana is not toxic to major organs like many other sleep aids and has very few side effects. Marijuana causes the body to drop temperature by half of a degree. This allows for a human to become more relaxed and stress free allowing you to fall asleep faster.

Smoking cannabis from a pipe can significantly reduce chronic pain in patients with damaged nerves, a study suggests.

“ Hi i am 22 yrs old and was diagnosed with SM due to chiari about 1 year ago. After a failed decompression surgery my only option would be to take out a piece of the cerebellum. I consume alot of marijuana everyday, and know of its effects on the brain. Mariuana slowed down the flow of CSF into the spine. Slowed down the effects of the syringomyelia. about 3 times. Also smoking takes away every single symptom that i have: stomach ache, cephalea in my temples, tingling sensations in my hands and feet.”

Marijuana, reduced pain in patients with nerve pain stemming from injuries or surgical complications, new research shows.

Patients smoking the highest potency marijuana (9.4 percent) reported less pain than those smoking samples containing no THC. Patients also reported better sleep and less anxiety, according to the Canadian study.

Best Strains for symptom relief of Syringomyelia:

Skunk #1, TrainWreck, Apollo 13, Afgani, NYCD, White Rhino, Purple Haze, Super Silver Haze, Sour Diesel, Big Kahuna, Blueberry, Romulan, G13, Blue Fruit, Green Queen, Queen Bee, Sweet Blu, Strawberry Cough,

Symptoms: tingling in feet and hands, numbness, burning, muscle spasm, pain, headache, stiffness or weakness in back, shoulders, arms/legs, ability to feel extremes of hot/cold especially in hands, abnormal sensations or loss of sensations especially in hands, paralysis (temporary/permanent), chronic pain.

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2. Golden JA, Bonnemann CG. Etiological categories of neurological diseases. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier; 2007:chap 28.
1. “Neurosurgical considerations in posttraumatic syringomyelia – Home Study Program”. AORN Journal. January 2003. Retrieved 2009-02-12.
2. Brewis M, Poskanzer DC, Rolland C, et al., “Neurological disease in an English city”. Acta Neurologica Scand Suppl 24:1–89, 1966.
3. Schurch B, Wichmann W, Rossier AB (January 1996). “Post-traumatic syringomyelia (cystic myelopathy): a prospective study of 449 patients with spinal cord injury”. J. Neurol. Neurosurg. Psychiatr. 60 (1): 61–7. doi:10.1136/jnnp.60.1.61. PMC 486191. PMID 8558154.
4. Greenberg, David A, et al.: Clinical Neurology. 5th ed. Feb 9, 2002.
5. Nishida, Takayasu, et al. “A large bladder stone caused by syringomyelia”. Japanese Journal of Clinical Urology, Vol.60, No. 6, pp 413-415, 2006. ISSN:0385-2393.
6. “Neuropathic Arthropathy of the Shoulder (Charcot Shoulder): Clinical Commentary” Medscape. Accessed 9 January 2011.
7. “Information about a Genetic Research Study for Chiari Type I Malformation (CMI) with or without Syringomyelia.”
8. Yeom JS, Lee CK, Park KW, et al. (2007). “Scoliosis associated with syringomyelia: analysis of MRI and curve progression”. Eur Spine J 16 (10): 1629–35. doi:10.1007/s00586-007-0472-1. PMC 2078323. PMID 17701226.
SOURCES: Mark Ware, M.D., director, clinical research, Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal; Henry McQuay, D.M., professor, chronic pain unit, Oxford University, Oxford, England; Aug. 30, 2010, Canadian Medical Association Journal