Syringomyelia

The article "Neurosurgical considerations in posttraumatic syringomyelia" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 3 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Jan 31, 2006.

Complete the multiple-choice examination and learner evaluation found on pages 153-156 and mail with appropriate fee to

or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES

After reading and studying the article on syringomyelia, the nurse will be able to

(1) identify the anatomy of the central nervous system,

(2) describe the pathophysiology of syringomyelia,

(3) discuss the nursing implications of caring for a patient with syringomyelia,

(4) explain the surgical procedures for treating syringomyelia, and

(5) identify the effects of syringomyelia on the patient's lifestyle.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Syringomyelia is a progressive degenerative disorder of the spinal cord that may result in chronic illness and disability. The disorder is characterized clinically by amyotrophy and segmented sensory loss and pathologically by cavitation of central parts of the spinal canal that results in changes in direction and freedom of flow of cerebral spinal fluid. Considered rare, this disorder is distinguished from other spinal pathologies by the development of a fluid-filled syrinx (ie, glial-lined cavity) that often expands during adolescence or early adulthood and causes severe neurological symptoms. (1) This chronic, disabling condition adversely affects approximately 21,000 American men and women. (2)

Syringomyelia causes spinal cord impairment that frequently manifests in

* progressive weakness and paralysis in both the upper and lower extremities;

* diminished sensation in the hands;

* chronic, severe pain; and

* body hypertrophy. (3)

Syringomyelia also may adversely affect sweating, sexual function, and bowel and bladder control. Additional symptoms include gastrointestinal symptoms, headaches, stiffness or shawl-like paralysis in the shoulders, and diminished temperature sensitivity and numbness. (4) Some people with syringomyelia experience severe pain and marked functional limitations that are permanent. (5) Symptoms vary among people, but for many they are a source of progressive disability.

Syringomyelia, by nature of its insidious onset and varying, unusual symptom pattern, is relatively unknown and poorly recognized by the public overall, which commonly delays diagnosis. (6) Little information is available about living with syringomyelia; therefore, contextual understanding of the phenomena virtually is nonexistent.

ANATOMY AND PHYSIOLOGY

Located at the base of the skull, the medulla oblongata is continuous with the spinal cord at the foramen magnum (Figure 1). Cranial nerves nine through 12 connect to the brain in the medulla. The medulla, a 1-inch long structure, houses cardiac, respiratory, sensory, and motor tracts. The spinal cord is an elongated mass of nerve tissue that occupies the upper two-thirds of the vertebral column and extends from the first cervical vertebra to the lower border of the first lumbar vertebra. This is the area of the spinal cord almost exclusively affected by syrinx development in syringomyelia. (7)

[FIGURE 1 OMITTED]

The entire spinal cord is surrounded by the meninges that provide resilient protection to fragile cord tissues. Of the 31 pairs of spinal nerves that extend off the spinal cord, eight are located in the cervical region. Spinal nerves innervate the upper extremities within the enlargement in the cervical region between the fifth cervical vertebra and the first thoracic vertebra. The lower extremities are innervated by the lumbosacral enlargement traversing the cord between the third lumbar and second sacral areas. (8) Anterior or efferent nerve roots convey efferent impulses from the spinal cord to the body, and posterior nerve roots convey afferent or sensory input from skin regions to the spinal cord. Sensory fibers of dorsal nerve roots carry impulses for pain, temperature, touch, and proprioception from either internal organs or from musculoskeletal structures. Both afferent and efferent nerve roots commonly are affected in syringomyelia. (9)

Cervical and brachial plexuses form a network of primary, interlacing nerves. The cervical plexus involves cervical nerve roots that innervate muscles of the neck and shoulders and the phrenic nerve. The brachial plexus involves innervation of the radial and ulnar nerves. (10) Various types of receptors convey specific types of stimuli, including exteroceptors, interoceptors, proprioceptors, or chemoceptors. Receptors affected in syringomyelia are those causing touch, light pressure, pain, temperature, position sense, muscle coordination, pain, and cramping to be absent or altered.

PATHOPHYSIOLOGY

Multiple illnesses and injuries appear to predispose development of syringomyelia, including

* intradural or extradural tumors;

* postoperative complications;

* postinflammatory (ie, either postinfectious or postchemical) origins;

* posttraumatic sources; and

* the "extradural mass effect" caused by disc protrusion or malformation. (11)

For the purpose of this article, type I Chiari malformation will be discussed.

In syringomyelia, softening and cavitation occur around the central canal of the spinal cord most often in the region of cervical enlargement (Figure 2). The foramen magnum, through which the medulla passes, is obstructed, and the central canal dilates alone or with other obstructive lesions of the foramen magnum. (12) A syrinx or fluid-filled cyst first occupies the central gray matter of the cervical portion of the spinal cord, interrupting lateral spinothalamic fibers in the central canal as they cross from one side to the other providing interaction between the thalamus and the cerebral cortex. Pain and temperature sensibility is decreased or lost with segmental distribution in the upper extremities on both sides because these networked fibers conduct pain and temperature impulses from dermatomes on either side of the body. There is no loss of sensory function in the lower extremities because there is no spinothalamic tract loss of integrity. (13) Proprioception and light touch are spared in the affected dermatomes of the arms. As the condition progresses, damage may extend into the ventral horns of each cerebral hemisphere, causing paralysis and atrophy of upper arm muscles that are innervated by involved segments of the cord.

[FIGURE 2 OMITTED]

In syringomyelia, the flow of cerebrospinal fluid (CSF) is interrupted in cervical portions of the spinal cord where it splits at several successive cord segments. (14) The syrinx develops in either a symmetrical or an asymmetrical pattern in the central canal of the spinal cord. This destroys the spinal cord in an irregular pattern, causing the unusual symptoms associated with syringomyelia. (15) Formation of this syrinx results in clinical symptoms that frequently manifest between the ages of 25 and 40 and affect men and women equally.

Symptoms. Onset usually is insidious with early symptoms demonstrating as a painless burn on a hand. (16) In some instances, symptoms manifest after an episode of strenuous coughing or straining. The course may be stable for many years or even decades, or it may worsen unexpectedly causing substantial limitations. (17) Clinical presentation depends on which spinal areas are affected by the syrinx development. Typical symptoms that present in most, if not all, people with syringomyelia are

* segmental weakness and atrophy of the hands and arms;

* loss of tendon reflexes;

* loss of pain and temperature sensation; with

* preservation of touch in the neck, shoulders, and arms. (18)

ETIOLOGY

Protrusion of the cerebellum from its normal location at the back of the head is thought to result in the syrinx development associated with syringomyelia. Several theories related to onset and development exist (ie, congenital, posttraumatic); however, the disorder is not associated conclusively with congenital anomalies and disruptions in the normal flow of CSF. Familial occurrence is rare. (19) The posttraumatic form of syringomyelia is a rare but recognized sequelae of both paraplegia and quadriplegia. (20) Type I syringomyelia is the more common form and includes obstruction of the foramen magnum. It is associated with type I Chiari malformation that is theorized to develop as a result of injury to the cervical area via trauma, meningitis, hemorrhage, tumor formation, or arachnoiditis. (21) The cervical portion of the spinal canal is susceptible to damage by these agents. A syrinx develops most often in the cervical portion of the spine and expands laterally and vertically, thereby producing symptoms that ascend the spinal cord to the site of the original injury. This process may occur months or even years after precipitating factors. The posttraumatic form of syringomyelia presents primarily with pain and paresthesias that may be unilateral, but symptoms are varied, and progression of symptoms generally is intermittent. (22)

TREATMENT

Treatment of syringomyelia differs substantially from other medically managed conditions. Several surgical procedures are performed for syringomyelia, including CSF shunting and Chiari-decompression, that help to arrest and correct disease progression in some cases and relieve problematic clinical signs and symptoms. (23) Neurological damage frequently is the inevitable result if surgical interventions are delayed or fail to correct existing pathological problems.

Preoperative testing and preparation. The patient must undergo extensive evaluation and testing before treatment can be initiated. This involves blood tests, diagnostic magnetic resonance imaging (MRI), computed tomography (CT), myelograms, blood typing and crossmatching, and an in-depth medical history and physical examination. Preoperative nursing care includes assessment of the patient's baseline

* physiological status,

* neurological function and existing deficiencies,

* understanding of the procedures, and

* knowledge of postoperative care.

The nurse should review the informed consent form with the patient; confirm known allergies; check for the presence of dentures, contact lenses, metal implants, or other devices; and confirm that the patient has not had anything to eat or drink since midnight. The nurse then places two large bore IVs. (24) After assessing the patient, the circulating nurse prepares a care plan specific to the patient (Table 1).

Intraoperative nursing considerations include preparation of the OR and the equipment needed for the procedure. Availability of evoked potential monitoring, surgical microscope, ultrasound equipment, positioning aids, electrosurgical unit and grounding pad, suction, and x-ray should be ensured. (25)

Positioning. The patient is kept on the stretcher until after the anesthesia care provider induces general anesthesia. The circulating nurse then inserts an indwelling Foley catheter and applies sequential compression boots. While maintaining optimum body alignment, the surgeon, anesthesia care provider, and circulating nurse roll the anesthetized patient onto the OR bed in the prone position using a neurosurgical stabilizing headrest. Careful positioning is essential; therefore, the circulating nurse ensures that gel pads and pressure reduction techniques are employed to prevent intraoperative positioning injuries.

The procedure. The circulating nurse preps the patient for a suboccipital incision, after which the scrub person and surgeon drape the patient accordingly. The goal of the procedure is to reduce the cerebellar tonsils with craniectomy and perform a C-1 laminectomy to decompress the brain stem and cranial nerves. (26) The laminectomy may involve the use of autologous or bank bone and artificial sheeting material to close the dura. If a shunt is used, it usually is placed before beginning the craniectomy so that CSF can be drained from the syrinx into the subarachnoid space. (27) The entire surgical team (eg, surgeon, anesthesia care provider, circulating nurse, scrub person, evoked potential technician) continuously monitor the patient throughout surgery for changes in

* evoked potentials;

* intraoperative vasospasms or hemorrhage resulting in cerebral ischemia;

* cardiovascular, urinary, and respiratory function; and

* normothermia. (28)

Postoperative care. Postoperatively, nursing care should focus on neurological, cardiac, and respiratory function. The patient is admitted to the intensive care unit for 24 to 48 hours and carefully monitored for

* CSF leaks;

* fluid and electrolyte balance;

* intracranial pressure changes;

* urinary, cardiac, and respiratory function;

* neurological function; and

* signs of deep vein thrombosis or peripheral edema. (29)

Hospital discharge usually occurs in four to eight days. (30) Complications may include

* CSF leak,

* wound infection,

* pain,

* neurological deficits,

* shunt malfunction or migration,

* spinal cord tethering to the shunt,

* respiratory problems, or

* cardiac changes. (31)

EFFECTS ON LIFESTYLE

A frequent complication of symptom progression is the person's ongoing need to adjust to evolving functional losses that accompany syringomyelia. These adjustments may result in feelings of bitterness, helplessness, or rage at being afflicted with a condition over which the person has little or no control. (32)

Loss of independence. Most people with neurological disorders achieve self-reliance even during episodes of symptom progression; however, with time they must learn to cope with loss of their functional capacities. People with syringomyelia become skilled at directing caregivers in performing functional activities of daily living for them. To the affected person, directing others may pose a daily challenge because it produces feelings of dependency and resentment. Effects of syringomyelia on functional status are varied and tend to aggregate with time as sensory and motor symptoms intensify and abilities diminish. Learning to accept assistance in everyday activities may pose problems related to decreased autonomy, loss of personal privacy, and decreased ability to engage in activities of choice, including work.

Loss of upper extremity mobility. Shoulder denervation and subsequent loss of shoulder joint range, strength, and sensory awareness results in markedly decreased ability to freely move the shoulders and upper extremities. As upper extremities become increasingly less mobile, muscle atrophy is common, and tasks requiring even minimal strength may become impossible. Dexterity may be adversely affected, and segmental weakness and disassociated anesthesia are common upper extremity symptoms that may affect dexterity further. (33) Executive functions, such as writing and using a keyboard or keypad, also require dexterity, and these functions also may be lost. A person's inability to raise his or her arms above the diaphragm level may make donning shirts or sweaters difficult, necessitating use of assistive devices or personnel. Fatigue may result from efforts to get dressed, which also may lead to discouragement.

The symptoms of syringomyelia also may involve complex self-concept and body image changes compounded by pain or sensations of upper extremities being squeezed or burned. Paradoxically, affected areas frequently are insensitive to changes in pain, temperature, or position sense. These sensory losses result in potential danger when hand-tools are used or hot substances are encountered. Loss of abilities related to manual dexterity may affect work performance and may threaten or end essential career options. These limitations can cause loss of personal status as a family wage earner.

Safety issues. Related safety issues may include entering and exiting a vehicle, using stairs enclosed by a low ceiling or walls, or using an escalator. Sensations of weakness or ataxia in the lower extremities may add to altered body image and aggravate safety and ambulation issues. Ataxia may cause sudden problems with balance and feelings of insecurity on stairs or uneven grades of pavement that necessitate extra safety precautions. Kyphoscoliosis results in postural changes. This common problem accompanies long-term syringomyelia and involves loss of upward gaze because the neck becomes fused in a cervico-occipital malformation. These changes may further limit self-care abilities and compound safety issues. (34)

Physical fitness. Health promotion activities that are encouraged for health related physical fitness might be affected by symptom development. One author notes that most American adults are sedentary. (35) Chronically ill and disabled people are at greater risk for being sedentary than able-bodied people. Those with syringomyelia who experience moderate symptom development face challenging tasks in developing and maintaining an exercise program that supports cardiovascular health. Fifty percent of able-bodied adults with syringomyelia are unable to maintain an exercise program. (36)

Barriers to physical activity are individualized and may include lack of an individually designed exercise program, lack of accessible transportation, diminished self-esteem, or lack of support systems necessary to provide encouragement to continue in a physical fitness program. Access to facilities is an important environmental determinant for adults to continue in an exercise program. (37)

Loss of career. An additional issue related to functional impairment may include loss of career or job, and, according to one author, fatigue from chronic illness adds to job stress. (38) Although surgical interventions produce marked benefits for some people, not all achieve noticeable improvement, and symptoms may remain arrested or worsen causing great physical discomfort and disability that discourages employment or career changing efforts.

RESEARCH

Limited use of qualitative methods to disclose contextual phenomena associated with syringomyelia was identified in nursing literature. Several articles that discussed incidence, prevalence, symptomatology, and surgical treatment were identified. (39) These descriptions of disease symptoms and treatment modalities provide useful, accurate information. There is, however, little information regarding contextual experiences and nursing care of those with syringomyelia. Only one article was identified that used qualitative data to uncover experiential phenomena associated with the disorder, and that article represented a woman's perspective. (40) Experiential phenomena are important to uncover because long-term disability may result in numerous problems for people of both genders. These phenomena offer information useful in planning nursing care for patients throughout all phases of care.

Issues from the patient's perspective. After obtaining internal review board approval and informed consent from the informant, several interviews were conducted with a middle-aged man who had been diagnosed with the disorder for more than 25 years and who experienced most of the symptoms associated with disease progression (see "Profile of the participant" on page 146). For the purpose of this study, the informant was questioned regarding experiences and perceptions he recalled both before and after development of syringomyelia. His responses to open-ended questions revealed an overall perception of engulfment by the condition. Further, three interwoven themes were identified from data, which consisted of loss of abilities, struggles to adapt to changes, and life as a disabled man. In discussing lost abilities, he described the following impressions.

He did not always deal with changes, even those producing pronounced new symptoms, because of the transient nature of some of the symptoms, including paresthesias in his upper arms, shoulders, and feet. During the next 18 months, he experienced declining functional abilities. He continued to function autonomously at home and at work with increasing difficulty.

As functional losses progressed, he indicated his priorities and perceptions changed. With deepening despair, he revealed suicidal ideations.

Despite shunting surgery, the disease progressed. During the next nine years, his existing symptoms worsened, and additional neurological problems developed. His family members urged him to consider additional recommended surgery to mitigate symptoms and improve his quality of life. He felt pressured to exhaust all treatment options available to thwart the disorder. Accordingly, a second procedure was performed in early 1990. It was placement of a shunt to drain CSF into the peritoneal cavity. The procedure was undertaken to correct spinal cord-related disease; it was not planned to alleviate existing symptoms. It was hoped that the second procedure would slow the progress of the disease, but ironically, symptom progression hastened. Instead of only right hand involvement, his left hand and leg rapidly deteriorated as well. Ensuing numbness was transient, but baseline sensory function was diminished greatly. An additional postoperative problem was diminished sensation in the pelvic area that produced sexual problems.

After the second procedure, insomnia became a persistent problem associated with discomfort from lying in one position. Nightly, he Was reluctant to awaken his wife to help him move into a new position but was unable to change his position independently. Finding a position in which he could sleep comfortably became a nightly challenge and resulted in severe sleep deprivation. Sleeplessness posed a particular hardship because he could not anticipate how he might feel in the morning; therefore, he could not reliably make plans to arise at a particular time or make and keep appointments.

Additional consequences of functional loss included loss of employment. He also lost the head-of-household position he always had occupied.

Social situations and age-associated developmental activities also were sources of loss. Discovering life as a disabled man compelled him to consider his future. He was neither optimistic nor pessimistic, but he found it difficult to make plans others his age were making. He believed that his circle of interests had narrowed and that his expectations reflected a life diminished by long-term disability. Clearly, pain affected his perceptions of the future. He unmistakably felt dispossessed of the future he should have had.

One unrecognized source of frustration he experienced was the lack of information the public had regarding his condition. He wanted his disability to be recognized and validated by others. He believed that others would recognize the authenticity of his suffering if more information was available that exposed syringomyelia as a spinal disease similar to spinal cord injury. He expressed issues related to being disabled, and acknowledged disability with difficulty even after 16 years of being unable to work because of his symptoms. He felt as if he had to reestablish his condition with everyone who interfaced with his family members.

He indicated that he wanted to take a greater interest in the disease that was claiming his autonomy, but he was intellectually and physically fatigued by the basic trials of daily living. He had little interest in what, if any, progress the scientific community was making with the disorder. He felt no connection to others with syringomyelia because he felt alienated from other people. He was resigned to living mostly within his home and enjoying television, good books, and his family members.

CONCLUSION

The experience of living with syringomyelia can be devastating to both patients and their family members. Although surgery does not offer a cure, it may provide these patients some measure of comfort and may, in some cases, slow the progression of the disease. It is hoped that the information from this article will help give nurses providing care to those with syringomyelia greater understanding so they are better able to provide holistic, empathetic, and competent professional care.

Mr G was the older of two children who were born three years apart to a couple who were married to each other all their adult lives. Mr G recalls an "average" childhood and adolescence in which there were several notable injuries, including a fall from a moving vehicle at the age of four that resulted in a fractured skull and a fall backwards off a bluff at the age of 14 that caused him to land flat on his back. He also recalled two motorcycle accidents in which he was thrown and landed without head or neck trauma. Mr G was a popular, well-liked student throughout school and was socially active in school and in his community in rural Iowa. Mr G's father died during his senior year in high school, and Mr G assumed his father's leadership position in the family.

In addition to working full time, he was involved in numerous hobbies and crafts, including model assembly, jewelry design, hunting, archery, artistic drawing and painting, driving sports cars, and some creative writing. Mr G graduated from high school and enlisted in the US Air Force during the Viet Nam era. He spent an overseas tour of duty in England working as an aircraft mechanic. He remained in regular contact with his sister and mother while in England. Upon discharge from the Air Force, he married in his mid-twenties and had two daughters.

After he became disabled and was unable to work outside of the home, Mr G cared for his daughters when they were young. He and his wife share a close, affectionate relationship. His wife works in a family-owned business in the town where they reside. Mr G's wife helps him with activities of daily living. They live in a ranch-style house in the city limits. No structural modifications to the house were necessary. Mr G no longer drives, but he frequently accompanies family members and friends on short trips and errands. His mother resides in a nursing home, and he and his wife visit her regularly. He also maintains close contact with several friends in the geographic area. Recently, Mr G was diagnosed with metastatic oral cancer and opted for supportive care measures only.

A picture of Mr G's background was made by anecdotal information given out during many years. A detailed history was not obtained specifically for the study, so there is a possibility of some omissions.

NOTES

(1.) "Syringomyelia fact sheet," National Organization for Rare Disorders (NORDS), http://www.tepstn.com /cgi-win/nord.exe (accessed 11 Nov 2002).

(2.) "Syringomyelia fact sheet," National Institute of Neurological Disorders and Stroke (NINDS), http: //www.ninds.nih.gov/health_and_medical/pubs/syringom yelia.htm (accessed 11 Nov 2002).

(3.) K Sudo et al, "Syringomyelia as a cause of body hypertrophy," Lancet 347 (June 1996) 1593-1595.

(4.) "Syringomyelia fact sheet," National Institute of Neurological Disorders and Stroke (N1NDS), http: //www.ninds.nih.gov/health_and_medical/pubs/syringom yelia.htm (accessed 11 Nov 2002).

(5.) R D Adams, M Victor, A H Ropper, Principles of Neurology, sixth ed (New York: McGraw-Hill Health Professions Division, 1997) 1064-1065, 1337-1341.

(6.) D M Mueller, "Brainstem conundrum: The Chiari I malformation," Journal of the American Academy of Nurse Practitioners 13 (April 2001) 154-159.

(7.) Adams, Victor, Ropper, Principles of Neurology, sixth ed, 1064-1065, 1337-1341.

(8.) J V Hickey, The Clinical Practice of Neurological and Neurosurgical Nursing, third ed (Philadelphia: J B Lippincott Co, 1992) 38-39.

(9.) A J Gatz, Manter's Essentials of Clinical Neuroanatomy and Neurophysiology, third ed (Philadelphia: F A Davis Co, 1966).

(10.) Hickey, The Clinical Practice of Neurological and Neurosurgical Nursing, third ed, 38-39.

(11.) U Batzdorf, "Primary spinal syringomyelia: A personal perspective," Neurosurgical Focus 8 (March 2000) 1-4.

(12.) Adams, Victor, Ropper, Principles of Neurology, sixth ed, 1064-1065, 1337-1341.

(13.) Gatz, Manter's Essentials of Clinical Neuroanatomy and Neurophysiology, third ed.

(14.) Adams, Victor, Ropper, Principles of Neurology, sixth ed, 1064-1065, 1337-1341.

(15.) Ibid.

(16.) Ibid.

(17.) Ibid.

(18.) Ibid.

(19.) Ibid.

(20.) J C Oakley, G A Ojemann, E C Alvord, "Posttraumatic syringomyelia," Journal of Neurosurgery 55 (August 1981) 276-281.

(21.) Adams, Victor, Ropper, Principles of Neurology, sixth ed, 10641065, 1337-1341.

(22.) Ibid.

(23.) M J Chandy, "Occipital fibrous dysplasia tonsillar herniation and cervical syringomyelia," British Journal of Neurosurgery 13 (April 1999) 217.

(24.) S C Smeltzer, B G Bare, eds Brunner & Suddarth's Textbook of Medical Surgical Nursing, ninth ed (Philadelphia: Lippincott, Williams & Wilkins, 2000) 1700-1760.

(25.) N H Fortunato, Berry & Kohn's Operating Room Technique, ninth ed (St Louis: Mosby, Inc, 2000) 809-831.

(26.) J C Alzate et al, "Treatment of Chiari type I malformation in patients with and without syringomyelia: A consecutive series of 66 cases," Neurosurgical Focus 11 (July 2001) 1-9.

(27.) H Kazutoshi, I Yoshinobu, "Syringosubarachnoid shunt for syringomyelia associated with Chiari I malformation," Neurosurgical Focus 11 (July 2001) 1-3.

(28.) Fortunato, Berry & Kohn's Operating Room Technique, ninth ed, 809-831.

(29.) Smeltzer, Bare, eds Brunner & Suddarth's Textbook of Medical Surgical Nursing, ninth ed, 17001760.

(30.) Alzate et al, "Treatment of Chiari type I malformation in patients with and without syringomyelia: A consecutive series of 66 cases," 1-9.

(31.) Ibid.

(32.) D R Falvo, Medical and Psychosocial Aspects of Chronic Illness and Disability, second ed (Gaithersburg, Md: Aspen Publishers, 1999).

(33.) Adams, Victor, Ropper, Principles of Neurology, sixth ed, 10641065, 1337-1341.

(34.) Ibid.

(35.) N J Pender, Health Promotion in Nursing Practice, third ed (Norwalk, Conn: Appleton & Lange, 1996) 189.

(36.) Ibid.

(37.) R K Dishman, J F Sallis, D R Orenstein, "The determinants of physical activity and exercise," Public Health Report 100 (March/April 1985) 158-171.

(38.) Falvo, Medical and Psychosocial Aspects of Chronic Illness and Disability, second ed.

(39.) E A Michaels, R G Ramsey, "Syringomyelia," Orthopedic Nursing 15 (September/October 1996) 33-40; Mueller, "Brainstem conundrum: The Chiari I malformation," 154-159; L Robinson, D Bisnaire, "Syringomyelia and syringobulbia: Pathophysiology, surgical treatment, and nursing implications," Journal of Neuroscience Nursing 22 (April 1990) 69-75; J Smith, B Geist, "Syringomyelia: A nursing review," Journal of Neurosurgical Nursing 11 (September 1979) 134-140; A Strayer, "Chiari I malformation: Clinical presentation and management," Journal of Neuroscience Nursing 33 (April 2001) 90-96.

(40.) L Leroux, "A wait on my mind," Nursing Times 92 (November 13-19, 1996) 46.

Edith L. Hilton, RN, DSN, PhD, APRN, BC, CRRN, is an associate professor at the School of Nursing; North Park University, Chicago.

Lesley J. Henderson, RN, MSN, CNOR, is an assistant professor of nursing at the State University of West Georgia, Carrollton.

Severe depression may result from pesticide exposure

Overexposure to agricultural pesticides may be linked to severe depression, according to a Nov 13, 2002, news release from Colorado State University, Ft Collins. Researchers studied 761 farmers and their spouses from eight northeastern Colorado counties between 1992 and 1997. The 69 participants who reported being sickened by pesticide poisoning were 5.8 times more likely to score high on tests measuring depression level compared to participants who reported they had not been poisoned by pesticides.

Industrial strength agricultural pesticides contain organophosphate compounds, which are highly toxic. Organophosphates are absorbed easily through the skin, mucus membranes, lungs, and intestines. A person poisoned by pesticides can experience immediate nausea, vomiting, abdominal pain, headaches, respiratory problems, and blurred vision. The study shows that long-term effects of pesticide poisoning can include anxiety, irritability, restlessness, and depression.

Previous studies have shown that farm residents suffer from higher rates of depression compared to other population groups, and farm workers have higher suicide rates than other groups. Other findings from this study indicate that female farm residents in poor physical health are more susceptible to depressive symptoms, and young farmers are more likely to suffer from severe depression compared to older farmers.

Colorado State University Professor Links Depression among Farm Residents to Pesticide Exposure (news release, Ft Collins, Colo: Colorado Slate University, Nov 13, 2002) http://www.newsinfo.colostate.edu/index.asp? page=news_item_display&news_item_id=1490429860 (accessed 27 Nov 2002).

Examination

NEUROSURGICAL CONSIDERATIONS IN POSTTRAUMATIC SYRINGOMYELIA

1. The area of the spinal cord almost exclusively affected by syrinx development in syringomyelia is the

a. anterior surface extending from the lumbar to the sacral area.

b. the upper two-thirds of the vertebra column from the first cervical vertebra to the lower border of the first lumbar vertebra.

c. the posterior surface in the thoracic region extending from the first thoracic vertebra to the upper border of the first lumbar vertebra.

d. the 1-inch long structure of the medulla oblongata that extends from the foramen magnum to the third cervical vertebra.

2. Multiple illnesses and injuries appear to predispose development of syringomyelia, including

a. postoperative complications and postinflammatory origins.

b. posttraumatic sources and postviral exposures.

c. postdisc injury and postencephalopathic complications.

d. posttumor sources and postpolio injuries.

3. Onset usually is insidious and in some instances, symptoms manifest after an episode of

a. flu-like symptoms.

b. sleeping in a chair or car.

c. emotional trauma.

d. strenuous coughing or straining.

4. Which of the following interventions is applicable to the nursing diagnosis "Acute pain related to altered neurovascular status and surgical intervention?"

a. Assesses factors related to risk for ineffective tissue perfusion (eg, chronic diseases).

b. Identifies mechanisms to prevent injury in place at patient's home and place of work.

c. Implements alternative methods of pain control (eg, perioperative sedation).

d. Works with patient and family members to identify additional mechanisms to prevent postoperative injury.

5. The goal of the procedure is to reduce the cerebellar tonsils with craniectomy and perform a C-1 laminectomy to

a. remove intervertebral ruptured disc material.

b. position transcutaneous electrical nerve stimulation wires.

c. aspirate localized fluid collection secondary to head trauma.

d. decompress the brain stem and cranial nerves.

6. The laminectomy may involve the use of autologous or bank bone and--to close the dura.

a. artificial sheeting material

b. gel foam

c. staples

d. stainless steel wire

7. Executive functions, such as--also may be lost.

a. long office hours and commuting times

b. the ability to make rapid decisions

c. personnel management skills

d. writing and using a keyboard or keypad

8. --results in loss of upward gaze because the neck becomes fused in a cervico-occipital malformation.

a. Kwashiorkor syndrome

b. Kyphorachitis

c. Koilonychia syndrome

d. Kyphoscoliosis

9. All of the following interwoven themes were identified in the study presented of a middle-aged man with syringomyelia except

a. financial burdens.

b. loss of abilities.

c. struggles to adapt to changes.

d. life as a disabled man.

10. Although infrequent, surgery can offer a cure to some people with syringomyelia.

a. true

b. false

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