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Viana Bonan de Aguiar V, Batista G, Gepp R, Falavigna A. Epidemiological aspects of syringomyelia in a 19-year old cohort of spinal cord injury patients. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:311-318. [PMID: 39357742 DOI: 10.1016/j.neucie.2024.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 09/16/2024] [Accepted: 09/17/2024] [Indexed: 10/04/2024]
Abstract
OBJECTIVE To determine the prevalence, clinical and radiological risk factors, and surgical management of post-traumatic syringomyelia (PTS) in a 19-year cohort study of Spinal Cord Injury (SCI) patients treated at a SCI rehabilitation center. METHODS Retrospective study of SCI patients in whom PTS was radiologically confirmed between January 2000 and December 2018. Protocols for assessing signs and symptoms of PTS were applied prior to PTS diagnosis and treatment and later at neurosurgical and rehabilitation reviews. The variables analyzed were prevalence, demographic data, trauma event, clinical and radiological risk factors, location and size of the syrinx, and effectiveness of the surgical procedures. RESULTS Over the 19-year period, review of 920 SCI patients revealed 85 patients who met the clinical and neuroradiological criteria for the diagnosis of PTS and who were prospectively followed. Road traffic accidents were the leading cause of injury (n = 58; 68.2%), syringomyelia was most commonly observed in the thoracic spine (n = 56; 65.9%), and upper extremity paresis was the most common indication for surgical treatment (n = 27; 45%). Surgical treatment was indicated in 48 patients and the operative procedures included 29 syringopleural shunts (60.4%), 17 adhesiolysis (35.4%), and two syringosubarachnoid shunts (4.1%). The prevalence of PTS was 9% and was higher in patients with ASIA impairment scale grade A injuries. Most patients with PTS (63/85, 74.1%) were treated surgically at the time of injury. There was a significant reduction both in the extent (p = 0.05) and largest area (p = 0.001) of the syrinx after surgical treatment. Reoperation rates were 47% and 37.9% for adhesiolysis and syringopleural shunting, respectively. CONCLUSION Follow-up and routine clinical examination of SCI patients is critical for the diagnosis of PTS in patients with late neurological deterioration. Surgical treatment has a positive impact in reducing the size of the syrinx as seen on postoperative MRI.
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Affiliation(s)
| | | | - Ricardo Gepp
- Sarah Network of Rehabilitation Hospitals, Brazil
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Akgun MY, Ates O, Akyoldas G, Tepebasili MA, Sasani M, Oktenoglu T, Ozer AF. Does long segment subarachnoido-subarachnoid shunt prevent posttraumatic and postinfectious spinal arachnoid cyst recurrence?: technical note and case series. Neurochirurgie 2024; 70:101555. [PMID: 38520969 DOI: 10.1016/j.neuchi.2024.101555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/15/2024] [Accepted: 03/19/2024] [Indexed: 03/25/2024]
Abstract
Syringomyelia associated with extensive spinal adhesive arachnoiditis (SAA) can be defined as a rare but progressive disease with potentially devastating clinical consequences. Diagnosis can be challenging due to the absence of specific clinical findings, confusion with other pathologies, and late imaging modalities. The treatment strategy for syringomyelia associated with extensive SAA should include direct drainage of the syringomyelia, and dissection of the adhesive arachnoid with expansive duraplasty. Hence, several approaches have been reported for arachnoid dissection and decompression of the subarachnoid space. The high risk of recurrence after the operation is one of the most challenging situations. First two cases were operated previously, and the cyst walls were removed and anastomosed to the intact subarachnoid space at the upper and lower ends by each other. However, in both cases, the cyst recurred after a short time and they were anastomosed again in our clinic. A subarachnoid-subarachnoid shunt was placed with a multi-hole silicone tube extending to the proximal and distal intact subarachnoid spaces and passing through the cyst removal area. In our third case, the shunt system we described was applied directly, and satisfactory results were obtained in the clinical follow-up of the patient. It has been demonstrated that subarachnoido-subarachnoid shunt is a very satisfactory treatment option for this type of pathology, which is difficult to follow and treat.
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Affiliation(s)
- Mehmet Yigit Akgun
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Ozkan Ates
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Goktug Akyoldas
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
| | | | - Mehdi Sasani
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Tunc Oktenoglu
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Ali Fahir Ozer
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey; Bioengineering and Orthopaedic Surgery Colleges of Engineering and Medicine, University of Toledo, Toledo, OH, USA.
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Jain N, Jaunozolina L, Putraima I, Auslands K, Millers A. Delayed spinal arachnoiditis with syringomyelia following aneurysmal subarachnoid haemorrhage: a case report with patient experience. Spinal Cord Ser Cases 2024; 10:41. [PMID: 38858362 PMCID: PMC11165000 DOI: 10.1038/s41394-024-00654-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Syringomyelia, or the formation of fluid-filled cysts within the spinal cord, associated with delayed spinal arachnoiditis is an uncommon complication of aneurysmal subarachnoid haemorrhage. To date, about 18 cases have been reported in medical literature, with just two reported in patients under the age of 35 years. CLINICAL PRESENTATION A 27-year-old female patient complained of sudden, severe headaches in the occipital region, nuchal rigidity, and drowsiness when she presented at our institution. A head computed tomography scan revealed intraventricular bleeding in the lateral and fourth ventricles with more extensive haemorrhaging in the frontal horns. A left posterior inferior cerebellar artery (PICA) aneurysm was confirmed via digital subtraction angiogram, and endovascular embolization was done. Two years later, the patient reported intense pain in the lower back along with symptoms suggestive of spinal cord compression. Spinal magnetic resonance imaging (MRI) showed spinal adhesions from C1 to L4, syringomyelia with some vasogenic oedema extending from T3 to T9 level, and a cyst in the lumbar region. Consequently, a right hemilaminectomy was performed along with microsurgical release of arachnoid adhesions and placement of a subdural drain. Radiological and symptomatic improvements were observed. Since then, the patient's clinical condition has remained stable during the past three years of follow-up visits. CONCLUSIONS Literature on optimal treatment modalities and patient prognosis is scarce and debated. The time for symptom improvement depends on the level and extent of spinal cord involvement. Rehabilitation may be required for most patients, as complete symptomatic recovery may not be attainable.
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Affiliation(s)
- Nityanand Jain
- Faculty of Medicine, Riga Stradinš University, 16 Dzirciema Street, Riga, LV-1007, Latvia.
| | - Liga Jaunozolina
- Faculty of Medicine, Riga Stradinš University, 16 Dzirciema Street, Riga, LV-1007, Latvia
| | - Inga Putraima
- Children Clinical University Hospital, Vienības Gatve 45, Riga, LV-1064, Latvia
| | - Kaspars Auslands
- Department of Neurosurgery, Riga East Clinical University Hospital, 2 Hipokrata Street, Riga, LV-1038, Latvia
- Department of Neurology and Neurosurgery, Riga Stradinš University, 16 Dzirciema Street, Riga, LV-1007, Latvia
| | - Andrejs Millers
- Department of Neurology and Neurosurgery, Riga Stradinš University, 16 Dzirciema Street, Riga, LV-1007, Latvia
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Wong G, Pivazyan G, Breton JM, Dowlati E, Felbaum DR. Considerations for delayed-onset spinal arachnoid web after intracranial subarachnoid hemorrhage. Brain Circ 2024; 10:89-93. [PMID: 39036301 PMCID: PMC11259322 DOI: 10.4103/bc.bc_99_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 07/23/2024] Open
Abstract
Spinal arachnoid web (AW) is a rare condition causing spinal cord-related issues. Its cause is often idiopathic but can be linked to past trauma or spine surgery. We describe two cases of AWs that developed after subarachnoid hemorrhage (SAH). Case #1 is a 71-year-old male with nonaneurysmal SAH who developed myelopathy 1 year later. Magnetic resonance imaging revealed upper thoracic cord edema and an AW. Case #2 is a 57-year-old female who underwent coiling of a ruptured basilar artery aneurysm and ventriculoperitoneal shunting for hydrocephalus. Twenty months later, she developed mid-thoracic AW requiring surgical resection. Both patients showed symptom improvement postresection avoiding further reoperation. History of SAH is emerging as a risk factor for AW development, emphasizing the importance of monitoring delayed-onset myelopathy and back pain in recent SAH patients.
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Affiliation(s)
- Georgia Wong
- Department of Neurosurgery, Georgetown University School of Medicine, Columbia, Washington, USA
| | - Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Columbia, Washington, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Columbia, Washington, USA
| | - Jeffrey M. Breton
- Department of Neurosurgery, MedStar Georgetown University Hospital, Columbia, Washington, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Columbia, Washington, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Columbia, Washington, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Columbia, Washington, USA
| | - Daniel R. Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Columbia, Washington, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Columbia, Washington, USA
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Xia P, Lv H, Yuan C, Duan W, Wang J, Guan J, Du Y, Zhang C, Liu Z, Wang K, Wang Z, Wang X, Wu H, Chen Z, Jian F. Role of Preoperative Albumin Quotient in Surgical Planning for Posttraumatic Syringomyelia: A Comparative Cohort Study. Neurospine 2024; 21:212-222. [PMID: 38317552 PMCID: PMC10992642 DOI: 10.14245/ns.2347152.576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE Surgical procedures for patients with posttraumatic syringomyelia (PTS) remain controversial. Until now, there have been no effective quantitative evaluation methods to assist in selecting appropriate surgical plans before surgery. METHODS We consecutively enrolled PTS patients (arachnoid lysis group, n = 42; shunting group, n = 14) from 2003 to 2023. Additionally, 19 intrathecal anesthesia patients were included in the control group. All patients with PTS underwent physical and neurological examinations and spinal magnetic resonance imaging preoperatively, 3-12 months postoperatively and during the last follow-up. Preoperative lumbar puncture was performed and blood-spinal cord barrier disruption was detected by quotient of albumin (Qalb, cerebrospinal fluid/serum). RESULTS The ages (p = 0.324) and sex (p = 0.065) of the PTS and control groups did not differ significantly. There were also no significant differences in age (p = 0.216), routine blood data and prognosis (p = 0.399) between the arachnoid lysis and shunting groups. But the QAlb level of PTS patients was significantly higher than that of the control group (p < 0.001), and the shunting group had a significantly higher QAlb (p < 0.001) than the arachnoid lysis group. A high preoperative QAlb (odds ratio, 1.091; 95% confidence interval, 1.004-1.187; p = 0.041) was identified as the predictive factor for the shunting procedure, with the receiver operating characteristic curve showing 100% specificity and 80.95% sensitivity for patients with a QAlb > 12.67. CONCLUSION Preoperative QAlb is a significant predictive factor for the types of surgery. For PTS patients with a QAlb > 12.67, shunting represents the final recourse, necessitating the exploration and development of novel treatments for these patients.
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Affiliation(s)
- Pingchuan Xia
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Houyuan Lv
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Chenghua Yuan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | | | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Yueqi Du
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Can Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zhenlei Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zuowei Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
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Nozaleda GL, Alaminos-Quesada J, Coenen W, Haughton V, Sánchez AL. An analytic model for the flow induced in syringomyelia cavities. JOURNAL OF FLUID MECHANICS 2024; 978:A22. [PMID: 38746046 PMCID: PMC11089288 DOI: 10.1017/jfm.2023.1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
A simple two-dimensional fluid-structure-interaction problem, involving viscous oscillatory flow in a channel separated by an elastic membrane from a fluid-filled slender cavity, is analyzed to shed light on the flow dynamics pertaining to syringomyelia, a neurological disorder characterized by the appearance of a large tubular cavity (syrinx) within the spinal cord. The focus is on configurations in which the velocity induced in the cavity, representing the syrinx, is comparable to that found in the channel, representing the subarachnoid space surrounding the spinal cord, both flows being coupled through a linear elastic equation describing the membrane deformation. An asymptotic analysis for small stroke lengths leads to closed-form expressions for the leading-order oscillatory flow, and also for the stationary flow associated with the first-order corrections, the latter involving a steady distribution of transmembrane pressure. The magnitude of the induced flow is found to depend strongly on the frequency, with the result that for channel flow rates of non-sinusoidal waveform, as those found in the spinal canal, higher harmonics can dominate the sloshing motion in the cavity, in agreement with previous in vivo observations. Under some conditions, the cycle-averaged transmembrane pressure, also showing a marked dependence on the frequency, changes sign on increasing the cavity transverse dimension (i.e. orthogonal to the cord axis), underscoring the importance of cavity size in connection with the underlying hydrodynamics. The analytic results presented here can be instrumental in guiding future numerical investigations, needed to clarify the pathogenesis of syringomyelia cavities.
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Affiliation(s)
- G. L. Nozaleda
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093-0411, USA
| | - J. Alaminos-Quesada
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093-0411, USA
| | - W. Coenen
- Grupo de Mecánica de Fluidos, Universidad Carlos III de Madrid, Leganés, 28911 Spain
| | - V. Haughton
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, 53706 USA
| | - A. L. Sánchez
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093-0411, USA
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Goel K, Phillips HW, Chen JS, Ngo J, Edmonds B, Ha PX, Wang A, Weil A, Russell BE, Salamon N, Nariai H, Fallah A. Hemispheric epilepsy surgery for hemimegalencephaly: The UCLA experience. Epilepsia 2024; 65:57-72. [PMID: 37873610 DOI: 10.1111/epi.17807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVES Hemimegalencephaly (HME) is a rare congenital brain malformation presenting predominantly with drug-resistant epilepsy. Hemispheric disconnective surgery is the mainstay of treatment; however, little is known about how postoperative outcomes compare across techniques. Thus we present the largest single-center cohort of patients with HME who underwent epilepsy surgery and characterize outcomes. METHODS This observational study included patients with HME at University of California Los Angeles (UCLA) from 1984 to 2021. Patients were stratified by surgical intervention: anatomic hemispherectomy (AH), functional hemispherectomy (FH), or less-than-hemispheric resection (LTH). Seizure freedom, functional outcomes, and operative complications were compared across surgical approaches. Regression analysis identified clinical and intraoperative variables that predict seizure outcomes. RESULTS Of 56 patients, 43 (77%) underwent FH, 8 (14%) underwent AH, 2 (4%) underwent LTH, 1 (2%) underwent unknown hemispherectomy type, and 2 (4%) were managed non-operatively. At median last follow-up of 55 months (interquartile range [IQR] 20-92 months), 24 patients (49%) were seizure-free, 17 (30%) required cerebrospinal fluid (CSF) shunting for hydrocephalus, 9 of 43 (21%) had severe developmental delay, 8 of 38 (21%) were non-verbal, and 15 of 38 (39%) were non-ambulatory. There was one (2%) intraoperative mortality due to exsanguination earlier in this cohort. Of 12 patients (29%) requiring revision surgery, 6 (50%) were seizure-free postoperatively. AH, compared to FH, was not associated with statistically significant improved seizure freedom (hazard ratio [HR] = .48, p = .328), although initial AH trended toward greater odds of seizure freedom (75% vs 46%, p = .272). Younger age at seizure onset (HR = .29, p = .029), lack of epilepsia partialis continua (EPC) (HR = .30, p = .022), and no contralateral seizures on electroencephalography (EEG) (HR = .33, p = .039) independently predicted longer duration of seizure freedom. SIGNIFICANCE This study helps inform physicians and parents of children who are undergoing surgery for HME by demonstrating that earlier age at seizure onset, absence of EPC, and no contralateral EEG seizures were associated with longer postoperative seizure freedom. At our center, initial AH for HME may provide greater odds of seizure freedom with complications and functional outcomes comparable to those of FH.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - H Westley Phillips
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jia-Shu Chen
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jacqueline Ngo
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Benjamin Edmonds
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Phong X Ha
- Department of Radiology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Andrew Wang
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Alexander Weil
- Brain and Development Research Axis, Sainte-Justine Research Center, Montréal, Québec, Canada
- Department of Surgery, Division of Neurosurgery, Sainte-Justine University Hospital Centre, Montréal, Québec, Canada
- Department of Surgery, Division of Neurosurgery, University of Montreal Hospital Centre (CHUM), Montréal, Québec, Canada
- Department of Neuroscience, University of Montreal, Montréal, Québec, Canada
| | - Bianca E Russell
- Department of Human Genetics, Division of Clinical Genetics, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Hiroki Nariai
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Aria Fallah
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, California, USA
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Chang HS. Hypothesis on the pathophysiology of syringomyelia based on analysis of phase-contrast magnetic resonance imaging of Chiari-I malformation patients. F1000Res 2023; 10:996. [PMID: 37637502 PMCID: PMC10450261 DOI: 10.12688/f1000research.72823.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/29/2023] Open
Abstract
Background: Despite several hypotheses, our understanding of syringomyelia's pathophysiology remains limited. The hypothesis proposed by Oldfield et al. suggests that piston-like movement of the cerebellar tonsils propels the cerebrospinal fluid (CSF) into the syrinx via the spinal perivascular space. However, a significant question remains unanswered: how does the CSF enter and stay in the syrinx, which has a higher pressure than the subarachnoid space. In the current study, we attempted to verify Oldfield's hypothesis using phase-contrast magnetic resonance imaging (MRI) data from patients with syringomyelia. Methods: We analyzed phase-contrast MRI scans of 18 patients with Chiari-I malformation associated with syringomyelia, all of whom underwent foramen magnum decompression, and 21 healthy volunteers. We obtained velocity waveforms for CSF and brain tissue from regions of interest (ROI) set at the various locations. These waveforms were synchronized at the peak timing of downward CSF flow. We compared the preoperative patient data with the control data and also compared the preoperative patient data with the postoperative patient data. Results: The syrinx shrank in 17 (94%) of the patients, and they experienced significant clinical improvement. When comparing pre- and postoperative MRI results, the only significant difference noted was the preoperative elevated velocity of the cerebellar tonsil, which disappeared post-surgery. The CSF velocities in the subarachnoid space were higher in the preoperative patients than in the controls, but they did not significantly differ in the postoperative MRI. The tonsillar velocity in the preoperative MRI was significantly lower than that of the CSF, suggesting that the elevated tonsillar velocity was more of an effect, rather than the cause, of the elevated CSF velocity. Conclusions: Given these findings, a completely new paradigm seems necessary. We, therefore, propose a novel hypothesis: the generative force of syringomyelia may be the direction-selective resistance to CSF flow in the subarachnoid space.
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Affiliation(s)
- Han Soo Chang
- Department of Neurosurgery, Tokai University, 143 Shimokasuya, Isehara, Kanagawa, 259-1143, Japan
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Chang HS. Hypothesis on the pathophysiology of syringomyelia based on analysis of phase-contrast magnetic resonance imaging of Chiari-I malformation patients. F1000Res 2023; 10:996. [PMID: 37637502 PMCID: PMC10450261 DOI: 10.12688/f1000research.72823.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 07/16/2024] Open
Abstract
Background: Despite several hypotheses, our understanding of syringomyelia's pathophysiology remains limited. The hypothesis proposed by Oldfield et al. suggests that piston-like movement of the cerebellar tonsils propels the cerebrospinal fluid (CSF) into the syrinx via the spinal perivascular space. However, a significant question remains unanswered: how does the CSF enter and stay in the syrinx, which has a higher pressure than the subarachnoid space. In the current study, we attempted to verify Oldfield's hypothesis using phase-contrast magnetic resonance imaging (MRI) data from patients with syringomyelia. Methods: We analyzed phase-contrast MRI scans of 18 patients with Chiari-I malformation associated with syringomyelia, all of whom underwent foramen magnum decompression, and 21 healthy volunteers. We obtained velocity waveforms for CSF and brain tissue from regions of interest (ROI) set at the various locations. These waveforms were synchronized at the peak timing of downward CSF flow. We compared the preoperative patient data with the control data and also compared the preoperative patient data with the postoperative patient data. Results: The syrinx shrank in 17 (94%) of the patients, and they experienced significant clinical improvement. When comparing pre- and postoperative MRI results, the only significant difference noted was the preoperative elevated velocity of the cerebellar tonsil, which disappeared post-surgery. The CSF velocities in the subarachnoid space were higher in the preoperative patients than in the controls, but they did not significantly differ in the postoperative MRI. The tonsillar velocity in the preoperative MRI was significantly lower than that of the CSF, suggesting that the elevated tonsillar velocity was more of an effect, rather than the cause, of the elevated CSF velocity. Conclusions: Given these findings, a completely new paradigm seems necessary. We, therefore, propose a novel hypothesis: the generative force of syringomyelia may be the direction-selective resistance to CSF flow in the subarachnoid space.
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Affiliation(s)
- Han Soo Chang
- Department of Neurosurgery, Tokai University, 143 Shimokasuya, Isehara, Kanagawa, 259-1143, Japan
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10
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Adib SD, Schittenhelm J, Kurucz P, Hauser TK, Tatagiba M. Surgical management of syringomyelia associated with spinal arachnoid web: strategies and outcomes. Neurosurg Rev 2023; 46:152. [PMID: 37358703 PMCID: PMC10293323 DOI: 10.1007/s10143-023-02071-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
Spinal arachnoid web (SAW) is a rare disease entity characterized as band-like arachnoid tissue that can cause spinal cord compression and syringomyelia. This study aimed to analyze the surgical management of the spinal arachnoid web in patients with syringomyelia, focusing on surgical strategies and outcomes. A total of 135 patients with syringomyelia underwent surgery at our department between November 2003 and December 2022. All patients underwent magnetic resonance imaging (MRI), with a special syringomyelia protocol (including TrueFISP and CINE), and electrophysiology. Among these patients, we searched for patients with SAW with syringomyelia following careful analysis of neuroradiological data and surgical reports. The criteria for SAW were as follows: displacement of the spinal cord, disturbed but preserved CSF flow, and intraoperative arachnoid web. Patients were evaluated for initial symptoms, surgical strategies, and complications by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. Of the 135 patients, 3 (2.22%) fulfilled the SAW criteria. The mean patient age was 51.67 ± 8.33 years. Two patients were male, and one was female. The affected levels were T2/3, T6, and T8. Excision of the arachnoid web was performed in all cases. No significant change in intraoperative monitoring was noted. Postoperatively, none of the patients presented new neurological symptoms. The MRI 3 months after surgery revealed that the syringomyelia improved in all cases, and caliber variation of the spinal cord could not be detected anymore. All clinical symptoms improved. In summary, SAW can be safely treated by surgery. Even though syringomyelia usually improves on MRI and symptoms also improve, residual symptoms might be observed. We advocate for clear criteria for the diagnosis of SAW and a standardized diagnostic (MRI including TrueFISP and CINE).
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Affiliation(s)
- Sasan Darius Adib
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Jens Schittenhelm
- Department of Neuropathology, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Peter Kurucz
- Department of Neurosurgery, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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11
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Wu J, Ji S, Niu P, Zhang B, Shao D, Li Y, Xie S, Jiang Z. Knowledge mapping of syringomyelia from 2003 to 2022: A bibliometric analysis. J Clin Neurosci 2023; 110:63-70. [PMID: 36822071 DOI: 10.1016/j.jocn.2023.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/26/2022] [Accepted: 01/04/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Syringomyelia is a chronic, progressive disease of the spinal cord. Syringomyelia is an etiologically diverse affliction caused by disturbance of normal cerebrospinal fluid flow dynamics. Lesions are characterized by the formation of tubular cavities in the gray matter of the spinal cord and gliosis; however, the etiology is unknown and treatment methods differ. Many existing studies have focused on the relationship between other diseases and syringomyelia. There is a lack of comprehensive and objective reports on the research status of syringomyelia. Therefore, this study aimed to conduct a bibliometric analysis to quantify studies on Syringomyelia and trending issues in the last 20 years. METHODS Articles were acquired from the Web of Science Core Collection database. We used the Library Metrology online analysis platform, BICOMB, gCLUTO, CiteSpace bibliometrics tools for analysis, VOSviewer 1.6.16 (Nees Jan van Eck and Ludo Waltman, 2010), and Microsoft Excel 2019 to perform bibliometric analysis and visualization. Individual impact and collaborative information were quantified by analyzing annual publications, journals, co-cited journals, countries/regions, institutions, authors, and co-cited authors. We then identified the trending research areas of syringomyelia by analyzing the co-occurrence of keywords and co-cited references. RESULTS From January 2003 to August 2022, 9,556 authors from 66 countries published a total of 1,902 research articles on syringomyelia in 518 academic journals. Most publications come from the United States, China, the United Kingdom, and Japan, with the United States dominating. Nanjing University and the University of Washington are the most active institutions, Dr. Claire Rusbridge has published the most papers, and Miholat has the most co-citations. The Journal of Neurosurgery has the highest number of co-cited articles, which are mainly in the fields of neurology, surgery, and biology. High-frequency keywords included syringomyelia, Chiari-I malformation, children, surgical treatment, and spinal cord. CONCLUSIONS The number of articles on syringomyelia has increased steadily over the past two decades. At present, research on syringomyelia is mainly focused on the age of onset, potential therapeutic interventions, surgical treatment, avoidance of recurrence, and delay of pain. The use of surgical treatment of the disease and the mechanism of further treatment are the current hot research topics. The correlation between trauma and congenital factors, translational application, the effect of surgical treatment, postoperative recurrence, and complications are further hot research areas. These may provide ideas for further research into a radical cure for syringomyelia.
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Affiliation(s)
- Junyong Wu
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Shuxin Ji
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Pengyuan Niu
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Binbin Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Dongqi Shao
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yu Li
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Shan Xie
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhiquan Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China.
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12
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Vadlamani T, Yagnick NS, Kagita R, Sinha S. Surgical Management of Lumbar Adhesive Arachnoiditis Postmeningitis: A Bermuda Triangle?—Case Report and Review of Literature. INDIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1055/s-0042-1756508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
AbstractSpinal arachnoiditis can occur as a delayed sequel of meningitis. Cerebrospinal fluid flow disturbances and adhesive loculations can cause cord compression and traction on roots causing the symptoms. The surgical treatment of this condition is often considered a limited option, because of the high chances of recurrence of symptoms and adhesions, often considered as surgical failure. Here, we report a patient with extensive lumbar–sacral adhesive arachnoiditis successfully treated with limited adhesiolysis under neuromonitoring and cystoperitoneal shunt placement.
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Affiliation(s)
- Tejaswi Vadlamani
- Department of Neurosurgery, Paras Hospitals, Gurgaon, Haryana, India
| | | | - Rakesh Kagita
- Department of Neurosurgery, Paras Hospitals, Gurgaon, Haryana, India
| | - Sumit Sinha
- Department of Neurosurgery, Paras Hospitals, Gurgaon, Haryana, India
- All India Institute of Medical Sciences, New Delhi, India
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13
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A Clinical Study on the Treatment of Recurrent Chiari (Type I) Malformation with Syringomyelia Based on the Dynamics of Cerebrospinal Fluid. BIOMED RESEARCH INTERNATIONAL 2022; 2022:9770323. [DOI: 10.1155/2022/9770323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022]
Abstract
Objective. Combining the dynamics of cerebrospinal fluid, our study investigates the clinical effects of syringomyelia after the combination of fourth ventricle-subarachnoid shunt (FVSS) for recurrent Chiari (type I) malformations after cranial fossa decompression (foramen magnum decompression (FMD)). Methods. From December 2018 to December 2020, 15 patients with recurrent syringomyelia following posterior fossa decompression had FVSS surgery. Before and after the procedure, the clinical and imaging data of these individuals were retrospectively examined. Results. Following FVSS, none of the 15 patients experienced infection, nerve injury, shunt loss, or obstruction. 13 patients improved dramatically after surgery, while 2 patients improved significantly in the early postoperative period, but the primary symptoms returned 2 months later. The Japanese Orthopedic Association (JOA) score was
, which was considerably better than preoperatively (
,
0.001). The MRI results revealed that the cavities in 13 patients were reduced by at least 50% compared to the cavities measured preoperatively. The shrinkage rate of syringomyelia was 86.67% (13/15). One patient’s cavities nearly vanished following syringomyelia. The size of the cavity in the patient remain unchanged, and the cavity’s maximal diameter was significantly smaller than the size measured preoperatively (
) PC-MRI results indicated that the peak flow rate of cerebrospinal fluid at the central segment of the midbrain aqueduct and the foramen magnum in patients during systole and diastole were significantly reduced after surgery (
). Conclusion. After posterior fossa decompression, FVSS can effectively restore the smooth circulation of cerebrospinal fluid and alleviate clinical symptoms in patients with recurrent Chiari (type I) malformation and syringomyelia. It is a highly effective way of treatment.
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14
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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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15
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Sankarappan K, Pack A, Patel A, Whiting B, Clifton W. Revision Thoracic Syringo-Subarachnoid Shunt for Recurrent Syrinx With Syringobulbia: Technique and Surgical Video. Cureus 2022; 14:e28577. [PMID: 36185845 PMCID: PMC9521303 DOI: 10.7759/cureus.28577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Syringomyelia and syringobulbia continue to remain a diagnosis without widely accepted treatment paradigms. Furthermore, the currently available treatment options can be complicated by delayed symptom recurrence and the need for revision surgery. Revision intradural surgery is challenging, and currently, there is a paucity of literature describing safe techniques for revision syringotomy and shunt placement. In this technical report, we present a surgical video describing the technique of revision syringo-subarachnoid shunt placement in a 61-year-old female with a history of multiple intradural surgeries who presented with progressively symptomatic ascending syringobulbia.
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16
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Nadeem SF, Baig AN, Tariq QUA, Shamim MS. Spinal arachnoiditis and syringomyelia: Review of literature with emphasis on postinfectious inflammation and treatment. Surg Neurol Int 2022; 13:299. [PMID: 35928312 PMCID: PMC9345109 DOI: 10.25259/sni_383_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Arachnoiditis refers to chronic inflammation of the arachnoid mater and subarachnoid space due to three major etiologies: chemical, mechanical, and postinfectious. As a rare disease with variable symptomatology and severity at presentation, arachnoiditis can be extremely debilitating with many complications, prominent among which is syringomyelia.
Methods:
We reviewed current literature concerning postinfectious spinal arachnoiditis and associated syringomyelia with emphasis on the treatment options that have been used to date and discuss their respective benefits and drawbacks.
Results:
It is critical to understand the natural history and potential complications of patient with postinfectious arachnoiditis. Surgical and medical treatments both have their own merits and demerits. Different surgical approaches have been employed with variable success rates.
Conclusion:
At present, no consensus exists regarding management of these patients due to the variable nature of the disease that affects treatment efficacy; however, surgical intervention in selected cases may be beneficial.
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Affiliation(s)
- Syed Faisal Nadeem
- Department of Neurosurgery, Medical College, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Ahmer Nasir Baig
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Qurat ul Ain Tariq
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
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17
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Champeaux-Depond C, Froelich S, Parker F, Birladeanu A. Magendie's foramen debridement and catheterisation for the treatment of syringomyelia due to diffuse craniocervical junction arachnoiditis. A case report and technical note. Neurochirurgie 2022; 68:674-678. [PMID: 35697525 DOI: 10.1016/j.neuchi.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/08/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
A 36 year old woman was referred to our department for symptomatic lumbar spinal arachnoiditis following an epidural anaesthesia for childbirth. She did not had other known causative factor and she was free of any neurological symptoms before. She rapidly developed lower limbs impairment by compressing intradural lumbar collections and arachnoiditis requiring surgical decompression and subsequently internal cerebrospinal fluid shunting for acute hydrocephalus. Three years and the half later, she developed a severe tetraparesis due to a massive syrinx consecutive to the fourth ventricle outlets obstruction cause by the ongoing diffuse craniocervical junction arachnoiditis. Our aim was to treat all the problems in one step. An open fourth ventriculostomy of the Magendie's foramen with catheter insertion from the fourth ventricle down to the upper cervical subarachnoid space improve both the patient status and imagery.
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Affiliation(s)
- Charles Champeaux-Depond
- Department of neurosurgery, Lariboisière hospital, 2, rue Ambroise Paré, 75010 Paris Cedex 10, France; INSERM U1153, Statistic and Epidemiologic Research Centre Sorbonne Paris Cité (CRESS), ECSTRRA team, Saint-Louis hospital, 1, avenue Claude Vellefaux, 75010 Paris, France.
| | - Sébastien Froelich
- Department of neurosurgery, Lariboisière hospital, 2, rue Ambroise Paré, 75010 Paris Cedex 10, France
| | - Fabrice Parker
- Department of neurosurgery, Bicêtre hospital, 78, rue du General-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - Andréi Birladeanu
- Department of neurosurgery, Lariboisière hospital, 2, rue Ambroise Paré, 75010 Paris Cedex 10, France
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18
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Diagnosis and treatment of Chiari malformation and syringomyelia in adults: international consensus document. Neurol Sci 2022; 43:1327-1342. [PMID: 34129128 DOI: 10.1007/s10072-021-05347-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Syringomyelia and Chiari malformation are classified as rare diseases on Orphanet, but international guidelines on diagnostic criteria and case definition are missing. AIM OF THE STUDY to reach a consensus among international experts on controversial issues in diagnosis and treatment of Chiari 1 malformation and syringomyelia in adults. METHODS A multidisciplinary panel of the Chiari and Syringomyelia Consortium (4 neurosurgeons, 2 neurologists, 1 neuroradiologist, 1 pediatric neurologist) appointed an international Jury of experts to elaborate a consensus document. After an evidence-based review and further discussions, 63 draft statements grouped in 4 domains (definition and classification/planning/surgery/isolated syringomyelia) were formulated. A Jury of 32 experts in the field of diagnosis and treatment of Chiari and syringomyelia and patient representatives were invited to take part in a three-round Delphi process. The Jury received a structured questionnaire containing the 63 statements, each to be voted on a 4-point Likert-type scale and commented. Statements with agreement <75% were revised and entered round 2. Round 3 was face-to-face, during the Chiari Consensus Conference (Milan, November 2019). RESULTS Thirty-one out of 32 Jury members (6 neurologists, 4 neuroradiologists, 19 neurosurgeons, and 2 patient association representatives) participated in the consensus. After round 2, a consensus was reached on 57/63 statements (90.5%). The six difficult statements were revised and voted in round 3, and the whole set of statements was further discussed and approved. CONCLUSIONS The consensus document consists of 63 statements which benefited from expert discussion and fine-tuning, serving clinicians and researchers following adults with Chiari and syringomyelia.
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19
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Mastorakos P, Pomeraniec IJ, Bryant JP, Chittiboina P, Heiss JD. Flexible thecoscopy for extensive spinal arachnoiditis. J Neurosurg Spine 2022; 36:325-335. [PMID: 34598155 PMCID: PMC9382886 DOI: 10.3171/2021.4.spine21483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic adhesive spinal arachnoiditis (SA) is a complex disease process that results in spinal cord tethering, CSF flow blockage, intradural adhesions, spinal cord edema, and sometimes syringomyelia. When it is focal or restricted to fewer than 3 spinal segments, the disease responds well to open surgical approaches. More extensive arachnoiditis extending beyond 4 spinal segments has a much worse prognosis because of less adequate removal of adhesions and a higher propensity for postoperative scarring and retethering. Flexible neuroendoscopy can extend the longitudinal range of the surgical field with a minimalist approach. The authors present a cohort of patients with severe cervical and thoracic arachnoiditis and myelopathy who underwent flexible endoscopy to address arachnoiditis at spinal segments not exposed by open surgical intervention. These observations will inform subsequent efforts to improve the treatment of extensive arachnoiditis. METHODS Over a period of 3 years (2017-2020), 10 patients with progressive myelopathy were evaluated and treated for extensive SA. Seven patients had syringomyelia, 1 had spinal cord edema, and 2 had spinal cord distortion. Surgical intervention included 2- to 5-level thoracic laminectomy, microscopic lysis of adhesions, and then lysis of adhesions at adjacent spinal levels performed using a rigid or flexible endoscope. The mean follow-up was 5 months (range 2-15 months). Neurological function was examined using standard measures. MRI was used to assess syrinx resolution. RESULTS The mean length of syringes was 19.2 ± 10 cm, with a mean maximum diameter of 7.0 ± 2.9 mm. Patients underwent laminectomies averaging 3.7 ± 0.9 (range 2-5) levels in length followed by endoscopy, which expanded exposure by an average of another 2.4 extra segments (6.1 ± 4.0 levels total). Endoscopic dissection of extensive arachnoiditis in the dorsal subarachnoid space proceeded through a complex network of opaque arachnoidal bands and membranes bridging from the dorsal dura mater to the spinal cord. In less severely problematic areas, the arachnoid membrane was transparent and attached to the spinal cord through multifocal arachnoid adhesions bridging the subarachnoid space. The endoscope did not compress or injure the spinal cord. CONCLUSIONS Intrathecal endoscopy allowed visual assessment and safe removal of intradural adhesions beyond the laminectomy margins. Further development of this technique should improve its effectiveness in opening the subarachnoid space and untethering the spinal cord in cases of extensive chronic adhesive SA.
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Affiliation(s)
- Panagiotis Mastorakos
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - I. Jonathan Pomeraniec
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jean-Paul Bryant
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - John D. Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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20
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Long-term outcome following surgical treatment of posttraumatic tethered cord syndrome: a retrospective population-based cohort study. Spinal Cord 2022; 60:516-521. [PMID: 35046540 PMCID: PMC9209326 DOI: 10.1038/s41393-022-00752-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN Retrospective population-based cohort study. OBJECTIVE To investigate the long-term outcome following surgery for posttraumatic spinal cord tethering (PSCT). SETTING Publicly funded tertiary care center. METHODS Patients surgically treated for PSCT between 2005-2020 were identified and included. No patients were excluded or lost to follow-up. Medical records and imaging data were retrospectively reviewed. RESULTS Seventeen patients were included. Median age was 52 (23-69) years and 7 (41%) were female. PSCT was diagnosed at a median of 5.0 (0.6-27) years after the initial trauma. Motor deficit was the most common neurological manifestation (71%), followed by sensory deficit (53%), spasticity (53%), pain (41%) and gait disturbance (24%). Median follow-up time was 5.1 (0.7-13) years. Fifteen patients (88%) showed satisfactory results following untethering, defined as improvement or halted progression of one or more of the presenting symptoms. Treatment goals were met for motor symptoms in 92%, sensory loss in 100%, spasticity in 100%, gait disturbance in 100% and pain in 86%. Statistically, a significant improvement in motor deficit (p = 0.031) and syrinx decrease (p = 0.004) was also seen. A postoperative complication occurred in four patients: three cases of cerebrospinal fluid leakage and one postoperative hematoma. Two patients showed a negative surgical outcome: 1 with increased neck pain and 1 with left arm weakness following the postoperative hematoma. CONCLUSION Surgical treatment of PSCT results in improved neurological function or halted neurological deterioration in the vast majority of patients.
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Abstract
Idiopathic syringomyelia (IS) and refractory syringomyelia (RS) are types of syringomyelia that often pose a management challenge and are associated with long-term clinical sequela. They are usually an epiphenomenon reflecting an underlying pathology where the treatment of the primary cause should be the aim for any surgical intervention. In the case of IS, the initial step is agreeing on the definition of the terms idiopathic and syringomyelia. After a rigorous exhaustive clinic-radiological workup, only IS patients with progressive neurology are treated, usually unblocking subarachnoid cerebrospinal fluid (CSF) pathway obstruction somewhere in the thoracic spinal canal and reserving shunting techniques to nonresponsive cases. Similar to IS, also RS is multifactorial, and its management varies based on the initial pathology, strongly supported by radiological and clinical features. We aim to address this topic focusing on the etiopathology, investigation paradigm, and surgical pathway, formulating algorithms of management with available evidence in literature. Surgical techniques are discussed in detail.
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Affiliation(s)
- Pasquale Gallo
- Department of Paediatric Neurosurgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
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Spinal arachnoid web-a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection: analysis of a multicenter patient population. Spine J 2022; 22:126-135. [PMID: 34175468 DOI: 10.1016/j.spinee.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal arachnoid web (SAW) is a rare condition characterized by focal thickening of the arachnoid membrane causing displacement and compression of the spinal cord with progressive symptoms and neurological deficits. Recent reports and clinical experience suggest that SAW is a distinct entity with specific radiological findings and treatment strategies distinguishable from other arachnopathies and potential differential diagnoses. PURPOSE To better define the diagnostic and clinical features, treatment options and outcomes of surgically treated SAW. STUDY DESIGN Multicentric retrospective cohort study. PATIENT SAMPLE Twelve cases of SAW surgically treated at three different centers. OUTCOME MEASURES Self-reported and neurological outcome measurements (pain, sensory-motor deficits, vegetative dysfunctions) were assessed at follow-up timepoints. METHODS Retrospective review of prospectively collected data on all patients surgically treated for SAW from three participating neurosurgical centers between 2014 and 2020. Clinicopathological data, including neurological presentation, radiological and histological findings and outcome data were analyzed. RESULTS Twelve radiologically and surgically confirmed cases of SAW were analyzed. Mean patient age was 54.7 [±12.7], 67% were male. All SAWs were located in the posterior thoracic dural sac. On magnetic resonance imaging (MRI), the "scalpel sign" - a characteristic focal dorsal indentation of the spinal cord resembling a scalpel blade - was identified in all patients. A focal intramedullary syrinx was present in 83%. Preoperative clinical symptoms included signs of myelopathy, pain, weakness and sensory loss, most commonly affecting the trunk/upper back or lower extremities. Laminectomy or laminoplasty with intradural excision of the SAW was the surgical treatment of choice in all cases. Intraoperative ultrasound was valuable to visualize the cerebrospinal fluid (CSF) flow obstruction, confirm the SAW location before dura incision and to control adequacy of resection. After surgery, sensory loss and weakness in particular showed significant improvement. CONCLUSIONS The present study comprises the largest series of surgically treated SAW, underscoring the unique clinical, radiographic, histopathological, and surgical findings. We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Intraoperative ultrasound aids visualizing the SAW before dural incision, as well as verifying restored CSF flow after resection.
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Bhatjiwale M, Bhatjiwale M. Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report. World J Surg Proced 2021; 11:1-9. [DOI: 10.5412/wjsp.v11.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/06/2021] [Accepted: 12/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.
CASE SUMMARY A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.
CONCLUSION We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.
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Affiliation(s)
- Mrudul Bhatjiwale
- Department of Neurosurgery, Narayana Health City, Bangalore 560099, Karnataka, India
- Neurological Science, Neuro Health Foundation, Mumbai 400091, India
| | - Mohinish Bhatjiwale
- Department of Neurosurgery, Rotary Medical Center, Mumbai 400068, India
- Department of Neurosurgery, Manav Kalyan Kendra & Navneet Hitech Hospitals, Mumbai 400068, India
- Department of Neurosurgery, Neuro Health Foundation, Mumbai 400091, India
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Pukale DD, Farrag M, Leipzig ND. Detection of locomotion deficit in a post-traumatic syringomyelia rat model using automated gait analysis technique. PLoS One 2021; 16:e0252559. [PMID: 34762669 PMCID: PMC8584658 DOI: 10.1371/journal.pone.0252559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022] Open
Abstract
Syringomyelia (SM) is a spinal cord disorder in which a cyst (syrinx) filled with fluid forms in the spinal cord post-injury/disease, in patients syrinx symptoms include loss of pain and temperature sensation or locomotion deficit. Currently, there are no small animal models and connected tools to help study the functional impacts of SM. The objective of this study was to determine the detectability of subtle locomotion deficits due to syrinx formation/expansion in post-traumatic syringomyelia (PTSM) rat model using the recently reported method of Gait Analysis Instrumentation, and Technology Optimized for Rodents (GAITOR) with Automated Gait Analysis Through Hues and Areas (AGATHA) technique. First videos of the rats were collected while walking in an arena (using GAITOR) followed by extracting meaningful locomotion information from collected videos using AGATHA protocol. PTSM injured rats demonstrated detectable locomotion deficits in terms of duty factor imbalance, paw placement accuracy, step contact width, stride length, and phase dispersion parameters compared to uninjured rats due to SM. We concluded that this technique could detect mild and subtle locomotion deficits associated with PTSM injury, which also in future work could be used further to monitor locomotion responses after different treatment strategies for SM.
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Affiliation(s)
- Dipak D. Pukale
- Department of Chemical, Biomolecular, and Corrosion Engineering, University of Akron, Akron, Ohio, United States of America
| | - Mahmoud Farrag
- Integrated Bioscience Program, University of Akron, Akron, Ohio, United States of America
| | - Nic D. Leipzig
- Department of Chemical, Biomolecular, and Corrosion Engineering, University of Akron, Akron, Ohio, United States of America
- Integrated Bioscience Program, University of Akron, Akron, Ohio, United States of America
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25
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Nguyen BQ, Tran DDT, Dang TC, Mai TD, Pham HD, Truong VT. Cervical intra-extradural meningioma with en-plaque, dumbbell-shaped, and an unusual calcified pattern in a young patient. Surg Neurol Int 2021; 12:454. [PMID: 34621569 PMCID: PMC8492428 DOI: 10.25259/sni_615_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/23/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Most spinal meningiomas primarily grow in the intradural extramedullary location. Epidural meningiomas are uncommon; if detected, they usually coexist with intradural lesions. They inhere more aggressive and invasive characteristics compared with their counterparts inside the dura. Case Description: We report a 22-year-old female who was admitted to the hospital with weakness and numbness in both lower limbs. Her cervical magnetic resonance imaging revealed an en-plaque and dumbbell-shaped lesion located from C5 to C8. After gadolinium injection, the whole mass was enhanced and unveiled two portions: intradural and extradural. The bone window of the computed tomography scan revealed calcification inside the lesion. The patient underwent tumor removal surgery. The pathology findings showed a psammomatous meningioma. After 6 months of surgery, the patient has been able to walk with walkers. Conclusion: We should consider spinal meningioma as a differential diagnosis when encountering an extradural lesion in the cervical region. The optimal surgical treatment for young patient with epidural meningiomas is radical surgery with dura attachment removal.
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Affiliation(s)
- Bao Quoc Nguyen
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Duc Duy Tri Tran
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Thuan Cong Dang
- Department of Histology, Embryology, Pathology and Forensic Medicine, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Thi Dang Mai
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Hai Duong Pham
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Van Tri Truong
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
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Agarwal P, Roy S, Sharma N, Stone J, Agarwal N, Moossy JJ. Arachnoid web associated with an intrathecal pain pump. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Technical Report: Durable efficacy of an endoscope-assisted syringo-panventriculoatrial shunt for concurrent hydrocephalus and syrinx. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hackert J, Maßmann L, Sure U, Forsting M, Kleinschnitz C, Pul R, Hagenacker T. Immunotherapies in chronic adhesive arachnoiditis - A case series and literature review. eNeurologicalSci 2021; 24:100350. [PMID: 34195394 PMCID: PMC8225987 DOI: 10.1016/j.ensci.2021.100350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/10/2021] [Accepted: 06/09/2021] [Indexed: 01/02/2023] Open
Abstract
Chronic spinal adhesive arachnoiditis (CSAA) is a rare condition with limited therapeutic options. Surgical treatment proves effective in approximately 60% of cases. Conservative treatment options have not been extensively investigated. Here, we report the course of the disease, analyze the effect of immune treatments in patients with CSAA who were treated in the University Hospital Essen between 2015 and 2020, and conduct a literature review. Three out of four patients showed no improvement after treatment with corticosteroids, methotrexate, or plasmapheresis. All non-responders suffered from CSAA for several years, while one patient who had a disease duration of less than one month fully recovered. It is necessary to verify whether treatment at an early stage of the disease is better than treatment after chronic adhesion manifestation, as it interrupts the development of adhesions and all subsequent complications. Surgical treatment of CSAA patients proves effective in approx. 60% of cases. High-dose steroid treatment may be effective in early stages of CSAA. Only conservative therapy cannot be recommended in long-standing CSAA.
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Affiliation(s)
- Jana Hackert
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Louisa Maßmann
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Ulrich Sure
- University Medicine Essen, Department of Neurosurgery and Spine Surgery, Hufelandstrasse 55, 45147 Essen, Germany
| | - Michael Forsting
- University Medicine Essen, Institute of Diagnostic and Interventional Radiology and Neuroradiology, Hufelandstrasse 55, 45147 Essen, Germany
| | - Christoph Kleinschnitz
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Refik Pul
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Tim Hagenacker
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
- Corresponding author.
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Guillaumet G, Aghakhani N, Morar S, Copaciu R, Parker F, Knafo S. Reintervention rate of arachnolysis versus shunting for nonforaminal syringomyelia. J Neurosurg Spine 2021; 34:673-679. [PMID: 33545681 DOI: 10.3171/2020.8.spine20928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical treatment for nonforaminal syringomyelia related to spinal arachnoiditis is still controversial. The authors sought to assess respective outcomes and rates of reintervention for shunting and spinal cord untethering (arachnolysis) in spinal arachnoiditis with syringomyelia. METHODS This retrospective cohort study was conducted at a single reference center for syringomyelia. Patients undergoing arachnolysis and/or shunting interventions for nonforaminal syringomyelia were screened. RESULTS The study included 75 patients undergoing 130 interventions. Arachnolysis without shunting was performed in 48 patients, while 27 patients underwent shunting. The mean follow-up between the first surgery and the last outpatient visit was 65.0 months (range 12-379 months, median 53 months). At the last follow-up, the modified McCormick score was improved or stabilized in 83.4% of patients after arachnolysis versus 66.7% after shunting. Thirty-one (41.3%) patients underwent reintervention during follow-up, with a mean delay of 33.2 months. The rate of reintervention was 29.2% in the arachnolysis group versus 63.0% in the shunting group (chi-square = 8.1, p = 0.007). However, this difference was largely driven by the extension of the arachnoiditis: in patients with focal arachnoiditis (≤ 2 spinal segments), the reintervention rate was 21.6% for arachnolysis versus 57.1% for shunting; in patients with extensive arachnoiditis, it was 54.5% versus 65.0%, respectively. Survival analysis assessing the time to the first reintervention demonstrated a better outcome in both the arachnolysis (p = 0.03) and the focal arachnoiditis (p = 0.04) groups. CONCLUSIONS Arachnolysis led to fewer reinterventions than shunting in patients with nonforaminal syringomyelia. There was a high risk of reintervention for patients with extensive arachnopathies, irrespective of the surgical technique.
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Affiliation(s)
- Gonzague Guillaumet
- 1Department of Neurosurgery, French National Center for Chiari and Syringomyelia (C-MAVEM), Bicêtre Hospital, AP-HP, Paris-Saclay University, Paris; and
| | - Nozar Aghakhani
- 1Department of Neurosurgery, French National Center for Chiari and Syringomyelia (C-MAVEM), Bicêtre Hospital, AP-HP, Paris-Saclay University, Paris; and
- 2Medical School, Paris-Saclay University, Le Kremlin-Bicêtre, Paris, France
| | - Silvia Morar
- 1Department of Neurosurgery, French National Center for Chiari and Syringomyelia (C-MAVEM), Bicêtre Hospital, AP-HP, Paris-Saclay University, Paris; and
| | - Razvan Copaciu
- 1Department of Neurosurgery, French National Center for Chiari and Syringomyelia (C-MAVEM), Bicêtre Hospital, AP-HP, Paris-Saclay University, Paris; and
| | - Fabrice Parker
- 1Department of Neurosurgery, French National Center for Chiari and Syringomyelia (C-MAVEM), Bicêtre Hospital, AP-HP, Paris-Saclay University, Paris; and
- 2Medical School, Paris-Saclay University, Le Kremlin-Bicêtre, Paris, France
| | - Steven Knafo
- 1Department of Neurosurgery, French National Center for Chiari and Syringomyelia (C-MAVEM), Bicêtre Hospital, AP-HP, Paris-Saclay University, Paris; and
- 2Medical School, Paris-Saclay University, Le Kremlin-Bicêtre, Paris, France
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Xu N, Xu T, Mirasol R, Holmberg L, Vincent PH, Li X, Falk A, Benedikz E, Rotstein E, Seiger Å, Åkesson E, Falci S, Sundström E. Transplantation of Human Neural Precursor Cells Reverses Syrinx Growth in a Rat Model of Post-Traumatic Syringomyelia. Neurotherapeutics 2021; 18:1257-1272. [PMID: 33469829 PMCID: PMC8423938 DOI: 10.1007/s13311-020-00987-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 01/01/2023] Open
Abstract
Posttraumatic syringomyelia (PTS) is a serious condition of progressive expansion of spinal cord cysts, affecting patients with spinal cord injury years after injury. To evaluate neural cell therapy to prevent cyst expansion and potentially replace lost neurons, we developed a rat model of PTS. We combined contusive trauma with subarachnoid injections of blood, causing tethering of the spinal cord to the surrounding vertebrae, resulting in chronically expanding cysts. The cysts were usually located rostral to the injury, extracanalicular, lined by astrocytes. T2*-weighted magnetic resonance imaging (MRI) showed hyperintense fluid-filled cysts but also hypointense signals from debris and iron-laden macrophages/microglia. Two types of human neural stem/progenitor cells-fetal neural precursor cells (hNPCs) and neuroepithelial-like stem cells (hNESCs) derived from induced pluripotent stem cells-were transplanted to PTS cysts. Cells transplanted into cysts 10 weeks after injury survived at least 10 weeks, migrated into the surrounding parenchyma, but did not differentiate during this period. The cysts were partially obliterated by the cells, and cyst walls often merged with thin layers of cells in between. Cyst volume measurements with MRI showed that the volumes continued to expand in sham-transplanted rats by 102%, while the cyst expansion was effectively prevented by hNPCs and hNESCs transplantation, reducing the cyst volumes by 18.8% and 46.8%, respectively. The volume reductions far exceeded the volume of the added human cells. Thus, in an animal model closely mimicking the clinical situation, we provide proof-of-principle that transplantation of human neural stem/progenitor cells can be used as treatment for PTS.
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Affiliation(s)
- Ning Xu
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Center for Reproductive Medicine, and Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tingting Xu
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Division of Neurogeriatrics, Karolinska Institutet, BioClinicum J10:30, Karolinska University Hospital, S17164, Solna, Sweden
| | - Raymond Mirasol
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- National Institute of Neurological Disorders and Stroke, Stroke Branch, National Institutes of Health, Bethesda, MD, USA
| | - Lena Holmberg
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Per Henrik Vincent
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Xiaofei Li
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Anna Falk
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eirikur Benedikz
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- TEK-Innovation, Faculty of Engineering, University of Southern Denmark, DK-5000, Odense, Denmark
| | - Emilia Rotstein
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, S-14186, Stockholm, Sweden
| | - Åke Seiger
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Elisabet Åkesson
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Stockholms Sjukhem Foundation, Box 12230, S-10226, Stockholm, Sweden
| | - Scott Falci
- Department of Neurosurgery, Craig Hospital, 3425 S. Clarkson St, Englewood, CO, 80110, USA
| | - Erik Sundström
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
- Division of Neurogeriatrics, Karolinska Institutet, BioClinicum J9:20, Karolinska University Hospital, S17164, Solna, Sweden.
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Kannapadi NV, Alomari SO, Caturegli G, Bydon A, Cho SM. Management of syringomyelia associated with tuberculous meningitis: A case report and systematic review of the literature. J Clin Neurosci 2021; 87:20-25. [PMID: 33863527 DOI: 10.1016/j.jocn.2021.01.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/16/2022]
Abstract
Determinants of tuberculosis (TB) syringomyelia, its management options and outcomes are still under investigation. The aim of this study is to present a case of TB syringomyelia with markedly improved symptoms status-post surgery and to understand the clinical characteristics and outcomes of 33 TB syringomyelia cases reported in the literature. Specifically, we examined the differences between patients who were managed medically and those who underwent surgical intervention. Inclusion criteria for the cases were (1) syringomyelia caused by TB infection rather than co-occurrence of these conditions, (2) management protocol described, and (3) post-treatment outcome described. The median age was 30 years (interquartile range (IQR): 23-40) with 55% males. The median time between TB onset to syringomyelia diagnosis was 2 years. Nineteen patients were surgically treated, 11 were medically treated, and 3 received no treatment. Twenty-one patients showed improvement in at least one prior symptom, but no patient experienced a full recovery. Those that underwent surgical intervention were more likely to have TB meningitis (95% vs. 64%, p < 0.05) upon initial TB presentation and have a greater interval between TB onset and syringomyelia presentation (median of 2.6 vs. 0.33 years, ns). A greater proportion of the surgically managed patients experienced improvement in any symptom (74% vs. 45%, ns). Future case-controlled studies with larger sample sizes are required to validate and further understand the outcomes of surgically-managed TB syringomyelia.
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Affiliation(s)
- Nivedha V Kannapadi
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Safwan O Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Miyao Y, Sasaki M, Taketsuna S, Yokota C, Umegaki M. Early Development of Syringomyelia after Spinal Cord Injury: Case Report and Review of the Literature. NMC Case Rep J 2020; 7:217-221. [PMID: 33062572 PMCID: PMC7538465 DOI: 10.2176/nmccrj.cr.2019-0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/23/2020] [Indexed: 11/30/2022] Open
Abstract
We report a case of post-traumatic syringomyelia (PTS), which developed 2 months after spinal cord injury (SCI). A 20-year-old man who was involved in a motorcycle accident sustained a complete SCI resulting from a burst fracture of the T5 vertebral body. He underwent posterior fixation with decompression at another hospital 2 days after the injury. Postoperative imaging suggested that spinal stenosis endured at the T4 level and swelling of the spinal cord above that level. Two months later, he felt dysesthetic pain in his forearms and hands, but the cause of the pain was not examined in detail. Four months after the injury, he presented with motor weakness in the upper extremities. Magnetic resonance imaging (MRI) showed syringomyelia ascending from the T3 level to the C1 level, and he was referred to our hospital immediately. The imaging studies suggested that PTS was caused by congestion of the cerebrospinal fluid (CSF) at the T3 level. The patient was treated with syringosubarachnoid (SS) shunt at the T1-T2 level, whereby neurological symptoms of the upper extremities were immediately relieved. Postoperative MRI showed shrinkage of the syrinx. At the latest follow-up 2 years postoperatively, there was no sign of recurrence. It is noteworthy that PTS potentially occurs in the early phase after severe SCI. We discuss relevant pathology and surgical treatment through a review of previous literature.
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Affiliation(s)
- Yasuyoshi Miyao
- Department of Neurosurgery, Suita Municipal Hospital, Suita, Osaka, Japan
| | - Manabu Sasaki
- Department of Neurosurgery, Iseikai Hospital, Osaka, Osaka, Japan
| | | | - Chisato Yokota
- Department of Neurosurgery, Suita Municipal Hospital, Suita, Osaka, Japan
| | - Masao Umegaki
- Department of Neurosurgery, Iseikai Hospital, Osaka, Osaka, Japan
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Werner C, Mathkour M, Scullen T, Dallapiazza RF, Dumont AS, Maulucci CM. Recurrent arachnoid cysts secondary to spinal adhesive arachnoiditis successfully treated with a ventriculoperitoneal shunt. Clin Neurol Neurosurg 2020; 194:105835. [PMID: 32305826 DOI: 10.1016/j.clineuro.2020.105835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/19/2022]
Abstract
Spinal adhesive arachnoiditis (SAA) with cyst formation secondary to infectious meningitis is a rare clinical entity. These cysts can compress the spinal cord and cause neurologic decline. We present a case of a patient who underwent resection for an intradural schwannoma which was complicated post-operatively by bacterial meningitis and development of several recurrent thoracic arachnoid cysts. After two separate thoracic decompressions with lysis of intradural adhesions, a permanent ventriculoperitoneal shunt (VPS) was eventually placed with complete recovery of his symptoms. Our review of the literature showed that CSF shunts have previously been successfully used to treat spinal fluid collections. Although there are many factors to consider when treating these patients, CSF diversion may be beneficial for similar SAA presentations in order to simultaneously treat and prevent recurrence of symptoms.
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Affiliation(s)
- Cassidy Werner
- Neurosurgery Department, Tulane/Ochsner Medical Centers, LA, USA.
| | - Mansour Mathkour
- Neurosurgery Department, Tulane/Ochsner Medical Centers, LA, USA.
| | - Tyler Scullen
- Neurosurgery Department, Tulane/Ochsner Medical Centers, LA, USA.
| | | | - Aaron S Dumont
- Neurosurgery Department, Tulane/Ochsner Medical Centers, LA, USA.
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Berliner J, Hemley S, Najafi E, Bilston L, Stoodley M, Lam M. Abnormalities in spinal cord ultrastructure in a rat model of post-traumatic syringomyelia. Fluids Barriers CNS 2020; 17:11. [PMID: 32111246 PMCID: PMC7049227 DOI: 10.1186/s12987-020-0171-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Syringomyelia is a serious complication of spinal cord trauma, occurring in approximately 28% of spinal cord injuries. Treatment options are limited and often produce unsatisfactory results. Post-traumatic syringomyelia (PTS) is presumably related to abnormalities of cerebrospinal fluid (CSF) and interstitial fluid hydrodynamics, but the exact mechanisms are unknown. METHODS Transmission electron microscopy (TEM) was used to investigate in detail the interfaces between fluid and tissue in the spinal cords of healthy Sprague-Dawley rats (n = 3) and in a rat model of PTS (n = 3). PTS was induced by computer-controlled impact (75 kDyn) to the spinal cord between C6 and C8, followed by a subarachnoid injection of kaolin to produce focal arachnoiditis. Control animals received a laminectomy only to C6 and C7 vertebrae. Animals were sacrificed 12 weeks post-surgery, and spinal cords were prepared for TEM. Ultra-thin spinal cord sections at the level of the injury were counterstained for structural anatomy. RESULTS Spinal cords from animals with PTS displayed several abnormalities including enlarged perivascular spaces, extracellular edema, cell death and loss of tissue integrity. Additionally, alterations to endothelial tight junctions and an abundance of pinocytotic vesicles, in tissue adjacent to syrinx, suggested perturbations to blood-spinal cord barrier (BSCB) function. CONCLUSIONS These findings support the hypothesis that perivascular spaces are important pathways for CSF flow into and out of the spinal cord, but also suggest that fluid may enter the cord through vesicular transport and an altered BSCB.
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Affiliation(s)
- Joel Berliner
- Faculty of Medicine and Health Sciences, 2 Technology Place, Macquarie University, Sydney, NSW, 2109, Australia.
| | - Sarah Hemley
- Faculty of Medicine and Health Sciences, 2 Technology Place, Macquarie University, Sydney, NSW, 2109, Australia
| | - Elmira Najafi
- Faculty of Medicine and Health Sciences, 2 Technology Place, Macquarie University, Sydney, NSW, 2109, Australia
| | - Lynne Bilston
- Neuroscience Research Australia, Margarete Ainsworth Building, 139 Barker Street, Randwick, NSW, 2031, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, 2031, Australia
| | - Marcus Stoodley
- Faculty of Medicine and Health Sciences, 2 Technology Place, Macquarie University, Sydney, NSW, 2109, Australia
| | - Magdalena Lam
- Faculty of Medicine and Health Sciences, 2 Technology Place, Macquarie University, Sydney, NSW, 2109, Australia
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Pruthi N, Vora TK, Shukla DP. Craniovertebral Junction Arachnoiditis: An Unusual Sequelae to Tuberculous Meningitis. J Neurosci Rural Pract 2019; 10:711-714. [PMID: 31831994 PMCID: PMC6906089 DOI: 10.1055/s-0039-1700664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Adhesive arachnoiditis at the craniovertebral junction should be suspected in patients with a history of meningitis having delayed onset gradually progressive tetra paresis. Patients can present after an asymptomatic interval of 2 to 20 years. Cardiac gated cine magnetic resonance imaging is useful for its diagnosis. Posterior fossa decompression with upper cervical laminectomy and adhesiolysis appears to be a reasonable treatment for the same. We illustrate two patients who presented to us with gradually progressive spastic tetra paresis; both had prior history of cured tuberculous meningitis.
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Affiliation(s)
- Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and NeurosciencesBangalore, KarnatakaIndia
| | - Tarang Kamalkishore Vora
- Department of Neurosurgery, National Institute of Mental Health and NeurosciencesBangalore, KarnatakaIndia
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and NeurosciencesBangalore, KarnatakaIndia
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Giner J, Pérez López C, Hernández B, Gómez de la Riva Á, Isla A, Roda J. Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Bhatnagar N, Kataria A, Lingaiah P, Karkhur Y. Tetraplegia associated with post-operative syringomyelia in spinal tuberculosis: a result of an epidural compartment syndrome? Spinal Cord Ser Cases 2019; 5:18. [PMID: 30774988 DOI: 10.1038/s41394-019-0159-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/06/2019] [Accepted: 01/13/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction The commonly recognized causes of post-operative neurological deterioration in spinal tuberculosis are inadequate decompression, damage to vascular supply of the spinal cord, and multi-drug resistant organisms. There are no known cases of syringomyelia developing after surgical decompression of spinal tuberculosis. Case presentation A teenage girl presented with rapid onset quadriparesis secondary to a tubercular epidural abscess extending from C4-T8. The neurological status deteriorated to quadriplegia immediately following decompression by hemilaminectomy at C7 and T7 levels. Investigations into the cause of neurological deterioration revealed syrinx formation at T5-9 levels. The patient had partial motor and sensory recovery in the first 3 weeks post-operatively. Tubercular infection was treated with a 1-year course of multi-drug anti-tubercular therapy. However, there was no further neurological improvement at 2 years follow-up. Discussion Syringomyelia in tuberculosis has been associated with tubercular meningitis, intradural tuberculomas, and post-surgical vascular insult. None of these were implicated as the cause of syrinx formation in this case. We hypothesize that the rapid evolution of epidural abscess in an intact vertebral column led to an acute "epidural compartment syndrome", which caused ischemic damage to the spinal cord. Compression caused by the epidural abscess was relieved by surgical decompression, allowing the central canal to dilate and expand into the softened spinal parenchyma, hence leading to syrinx formation.
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Affiliation(s)
- Nishit Bhatnagar
- Department of Orthopaedics, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India.
| | - Ankit Kataria
- Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | | | - Yugal Karkhur
- Department of Orthopaedics, Max Smart Super Specialty Hospital, New Delhi, India
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Miki J, Imae S, Kitayama M, Asamoto S, Hirohata Y, Ogura M, Nakao N. Dural Laceration Resulting in the Formation of Syringomyelia Caused by a Loosened Hydroxyapatite Intraspinous Spacer after Spinous Process-splitting Laminoplasty. NMC Case Rep J 2019; 6:117-120. [PMID: 31592152 PMCID: PMC6776752 DOI: 10.2176/nmccrj.cr.2018-0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 04/23/2019] [Indexed: 11/20/2022] Open
Abstract
A 63-year-old man was admitted in our hospital with the chief complaint of upper limb numbness 3 years after undergoing spinous process-splitting laminoplasty (C3–C7) in another hospital. The hydroxyapatite spacers used for the laminoplasty had dislocated, resulting sensory disorders of the upper extremities. Additionally, loosened hydroxyapatite intraspinous spacers and syringomyelia were confirmed. A revision operation was performed, during which the C5 spacer was observed to have dislodged into the spinal canal, and a dural membrane defect, arachnoid membrane tear, cerebrospinal fluid leakage, and marked adhesion change were observed. The adhesion was exfoliated as far as possible; moreover, to prevent the reflux of syringomyelia, a syrinx-subarachnoid shunt (SS shunt) was placed. Although there was concern of further adhesion by putting foreign matter, SS shunt indwelling was chosen to obtain sure disappearance of syringomyelia. The postoperative course was uneventful. A gradual improvement in the upper limb numbness was observed without a recurrence of syringomyelia at 9 years of follow-up.
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Affiliation(s)
- Junichiro Miki
- Department of Neurosurgery, Saiseikai Wakayama Hospital, Wakayama, Wakayama, Japan
| | | | - Mari Kitayama
- Department of Neurosurgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Shunji Asamoto
- Department of Neurosurgery, Makita General Hospital, Tokyo, Japan
| | - Yoko Hirohata
- Department of Neurosurgery, Saiseikai Wakayama Hospital, Wakayama, Wakayama, Japan
| | - Mitsuhiro Ogura
- Department of Neurosurgery, Saiseikai Wakayama Hospital, Wakayama, Wakayama, Japan
| | - Naoyuki Nakao
- Department of Neurosurgery, Wakayama Medical University, Wakayama, Wakayama, Japan
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Cervicothoracic arachnoiditis—a rare complication of aneurysmal intracranial subarachnoid haemorrhage. Spinal Cord Ser Cases 2018; 4:57. [DOI: 10.1038/s41394-018-0089-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 11/08/2022] Open
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Hirai T, Taniyama T, Yoshii T, Mizuno K, Okamoto M, Inose H, Yuasa M, Otani K, Shindo S, Nakai O, Okawa A. Clinical Outcomes of Surgical Treatment for Arachnoid Web: A Case Series. Spine Surg Relat Res 2018; 3:43-48. [PMID: 31435550 PMCID: PMC6690113 DOI: 10.22603/ssrr.2018-0027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/10/2018] [Indexed: 12/01/2022] Open
Abstract
Introduction We describe 5 patients who underwent operative treatment for arachnoid web (AW) and discuss the postoperative clinical outcome in each case. AW is an extremely rare disease that causes cord compression and syringomyelia in the thoracic spine. To date, 14 cases only of AW have been reported, and the effect of surgical intervention on clinical and radiologic outcomes is unknown. Methods Five patients who underwent surgical treatment for AW were retrospectively reviewed. The clinical outcomes were evaluated using the thoracic Japanese Orthopaedic Association (T-JOA) score. Preoperative and postoperative images were reviewed. Results All the patients presented with spastic gait and numbness in the lower extremities. Two patients also presented with bladder-bowel dysfunction (BBD). AW, or the so-called “scalpel” sign, was seen dorsally in the thoracic spine on magnetic resonance imaging in all the patients. Syringomyelia adjacent to the web was observed in 4 patients. Fenestration and web resection without instrumentation was performed in all the cases. Overall, significant improvement was seen in locomotion and the total T-JOA score postoperatively. However, numbness in the lower extremities improved in 2 patients but was unchanged in 3 cases. BBD was ameliorated in 1 patient but remained unchanged in the other patient. Conclusions Our experience suggests that surgical treatment, including the another patient and resection of the web, can correct the flow dynamics of cerebrospinal fluid and allow neurologic recovery, in particular locomotion, in patients with AW.
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Affiliation(s)
- Takashi Hirai
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Taniyama
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichi Mizuno
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Mikio Okamoto
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masato Yuasa
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuyuki Otani
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Shigeo Shindo
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Osamu Nakai
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Neurosurgical untethering with or without syrinx drainage results in high patient satisfaction and favorable clinical outcome in post-traumatic myelopathy patients. Spinal Cord 2018; 56:873-882. [DOI: 10.1038/s41393-018-0094-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 12/16/2022]
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Lee JH, Jeon I, Kim SW. Intradural Extramedullary Capillary Hemangioma In the Upper Thoracic Spine with Simultaneous Extensive Arachnoiditis. KOREAN JOURNAL OF SPINE 2017; 14:57-60. [PMID: 28704911 PMCID: PMC5518430 DOI: 10.14245/kjs.2017.14.2.57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/25/2017] [Accepted: 04/24/2017] [Indexed: 11/30/2022]
Abstract
Capillary hemangiomas are common benign vascular tumors on skin and soft tissues, but developing as an intradural and extramedullary (IDEM) tumor in spine is extremely rare. In this report, we present IDEM tumor compressing thoracic cord in T2–3 level with extensive arachnoiditis below the tumor level in a 60-year-old man. The lesion was removed and histological diagnosis was capillary hemangioma. Prompt diagnosis and resection are important to avoid neurological deterioration from acute hemorrhagic condition. Simultaneous arachnoiditis may be originated from old subarachnoid hemorrhage associated tumor before diagnosis, and we suggest it as a helpful diagnostic feature to suspect vascular tumors such as capillary hemangioma.
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Affiliation(s)
- Jae Ho Lee
- Department of Neurosurgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Sang Woo Kim
- Department of Neurosurgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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Lee JS, Song GS, Son DW. Surgical Management of Syringomyelia Associated with Spinal Adhesive Arachnoiditis, a Late Complication of Tuberculous Meningitis: A Case Report. Korean J Neurotrauma 2017; 13:34-38. [PMID: 28512616 PMCID: PMC5432447 DOI: 10.13004/kjnt.2017.13.1.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/21/2016] [Accepted: 11/24/2016] [Indexed: 12/24/2022] Open
Abstract
Syringomyelia associated with tuberculous meningitis is an extremely rare condition. Only a few studies have reported clinical experience with syringomyelia as a late complication of tuberculous meningitis. Twenty-six years after a tuberculous meningitis episode, a 44-year-old man presented with progressively worsening spastic paresis of the lower limbs and impaired urinary function for 2 years. Radiological examination revealed syringomyelia extending from the level of C2 to T9 and arachnoiditis with atrophy of the spinal cord between C2 and T3. We performed laminectomy from C7 to T1, dissected the arachnoid adhesion and placed a syringo-pleural shunt via keyhole myelotomy. One year after the operation, his neurological condition improved. The postoperative control magnetic resonance imaging revealed the correctly located shunt and significantly diminished syringomyelia cavities. We aim to discuss the mechanism of syrinx formation following tuberculous meningitis and to share our surgical therapeutic experience with this rare disease entity.
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Affiliation(s)
- Jun Seok Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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Syringomyelia caused by an arachnoid web in a patient with shunted Dandy-Walker malformation. Childs Nerv Syst 2017; 33:665-670. [PMID: 27822765 DOI: 10.1007/s00381-016-3293-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Dandy-Walker malformation (DWM) is a congenital brain anomaly characterized by dysgenesis of the cerebellar vermis and the presence of a posterior fossa cyst. The association of syringomyelia with DWM is extremely rare. CASE REPORT A 10-year-old patient who was diagnosed with DWM in infancy presented with progressive scoliosis and fecal incontinence. He had been treated with cystoventriculoperitoneal shunting with a Y-connection during infancy, which was followed by a revision 6 years later. During the revision surgery, intraventricular bleeding occurred and was managed conservatively. Imaging studies for the current visit revealed syringomyelia along the cervicothoracic spinal cord and a membranous structure around the cervicomedullary junction. Phase-contrast cine magnetic resonance imaging (MRI) revealed disturbed cerebrospinal fluid (CSF) flow across the membrane. We excised the arachnoid web that was tethering the brainstem and blocking CSF flow. Postoperatively, the patient experienced symptom relief, and the follow-up imaging study demonstrated a dramatic decrease in the size of the syringomyelia. DISCUSSION We suggest that syrinx formation in this patient was possibly caused by disturbed CSF flow and tethering of the brainstem. CONCLUSION We experienced an unusual case of DWM with syringomyelia which was caused by an arachnoid web blocking CSF flow and tethering the brainstem. The arachnoid web seems to be formed by previous bleeding which occurred at the time of shunt revision. After excision of the arachnoid web, the patient showed good outcome.
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Tassigny D, Abu-Serieh B, Fofe DT, Born J, Milbouw G. Shunting of Syringomyelic Cavities by Using a Myringotomy Tube: Technical Note and Long-Term Results. World Neurosurg 2017; 98:1-5. [DOI: 10.1016/j.wneu.2016.10.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/09/2016] [Accepted: 10/12/2016] [Indexed: 11/30/2022]
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Zuev AA, Lebedev VB, Pedyash NV, Epifanov DS, Levin RS. [Treatment of syringomyelia associated with adhesive arachnoiditis]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:39-47. [PMID: 28665387 DOI: 10.17116/neiro201781339-47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED The prevalence of syringomyelia (SM) caused by adhesive arachnoiditis (AA) is 2 to 4 cases per 100000 population. Surgical treatment of this pathology usually includes implantation of shunts into the cyst cavity or opening and drainage of the cavity. In this case, SM continues to progress in 72-100% of patients. Unsatisfactory outcomes of this surgical approach necessitate searching for other treatment options. PURPOSE To define the optimal amount of surgery for SM associated with AA and the criteria for assessment of surgery outcomes. MATERIAL AND METHODS The authors treated 47 SM patients in the period from 2010 to 2015. Of these, 34 (72.3%) patients underwent surgery; a total of 40 operations were performed. The patients' age ranged from 18 to 64 years (mean, 43.5 years). Tethering of the spinal cord was eliminated in 25 patients; 9 patients underwent cyst shunting. RESULTS Among operated patients, 5 patients had grade 1 arachnopathy, 13 patients had grade 2 arachnopathy, 12 patients had grade 3 arachnopathy, and 4 patients had grade 4 arachnopathy. The minimal postoperative follow-up period was 11 months. After shunting, the condition improved in 8 of 9 patients; in 7 patients, the condition returned to the baseline level within the first postoperative year; in 6 (66.7%) of these patients, the disease continued to progress. After surgical release of spinal cord tethering, satisfactory long-term results were achieved in 13 (86.6%) patients with grade 1-2 arachnopathy. In 3 (50%) patients with grade 3 arachnopathy, the condition was stabilized. Among patients with grade 4 arachnopathy, progression of the disease was stopped in 1 patient; the condition worsened in 2 (50%) patients. Among all the operated patients, complications developed in 7 patients. There were no lethal outcomes. CONCLUSIONS In grade 1-2 arachnopathy, progression of SM after release of spinal cord tethering occurs only in 13.4% of patients. Therefore, release of spinal cord tethering is recommended for these patients. In grade 3-4 arachnopathy, the rate of relapse after this surgery is more than 80%. Therefore, given the simplicity and a lower risk of complications of cyst shunting, this procedure is advisable for these patients.
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Affiliation(s)
- A A Zuev
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - V B Lebedev
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - N V Pedyash
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - D S Epifanov
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - R S Levin
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
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Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation. Neurologia 2016; 34:318-325. [PMID: 27939111 DOI: 10.1016/j.nrl.2016.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/20/2016] [Accepted: 09/30/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Much has been published on syringomyelia related to Chiari malformation. In contrast, little is known about the condition when it is not associated with this malformation, but this presentation of syringomyelia constitutes a different entity and therefore requires specific management. We conducted a literature review to summarise the most accepted and widespread ideas about the pathophysiology, management and other aspects of syringomyelia unrelated to Chiari malformation. DEVELOPMENT We reviewed the most relevant literature on this condition, focusing on the pathophysiology, clinical presentation, diagnosis, and treatment. CONCLUSIONS Syringomyelia unrelated to Chiari malformation is a distinct entity that must be well understood to guarantee correct diagnosis, monitoring, and management. When the disease is suspected, a thorough study should be conducted to identify its aetiology. Treatment must aim to eliminate the cause of the disease; symptomatic treatment should remain a second-line option.
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Wong JHY, Song X, Hemley SJ, Bilston LE, Cheng S, Stoodley MA. Direct-trauma model of posttraumatic syringomyelia with a computer-controlled motorized spinal cord impactor. J Neurosurg Spine 2016; 24:797-805. [PMID: 26824588 DOI: 10.3171/2015.10.spine15742] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The pathogenesis of posttraumatic syringomyelia remains enigmatic and is not adequately explained by current theories. Experimental investigations require a reproducible animal model that replicates the human condition. Current animal models are imperfect because of their low reliability, severe neurological deficits, or dissimilar mechanism of injury. The objective of this study was to develop a reproducible rodent model of posttraumatic syringomyelia using a spinal cord impactor that produces an injury that more closely mimics the human condition and does not produce severe neurological deficits. METHODS The study consisted of 2 parts. Seventy animals were studied overall: 20 in Experiment 1 and 48 in Experiment 2 after two rats with severe deficits were killed early. Experiment 1 aimed to determine the optimal force setting for inducing a cystic cavity without neurological deficits using a computer-controlled motorized spinal cord impactor. Twenty animals received an impact that ranged from 50 to 150 kDyn. Using the optimal force for producing an initial cyst determined from Experiment 1, Experiment 2 aimed to compare the progression of cavities in animals with and those without arachnoiditis induced by kaolin. Forty-eight animals were killed at 1, 3, 6, or 12 weeks after syrinx induction. Measurements of cavity size and maximum anteroposterior and lateral diameters were evaluated using light microscopy. RESULTS In Experiment 1, cavities were present in 95% of the animals. The duration of limb weakness and spinal cord cavity size correlated with the delivered force. The optimal force chosen for Experiment 2 was 75 kDyn. In Experiment 2, cavities occurred in 92% of the animals. Animals in the kaolin groups developed larger cavities and more vacuolations and enlarged perivascular spaces than those in the nonkaolin groups. CONCLUSIONS This impact model reliably produces cavities that resemble human posttraumatic syringomyelia and is suitable for further study of posttraumatic syringomyelia pathophysiology.
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Affiliation(s)
- Johnny H Y Wong
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Xin Song
- Centre for Advanced Imaging, University of Queensland, St. Lucia, Queensland, Australia
| | | | - Lynne E Bilston
- Neuroscience Research Australia;,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales; and
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Surgical management of syringomyelia unrelated to Chiari malformation or spinal cord injury. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1836-46. [DOI: 10.1007/s00586-015-4262-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 09/27/2015] [Accepted: 09/27/2015] [Indexed: 10/23/2022]
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The roads to mitochondrial dysfunction in a rat model of posttraumatic syringomyelia. BIOMED RESEARCH INTERNATIONAL 2015; 2015:831490. [PMID: 25685811 PMCID: PMC4309244 DOI: 10.1155/2015/831490] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/13/2014] [Indexed: 11/26/2022]
Abstract
The pathophysiology of posttraumatic syringomyelia is incompletely understood. We examined whether local ischemia occurs after spinal cord injury. If so, whether it causes neuronal mitochondrial dysfunction and depletion, and subsequent energy metabolism impairment results in cell starvation of energy and even cell death, contributing to the enlargement of the cavity. Local blood flow was measured in a rat model of posttraumatic syringomyelia that had received injections of quisqualic acid and kaolin. We found an 86 ± 11% reduction of local blood flow at C8 where a cyst formed at 6 weeks after syrinx induction procedure (P < 0.05), and no difference in blood flow rate between the laminectomy and intact controls. Electron microscopy confirmed irreversible neuronal mitochondrion depletion surrounding the cyst, but recoverable mitochondrial loses in laminectomy rats. Profound energy loss quantified in the spinal cord of syrinx animals, and less ATP and ADP decline observed in laminectomy rats. Our findings demonstrate that an excitotoxic injury induces local ischemia in the spinal cord and results in neuronal mitochondrial depletion, and profound ATP loss, contributing to syrinx enlargement. Ischemia did not occur following laminectomy induced trauma in which mitochondrial loss and decline in ATP were reversible. This confirms excitotoxic injury contributing to the pathology of posttraumatic syringomyelia.
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