Neuroendoscopic technique for the operative treatment of septated syringomyelia

Treatment of Posttubercular Syringomyelia Not Responsive to Antitubercular Therapy: Case Report and Review of Literature

Posttubercular adhesive arachnoiditis is a rare, late complication of tubercular meningitis. Syringomyelia can develop as a consequence of intramedullary cystic lesions and cerebrospinal fluid (CSF) flow disturbance around the spinal cord, even after successful chemotherapy. We reviewed the literature related to posttubercular syringomyelia treatment and suggest a new combined surgical approach. A 25-year-old Nigerian male patient presented with legs numbness, urinary disturbance, and legs weakness. Spinal magnetic resonance revealed a T5-T7 syringomyelia, secondary to adhesive spinal arachnoiditis related to a history of tuberculous meningitis. Adhesiolysis by direct visualization with a flexible endoscope was performed and a handmade S-italic syringe-subdural shunt was placed to restore CSF flow. During the postoperative course, the neurological deficits improved together with the resolution of the syrinx. Long-term magnetic resonance imaging follow-up documented no recurrences or shunt displacements. We suggest that, when antitubercular therapy is not effective to resolve postarachnoiditis syrinx, arachnolysis with a flexible endoscope together with the placement of an S-italic shunt allowed free CSF communication between the syrinx and the subarachnoid space. Furthermore, we support that the use of an s-shaped shunt could prevent displacement or migration of the device and allows an easier revision in case of acute or late complications.

Endoscopic biopsy of cystic intracerebral tumours

This technical note describes the application of neuroendoscopy for decompressing and obtaining tissue samples from cystic intracerebral tumours. The method provides for visualisation of the solid tumour component prior to biopsy and retains the advantages of being a burr hole procedure.

Endoscope-assisted surgery of spinal intradural adhesions in the presence of cerebrospinal fluid flow obstruction

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To investigate whether the adjunctive use of endoscopy of the subarachnoid space (arachnoscopy) can improve the success of microsurgery for spinal arachnoid adhesions.

SUMMARY OF BACKGROUND DATA

Intradural adhesions that obstruct pulsatile cerebrospinal fluid (CSF) flow are a typical spinal cause of syringomyelia. Phase-contrast magnetic resonance imaging (MRI) allows CSF flow obstructions to be reliably localized. The treatment of choice is the microsurgical removal of CSF flow obstructions caused by adhesions. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. In this study, we therefore investigated whether endoscopic assistance allows adhesions in the vicinity of the exposed area to be detected.

METHODS

From 2006 to 2009, a single neurosurgeon performed 27 consecutive microsurgical procedures with endoscopic assistance in 25 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. CSF flow was studied before and after surgery in all patients using phase-contrast MRI in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine.

RESULTS

In all 27 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MRI. In 25 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In six cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery.Postoperative MRI scans demonstrated free CSF flow in all patients and a decrease in syrinx size in six patients.

CONCLUSION

Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space, which would remain undetected by microscopy alone.

Arachnoscopy: a special application of spinal intradural endoscopy

Object

The microsurgical removal of obstructions to CSF flow is the treatment of choice in the surgical management of intradural arachnoid cysts. Cardiac-gated phase-contrast MR imaging is an effective tool for the primary diagnosis and localization of arachnoid cysts. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. The use of a thin endoscope allows surgeons to assess intraoperatively whether the exposure is wide enough.

Methods

Between 2006 and 2010, a single neurosurgeon performed 31 consecutive microsurgical procedures with endoscopic assistance in 28 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. The CSF flow was studied before and after surgery in all patients by using phase-contrast MR imaging in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine.

Results

In all 31 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MR imaging. In 29 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In 6 cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space that were not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery.

Conclusions

Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space that would remain undetected by microscopy alone.

Anesthesia for Minimally Invasive Cranial and Spinal Surgery

The field of minimally invasive neurosurgery has evolved rapidly in its indications and applications over the last few years. New, less invasive techniques with low morbidity and virtually no mortality are replacing conventional neurosurgical procedures. Providing anesthesia for these procedures differs in many ways from conventional neurosurgical operations. Anesthesiologists are faced with the perioperative requirements and risks of newly developed procedures. This review calls attention to the anesthetic issues in various minimally invasive neurosurgical procedures for cranial and spinal indications. Among the procedures specifically discussed are endoscopic third ventriculostomy, endoscopic transsphenoidal hypophysectomy, endoscopic strip craniectomy, deep brain stimulation, video-assisted thorascopic surgery, vertebroplasty and kyphoplasty, cervical discectomy and foraminectomy, and laparoscopically assisted lumbar spine surgery.

Percutaneous endoscopic cellular transplantation into the lower lumbar spinal cord

OBJECTIVE

To explore the feasibility of performing percutaneous endoscopic cellular transplantation into the lumbar spinal cord of pigs to create intramedullary cellular trails.

METHODS

The lumbar subarachnoid space was accessed using a 10-gauge needle inserted between L5 and L6. A 12.5-French flexible introducer sheath was fed over the needle into the subarachnoid space. A 3.2-mm-diameter flexible, steerable endoscope was then directed intradurally through the sheath. The thecal space was distended by saline infusion. A microcatheter with an attached needle then was advanced through the working channel into the dorsal surface of the lumbar spinal cord. Five microliters of Hoechst-labeled fibroblasts were injected while the catheter was withdrawn slowly to create a trail of cells within the spinal cord. The spinal canal then was perfused with fixative. The injected spinal cord segment was removed and studied histologically. Endoscopic video was analyzed offline.

RESULTS

The endoscope could be navigated under visual guidance. The sacral and lumbar rootlets, the spinal cord, and associated vessels were visualized. In fixed sagittal sections, a linear trail of fluorescent fibroblasts could be seen within the lumbar spinal cord in each specimen.

CONCLUSION

Percutaneous endoscopic cellular injection may be useful for cellular transplantation, may reduce surgical and anesthetic time, may be compatible with local anesthesia, may eliminate the need to disrupt spinal instrumentation and bone grafts, and may allow greater flexibility in the respective timing of spinal fixation and cellular transplantation after spinal cord injury. This is the first report of the use of endoscopic intraspinal cellular transplantation.

Anaesthesia for minimally invasive neurosurgery

Technological advances in imaging, computing and surgical instrumentation have encouraged the application of minimally invasive surgical techniques to various neurosurgical disorders. This chapter discusses the wide application of neurosurgery and the implications for anaesthesia, focusing on the specific anaesthetic considerations for neuroendoscopy, stereotactic procedures and radiosurgery.

Intracranial endoscopy

Since 1910, when Lespinasse [73] in Chicago was the first surgeon to use an endoscopic device for the treatment of a neurologic disease, various methods of endoscopy have evolved into accepted diagnostic and therapeutic adjuncts of modern neurosurgery. Nevertheless, until recently technical shortcomings of the available endoscopes have prevented the widespread use of neuroendoscopy. However, now, at the end of the 20th century, endoscopes can be regarded as some of the most important instruments for the development of microneurosurgery into the 3rd millennium. The aim of this review of intracranial endoscopy in neurosurgery, which admittedly might not be completely objective in the authors' personal assessment of various endoscopic techniques, is first to depict the historical evolution of neuroendoscopy, second to describe the technical equipment used in intracranial endoscopic neurosurgery, third to characterize the most frequent endoscopic methods in brain surgery, and fourth to indicate how neuroendoscopy might develop in the near future. It will be shown that this ongoing evolutionary process in neuroendoscopy was only possible with the mutual influence of improved diagnostic techniques, increased microanatomical knowledge, refined neurosurgical instrumentation--especially the introduction of the surgical microscope, and endoscopic diagnostic and therapeutic strategies.

A critical appraisal of syrinx cavity shunting procedures

OBJECT

This study was conducted to evaluate the results of shunting procedures for syringomyelia.

METHODS

In a follow-up analysis of 42 patients in whom shunts were placed in syringomyelic cavities, the authors have demonstrated that 21 (50%) developed recurrent cyst expansion indicative of shunt failure. Problems were encountered in patients with syringomyelia resulting from hindbrain herniation, spinal trauma, or inflammatory processes. A low-pressure cerebrospinal fluid state occurred in two of 18 patients; infection was also rare (one of 18 patients), but both are potentially devastating complications of shunt procedures. Shunt obstruction, the most common problem, was encountered in 18 patients; spinal cord tethering, seen in three cases, may account for situations in which the patient gradually deteriorated neurologically, despite a functioning shunt.

CONCLUSIONS

Placement of all types of shunts (subarachnoid, syringoperitoneal, and syringopleural) may be followed by significant morbidity requiring one or more additional surgical procedures.

Management of posttraumatic syringomyelia using an expansile duraplasty. A case report

STUDY DESIGN

A patient in whom posttraumatic syringomyelia developed 34 years after an L2 fracture is reported.

OBJECTIVES

To review the pathophysiology and current management modalities for posttraumatic syringomyelia. The delayed presentation and management rationale of this case are emphasized.

SUMMARY OF BACKGROUND DATA

This case represents the most delayed onset of symptoms from a posttraumatic syrinx reported in the literature. Although lysis of arachnoid adhesions and expansile duraplasty to recreate the subarachnoid space have been described for nonshuntable syrinxes, this form of management was used as the primary management modality in this case.

METHODS

A posttraumatic syrinx was managed by lysis of the arachnoid adhesions, fenestration of the cyst, and an expansile duraplasty.

RESULTS

After surgery, the patient's symptoms improved, and magnetic resonance imaging showed a decrease in the size of the syrinx.

CONCLUSION

Posttraumatic syringomyelia represents one of the few surgically remediable presentations of spinal cord injury. Consequently, it is necessary to continuously develop and monitor new management options for this disease. In the case reported here, the syrinx was treated successfully without the implanting a drainage tube.

Computer-assisted endoscopy for neurosurgical procedures: technical note

OBJECTIVE

As neuroendoscopy technology evolves, the ventriculoscope is playing a greater role in the diagnosis and treatment of disorders affecting the ventricular system. However, even with direct visualization, correctly orienting and safely navigating an endoscope may be difficult with abnormal anatomy, in small ventricles, or when searching for small periventricular lesions identified on neuroimaging studies. The ability to define the location of the endoscope during such procedures enhances its effectiveness and safety.

INSTRUMENTATION

We report the successful adaptation of an image-guided stereotactic wand to a rigid neuroendoscope. With computer-assisted neuroendoscopy (CANE), the tip position and orientation of a rigid ventriculoscope were visualized in real-time on neuroimaging studies that were obtained before surgery. Because computer guidance may also be used with the neuroendoscope obturator during ventricular access, uncertainty in accessing small ventricles is minimized.

RESULTS

Eleven patients were operated on at The Cleveland Clinic Foundation using the CANE system. All patients except one were improved after surgery. Early experience suggests that CANE is useful for certain endoscopic procedures by aiding in trajectory planning, ventricular navigation, and localizing certain pathological conditions.

CONCLUSION

Even with direct visualization, ventriculoscopy in abnormal anatomy may be difficult. Although the CANE system may not always be necessary in neuroendoscopy, correlation of the endoscope tip location, with an intraoperative magnetic resonance image via continuous computer updates, may enhance the safety, as well as the efficiency, of neuroendoscopy in the future.

The surgical treatment of Chiari I malformation

A retrospective study was undertaken on 133 patients with a Chiari I malformation treated within the last 16 years at the Departments of Neurosurgery at the Nordstadt Hospital Hannover, Germany, and the University of California, Los Angeles, U.S.A. Ninety-seven patients presented with symptoms related to accompanying syringomyelia and 4 with associated syringobulbia. They underwent 149 surgical procedures and were followed for a mean of 39 +/- 52 months. A decompression at the foramen magnum was performed in 124 patients, while 22 of those with syringomyelia were treated by shunting (7 syringosubarachnoid shunts, 15 syringoperitoneal or -pleural shunts), and 3 by ventriculoperitoneal shunts for hydrocephalus. Except for ventriculoperitoneal shunting, at least a short-term decrease in size of an associated syrinx was observed for all procedures in the majority of cases. However, no long-term benefit was observed for syrinx shunting operations. The best clinical long-term results were obtained with decompression of the foramen magnum in patients with (86% free of a clinical recurrence) and without syringomyelia (77% free of a clinical recurrence). We advise against syrinx shunting, a large craniectomy, and obex plugging which are associated with higher recurrence rates. Instead, surgery should consist of a small craniectomy, opening of the dura, archnoid dissection to establish normal cerebrospinal fluid (CSF) outflow from the 4th ventricle, and a fascia lata dural graft.

Incidence, management, and outcome of post-traumatic syringomyelia. In memory of Mr Bernard Williams

OBJECTIVE

To determine the incidence of clinically diagnosable post-traumatic syringomyelia (PTS).

METHODS

A population of 815 consecutive patients with traumatic spinal cord injuries was studied between January 1990 and December 1992.

RESULTS

Reviews of all records, full clinical evaluation, and thorough neurological examination of all patients disclosed 28 patients in whom PTS was confirmed radiologically (3.43%). The incidence of the presenting symptoms, including bladder dysfunction, is described. The level and density of cord lesion was correlated with incidence and it was found that posttraumatic syringomyelia was twice as common in patients with complete injuries than in patients with incomplete injuries. The highest incidence was found in patients with complete dorsal and complete dorsolumbar injuries. The interval between injury and diagnosis ranged from six months to 34 years (mean 8.6 years). This interval was shortest in patients with complete dorsal and incomplete cervical and dorsolumbar cord injuries.

CONCLUSIONS

Reduction of the size of the syrinx seen on postoperative MRI correlated well with a satisfactory clinical outcome in 85% of patients.

Evaluation of endoscopy in the treatment of rare meningoceles: preliminary results

BACKGROUND

Endoscopy is used on different occasions-for instance, to open the floor of the third ventricule in triventricular hydrocephalus, to open a cyst into the cerebrospinal fluid circulation, for biopsy or for partial resection of some tumors, or to insert a shunt in hydrocephalus or syringohydromyelia. However, the use of endoscopes for evaluating and treating meningoceles remains to be assessed.

METHODS

Five different kinds of rare meningoceles are presented. In each, neuroendoscopy was used as the main tool for exploration and treatment.

RESULTS

Two sacral meningoceles and one oral cephalocele were cured through a keyhole opening under endoscopic control. One posterior sacral meningocele was explored and no communication with normal subarachnoid spaces was observed, allowing a simple suture of the posterior to the anterior walls. And, last, a complex case with three intrasacral meningocles was explored and partially treated.

CONCLUSIONS

Meningocles with very small communication within the normal subarachnoid spaces appeared the most suitable to be cured by an endoscopic procedure. In case of a larger communication, the meningocele could be treated, or at least the morphology can be better understood, by using a keyhole procedure under endoscopic control. In all cases the surgery was of short duration (less than 1 hour) and very well tolerated.

The cystic spinal cord

Images

Median nerve somatosensory evoked potentials in cervical syringomyelia: correlation of preoperative versus postoperative findings with upper limb clinical somatosensory function

Median nerve somatosensory evoked potentials (SEPs) were recorded in 30 patients with cervical syringomyelia before and after surgery. The different SEP components were compared with clinical somatosensory findings. The N13 potential (generated in the dorsal horn at C5-C6) was pathological in 85% of the upper extremities, or 90% of the patients, and correlated with pain/temperature as well as vibration/joint position sense; it was of higher sensitivity in syringomyelia than any other clinical symptom or SEP component. P14 (brain stem) and N20 (postcentral cortex) were less often affected and correlated with only vibration/joint position sense. Short-term postoperative clinical or SEP changes were most often seen after syringoendoscopy and less often after syringostomy, resection of cerebellar tonsils, or tumor extirpation. Alterations of SEPs after surgery occurred in more patients (60%) than did changes in clinical condition (approximately 27%); there was, however, no general correlation between these findings. We conclude that median nerve SEP testing with a proper recording technique identifying the different subcortical components is a valuable supplement in the pre- and postoperative diagnostic evaluation of syringomyelia and is of higher sensitivity than clinical somatosensory examination alone.

A critical appraisal of drainage in syringomyelia

The use of drains in the treatment of syringomyelia has a simple and immediate appeal and has been practiced widely since the report of Abbe and Coley over 100 years ago. Good short-term results have been claimed in the past, but long-term outcome is largely unknown. An experience in Birmingham, England is reviewed in which 73 patients who had had some form of syrinx drainage procedure performed were subsequently followed up. In these cases, a total of 56 syringopleural and 14 syringosubarachnoid shunts had been inserted. Ten years after the operations, only 53.5% and 50% of the patients, respectively, continued to remain clinically stable. A 15.7% complication rate was recorded, including fatal hemorrhage, infection, and displacement of the drain from the pleural and syrinx cavities. At second operation or necropsy, at least 5% of shunts were discovered to be blocked. The effect of other drainage procedures that do not use artificial tubing, such as syringotomy and terminal ventriculostomy, was analyzed but found not to offer any substantial benefit. These results indicate that drainage procedures are not an effective solution to remedying the progressive, destructive nature of syringomyelia. It is suggested that, rather than attempting to drain the syrinx cavity, disabling the filling mechanism of the syrinx is more appropriate. Most forms of syringomyelia have a blockage at the level of the foramen magnum or in the subarachnoid space of the spine. Surgical measures that aim to reconstruct the continuity of the subarachnoid space at the site of the block are strongly recommended. Lowering the overall pressure of the cerebrospinal fluid is advocated when reestablishment of the pathways proves impossible. Syrinx drainage as an adjuvant to more physiological surgery may have a place in the treatment of syringomyelia. If two procedures are done at the same time, however, it is difficult to ascribe with certainty a success or failure, and it is suggested that the drainage procedure be reserved for a later attempt if the elective first operation fails.

Post-traumatic syringomyelia: a review of the literature

The need for increased awareness and a high index of suspicion for post traumatic syringomyelia is emphasised. Early clinical diagnosis confirmed by MRI and early treatment can avert or minimise the potentially devastating effects of post traumatic syringomyelia. The regular and frequent follow up of the patient on a yearly or alternate year basis to monitor the patient with spinal injury for this complication, as well as other complications, is the best way to ensure that post traumatic syringomyelia is diagnosed and managed early in order to avoid further disability.

Operative spinal endoscopy: stereotopography and surgical possibilities

The polyprojective microstereotopography of spinal canal structures at the cerebello-spinal, cervical, thoracic, lumbosacral and cauda equina levels on 20 fresh cadavers is presented using flexiscopes 3.7-3.9 mm diameter. This is possible due to the space between spinal cord-vertebral canal which is about 10 mm at all levels. This also allows one to insert the endoscopic tube by posterior or interradicular approach. The subdural and subarachnoid endoscopic examinations have been performed through small foraminotomic openings with resection of the base of the spinous process. The anterior and posterior roots, the spinal cord, dural root sleeves, cerebellar tonsils, orifice of the IV ventricle, vertebral artery and its lower branches can be visualised. On the stereotopographic basis the first operations in patients with severe spinal cord injury (detection of multilevel cord compression, removal of massive subarachnoid bleeding), syringomyelia and haemorrhage into the IV ventricle (clot removal by the ascending cervical route) were undertaken. More than 10 real and probable indications for operative spinal endofiberoscopy are discussed.