Progressive myelopathy due to meningeal thickening in shunted patients: description of a novel entity and the role of surgery

Encasement of the Cauda Equina After Early Childhood Meningitis: Case Report and Review of the Literature

BACKGROUND

Arachnopathy following meningitis has been described in the setting of chronic spinal arachnoiditis and more recently as shunt-related progressive myelopathy due to meningeal thickening.

CASE DESCRIPTION

We describe an atypical case of a patient who presented with chronic arachnopathy 5 decades after an episode of meningitis. We also review the literature concerning arachnopathies occurring in the context of early childhood meningitis. Although our case bore clinical and radiologic similarities to chronic spinal arachnoiditis and shunt-related progressive myelopathy, time to symptom onset, intraoperative findings, pathophysiology, and surgical outcome set it apart from both conditions.

CONCLUSIONS

It is challenging but worthwhile to recognize this separate entity because, in contrast to both shunt-related progressive myelopathy due to meningeal thickening and adhesive arachnoiditis, surgery involving microsurgical dissection of the thick arachnoid encasement of the cauda equina may be curative in medically refractory cases.

Acquired transverse myelopathy in children in the United Kingdom--a 2 year prospective study

AIMS

To define the incidence, describe presentation, management and outcome and identify prognostic factors in Acquired Transverse Myelopathy (ATM) in children under 16 years.

METHODS

A prospective population-based surveillance study, involving all consultant paediatric neurologists in the United Kingdom from 1 July 2002 to 30 June 2004.

RESULTS AND DISCUSSION

Response rate was 91%, and 60 children were reported, of whom 41 were included. Median age was 9 years. The incidence of ATM in children under 16 years in confirmed cases is at least 1.72 per million children per year. There was a previously unrecognised male predominance (M:F 25:16). Early evaluation of bladder function is sometimes omitted. MR imaging should include whole spine and brain to maximise diagnostic information. Despite the use of high dose steroids, 25% of cases were left with significant sequelae. Outcome data was available for 36 children in whom recovery was defined as 'complete' in 19, 'good' in 8, 'fair' in 3 and 'poor' in 6. Significant positive prognostic factors were preceding infection, start of recovery within a week of onset, age less than 10 years, and lumbosacral spinal level on clinical assessment. Significant negative predictors were flaccid legs at presentation, sphincter involvement and rapid progression from onset to nadir within 24h.

Cervical extramedullary mass lesion due to chronic CSF overshunting: case report and literature review

INTRODUCTION

Several emerging clinical and neuroimaging conditions due to CSF intracranial hypotension have been documented. Recently, a few instances of a severe form of cervical myelopathy due to CSF overshunting have also been reported. Patients with this type of cervical myelopathy usually evolve with marked clinical manifestations of spinal cord involvement.

MATERIALS AND METHODS

In this article, we report a 20-year-old girl, previously given a ventriculoperitoneal shunt at age 6 years, who presented with neck pain after a whiplash injury.

RESULTS AND DISCUSSION

Magnetic resonance imaging revealed a cervical extramedullary mass that mimicked a cervical extradural hematoma. Further neuroimaging studies demonstrated that it corresponded to an engorged cervical epidural venous plexus that we attributed to chronic CSF overdrainage. After expectant management, the patient experienced a total recovery of her symptoms. To our knowledge, this is the first report of this condition occurring in an asymptomatic patient. Our aim in reporting this patient is twofold: (1) to warn the clinician about these neuroimaging findings that may mimic a cervical extradural hematoma and (2) to illustrate that engorged cervical epidural plexus may occur in patients in the absence of clinical manifestations of myelopathy. Recognition of this entity is important to distinguish it from a mass lesion in which a surgical intervention might be indicated.