Arachnoiditis and communicating hydrocephalus as a complication of epidural blood patch

Corticosteroid Therapy in Acute and Subacute Arachnoiditis - A Case Series

Arachnoiditis is difficult to treat. Patients are often left frustrated after many failed trials of conservative therapies without symptom resolution. Surgery may provide symptom relief for a short period of time, but their pain often returned. Herein, we present three cases of acute arachnoiditis following three different pain procedures: epidural blood patch, IDDS implant, and epidural steroid injection. The patients were diagnosed and treated with corticosteroids within 10 days of the procedure. Two patients were treated with the same oral steroid regiment, while the third patient was treated with both oral and IV steroid. All three patients had good outcomes at the completion of their steroid therapy. This case series may provide insight into treating acute and subacute arachnoiditis from pain interventions.

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

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.

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

[Arachnoiditis following spinal anesthesia-Case report and review of the literature]

A 61-year-old woman underwent a tension-free vaginal tape (TVT) operation due to stress incontinence. After technically difficult spinal anesthesia with two attempts the patient developed symptoms of nerve irritation, complained about neckache and headache and showed signs of agitation. The regimen was shifted to general anesthesia and surgery was performed. Because of postoperatively persistent headache and sensory disturbances an MRI scan of the lumbar spine was performed on the first postoperative day without pathological findings. The patient was able to leave the hospital after 1 week with significant relief of symptoms but 3 weeks later she developed neurocognitive impairment with memory deficits. A second MRI scan of the head now showed signs of disturbance of CSF circulation with hydrocephalus. Treatment was performed with drainage and ventriculoperitoneal shunt. Further evaluation showed a severe, multisegmental arachnoiditis and the patient developed a progressive paraparesis. The patient presented her case for assessment to a commission on medical malpractice 13 months after anesthesia. The commission detected no treatment errors. In connection to the case report a literature review of characteristics and etiologies of chronic adhesive arachnoiditis is given, which is a known but very rare complication of spinal anesthesia or similar procedures.

Communicating hydrocephalus, a long-term complication of dural tear during lumbar spine surgery

PURPOSE

Iatrogenic dural tears during lumbar spine surgery are not uncommon and may have multiple long-term sequelae if not managed promptly and definitively. Sequelae include pseudomeningocoeles due to a persistent cerebrospinal fluid leak, which may result in a subarachnoid hemorrhage or subdural hematoma. These, in turn, can lead to adult communicating hydrocephalus. The purpose of this study is to describe a case of an intraoperative iatrogenic dural tear leading to the formation of a pseudomeningocoele and progressing to hydrocephalus.

METHODS

We present a case of a 62-year-old female who had an iatrogenic dural tear during a lumbar decompression and instrumented fusion. Attempts at closure were unsuccessful, which led to the formation of a pseudomeningocoele and an ascending subdural hygroma, progressing into a communicating hydrocephalus which was treated with a ventriculoperitoneal shunt.

RESULTS

Imaging studies and clinical follow up after the incidental durotomy demonstrate complications arising from the persistent cerebrospinal fluid leak, beginning with the formation of the pseudomeningocoele and progression to hydrocephalus. Based on these imaging studies, it was possible to illustrate the development of each of the complications.

CONCLUSION

The need for prompt recognition and proper management of iatrogenic dural tears are emphasized in order to avoid future complications that may arise from inadequate or proper treatment.

A phase-contrast MRI study of acute and chronic hydrodynamic alterations after hydrocephalus induced by subarachnoid hemorrhage

OBJECTIVE

To determine acute intracranial hydrodynamic changes after subarachnoid hemorrhage (SAH) via phase-contrast MRI (PC-MRI) analysis of the CSF stroke volume in the aqueduct (SVaq) and the foramen magnum (SVfm).

METHODS

A prospective PC-MRI study was performed on 34 SAH patients in the acute and late phase. Data on CSF flow and hemorrhage site were analyzed according to acute or chronic hydrocephalus (HC).

RESULTS

In the acute phase, CSF analysis was performed for 31 patients, 12 of whom presented HC. All 12 had an abnormal SVaq; those with communicating HC (n = 7) had an elevated SV and those with noncommunicating HC (n = 5) had a nil SV. None of the patients with a normal SVaq (n = 11) developed acute HC. Intraventricular bleeding led to more cases of acute HC (P = .005), which was communicating in 58% of cases. In the chronic phase, CSF analysis was performed for 27 patients, 7 of whom presented HC. None of these 7 patients displayed a depressed SVaq.

CONCLUSION

SAH led to changes in cerebrospinal fluid hydrodynamics in the majority of patients. Acute HC was communicating in most cases, even when there was intraventricular bleeding. In the late phase, all chronic HC were communicating and did not display aqueductal stenosis.