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Santorella E, Balsbaugh JL, Ge S, Saboori P, Baker D, Pachter JS. Proteomic interrogation of the meninges reveals the molecular identities of structural components and regional distinctions along the CNS axis. Fluids Barriers CNS 2023; 20:74. [PMID: 37858244 PMCID: PMC10588166 DOI: 10.1186/s12987-023-00473-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023] Open
Abstract
The meninges surround the brain and spinal cord, affording physical protection while also serving as a niche of neuroimmune activity. Though possessing stromal qualities, its complex cellular and extracellular makeup has yet to be elaborated, and it remains unclear whether the meninges vary along the neuroaxis. Hence, studies were carried-out to elucidate the protein composition and structural organization of brain and spinal cord meninges in normal, adult Biozzi ABH mice. First, shotgun, bottom-up proteomics was carried-out. Prominent proteins at both brain and spinal levels included Type II collagen and Type II keratins, representing extracellular matrix (ECM) and cytoskeletal categories, respectively. While the vast majority of total proteins detected was shared between both meningeal locales, more were uniquely detected in brain than in spine. This pattern was also seen when total proteins were subdivided by cellular compartment, except in the case of the ECM category where brain and spinal meninges each had near equal number of unique proteins, and Type V and type III collagen registered exclusively in the spine. Quantitative analysis revealed differential expression of several collagens and cytoskeletal proteins between brain and spinal meninges. High-resolution immunofluorescence and immunogold-scanning electronmicroscopy on sections from whole brain and spinal cord - still encased within bone -identified major proteins detected by proteomics, and highlighted their association with cellular and extracellular elements of variously shaped arachnoid trabeculae. Western blotting aligned with the proteomic and immunohistological analyses, reinforcing differential appearance of proteins in brain vs spinal meninges. Results could reflect regional distinctions in meninges that govern protective and/or neuroimmune functions.
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Affiliation(s)
- Elise Santorella
- Department of Immunology, UConn Health, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Jeremy L Balsbaugh
- Proteomics and Metabolomics Facility, Center for Open Research Resources & Equipment, University of Connecticut, Storrs, CT, 06269, USA
| | - Shujun Ge
- Department of Immunology, UConn Health, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Parisa Saboori
- Department of Mechanical Engineering, Manhattan College, Bronx, NY, 10071, USA
| | - David Baker
- Blizard Institute, Queen Mary University of London, London, England
| | - Joel S Pachter
- Department of Immunology, UConn Health, 263 Farmington Ave, Farmington, CT, 06030, USA.
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Rai S, Srivastava S, Kamath M, Murlimanju BV, Parmar G, Chebrolu G. Delineation of Subarachnoid Cisterns Using CT Cisternography, CT Brain Positive and Negative Contrast, and a Three Dimensional MRI Sequence: A Pictorial Review. Cureus 2022; 14:e23741. [PMID: 35509744 PMCID: PMC9057636 DOI: 10.7759/cureus.23741] [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] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
The basic anatomy and morphology of subarachnoid cisterns of the brain are interesting and challenging topics with high clinical significance. These enlarged CSF-filled expansions are important as they transmit various neurovascular structures. The cisterns can be classified based on their location as supratentorial, at the level of the tentorium, and infratentorial. They are also classified as paired and unpaired cisterns. The anatomical and radiological information about the cisterns is clinically and surgically relevant in diagnosing and managing many neurological disorders. It is also essential in medical teaching. This pictorial essay reviews the radiological images where the subarachnoid cisterns are delineated in four unique circumstances.
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Koyanagi I, Chiba Y, Uemori G, Imamura H, Yoshino M, Aida T. Pathophysiology and surgical treatment of spinal adhesive arachnoid pathology: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21426. [PMID: 35855276 PMCID: PMC9281495 DOI: 10.3171/case21426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal adhesive arachnoid pathology is a rare cause of myelopathy. Because of rarity and variability, mechanisms of myelopathy are unknown. The authors retrospectively analyzed patients to understand pathophysiology and provide implications for surgical treatment. OBSERVATIONS Nineteen consecutive patients were studied. Thirteen patients had a secondary pathology due to etiological disorders such as spinal surgery or hemorrhagic events. They received arachnoid lysis (4 patients), syringo-subarachnoid (S-S) shunt (8 patients) with or without lysis, or anterior decompression. Three of them developed motor deterioration after lysis, and 6 patients needed further 8 surgeries. Another 6 patients had idiopathic pathology showing dorsal arachnoid cyst formation at the thoracic level that was surgically resected. With mean follow-up of 44.3 months, only 4 patients with the secondary pathology showed improved neurological grade, whereas all patients with idiopathic pathology showed improvement. LESSONS The idiopathic pathology was the localized dorsal arachnoid adhesion that responded to surgical treatment. The secondary pathology produced disturbed venous circulation of the spinal cord by extensive adhesions. Lysis of the thickened fibrous membrane with preservation of thin arachnoid over the spinal veins may provide safe decompression. S-S shunt was effective if the syrinx extended to the level of normal subarachnoid space.
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Affiliation(s)
- Izumi Koyanagi
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Yasuhiro Chiba
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Genki Uemori
- Department of Neurosurgery, Moriyama Hospital, Asahikawa, Hokkaido, Japan
| | - Hiroyuki Imamura
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Masami Yoshino
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Toshimitsu Aida
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
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Ball T, Aljuboori Z, Nauta H. Punctate Midline Myelotomy: A Historical Overview and Case Series with Detailed Efficacy and Side Effect Profiles. World Neurosurg 2021; 154:e264-e276. [PMID: 34256176 DOI: 10.1016/j.wneu.2021.07.021] [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: 05/02/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To review our experience with punctate midline myelotomy (PMM) for malignant and benign visceral pain with an emphasis on detailed side-effect profiles and efficacy. METHODS Thirteen adults (5 men) underwent microsurgical transverse-crush PMM. RESULTS Median follow-up for the benign pain group (n = 6) was 17.5 months (10-72) and for the malignant group (n = 7) was 8 months (0.5-31). Five of seven patients in the malignant pain group obtained excellent, lasting relief. Two had initial relief followed by worsening pain with disease progression. In the benign pain group, two patients with endodermal-origin pain (gastrointestinal tract, bladder) had complete, long-lasting relief. Three patients with mesodermal-origin pain (ureter) had excellent relief for 2-3 months, followed by recurrence in two and partial (40%) recurrence in the third. One man with pre-existing cervical myelopathy underwent PMM for benign testicular-region pain from which he had long-term relief but only transient relief of coexisting low-back and leg pain. There were no motor deficits in either group, and all patients remained ambulatory and continent. The most common side effect was transient numbness of the medial leg and foot. Two patients (both with pre-existing spinal pathology) reported persistent moderate reduction of bowel, bladder, and sexual sensation. CONCLUSIONS PMM offers substantial pain relief for carefully selected patients with intractable visceral pain. Relief from primarily endoderm-derived structures was most complete and long-lasting. Relief from mesoderm-derived structures was typically transient or incomplete. There was essentially no relief from pain of ectoderm-derived structures. Detailed preoperative counseling is important, especially for those with pre-existing neurologic deficits.
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Affiliation(s)
- Tyler Ball
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA.
| | - Zaid Aljuboori
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Haring Nauta
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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Arachnoid and dural reflections. HANDBOOK OF CLINICAL NEUROLOGY 2021; 169:17-54. [PMID: 32553288 DOI: 10.1016/b978-0-12-804280-9.00002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The dura mater is the major gateway for accessing most extra-axial lesions and all intra-axial lesions of the central nervous system. It provides a protective barrier against external trauma, infections, and the spread of malignant cells. Knowledge of the anatomical details of dural reflections around various corners of the skull bases provides the neurosurgeon with confidence during transdural approaches. Such knowledge is indispensable for protection of neurovascular structures in the vicinity of these dural reflections. The same concept is applicable to arachnoid folds and reflections during intradural excursions to expose intra- and extra-axial lesions of the brain. Without a detailed understanding of arachnoid membranes and cisterns, the neurosurgeon cannot confidently navigate the deep corridors of the skull base while safely protecting neurovascular structures. This chapter covers the surgical anatomy of dural and arachnoid reflections applicable to microneurosurgical approaches to various regions of the skull base.
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Benko N, Luke E, Alsanea Y, Coats B. Spatial distribution of human arachnoid trabeculae. J Anat 2020; 237:275-284. [PMID: 32202332 DOI: 10.1111/joa.13186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/20/2020] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
Traumatic brain injury (TBI) is a common injury modality affecting a diverse patient population. Axonal injury occurs when the brain experiences excessive deformation as a result of head impact. Previous studies have shown that the arachnoid trabeculae (AT) in the subarachnoid space significantly influence the magnitude and distribution of brain deformation during impact. However, the quantity and spatial distribution of cranial AT in humans is unknown. Quantification of these microstructural features will improve understanding of force transfer during TBI, and may be a valuable dataset for microneurosurgical procedures. In this study, we quantify the spatial distribution of cranial AT in seven post-mortem human subjects. Optical coherence tomography (OCT) was used to conduct in situ imaging of AT microstructure across the surface of the human brain. OCT images were segmented to quantify the relative amounts of trabecular structures through a volume fraction (VF) measurement. The average VF for each brain ranged from 22.0% to 29.2%. Across all brains, there was a positive spatial correlation, with VF significantly greater by 12% near the superior aspect of the brain (p < .005), and significantly greater by 5%-10% in the frontal lobes (p < .005). These findings suggest that the distribution of AT between the brain and skull is heterogeneous, region-dependent, and likely contributes to brain deformation patterns. This study is the first to image and quantify human AT across the cerebrum and identify region-dependencies. Incorporation of this spatial heterogeneity may improve the accuracy of computational models of human TBI and enhance understanding of brain dynamics.
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Affiliation(s)
- Nikolaus Benko
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Emma Luke
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - Yousef Alsanea
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Brittany Coats
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, USA
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Dauleac C, Jacquesson T, Mertens P. Anatomy of the human spinal cord arachnoid cisterns: applications for spinal cord surgery. J Neurosurg Spine 2019; 31:756-763. [PMID: 31299646 DOI: 10.3171/2019.4.spine19404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/29/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The goal in this study was to describe the overall organization of the spinal arachnoid mater and spinal subarachnoid space (SSAS) as well as its relationship with surrounding structures, in order to highlight spinal cord arachnoid cisterns. METHODS Fifteen spinal cords were extracted from embalmed adult cadavers. The organization of the spinal cord arachnoid and SSAS was described via macroscopic observations, optical microscopic views, and scanning electron microscope (SEM) studies. Gelatin injections were also performed to study separated dorsal subarachnoid compartments. RESULTS Compartmentalization of SSAS was studied on 3 levels of axial sections. On an axial section passing through the tips of the denticulate ligament anchored to the dura, 3 subarachnoid cisterns were observed: 2 dorsolateral and 1 ventral. On an axial section passing through dural exit/entrance of rootlets, 5 subarachnoid cisterns were observed: 2 dorsolateral, 2 lateral formed by dorsal and ventral rootlets, and 1 ventral. On an axial section passing between the two previous ones, only 1 subarachnoid cistern was observed around the spinal cord. This compartmentalization resulted in the anatomical description of 3 elements: the median dorsal septum, the arachnoid anchorage to the tip of the denticulate ligament, and the arachnoid anchorage to the dural exit/entrance of rootlets. The median dorsal septum already separated dorsal left and right subarachnoid spaces and was described from C1 level to 3 cm above the conus medullaris. This septum was anchored to the dorsal septal vein. No discontinuation was observed in the median dorsal arachnoid septum. At the entrance point of dorsal rootlets in the spinal cord, arachnoid trabeculations were described. Using the SEM, numerous arachnoid adhesions between the ventral surface of the dorsal rootlets and the pia mater over the spinal cord were observed. At the ventral part of the SSAS, no septum was found, but some arachnoid trabeculations between the arachnoid and the pia mater were present and more frequent than in the dorsal part. Laterally, arachnoid was firmly anchored to the denticulate ligaments' fixation at dural points, and dural exit/entrance of rootlets made a fibrous ring of arachnoidodural adhesions. At the level of the cauda equina, the arachnoid mater surrounded all rootlets together-as a sac and not individually. CONCLUSIONS Arachnoid cisterns are organized on each side of a median dorsal septum and compartmentalized in relation with the attachments of denticulate ligament and exit/entrance of rootlets.
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Affiliation(s)
- Corentin Dauleac
- 1Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon
- 2University of Lyon, Université Claude Bernard Lyon I; and
| | - Timothée Jacquesson
- 1Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon
- 2University of Lyon, Université Claude Bernard Lyon I; and
- 3Laboratory of Anatomy, Université Claude Bernard Lyon I, Lyon, France
| | - Patrick Mertens
- 1Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon
- 2University of Lyon, Université Claude Bernard Lyon I; and
- 3Laboratory of Anatomy, Université Claude Bernard Lyon I, Lyon, France
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Altafulla J, Bordes S, Jenkins S, Litvack Z, Iwanaga J, Loukas M, Tubbs RS. The Basal Subarachnoid Cisterns: Surgical and Anatomical Considerations. World Neurosurg 2019; 129:190-199. [PMID: 31136838 DOI: 10.1016/j.wneu.2019.05.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Abstract
The basal subarachnoid cisterns are expansions of the subarachnoid space and transmit cranial nerves and intracranial vessels. Providing neurosurgeons with key concepts, anatomical landmarks, and techniques can result in safer procedures and better patient outcomes. In this review, we discuss the major basal subarachnoid cisterns including their embryology, history, anatomical descriptions, and use during surgical approaches.
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Affiliation(s)
- Juan Altafulla
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Stephen Bordes
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Skyler Jenkins
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Zachary Litvack
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA.
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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Mortazavi MM, Quadri SA, Khan MA, Gustin A, Suriya SS, Hassanzadeh T, Fahimdanesh KM, Adl FH, Fard SA, Taqi MA, Armstrong I, Martin BA, Tubbs RS. Subarachnoid Trabeculae: A Comprehensive Review of Their Embryology, Histology, Morphology, and Surgical Significance. World Neurosurg 2017; 111:279-290. [PMID: 29269062 DOI: 10.1016/j.wneu.2017.12.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Brain is suspended in cerebrospinal fluid (CSF)-filled subarachnoid space by subarachnoid trabeculae (SAT), which are collagen-reinforced columns stretching between the arachnoid and pia maters. Much neuroanatomic research has been focused on the subarachnoid cisterns and arachnoid matter but reported data on the SAT are limited. This study provides a comprehensive review of subarachnoid trabeculae, including their embryology, histology, morphologic variations, and surgical significance. METHODS A literature search was conducted with no date restrictions in PubMed, Medline, EMBASE, Wiley Online Library, Cochrane, and Research Gate. Terms for the search included but were not limited to subarachnoid trabeculae, subarachnoid trabecular membrane, arachnoid mater, subarachnoid trabeculae embryology, subarachnoid trabeculae histology, and morphology. Articles with a high likelihood of bias, any study published in nonpopular journals (not indexed in PubMed or MEDLINE), and studies with conflicting data were excluded. RESULTS A total of 1113 articles were retrieved. Of these, 110 articles including 19 book chapters, 58 original articles, 31 review articles, and 2 case reports met our inclusion criteria. CONCLUSIONS SAT provide mechanical support to neurovascular structures through cell-to-cell interconnections and specific junctions between the pia and arachnoid maters. They vary widely in appearance and configuration among different parts of the brain. The complex network of SAT is inhomogeneous and mainly located in the vicinity of blood vessels. Microsurgical procedures should be performed with great care, and sharp rather than blunt trabecular dissection is recommended because of the close relationship to neurovascular structures. The significance of SAT for cerebrospinal fluid flow and hydrocephalus is to be determined.
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Affiliation(s)
- Martin M Mortazavi
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA.
| | - Syed A Quadri
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Muhammad A Khan
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Aaron Gustin
- Advocate BroMenn Medical Center, Normal, Illinois, USA
| | - Sajid S Suriya
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | | | | | - Farzad H Adl
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Salman A Fard
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - M Asif Taqi
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Ian Armstrong
- National Skull Base Center, Thousand Oaks, California, USA; California Institute of Neuroscience, Thousand Oaks, California, USA
| | - Bryn A Martin
- National Skull Base Center, Thousand Oaks, California, USA; University of Idaho, Moscow, Idaho, USA
| | - R Shane Tubbs
- National Skull Base Center, Thousand Oaks, California, USA; Seattle Science Foundation, Seattle, Washington, USA
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Pizzichelli G, Kehlet B, Evju Ø, Martin BA, Rognes ME, Mardal KA, Sinibaldi E. Numerical study of intrathecal drug delivery to a permeable spinal cord: effect of catheter position and angle. Comput Methods Biomech Biomed Engin 2017; 20:1599-1608. [DOI: 10.1080/10255842.2017.1393805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- G. Pizzichelli
- Istituto Italiano di Tecnologia, Center for Micro-BioRobotics, Pontedera, Italy
| | - B. Kehlet
- Simula Research Laboratory, Lysaker, Norway
| | - Ø. Evju
- Simula Research Laboratory, Lysaker, Norway
| | - B. A. Martin
- Department of Biological Engineering, The University of Idaho, Moscow, ID, USA
| | - M. E. Rognes
- Simula Research Laboratory, Lysaker, Norway
- Departments of Mathematics and Informatics, University of Oslo, Oslo, Norway
| | - K. A. Mardal
- Simula Research Laboratory, Lysaker, Norway
- Departments of Mathematics and Informatics, University of Oslo, Oslo, Norway
| | - E. Sinibaldi
- Istituto Italiano di Tecnologia, Center for Micro-BioRobotics, Pontedera, Italy
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Thyagaraj S, Pahlavian SH, Sass LR, Loth F, Vatani M, Choi JW, Tubbs RS, Giese D, Kroger JR, Bunck AC, Martin BA. An MRI-Compatible Hydrodynamic Simulator of Cerebrospinal Fluid Motion in the Cervical Spine. IEEE Trans Biomed Eng 2017; 65:1516-1523. [PMID: 28961100 DOI: 10.1109/tbme.2017.2756995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOAL Develop and test an MRI-compatible hydrodynamic simulator of cerebrospinal fluid (CSF) motion in the cervical spinal subarachnoid space. Four anatomically realistic subject-specific models were created based on a 22-year-old healthy volunteer and a five-year-old patient diagnosed with Chiari I malformation. METHODS The in vitro models were based on manual segmentation of high-resolution T2-weighted MRI of the cervical spine. Anatomically realistic dorsal and ventral spinal cord nerve rootlets (NR) were added. Models were three dimensional (3-D) printed by stereolithography with 50-μm layer thickness. A computer controlled pump system was used to replicate the shape of the subject specific in vivo CSF flow measured by phase-contrast MRI. Each model was then scanned by T2-weighted and 4-D phase contrast MRI (4D flow). RESULTS Cross-sectional area, wetted perimeter, and hydraulic diameter were quantified for each model. The oscillatory CSF velocity field (flow jets near NR, velocity profile shape, and magnitude) had similar characteristics to previously reported studies in the literature measured by in vivo MRI. CONCLUSION This study describes the first MRI-compatible hydrodynamic simulator of CSF motion in the cervical spine with anatomically realistic NR. NR were found to impact CSF velocity profiles to a great degree. SIGNIFICANCE CSF hydrodynamics are thought to be altered in craniospinal disorders such as Chiari I malformation. MRI scanning techniques and protocols can be used to quantify CSF flow alterations in disease states. The provided in vitro models can be used to test the reliability of these protocols across MRI scanner manufacturers and machines.
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Barbagallo GMV, Maione M, Raudino G, Certo F. Thoracic Intradural-Extramedullary Epidermoid Tumor: The Relevance for Resection of Classic Subarachnoid Space Microsurgical Anatomy in Modern Spinal Surgery. Technical Note and Review of the Literature. World Neurosurg 2017; 108:54-61. [PMID: 28843754 DOI: 10.1016/j.wneu.2017.08.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intradural epidermoid tumors of the spinal cord are commonly associated with spinal cord dysraphism or invasive procedures. We report the particular relationships between spinal subarachnoid compartments and thoracic intradural-extramedullary epidermoid tumor, highlighting the relevant anatomic changes that may influence microsurgery. METHODS A 40-year-old woman from compressive myelopathy owing to a thoracic epidermoid tumor extending from T3 to T4 and not associated with spina bifida, trauma, previous surgery, or lumbar spinal puncture underwent microsurgical excision. Accurate tumor membrane dissection, respecting spinal arachnoidal compartments, was performed. Reposition of a laminoplasty plateau helped in restoring thoracic spine anatomic integrity. RESULTS Safe gross total tumor resection was achieved. Complete neurologic recovery as well as absence of recurrent tumor was documented at 4-year follow-up. A literature review revealed only 2 other cases of "isolated" thoracic spine epidermoid tumor. However, description of the relationship between tumor membranes and spinal subarachnoid compartments was not available in either case. CONCLUSIONS A thorough knowledge of spinal subarachnoid space anatomy is helpful to distinguish between tumor membranes and arachnoidal planes and to achieve a safe and complete resection to avoid recurrences.
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Affiliation(s)
- Giuseppe M V Barbagallo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy.
| | - Massimiliano Maione
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Giuseppe Raudino
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Francesco Certo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
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Obil-Chavarría CA, García-Ramos CL, Castro-Quiñonez SA, Huato-Reyes R, Santillán-Chapa CG, Reyes-Sánchez AA. [Clinical presentation of a dorsal epidural arachnoid cyst after an epidural anesthesia]. CIR CIR 2015; 84:487-492. [PMID: 26698384 DOI: 10.1016/j.circir.2015.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 08/06/2015] [Accepted: 08/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Arachnoid cysts are dural diverticula with liquid content similar to cerebrospinal fluid, with 1% occurring in the spinal cord. They locate mainly in the dorsal region of the thoracic spine, and are unusual causes of spinal cord compression. CLINICAL CASE The case is presented of a previously healthy 15-year-old boy, with a 20-month history of spastic paraparesis that started apparently after epidural block for ankle osteosynthesis. There was decreased sensitivity and strength of the pelvic limbs and gradually presented with anaesthesia from T12 to L4 dermatomes, L5 and S1 bilateral hypoaesthesia and 4+/5 bilateral strength, in the L2 root and 2+/5 in L3, L4, L5, S1, hyperreflexia, Babinski and clonus, but with no alteration in the sacral reflexes. In the magnetic resonance it was diagnosed as an extradural arachnoid cyst from T6 to T9. The patient underwent a T6 to T10 laminotomy, cyst resection, dural defect suture, and laminoplasty. One year after surgery, the patient had recovered sensitivity, improvement of muscle strength up to 4+/5 in L2 to S1, and normal reflexes. CONCLUSIONS After the anaesthetic procedure, increased pressure and volume changes within the cyst could cause compression of the spinal cord, leading to symptoms. Despite being a long-term compression, the patient showed noticeable improvement.
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Affiliation(s)
| | - Carla Lisette García-Ramos
- División de Cirugía de Columna Vertebral, Instituto Nacional de Rehabilitación, Ciudad de México, México
| | | | - Raúl Huato-Reyes
- Servicio de Neurocirugía, Centro Médico Adolfo López Mateos, Instituto de Salud del Estado de México y Municipios, Toluca de Lerdo, México
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Heidari Pahlavian S, Bunck AC, Loth F, Shane Tubbs R, Yiallourou T, Kroeger JR, Heindel W, Martin BA. Characterization of the discrepancies between four-dimensional phase-contrast magnetic resonance imaging and in-silico simulations of cerebrospinal fluid dynamics. J Biomech Eng 2015; 137:051002. [PMID: 25647090 DOI: 10.1115/1.4029699] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Indexed: 02/05/2023]
Abstract
The purpose of the present study was to compare subject-specific magnetic resonance imaging (MRI)-based computational fluid dynamics (CFD) simulations with time-resolved three-directional (3D) velocity-encoded phase-contrast MRI (4D PCMRI) measurements of the cerebrospinal fluid (CSF) velocity field in the cervical spinal subarachnoid space (SSS). Three-dimensional models of the cervical SSS were constructed based on MRI image segmentation and anatomical measurements for a healthy subject and patient with Chiari I malformation. CFD was used to simulate the CSF motion and compared to the 4D PCMRI measurements. Four-dimensional PCMRI measurements had much greater CSF velocities compared to CFD simulations (1.4 to 5.6× greater). Four-dimensional PCMRI and CFD both showed anterior and anterolateral dominance of CSF velocities, although this flow feature was more pronounced in 4D PCMRI measurements compared to CFD. CSF flow jets were present near the nerve rootlets and denticulate ligaments (NRDL) in the CFD simulation. Flow jets were visible in the 4D PCMRI measurements, although they were not clearly attributable to nerve rootlets. Inclusion of spinal cord NRDL in the cervical SSS does not fully explain the differences between velocities obtained from 4D PCMRI measurements and CFD simulations.
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Jacquesson T, Streichenberger N, Sindou M, Mertens P, Simon E. What is the dorsal median sulcus of the spinal cord? Interest for surgical approach of intramedullary tumors. Surg Radiol Anat 2013; 36:345-51. [PMID: 23995517 DOI: 10.1007/s00276-013-1194-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 08/19/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE For intramedullary tumor (IMT) surgery, a balance has to be found between aggressively resecting the tumor and respecting all the sensory and motor pathways. The most common surgical approach is through the dorsal median sulcus (DMS) of the spinal cord. However, the precise organization of the meningeal sheats in the DMS remains obscure in the otherwise well-described anatomy of the spinal cord. A better understanding of this architecture may be of benefit to IMT surgeon to spare the spinal cord. METHODS Three spinal cords were studied. The organization of the spinal cord meninges in the DMS was described via macroscopic, microsurgical and optical microscopic views. A micro dissection of the DMS was also performed. RESULTS No macroscopic morphological abnormalities were observed. With the operative magnifying lens, the dura was opened, the arachnoid was removed and the pia mater was cut to access the DMS. The histological study showed that the DMS was composed of a thin rim of capillary-carrying connective tissue extending from the pia mater and covering the entire DMS. There was no true space between the dorsal columns, no arachnoid or crossing axons either. CONCLUSION Our work indicates that the DMS is not a sulcus but a thin blade of collagen extending from the pia mater. Its location is given by tiny vessels coming from the surface towards the deep. Thus, the surgical corridor has to follow the DMS as closely as possible to prevent damage to the spinal cord during midline IMT removal.
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Affiliation(s)
- Timothée Jacquesson
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, 59 Bd Pinel, 69677, Bron, Cedex, France,
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16
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Papisov MI, Belov VV, Gannon KS. Physiology of the intrathecal bolus: the leptomeningeal route for macromolecule and particle delivery to CNS. Mol Pharm 2013; 10:1522-32. [PMID: 23316936 PMCID: PMC3646927 DOI: 10.1021/mp300474m] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Presently, there are no effective treatments for several diseases involving the CNS, which is protected by the blood-brain, blood-CSF, and blood-arachnoid barriers. Traversing any of these barriers is difficult, especially for macromolecular drugs and particulates. However, there is significant experimental evidence that large molecules can be delivered to the CNS through the cerebrospinal fluid (CSF). The flux of the interstitial fluid in the CNS parenchyma, as well as the macro flux of CSF in the leptomeningeal space, are believed to be generally opposite to the desirable direction of CNS-targeted drug delivery. On the other hand, the available data suggest that the layer of pia mater lining the CNS surface is not continuous, and the continuity of the leptomeningeal space (LMS) with the perivascular spaces penetrating into the parenchyma provides an unexplored avenue for drug transport deep into the brain via CSF. The published data generally do not support the view that macromolecule transport from the LMS to CNS is hindered by the interstitial and CSF fluxes. The data strongly suggest that leptomeningeal transport depends on the location and volume of the administered bolus and consists of four processes: (i) pulsation-assisted convectional transport of the solutes with CSF, (ii) active "pumping" of CSF into the periarterial spaces, (iii) solute transport from the latter to and within the parenchyma, and (iv) neuronal uptake and axonal transport. The final outcome will depend on the drug molecule behavior in each of these processes, which have not been studied systematically. The data available to date suggest that many macromolecules and nanoparticles can be delivered to CNS in biologically significant amounts (>1% of the administered dose); mechanistic investigation of macromolecule and particle behavior in CSF may result in a significantly more efficient leptomeningeal drug delivery than previously thought.
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Affiliation(s)
- Mikhail I. Papisov
- Massachusetts General Hospital, Shriners Hospitals for Children – Boston, and Harvard Medical School, 51 Blossom St, Boston, MA 02114 USA
| | - Vasily V. Belov
- Massachusetts General Hospital, Shriners Hospitals for Children – Boston, and Harvard Medical School, 51 Blossom St, Boston, MA 02114 USA
| | - Kimberley S. Gannon
- NeuroPhage Pharmaceuticals, Inc. 3222 Third Street, Suite 31203 Cambridge, MA 02142 USA
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Klekamp J. Treatment of Syringomyelia Related to Nontraumatic Arachnoid Pathologies of the Spinal Canal. Neurosurgery 2012. [DOI: 10.1227/neu.0b013e31827fcc8f] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Abstract
BACKGROUND:
Disturbances of cerebrospinal fluid (CSF) flow are the commonest cause of syringomyelia. Spinal arachnopathies may lead to CSF flow obstructions but are difficult to diagnose. Consequently, associated syringomyelias are often categorized as idiopathic.
OBJECTIVE:
To present and analyze the diagnosis of and long-term outcomes in an observational study of patients with nontraumatic arachnopathies from 1991 to 2011.
METHODS:
A total of 288 patients (mean age, 47 ± 15 years; follow-up, 54 ± 46 months) were evaluated. Decompression with arachnolysis, untethering, and duraplasty for restoration of CSF flow was recommended to patients with neurological progression. Neurological examinations, magnetic resonance images, and follow-up data were evaluated. Individual symptoms were analyzed during the first postoperative year, and long-term outcomes were analyzed with Kaplan-Meier statistics to determine rates of progression-free survival.
RESULTS:
In total,189 patients either refused an operation or were managed conservatively for lack of progression. Among 79 unoperated patients with follow-up information available for up to 8 years, 2 patients deteriorated. Ninety-nine patients with progressive symptoms underwent 116 operations: 108 decompressions and 8 other surgeries. Three months postoperatively, 53% considered their status improved and 37% were unchanged. In the long term, surgery on arachnopathies limited to 2 spinal segments was followed by progression-free survival for 78% over 10 years, in contrast to 31% with extensive arachnopathies.
CONCLUSION:
Surgery on nontraumatic arachnopathies related to syringomyelia should be reserved for patients with progressive symptoms. Arachnolysis, untethering, and duraplasty provide good long-term results for focal arachnopathies. For extensive pathologies with a history of subarachnoid hemorrhage or meningitis, treatment remains a major challenge.
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Affiliation(s)
- Jörg Klekamp
- Christliches Krankenhaus, Department of Neurosurgery, Quakenbrück, Germany
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Pulsatile wall movement of spinal arachnoid cyst deteriorates spinal cord symptoms: report of three cases. Acta Neurochir (Wien) 2010; 152:1245-9. [PMID: 20012452 DOI: 10.1007/s00701-009-0571-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 11/24/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Symptomatic spinal arachnoid cyst is a rare disease and the pathophysiology causing spinal cord symptoms has not been well clarified. PATIENTS AND METHODS The authors report three symptomatic cases of spinal arachnoid cyst at the thoracic level. These patients, aged from 70 to 73 years, showed progressive gait disturbance for a few months before admission. Phase-contrast cine magnetic resonance imaging demonstrated significant compression at the rostral side of the cyst during the diastolic phase of the cardiac cycle. Intraoperative ultrasonography demonstrated that the maximum expansion of the cyst and compression of the dorsal spinal cord occurred when the cerebrospinal fluid moved rostrally during diastole. All patients showed good improvement of their symptoms after surgical removal of the arachnoid cyst. CONCLUSION This report proposes the pathophysiology that the pulsatile enlargement of the arachnoid cyst during diastolic cardiac phase can be an important factor for deterioration of spinal cord symptoms.
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Pathogenesis of syringomyelia associated with Chiari type 1 malformation: review of evidences and proposal of a new hypothesis. Neurosurg Rev 2010; 33:271-84; discussion 284-5. [PMID: 20532585 DOI: 10.1007/s10143-010-0266-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 03/23/2010] [Accepted: 05/02/2010] [Indexed: 02/08/2023]
Abstract
The exact pathogenesis of syringomyelia associated with Chiari type 1 malformation is unknown, although a number of authors have reported their theories of syrinx formation. The purpose of this review is to understand evidences based on the known theories and to create a new hypothesis of the pathogenesis. We critically review the literatures on clinicopathological, radiological, and clinical features of this disorder. The previously proposed theories mainly focused on the driven mechanisms of the cerebrospinal fluid (CSF) into the spinal cord. They did not fully explain radiological features or effects of surgical treatment such as shunting procedures. Common findings of the syrinx in clinicopathological studies were the communication with the central canal and extracanalicular extension to the posterior gray matter. Most of the magnetic resonance imaging studies demonstrated blockade and alternated CSF dynamics at the foramen magnum, but failed to show direct communication of the syrinx with the CSF spaces. Pressure studies revealed almost identical intrasyrinx pressure to the subarachnoid space and decreased compliance of the spinal CSF space. Recent imaging studies suggest that the extracellular fluid accumulation may play an important role. The review of evidences promotes a new hypothesis of syrinx formation. Decreased absorption mechanisms of the extracellular fluid may underlie the pathogenesis of syringomyelia. Reduced compliance of the posterior spinal veins associated with the decreased compliance of the spinal subarachnoid space will result in disturbed absorption of the extracellular fluid through the intramedullary venous channels and formation of syringomyelia.
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Barshes N, Demopoulos A, Engelhard HH. Anatomy and physiology of the leptomeninges and CSF space. Cancer Treat Res 2005; 125:1-16. [PMID: 16211880 DOI: 10.1007/0-387-24199-x_1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The arachnoid membrane and pia mater are the two membranous layers that comprise the leptomeninges. Cerebrospinal fluid is made within the ventricular system by cells of the choroid plexus and ependyma. This chapter describes in detail the normal anatomic structure and physiologic interactions of the cerebrospinal fluid and leptomeningeal space that are critical to our understanding and treatment of leptomeningeal metastases.
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Affiliation(s)
- Neil Barshes
- The University of Illinois at Chicago, Chicago, IL 60612, USA
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23
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Hida K, Iwasaki Y. Syringosubarachnoid shunt for syringomyelia associated with Chiari I malformation. Neurosurg Focus 2001; 11:E7. [PMID: 16724817 DOI: 10.3171/foc.2001.11.1.8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors describe the surgical procedures for placing syringosubarachnoid shunts and the results of surgery, as well as the prevention of shunt malfunction. METHODS The series consisted of 59 patients with syringomyelia associated with Chiari I malformation in whom syringosubarachnoid shunts were placed. Their ages ranged from 4 to 62 years (median 28 years). The follow-up period ranged from 13 to 219 months. The authors principally implanted the shunts in patients with large-sized syringes. Neurological improvement was satisfactory, and postoperative magnetic resonance imaging demonstrated that the syringes had resolved or decreased in size in all patients. Reoperation was necessary in 10 patients who were treated before 1993. CONCLUSIONS To prevent shunt malfunction, both dorsal root entry zone myelotomy and placement of the syringosubarachnoid shunt tube into the ventral subarachnoid space are useful.
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Affiliation(s)
- K Hida
- Department of Neurosurgery, University of Hokkaido Graduate School of Medicine, Sapporo, Japan.
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Nauta HJ, Soukup VM, Fabian RH, Lin JT, Grady JJ, Williams CG, Campbell GA, Westlund KN, Willis WD. Punctate midline myelotomy for the relief of visceral cancer pain. J Neurosurg 2000; 92:125-30. [PMID: 10763680 DOI: 10.3171/spi.2000.92.2.0125] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study offers clinical support for the concept that neurosurgical interruption of a midline posterior column pathway by performing a punctate midline myelotomy (PMM) provides significant pain relief without causing adverse neurological sequelae in cancer patients with visceral pain refractory to other therapies. METHODS A PMM of the posterior columns was performed in six cancer patients in whom visceral pain had been refractory to other therapies. The cause of the visceral pain was related to residual, progressive, or recurrent local cancer or postirradiation effects. Clinical efficacy of the procedure was examined by comparing patient pain ratings and narcotic usage pre- and post-PMM. Follow-up periods ranged from 3 to 31 months. Examination of the results indicates a significant reduction in pain ratings as well as a significant reduction in daily narcotic use. No adverse neurological effects were observed. One spinal cord has been recovered for postmortem examination. CONCLUSIONS These findings provide corroborating clinical evidence for the existence of a newly recognized midline posterior column pathway that mediates the perception of visceral pelvic and abdominal pain. Preliminary data indicate that significant pain relief can be obtained following PMM with minimal neurological morbidity and suggest that the procedure may provide an alternative treatment modality for cancer-related pain in patients in whom adequate pain control with narcotics cannot be achieved or narcotic side effects cannot be tolerated.
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Affiliation(s)
- H J Nauta
- Department of Neurology, University of Texas Medical Branch, Galveston 77555-0517, USA.
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Salpietro FM, Alafaci C, Lucerna S, Iacopino DG, Tomasello F. Do spinal meningiomas penetrate the pial layer? Correlation between magnetic resonance imaging and microsurgical findings and intracranial tumor interfaces. Neurosurgery 1997; 41:254-7; discussion 257-8. [PMID: 9218314 DOI: 10.1097/00006123-199707000-00041] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To study the relationships between spinal dura-arachnoid and tumor-cord interfaces in spinal meningiomas and to investigate whether a disruption of the pial layer and penetration of the tumor in the spinal cord occurs. METHODS Fifteen patients with histologically proven meningiomas underwent magnetic resonance imaging (MRI) preoperatively. All patients underwent microsurgery. The histological characteristics of the tumors were compared with MRI and microsurgical findings. RESULTS At surgery, the peritumoral hypointense rim revealed by MRI in 10 of 15 patients corresponded to a well-defined cerebrospinal fluid-containing space confined between the outer arachnoidal layer and the inner leptomeningeal layer. In those patients in whom the hypointense peritumoral rim was absent, the inner layer was either difficult to identify or clearly absent, and the blood vessels were extremely adherent to the tumor, requiring a more cautious dissection. Penetration of the tumors through disruption of the pial surface was not documented. CONCLUSION Previous anatomic and electron microscopy studies demonstrated, in human spinal meninges, the presence of an intermediate layer attached to the inner aspect of the arachnoid, extending laterally over the dorsal surface of the spinal cord and arborizing over the nerve roots and blood vessels. The intermediate layer is not present in human cerebral leptomeninges. The presence/absence of this layer might explain the hypointense rim detected by MRI and might also explain why no penetration and no peritumoral edema is observed in spinal meningiomas as compared with intracranial meningiomas.
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Affiliation(s)
- F M Salpietro
- Department of Neurosurgery, University of Messina, Italy
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26
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Nauta HJ, Hewitt E, Westlund KN, Willis WD. Surgical interruption of a midline dorsal column visceral pain pathway. Case report and review of the literature. J Neurosurg 1997; 86:538-42. [PMID: 9046313 DOI: 10.3171/jns.1997.86.3.0538] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.
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Affiliation(s)
- H J Nauta
- Department of Neurology, University of Texas Medical Branch, Galveston, USA
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Abstract
Spinal anaesthesia has been used since the 1800s but, due to a number of complications, the popularity of this technique has waxed and waned. In the 1950s, it was the most widely used method of anaesthesia and analgesia in obstetrics but it fell out of fashion with the arrival of the epidural technique which allowed a continuous method of delivering analgesia with relatively few complications. Hypotension and the high incidence of postdural puncture headaches were two reasons for the decline in the popularity of spinal anaesthesia in the young, otherwise healthy pregnant population. With the development of newer needles and bevel designs and methods whereby the incidence of hypotension can be minimized, spinal anaesthesia is making a reappearance in obstetrical anaesthesia spheres. The purpose of this article is to review the history, effects, technique, indications, contraindications and complications of this method of anesthesia as it applies to the obstetrical patient.
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Affiliation(s)
- P Morgan
- Department of Anaesthesia, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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Blomberg RG. Fibrous structures in the subarachnoid space: a study with spinaloscopy in autopsy subjects. Anesth Analg 1995; 80:875-9. [PMID: 7726427 DOI: 10.1097/00000539-199505000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The lumbar and lower thoracic subarachnoid space of 26 human autopsy subjects was studied using rigid endoscopy, spinaloscopy. Fibrous attachments were found between nerve roots and/or nerve roots and the arachnoid membrane at least at one spinal level in 16 subjects. The appearance and density of the structures varied, and caused restriction of nerve root mobility in nine subjects. In three of them, the impeded mobility prevented the nerve root from yielding to the contact and pressure exerted either by the tip of the endoscope or by a spinal needle introduced into the subarachnoid space. In another three subjects, a distinct membranous structure was identified in the posterior midline of the subarachnoid space in the lower thoracic and upper lumbar regions. These findings may possibly be associated with the variation in the extent of subarachnoid block and to the development of isolated nerve root trauma in connection with this procedure.
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Affiliation(s)
- R G Blomberg
- Department of Anesthesia, Central Hospital, Norrköping, Sweden
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Abstract
The development of a unilateral block after subarachnoid anaesthesia is described. Other reported cases are discussed and the anatomy of subarachnoid space summarised.
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Affiliation(s)
- P J Armstrong
- Department of Anaesthesia, Royal Infirmary Edinburgh
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Abstract
Unilateral block is a rare complication of spinal anaesthesia. A case where a unilateral block occurred following the administration of a spinal anaesthetic, and where a second spinal anaesthetic to complete the block was successfully administered, is reported. The possible causes of unilateral block are discussed.
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