Lumbar arachnoiditis: Does imaging associate with clinical features?

Spinal subdural hematoma with sudden onset of paraplegia in a patient on oral anticoagulant therapy

Spinal subdural hematoma is uncommon but may become more prevalent with increasing anticoagulant use. Early diagnosis from symptoms like lower back pain and leg paralysis is crucial for timely intervention.

Spontaneous-Onset Delayed Spinal Arachnoiditis With Dorsal Cord Herniation in a 29-Year-Old Paraplegic Patient: A Case Report

Spinal adhesive arachnoiditis is a rare occurrence with a diverse etiology. The clinical picture is not universal, and varying degrees of neurodeficit have been mentioned. Spontaneous spinal cord herniation or idiopathic spinal cord herniation occurs due to displacement of the cord through a dural or arachnoid defect. We report a case of a 29-year-old male paraplegic patient with a nontraumatic spinal cord injury (SCI) following surgery for an intradural extramedullary lesion at T10-T11 level who developed loss of truncal balance after two years of the index surgery. After a thorough clinical examination and MRI as well as other investigations, the patient was diagnosed as having spontaneous-onset delayed spinal arachnoiditis with dorsal cord herniation through the laminectomy window with effacement of neural tissue and ascending edema up to T6 level. A new-onset weakness or the development of an ascending loss of sensory level with a loss of truncal balance should alarm the therapist about some new pathology happening at the cord level in patients with SCI. In this regard, spinal adhesive arachnoiditis with or without cord herniation should always be suspected in a paraplegic patient with delayed-onset deterioration of neurology. Differential diagnoses like arachnoid web and arachnoid cysts should also be kept in mind.

Delta Cord as a Radiological Localization Sign of Postoperative Adhesive Arachnoiditis: A Case Report and Literature Review

Postoperative adhesive arachnoiditis is an inflammatory response of the spinal leptomeninges that occurs after surgery and results in scar formation in the avascular nature of the arachnoid layer. Clinical manifestations of postoperative adhesive arachnoiditis include pain, sensory deficits, motor dysfunction, reflex abnormalities, and bladder or bowel impairment. In magnetic resonance imaging scans, signs of postoperative adhesive arachnoiditis can vary; however, some indicators can assist surgeons in locating the lesion accurately and, thus, in planning effective surgical interventions. This paper reports the case of a 37-year-old man with postoperative adhesive arachnoiditis after two surgeries for Chiari I malformation. This case illustrates the progressive development of the "delta cord sign", which refers to the formation of a thick arachnoid band causing the spinal cord to adopt a triangular shape in the axial view. This phenomenon is accompanied by the sequential occurrence of syringomyelia. During intraoperative examination, we identified the presence of the delta cord sign, which had been formed by an arachnoid scar that tethered the dorsal spinal cord to the dura. This discovery enabled us to precisely pinpoint the location of the arachnoid scar and thus provided us with guidance that enabled us to avoid unnecessary exploration of unaffected structures during the procedure. Other localization signs were also reviewed.

Spinal Adhesive Arachnoiditis: A Literature Review

Adhesive arachnoiditis (AA) is a rare inflammatory and scar-forming disease with several etiologies that may lead to incapacitating sequelae if not managed early. Nevertheless, as the onset of symptoms varies from days to years, the etiology is not often discovered. The disease is characterized by adhesions disrupting the cerebrospinal fluid flow and causing encapsulation and atrophy of the nerve root. Therefore, a range of clinical features may be present, including urinary, gastroenterology, dermatologic, and neurologic. In terms of diagnosis, magnetic resonance imaging is the gold standard showing pseudocysts with adherent and narrow nerve roots toward the center of the dural sac or peripherally cluster and narrow nerve roots with empty thecal sac. Despite its sensitivity and specificity, the imaging findings are not often associated with clinical manifestations, requiring treatment being based on anamneses and clinical findings. Nowadays, AA can be managed with pharmacological and non-pharmacological treatment, although none provides a completely satisfying result.

Evaluation of neurotrophic factor secreting mesenchymal stem cells in progressive multiple sclerosis

BACKGROUND

Autologous mesenchymal stem cell neurotrophic factor-secreting cells (NurOwn^®) have the potential to modify underlying disease mechanisms in progressive multiple sclerosis (PMS).

OBJECTIVE

This open-label phase II study was conducted to evaluate safety/efficacy of three intrathecal cell treatments.

METHODS

Eighteen participants with non-relapsing PMS were treated. The primary endpoint was safety. Secondary endpoints included: cerebrospinal fluid (CSF) biomarkers; timed 25-foot walk speed, nine-hole peg test (9-HPT), low-contrast letter acuity, symbol digit modalities test, and 12-item multiple sclerosis (MS) walking scale. Seventeen participants received all treatments.

RESULTS

No deaths/adverse events related to worsening of MS, clinical/magnetic resonance imaging (MRI) evidence of disease activation, and clinically significant changes in safety lab results were reported. Two participants developed symptoms of low back and leg pain, consistent with a diagnosis of arachnoiditis, occurring in one of three intrathecal treatments in both participants. Nineteen percent of treated participants achieved pre-specified ⩾ 25% improvements in timed 25-foot walk speed/nine-HPT at 28 weeks compared to baseline, along with consistent efficacy signals for pre-specified response criteria across other secondary efficacy outcomes. CSF neuroprotective factors increased, and inflammatory biomarkers decreased after treatment, consistent with the proposed mechanism of action.

CONCLUSION

Based on these encouraging preliminary findings, further confirmation in a randomized study is warranted.

Perspective: Lumbar adhesive arachnoiditis (AA)/ Chronic AA (CAA) are clinical diagnoses that do not require radiographic confirmation

Background:

Our hypothesis was that lumbar adhesive arachnoiditis (AA)/chronic lumbar AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Therefore, patients with these syndromes do not necessarily have to demonstrate significant radiographic abnormalities on myelograms, MyeloCT studies, and/or MR examinations. When present, typical AA/CAA findings may include; central or peripheral nerve root/cauda equina thickening/clumping (i.e. latter empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/Myelo-CT studies.

Methods :

We reviewed 3 articles and 7 clinical series that involved a total of 253 patients with AA/CAA to determine whether there was a significant correlation between these clinical syndromes, and myelographic, Myelo-CT, and/or MR imaging pathology.

Results:

We determined that patients with the clinical diagnoses of AA/CAA do not necessarily exhibit associated radiographic abnormalities. However, a subset of patients with AA/CAA may show the classical AA/CAA findings of; central or peripheral nerve root/cauda equina thickening/clumping (empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/ Myelo-CT studies.

Conclusion:

Patients with clinical diagnoses of AA/CAA do not necessary show associated neuroradiagnostic abnormalities on myelograms, Myelo-CT studies, or MR. Rather, the clinical syndromes of AA/CAA may exist alone without the requirement for radiolographic confirmation.

Immunotherapies in chronic adhesive arachnoiditis - A case series and literature review

Chronic spinal adhesive arachnoiditis (CSAA) is a rare condition with limited therapeutic options. Surgical treatment proves effective in approximately 60% of cases. Conservative treatment options have not been extensively investigated. Here, we report the course of the disease, analyze the effect of immune treatments in patients with CSAA who were treated in the University Hospital Essen between 2015 and 2020, and conduct a literature review. Three out of four patients showed no improvement after treatment with corticosteroids, methotrexate, or plasmapheresis. All non-responders suffered from CSAA for several years, while one patient who had a disease duration of less than one month fully recovered. It is necessary to verify whether treatment at an early stage of the disease is better than treatment after chronic adhesion manifestation, as it interrupts the development of adhesions and all subsequent complications.

•

Surgical treatment of CSAA patients proves effective in approx. 60% of cases.

•

High-dose steroid treatment may be effective in early stages of CSAA.

•

Only conservative therapy cannot be recommended in long-standing CSAA.

Filum Terminale Arteriovenous Fistula Coexisting with a Large L2-L3 Disc Sequestration and Associated Diffuse Lumbar Arachnoiditis

The authors describe a case of filum terminale arteriovenous fistula (FTAVF) in association with a large L2–L3 disc sequestration and diffuse lumbar arachnoiditis. A 64-year-old male manifested with chronic back pain and gait difficulty. Magnetic resonance imaging (MRI) of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T9. There was a large disc sequestration came from L2–L3 disc herniation. In addition, thickening, clumping, and enhancement of the entire cauda equina were noted, probably representing arachnoiditis. MR angiography (MRA) and spinal angiography confirmed FTAVF at the level of L5. The patient underwent laminectomy with lysis adhesions and obliteration of the fistula. His postoperative course was uneventful. MRI and MRA of the thoracolumbar spine obtained 4 months after surgery revealed complete obliteration of the fistula and significant resolution of spinal cord congestion. Enhancement of the cauda equina roots was no longer visible. Interestingly, the significant resorption of the sequestrated disc was documented on MRI. The formation of the FTAVF in the present study may result from severe spinal canal stenosis caused by a large disc sequestration blocking the rostral venous drainage of the fistula, or chronic inflammation, and adhesions of the caudal nerve roots from lumbar arachnoiditis. It seems that FTAVF may be of acquired origin by this evidence.

Perspective: Early diagnosis and treatment of postoperative recurrent cerebrospinal fluid fistulas/ dural tears to avoid adhesive arachnoiditis

Background:

Intraoperative traumatic cerebrospinal fluid (CSF) fistulas/dural tears (DT) occur in up to 8.7–9.5% of primary lumbar surgical procedures. Further, they recur secondarily in between 8.1% and 17% of cases. It is critical to diagnose and treat these recurrent lumbar DT early (i.e. within 3–4 weeks of the index surgery) to avoid the evolution of adhesive arachnoiditis (AA), and its’ permanent neurological sequelae.

Methods:

Postoperative lumbar CSF fistulas/DT should be diagnosed on postoperative MR scans, and confirmed on Myelo-CT studies if needed. They should be definitively treated/occluded early on (e.g. within 3–4 postoperative weeks) to avoid the evolution of AA which can be readily diagnosed on MR studies, and corroborated, if warranted, on Myelo-CT examinations. The most prominent MR/Myelo-CT findings include; nerve roots aggregated in the central thecal sac, nerve roots peripherally scarred/adherent to the surrrounding meningeal wall (“empty thecal sac sign”), soft tissue masses in the subarachnoid space, and/or multiple loculated/scarred compartments.

Results:

Percutaneous interventional procedures (i.e. epidural blood patches, injection of fibrin glue (FG)/fibrin sealants (FS)) are rarely effective for treating postoperative recurrent lumbar CSF fistulas. Rather, direct surgical occlusion is frequently warranted including the use of; an operating microscope, adequate surgical exposure, 7-0 Gore-Tex sutures, muscle/dural patch grafts or suture anchors, followed by the application of microfibrillar collagen, and fibrin sealant/glue.

Conclusion:

Lumbar AA most commonly results from the early failure to diagnose and treat recurrent postoperative CSF fistulas. Since the clinical course of lumbar AA is typically one of progressive neurological deterioration, avoiding its’ initial onset is key.

MRI Findings of Arachnoiditis, Revisited. Is Classification Possible?

BACKGROUND

Prior imaging studies characterizing lumbar arachnoiditis have been based on small sample numbers and have reported inconsistent results.

PURPOSE

To review the different imaging patterns of lumbosacral arachnoiditis, their significance, and clinical implications.

STUDY TYPE

Retrospective.

POPULATION

A total of 96 patients (43 women; average age 61.3 years) with imaging findings of arachnoiditis (postsurgical: N = 49; degenerative: N = 29; vertebral fracture: N = 6; epidural and subdural hemorrhage: N = 3, infectious: N= 1; other: N = 8) from January 2009 to April 2018.

FIELD STRENGTH/SEQUENCE

Sagittal and axial T2-weighted Turbo Spin Echo at 1.5 T and 3 T.

ASSESSMENT

Chart review was performed to assess the cause of arachnoiditis, and imaging was reviewed by two musculoskeletal and three neurology radiologists, blinded to the clinical data and to each other's imaging interpretation. Previous classification included a three-group system based on the appearance of the nerve roots on T2-weighted images. A fourth group was added in our review as "nonspecified" and was proposed for indeterminate imaging findings that did not fall into the classical groups. The presence/absence of synechiae/fibrous bands that distort the nerve roots and of spinal canal stenosis was also assessed.

STATISTICAL TESTS

The kappa score was used to assess agreement between readers for both classification type and presence/absence of synechiae.

RESULTS

Postsurgical (51%) and degenerative changes (30%) were the most common etiologies. About 7%-55% of arachnoiditis were classified as group 4. There was very poor classification agreement between readers (kappa score 0.051). There was also poor interreader agreement for determining the presence of synechiae (kappa 0.18) with, however, strong interreader agreement for the presence of synechia obtained between the most experienced readers (kappa 0.89).

DATA CONCLUSION

This study demonstrated the lack of consensus and clarity in the classification system of lumbar arachnoiditis. The presence of synechia has high interreader agreement only among most experienced readers and promises to be a useful tool in assessing arachnoiditis.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Delayed symptomatic spinal adhesive arachnoiditis after surgery for thoracolumbar flexion-distraction injury: A case report

•

First description of delayed spinal adhesive arachnoiditis after spine trauma surgery.

•

Titanium instrumentation produces less artifacts make MRI a useful to evaluate operated lesions.

•

Gabapentin can be the treatment of good option for delayed adhesive arachnoiditis.

Background

Adhesive arachnoiditis is an uncommon lesion caused by an inflammatory reaction in spinal nerves. Reports of substantial symptomatic thoracolumbar (TL) adhesive arachnoiditis after spinal surgery are rare. To the best of our knowledge, this is the first presentation of delayed adhesive arachnoiditis with cauda equina syndrome after decompression and fusion for a traumatic TL flexion-distraction injury.

Presentation of case

A 51-year-old man presented to the emergency room with absence of lower extremity muscle power and partial sensation preservation below T12 after slipping. Magnetic resonance imaging (MRI) and computed tomography demonstrated a flexion-distraction injury at T12-L1 and unstable burst fracture at L1 with posterior fragment displacement and cauda equina compression. Emergency decompression, fracture reduction, and posterior fusion with pedicle screw instrumentation (T11-L2) were performed. After the surgical wound completely healed, the patient was transferred to the rehabilitation department. Three months after surgery, the patient complained of severe pain around the anal and testis area and had absent anal sensation and sphincter tone. We re-evaluated the spine MRI and diagnosed the patient with adhesive arachnoiditis in the previous injury site. After gabapentin was administered, the symptoms dramatically subsided.

Conclusion

To the best of our knowledge, this is the first description of delayed spinal adhesive arachnoiditis after TL spinal surgery due to trauma. Developments in technology and resolution and the fact that titanium instrumentation produces less artifacts make MRI a useful tool to evaluate previously operated lesions. Gabapentin may be a good option in the treatment for delayed-onset postoperative adhesive arachnoiditis.

Formation of Adhesive Arachnoiditis with Epidural Fibrosis as a Cause of Repeated Surgical Interventions (Clinical Case)

The work presents a rare clinical case of adhesive arachnoiditis, which developed against the background of epidural fibrosis during repeated surgical interventions. The cicatricial adhesion in the epidural space is formed in 100% of cases after surgery and is a frequent cause of intraoperative complications during repeated surgical interventions (bleeding, damage to the spinal cord and the dura mater with subsequent outflow of cerebrospinal fluid) and, therefore, an unsatisfactory result of surgical treatment with the formation of constant pain of various intensity, pseudomeningocele, commissural arachnoiditis, etc. The cicatricial adhesion in the epidural space is the main reason for the development of failed back surgery syndrome (FBSS), which today is an important and unresolved problem in spinal surgery. The epidural, as well as the subdural and subarachnoid space of the operated spinal motor segment of the spinal canal can be involved in the cicatricial adhesion, as it is shown in our clinical example. In this regard, it is important to prevent the development of the cicatricial adhesion in the epidural space during primary spinal surgeries, since with the increase in life expectancy of the population and increase in surgical activity during spinal surgeries, the patient can be operated repeatedly. Consequently, the question arises of preventing the formation of the cicatricial adhesion in 100% of cases with each surgical intervention, since the formed cicatricial adhesion in the epidural space does not have effective methods of conservative and surgical treatment and worsens favorable and satisfactory forecasts of surgical treatment for repeated surgical interventions.