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Choi JW, DeSimone KE, Dacumos VM, Hoshide RR, Qiao Y, Hui FK. Scalpellum occulta: A rare case of dorsal spinal arachnoid web without the scalpel sign. Radiol Case Rep 2024; 19:1552-1555. [PMID: 38317702 PMCID: PMC10839584 DOI: 10.1016/j.radcr.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
Spinal arachnoid web is a rare condition characterized by extramedullary bands of arachnoid tissue at the level of the dorsal thoracic spinal cord that may lead to progressive, permanent neurological deficits. To date, this condition has been radiographically characterized by a scalpel sign, which has been pathognomonic in all reported cases of spinal arachnoid webs. In this case, we report the first known patient with confirmed spinal arachnoid web without radiographic evidence of the scalpel sign. In reporting our finding, we encourage a higher clinical suspicion for spinal arachnoid web in patients presenting with progressive thoracic myelopathy following trauma, and radiographic evidence of ventrally displaced spinal cord and turbulent cerebrospinal fluid flow, even in the absence of a scalpel sign.
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Affiliation(s)
- Joo Won Choi
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Kulani E. DeSimone
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Vianca Mae Dacumos
- College of Tropical Agriculture and Human Resources, University of Hawaiʻi at Mānoa, 3050 Maile Way, Honolulu, HI 96822, USA
| | - Reid R. Hoshide
- Department of Neurosurgery, The Queen's Medical Center, 550 South Beretania Street, Honolulu, HI 96813, USA
| | - Yang Qiao
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston, 7000 Fannin Street Suite #1200, Houston, TX 77030, USA
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Ferdinand K. Hui
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, 651 Ilalo Street, Honolulu, HI, 96813, USA
- Department of Neurointerventional Surgery, The Queen's Medical Center, 550 South Beretania Street, Honolulu, HI 96813, USA
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2
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Adib SD, Schittenhelm J, Kurucz P, Hauser TK, Tatagiba M. Surgical management of syringomyelia associated with spinal arachnoid web: strategies and outcomes. Neurosurg Rev 2023; 46:152. [PMID: 37358703 PMCID: PMC10293323 DOI: 10.1007/s10143-023-02071-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
Spinal arachnoid web (SAW) is a rare disease entity characterized as band-like arachnoid tissue that can cause spinal cord compression and syringomyelia. This study aimed to analyze the surgical management of the spinal arachnoid web in patients with syringomyelia, focusing on surgical strategies and outcomes. A total of 135 patients with syringomyelia underwent surgery at our department between November 2003 and December 2022. All patients underwent magnetic resonance imaging (MRI), with a special syringomyelia protocol (including TrueFISP and CINE), and electrophysiology. Among these patients, we searched for patients with SAW with syringomyelia following careful analysis of neuroradiological data and surgical reports. The criteria for SAW were as follows: displacement of the spinal cord, disturbed but preserved CSF flow, and intraoperative arachnoid web. Patients were evaluated for initial symptoms, surgical strategies, and complications by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. Of the 135 patients, 3 (2.22%) fulfilled the SAW criteria. The mean patient age was 51.67 ± 8.33 years. Two patients were male, and one was female. The affected levels were T2/3, T6, and T8. Excision of the arachnoid web was performed in all cases. No significant change in intraoperative monitoring was noted. Postoperatively, none of the patients presented new neurological symptoms. The MRI 3 months after surgery revealed that the syringomyelia improved in all cases, and caliber variation of the spinal cord could not be detected anymore. All clinical symptoms improved. In summary, SAW can be safely treated by surgery. Even though syringomyelia usually improves on MRI and symptoms also improve, residual symptoms might be observed. We advocate for clear criteria for the diagnosis of SAW and a standardized diagnostic (MRI including TrueFISP and CINE).
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Affiliation(s)
- Sasan Darius Adib
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Jens Schittenhelm
- Department of Neuropathology, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Peter Kurucz
- Department of Neurosurgery, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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3
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Suzuki YI, Kobayashi M, Kuwabara S. Spinal Arachnoid Web Probably Associated with Systemic Inflammation. Intern Med 2022. [PMID: 36418090 PMCID: PMC10372280 DOI: 10.2169/internalmedicine.0260-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yo-Ichi Suzuki
- Department of Neurology, Asahi General Hospital, Japan
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
| | | | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
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4
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Thoracic spinal arachnoid web and syringomyelia with rostral expansion to the first cervical spinal cord level: Case report. Int J Surg Case Rep 2022; 96:107360. [PMID: 35779315 PMCID: PMC9284059 DOI: 10.1016/j.ijscr.2022.107360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE A spinal arachnoid web is a rare pathology that has been associated with the development of syringomyelia. Syrinx expansion can occur, which can result in the development of new symptoms. In the current literature, the farthest rostral expansion of the associated syrinx has been to the C3 spinal level. CASE PRESENTATION We present a 49-year-old Hispanic male with a thoracic spinal arachnoid web and an associated syrinx spanning from C1 to T7 spinal level. The patient developed upper extremities radicular symptoms that worsened over time. He underwent surgical management with T6-8 laminectomy and excision of the web. Postoperative follow-up evaluations demonstrated progressive clinical improvement with eventual resolution of symptoms and syringomyelia. CLINICAL DISCUSSION Syringomyelia secondary to a thoracic spinal arachnoid web is a progressive disease that can expand rostrally to the C1 spinal level. The clinical presentation usually involves the lower extremities. However, if the upper thoracic or cervical spinal cord is involved, patients can also present symptoms in the upper extremities. Management usually involves surgical excision of the web in order to decompress the subarachnoid space and restore the normal cerebrospinal fluid (CSF) flow. CONCLUSION Our case suggests that syringomyelia secondary to a spinal arachnoid web may continuously expand with concomitant worsening of symptoms. However, surgical resection is curative with possible remission of symptoms and normalization of spinal anatomy.
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5
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Delgardo M, Higgins D, McCormick KL, Reid P, Canoll P, McCormick PC. Clinical Characteristics, Outcomes, and Pathology Analysis in Patients With Dorsal Arachnoid Web. Neurosurgery 2022; 90:581-587. [PMID: 35290255 DOI: 10.1227/neu.0000000000001884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 11/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dorsal arachnoid webs (DAWs) are rare pathological abnormalities of the arachnoid layer of the spinal cord that can result in pain and myelopathy. OBJECTIVE To present clinical, imaging, and pathological characteristics of patients diagnosed with DAW, case illustrations, and a review of the literature. METHODS Seventeen cases of DAW between 2015 and 2019 at a tertiary medical center were retrospectively identified through a case log search. Patient characteristics, preoperative imaging, operative notes, and pathology reports were collected. Our main outcome assessed was postoperative resolution of symptoms. Odds ratios were used to determine associations between preoperative signs and symptoms with postoperative symptom resolution. RESULTS The mean age of the cohort was 50.5 years (IQR = 16) and presented primarily with back pain (64.7%). On imaging, all patients were found to have the "scalpel sign," and nearly half had a syrinx present (41.2%). All DAWs were located in the thoracic spine, with the most common location being the midthoracic (70.6%). The mean follow-up length for all patients was 4.3 months. There were no preoperative symptoms significantly associated with postoperative symptom resolution; however, a trend was noted with the presence of a preoperative syrinx. Pathology samples consistently demonstrated fibroconnective or collagenous tissue with no evidence of inflammation or neoplasm. CONCLUSION DAW is a rare pathology that can result in myelopathy or inappropriate interventions if misdiagnosed. Surgical intervention using laminectomy with intradural exploration should be considered in symptomatic patients with DAW because it is curative with a strong chance of preoperative symptom resolution with relatively low complication rates.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Dominique Higgins
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Kyle L McCormick
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Patrick Reid
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Paul C McCormick
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
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6
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Laxpati N, Malcolm JG, Tsemo GB, Mustroph C, Saindane AM, Ahmad F, Refai D, Gary MF. Spinal Arachnoid Webs: Presentation, Natural History, and Outcomes in 38 Patients. Neurosurgery 2021; 89:917-927. [PMID: 34432878 DOI: 10.1093/neuros/nyab321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Spinal arachnoid webs are rarely described bands of thickened arachnoid tissue in the dorsal thoracic spine. Much is unknown regarding their origins, risk factors, natural history, and outcomes. OBJECTIVE To present the single largest case series, detailing presenting symptoms and outcomes amongst operative and nonoperative patients, to better understand the role of intervention. METHODS This retrospective chart review identified 38 patients with arachnoid webs. Patient demographics, radiologic signs, symptoms, and surgical history data were extracted from the electronic medical record. Symptoms were divided by location and character. 28 patients were successfully contacted for follow up outcome surveys. RESULTS 26 patients (68%) underwent surgical intervention, 12 (32%) were managed non-operatively. 15 (39%) patients had undergone a previous unsuccessful surgery at a different site for their symptoms prior to arachnoid web diagnosis. Commonly presenting symptoms included myelopathy (68%), focal thoracic back pain (68%), lower extremity weakness (45%), numbness and sensory changes (58%), and lower extremity radicular pain (42%), upper extremity weakness (24%), and radicular pain (37%). Focal thoracic pain was associated with thoracic level (P < .02). Myelopathic symptoms were less common in postoperative patients. Postoperative patients described significantly more upper extremity (P < .01) and thoracic (P < .01) numbness and paresthesias. Surveyed nonoperative patients universally described their symptoms as either stable or worsening. CONCLUSION Spinal arachnoid webs present with thoracic myelopathy and back pain but can also present with upper extremity symptoms. Surgical intervention stabilizes or improves symptoms and is well received. Nonoperative patients do not spontaneously improve.
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Affiliation(s)
- Nealen Laxpati
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - James G Malcolm
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Christian Mustroph
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amit M Saindane
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Faiz Ahmad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Daniel Refai
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Orthopedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew F Gary
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Orthopedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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7
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Ruella M, Marco Del Pont F, Martin A, María Giovannini SJ, Centeno TR, Cervio A. Scalpel Sign in Spine Pathology: Presentation in 3 Different Rare Diagnoses. World Neurosurg 2021; 157:e77-e87. [PMID: 34587520 DOI: 10.1016/j.wneu.2021.09.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The scalpel sign is a radiological finding observed on sagittal magnetic resonance imaging and computed tomography myelography corresponding to an indentation in the dorsal aspect of the spinal cord resembling a surgical scalpel blade. It is said to be a pathognomonic imaging discovery linked to dorsal arachnoid webs. However, other spine-related conditions may mimic dorsal arachnoid webs on magnetic resonance imaging, such as spinal arachnoid cysts or ventral spinal cord herniation, leading to misdiagnosis. METHODS A retrospective review was performed of cases involving 3 different diagnoses at our institution in the last 5 years that shared in common the characteristic focal dorsal indentation of the spinal cord. RESULTS Of 7 cases identified, all but 1 were treated and confirmed intraoperatively. All lesions were located at the dorsal spinal cord. Magnetic resonance imaging was the study of choice for evaluation. Clinical manifestations included back pain and lower extremity numbness and weakness together with compressive myelopathy signs and urinary symptoms. Mean follow-up was 16.8 months with satisfactory postoperative results. CONCLUSIONS Isolated radiological presentation of the scalpel sign is not sufficient to distinguish between dorsal arachnoid webs, arachnoid cysts, and ventral herniation of the spine. However, awareness of its importance is relevant for accurate curative surgical planning.
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Affiliation(s)
- Mauro Ruella
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina.
| | | | - Aguilar Martin
- Department of Neuroradiology, FLENI, Buenos Aires, Argentina
| | | | | | - Andres Cervio
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
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8
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Dorsal thoracic arachnoid web – Confounders of a rare entity in the developing setting. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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9
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Bertholon S, Grange S, Grange R, Forest F, Tetard MC, Boutet C, Vassal F. Spinal Arachnoid Web: A didactic report of two cases with clinical, radiological, surgical and pathological correlations. Neurochirurgie 2021; 68:11-15. [PMID: 34329657 DOI: 10.1016/j.neuchi.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/01/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arachnoid web (AW) is a rare but probably underestimated cause of spinal cord injury that is complex to diagnose due to subtle MRI findings and similarities to other better-known diseases such as arachnoid cyst (AC) or transdural spinal cord herniation (TSCH). Increased recognition of AW is mandatory since delay in diagnosis can lead to potentially serious neurological sequelae. CASE PRESENTATIONS We report two additional cases of AW for didactic purposes, with special emphasis on the distinctive MRI and intraoperative findings. Both patients presented with progressively worsening neurological symptoms, including proprioceptive ataxia, motor weakness, numbness and neuropathic pain. The diagnosis of AW was suspected on the basis of specific MRI criteria, especially the so-called "scalpel sign". Formal confirmation of the diagnosis was obtained in two patients that were managed surgically. Postoperative follow-up demonstrated significant functional recovery. DISCUSSION There is a need for better recognition of AW by the medical community. Careful analysis of MRI semiology is crucial for the distinction between AW, AC and TSCH. Prompt and accurate diagnosis is mandatory to conserve functional prognosis, since appropriate surgical treatment with AW resection is curative, halting or even resolving the neurological symptoms.
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Affiliation(s)
- S Bertholon
- Department of Radiology, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - S Grange
- Department of Radiology, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France.
| | - R Grange
- Department of Radiology, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - F Forest
- Department of Pathology, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - M-C Tetard
- Department of Neurosurgery, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - C Boutet
- Department of Radiology, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France
| | - F Vassal
- Department of Neurosurgery, University Hospital of Saint-Etienne, 42055 Saint-Etienne cedex 2, France
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10
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Hines T, Wang C, Duttlinger C, Thompson J, Watford K, Motley B, Wheeler G. Thoracic dorsal arachnoid web with rapid onset of symptoms: A report of two cases and brief review of the literature. Surg Neurol Int 2021; 12:323. [PMID: 34345464 PMCID: PMC8326092 DOI: 10.25259/sni_339_2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/03/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Thoracic arachnoid webs are a rare entity and can be challenging to diagnose with sometimes subtle radiographic findings. Arachnoid webs can cause severe cord compression with associated syrinx and resulting myelopathy, weakness, sensory loss, and bowel/bladder dysfunction. There have been a little over 60 cases total reported in the literature with only one systematic review. The cases presented here have unique features including rapid onset of symptoms, symptomatic syrinx extending into the cervical spine, and intraoperative syrinx drainage, all of which are quite rare in the current published literature for arachnoid webs. Case Description: Here, we present two patients, a 73-year-old man and 58-year-old man presenting with different symptoms and timing of symptom progression but both with “scalpel sign” and associated syrinx present on their MRIs. Each patient underwent a laminectomy with resection of arachnoid web with complete resolution of symptoms in the first case and significant improvement in the second case. Postoperative imaging in both cases showed almost complete resolution of the syrinx. Conclusion: Early clinical evaluation and workup followed by early surgical treatment can lead to dramatic improvement in outcomes after surgery. For patients that are symptomatic from an associated syrinx, a midline myelotomy to facilitate drainage can be considered to be done concomitantly with the arachnoid web resection.
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Affiliation(s)
- Tripp Hines
- Department of Neurosurgery, University of Kentucky
| | | | - Christine Duttlinger
- Department of Neurosurgery, Lexington Veterans Affairs Medical Center, Lexington, Kentucky, United States
| | - Jay Thompson
- Department of Neurosurgery, Lexington Veterans Affairs Medical Center, Lexington, Kentucky, United States
| | - Kevin Watford
- Department of Neurosurgery, Lexington Veterans Affairs Medical Center, Lexington, Kentucky, United States
| | | | - Greg Wheeler
- Department of Neurosurgery, University of Kentucky.,Department of Neurosurgery, Lexington Veterans Affairs Medical Center, Lexington, Kentucky, United States
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11
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Rodrigues AB, Rodrigues DB, Queiroz JWM, Laube KAC, Braga MCM, Kita WS, De Luna AAANF, De Souza RW, Netto RHD. Surgical treatment of spinal arachnoid web: Report of two cases and literature review. Surg Neurol Int 2021; 12:316. [PMID: 34345457 PMCID: PMC8326061 DOI: 10.25259/sni_493_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/05/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Arachnoid webs (AWs) can cause cord compression and syringomyelia in the thoracic spine. Here, we describe two patients who underwent operative treatment for AW and reviewed the literature. CASE DESCRIPTION Two patients underwent surgical treatment for thoracic AW. Both presented with spastic gait and numbness in the lower extremities. On MR, these lesions exhibited the "scalpel" sign (i.e. due to the accumulation of cerebrospinal fluid on the dorsal aspect of the spinal cord). Operative intervention, consisting of fenestration and web resection, resulted in symptom resolution. CONCLUSION Thoracic AWs are rare lesions that should be considered among the differential diagnosis of spinal compressive syndromes. Surgical fenestration and resection of the AW correct the flow dynamics allowing for full symptoms resolution.
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12
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Pham N, Ebinu JO, Karnati T, Hacein-Bey L. Neuroimaging findings and pathophysiology of dorsal spinal arachnoid webs: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2142. [PMID: 35855021 PMCID: PMC9245846 DOI: 10.3171/case2142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spinal arachnoid webs are uncommon and difficult to diagnose, especially because causative intradural transverse bands of arachnoid tissue are radiographically occult. Left untreated, arachnoid webs may cause progressive, debilitating, and permanent neurological dysfunction. Conversely, more than 90% of patients may experience rapid neurological recovery after resection, even with a prolonged duration of presenting symptoms. Indirect imaging signs such as spinal cord indentation and compression with cerebrospinal fluid (CSF) flow alteration provide crucial diagnostic clues that are critical in guiding appropriate management of such patients. OBSERVATIONS The authors reported a patient with no significant medical history who presented with back pain, progressive lower extremity weakness, gait ataxia, and bowel and bladder incontinence. They discussed multimodality imaging for determining the presence of arachnoid webs, including magnetic resonance imaging, phase-contrast CSF flow study, computed tomography myelography, and intraoperative ultrasound. They also discussed the detailed anatomy of the spinal subarachnoid space and a plausible pathophysiological mechanism for dorsal arachnoid webs. LESSONS The authors report on a patient who underwent comprehensive imaging evaluation detailing the arachnoid web and whose subsequent anatomical localization and surgical treatment resulted in a full neurological recovery.
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Affiliation(s)
- Nancy Pham
- Department of Radiology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California; and
| | | | | | - Lotfi Hacein-Bey
- Radiology, University of California, Davis, School of Medicine, Sacramento, California
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13
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Delhaas EM, Harhangi BS, van Doormaal PJ, Dinkelaar W, van Es AC, van Assema DM, Frankema SP, van der Lugt A, Huygen FJ. Restoration of rostral cerebrospinal fluid flow to solve treatment failure caused by obstruction in long-term intrathecal baclofen administration. J Spinal Cord Med 2021; 44:312-321. [PMID: 31418647 PMCID: PMC7952057 DOI: 10.1080/10790268.2019.1646476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objects: We describe five traumatic spinal cord injury (SCI) patients with an intrathecal baclofen administration (ITB) failure caused by a rostral CSF flow obstruction referred to our expert center between January 2014 and January 2019. We discuss the diagnostic workup, rostral CSF flow obstruction as the cause of the ITB failure and treatment.Methods: When we could not determine the cause of the ITB failure through the patient's history, physical spasticity examination, pump readout, absence of fluid in the pump reservoir during aspiration, or plain radiography, we performed pump catheter access port (computed tomography [CT]) myelography. When CT myelography did not reveal the diagnosis, we used scintigraphy. In an obstruction, we aimed for CSF flow restoration. In three cases, we conducted a laminectomy with microsurgical adhesiolysis. In two of these patients, we could not achieve CSF flow restoration; thus, we placed an intradural catheter bypass. Recently, in three patients, we applied a less invasive technique of percutaneous fenestration of the obstruction.Results: In one case, we performed a successful catheter replacement. In another case using surgical adhesiolysis, spasticity control was complete. In two cases, we could obtain improvement with an additional intradural bypass, followed by a percutaneous fenestration of the obstruction, resulting in further improved CSF flow restoration. In one case, percutaneous fenestration was the first line of treatment. In all cases with percutaneous fenestration, we experienced spasticity control.Conclusion: Preliminary results showed that the restoration of rostral CSF flow might result in an effective ITB treatment in patients with an intrathecal obstruction.
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Affiliation(s)
- Elmar M. Delhaas
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands,Correspondence to: Elmar M. Delhaas, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, P.O. Box 2040, Rotterdam, CA3000, The Netherlands.
| | - Biswadjiet S. Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter J. van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wouter Dinkelaar
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ad C.G.M. van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Danielle M.E. van Assema
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sander P.G. Frankema
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Frank J.P.M. Huygen
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Strong MJ, North RY, Yee TJ, Oppenlander ME. Commentary: Decompression of a Dorsal Arachnoid Web of the Spine: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E144-E145. [PMID: 33294934 DOI: 10.1093/ons/opaa359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J Strong
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Robert Y North
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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YAMAMOTO A, FUJIMOTO M, AOKI K, SUZUKI Y, MIZUNO M, SUZUKI H. A Dorsal Arachnoid Web of the Cervical Spine: A Case Report. NMC Case Rep J 2021; 8:281-286. [PMID: 35079476 PMCID: PMC8769406 DOI: 10.2176/nmccrj.cr.2020-0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Atsushi YAMAMOTO
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi FUJIMOTO
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kazuaki AOKI
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yume SUZUKI
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masaki MIZUNO
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
- Department of Minimum-Invasive Neurospinal Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hidenori SUZUKI
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Nada A, Mahdi E, Mahmoud E, Cousins J, Ahsan H, Leiva-Salinas C. Multi-modality imaging evaluation of the dorsal arachnoid web. Neuroradiol J 2020; 33:508-516. [PMID: 33135580 PMCID: PMC7788682 DOI: 10.1177/1971400920970919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Dorsal arachnoid web (DAW) is a rare intradural abnormality which is associated with progressive myelopathy. Our objective was to review multi-modality imaging techniques demonstrating the scalpel sign appearance in evaluation of DAW. METHODS We retrospectively reviewed various imaging modalities of patients found to have DAW at our institution during January 2015 to February 2020. Five patients underwent surgical decompression with pathological correlation. The remaining patients were presumptively diagnosed based on the characteristic finding of scalpel sign. Clinical data were evaluated and correlated to imaging findings. All imaging modalities demonstrated the characteristic scalpel sign. RESULTS Sixteen patients (10 females, and six males) with multi-imaging modalities were evaluated. Their mean age was 52 year (range 23-74 years). Fifteen patients underwent conventional spine MRI. Further high-resolution MR imaging techniques, e.g. 3D T2 myelographic sequence, were utilized with two patients. MRI spine CSF flow study was performed to evaluate the flow dynamic across the arachnoid web in one patient. Eight patients were evaluated with CT myelogram. Syrinx formation was discovered in seven (44%) patients; five (71%) of them underwent surgical resection and decompression. Two patients underwent successful catheter-directed fenestration of the web with clinical improvement. We found a statically significant positive correlation between the degree of cord displacement and compression with syrinx formation (r = 0.55 and 0.65 with p-value of 0.03 and 0.009, respectively). CONCLUSION DAW has characteristic scalpel sign independent of imaging modality. Multi-modality imaging evaluation of DAW is helpful for evaluation and surgical planning.
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Affiliation(s)
- A Nada
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - E Mahdi
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - E Mahmoud
- Department of Diagnostic and Interventional Radiology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - J Cousins
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - H Ahsan
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - C Leiva-Salinas
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
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Diagnosis and Surgical Treatment of Thoracic Dorsal Arachnoid Web: A Report of Two Cases. Case Rep Orthop 2020; 2020:8816598. [PMID: 33005467 PMCID: PMC7509563 DOI: 10.1155/2020/8816598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction An arachnoid web (AW) is a relatively rare disease and shows clinical symptoms and radiological findings similar to those of an arachnoid cyst (AC) or spinal cord herniation (SCH). Since the operative procedures for an AW are generally different from those intrathecal disorders, correct preoperative differential diagnosis is important. The purposes of this study were to report the usefulness of magnetic resonance imaging (MRI) and computed tomography (CT) myelography for diagnosing AW and to show the histological findings and clinical results. Case Description. Two patients, a 79-year-old man and a 43-year-old woman, are presented. The primary diagnoses were AC with ossification of the ligamentum flavum and epidural hematoma, respectively, in previous hospitals. They were finally diagnosed by the characteristic MRI and CT myelogram finding called the “scalpel sign.” Histological findings showed epithelial cells and fibrous tissue derived from arachnoid tissues and microcalcifications. After surgery, the scalpel sign has vanished, and aggravation of their symptoms was prevented. Conclusion An AW is refractory, but early detection by MRI and CT myelography and early treatment improve outcomes after surgery.
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Zakhari N, Nguyen T, Omaiche S, Chakraborty S. Posterior spinal cord indentation: imaging findings and clinical outcome. Clin Radiol 2020; 75:615-621. [DOI: 10.1016/j.crad.2020.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
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Schmutzer M, Tonn JC, Zausinger S. Spinal intradural extramedullary arachnoid cysts in adults-operative therapy and clinical outcome. Acta Neurochir (Wien) 2020; 162:691-702. [PMID: 31813001 DOI: 10.1007/s00701-019-04156-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/25/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Spinal arachnoid cysts (SAC) are rare mostly idiopathic intradural lesions with compression of the spinal cord and clinical signs of radiculo- and/or myelopathy. We retrospectively analyzed radiological and clinical characteristics of patients with surgical treatment of SAC including a subgroup evaluation of long-term outcome and QoL. METHOD Patients with SAC treated between 1993 and 2017 were evaluated. Craniocaudal (c.c.) and anteroposterior (a.p) cyst diameters were measured pre- and post-OP. McCormick and Odom score for myelopathy, general outcome and QoL (SF-36, EORTC-QLQ30) were recorded. RESULTS A total of 72 patients (female:male = 1.9:1) were analyzed with mean FU of 44.8 ± 60 months (long-term data from 25 patients with FU 78.2 ± 63.9 months). All had surgery due to solitary cysts: 10 cervical (13.9%), 45 thoracic (62.5%), and 17 lumbosacral (23.6%), the majority (79.2%) located dorsally. Main symptoms were gait disturbance (80%), dysesthesia (64%) and paresis (80%). Patients had (hemi-)laminectomy with cyst fenestration in 48 (66.7%) and complete resection in 18 cases (25.0%). Four cases (5.5%) were treated by cystoperitoneal shunt, 2 by marsupialization (2.8%). In total, 11 revisions were necessary in 9/72 (12.5%) patients (one patient underwent 3 revisions). Two patients were reoperated for wound revision/epidural hematoma (each n = 1). Seven patients needed additional cyst wall resection after 1.5-31.0 months due to insufficient cyst shrinking and persistent clinical symptoms after first surgery; most of the cysts were multiple septated and of post-hemorrhagic origin. The mean c.c. size decreased from 5.2 ± 3.7 cm pre-OP to 2.7 ± 3.9 cm (p < 0.05); the a.p. diameter decreased from 1.0 ± 0.5 cm to 0.3 ± 0.3 cm (p < 0.0001) without significant differences between fenestration and resection. McCormick and Odom scores revealed improved symptoms, particularly of gait disturbance, sensory deficits, and general performance. Long-term FU displayed satisfying QoL performance without differences of fenestration or resection. CONCLUSION SAC mostly affect women and are predominantly located in the thoracic spine, becoming apparent with clinical myelopathy. For cysts without intracystic septae and compartments, both fenestration and resection of the cyst wall provided significant reduction of cyst size and clinical improvement.
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Nisson PL, Hussain I, Härtl R, Kim S, Baaj AA. Arachnoid web of the spine: a systematic literature review. J Neurosurg Spine 2019; 31:175-184. [PMID: 31003220 DOI: 10.3171/2019.1.spine181371] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/31/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE An arachnoid web of the spine (AWS) is a rare and oftentimes challenging lesion to diagnose, given its subtle radiographic findings. However, when left untreated, this lesion can have devastating effects on a patient's neurological function. To date, only limited case reports and series have been published on this topic. In this study, the authors sought to better describe this lesion, performing a systematic literature review and including 2 cases from their institution's experience. METHODS A systematic literature search was performed in September 2018 that queried Ovid MEDLINE (1946-2018), PubMed (1946-2018), Wiley Cochrane Library: Central Register of Controlled Trials (1898-2018), and Thompson Reuters Web of Science: Citation Index (1900-2018), per PRISMA guidelines. Inclusion criteria specified all studies and case reports of patients with an AWS in which any relevant surgery types were considered and applied. Studies on arachnoid cysts and nonhuman populations, and those that did not report patient treatments or outcomes were excluded from the focus review. RESULTS A total of 19 records and 2 patients treated by the senior authors were included in the systematic review, providing a total of 43 patients with AWS. The mean age was 52 years (range 28-77 years), and the majority of patients were male (72%, 31/43). A syrinx was present in 67% (29/43) of the cases. All AWSs were located in the thoracic spine, and all but 2 (95%) were located dorsally (1 ventrally and 1 circumferentially). Weakness was the most frequently reported symptom (67%, 29/43), followed by numbness and/or sensory loss (65%, 28/43). Symptoms predominated in the lower extremities (81%, 35/43). It was found that nearly half (47%, 20/43) of patients had been experiencing symptoms for 1 year or longer before surgical intervention was performed, and 35% (15/43) of reports stated that symptoms were progressive in nature. The most commonly used surgical technique was a laminectomy with intradural excision of the arachnoid web (86%, 36/42). Following surgery, 91% (39/43) of patients had reported improvement in their neurological symptoms. The mean follow-up was 9.2 months (range 0-51 months). CONCLUSIONS AWS of the spine can be a debilitating disease of the spine with no more than an indentation of the spinal cord found on advanced imaging studies. The authors found this lesion to be reported in twice as many males than females, to be associated with a syrinx more than two-thirds of the time, and to only have been reported in the thoracic spine; over 90% of patients experienced improvement in their neurological function following surgery.
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Affiliation(s)
- Peyton L Nisson
- 1University of Arizona, College of Medicine, Tucson, Arizona; and
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Ibrahim Hussain
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Roger Härtl
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Samuel Kim
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Ali A Baaj
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
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Hirai T, Taniyama T, Yoshii T, Mizuno K, Okamoto M, Inose H, Yuasa M, Otani K, Shindo S, Nakai O, Okawa A. Clinical Outcomes of Surgical Treatment for Arachnoid Web: A Case Series. Spine Surg Relat Res 2018; 3:43-48. [PMID: 31435550 PMCID: PMC6690113 DOI: 10.22603/ssrr.2018-0027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/10/2018] [Indexed: 12/01/2022] Open
Abstract
Introduction We describe 5 patients who underwent operative treatment for arachnoid web (AW) and discuss the postoperative clinical outcome in each case. AW is an extremely rare disease that causes cord compression and syringomyelia in the thoracic spine. To date, 14 cases only of AW have been reported, and the effect of surgical intervention on clinical and radiologic outcomes is unknown. Methods Five patients who underwent surgical treatment for AW were retrospectively reviewed. The clinical outcomes were evaluated using the thoracic Japanese Orthopaedic Association (T-JOA) score. Preoperative and postoperative images were reviewed. Results All the patients presented with spastic gait and numbness in the lower extremities. Two patients also presented with bladder-bowel dysfunction (BBD). AW, or the so-called “scalpel” sign, was seen dorsally in the thoracic spine on magnetic resonance imaging in all the patients. Syringomyelia adjacent to the web was observed in 4 patients. Fenestration and web resection without instrumentation was performed in all the cases. Overall, significant improvement was seen in locomotion and the total T-JOA score postoperatively. However, numbness in the lower extremities improved in 2 patients but was unchanged in 3 cases. BBD was ameliorated in 1 patient but remained unchanged in the other patient. Conclusions Our experience suggests that surgical treatment, including the another patient and resection of the web, can correct the flow dynamics of cerebrospinal fluid and allow neurologic recovery, in particular locomotion, in patients with AW.
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Affiliation(s)
- Takashi Hirai
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Taniyama
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichi Mizuno
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Mikio Okamoto
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masato Yuasa
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuyuki Otani
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Shigeo Shindo
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Osamu Nakai
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Ganau M, Syrmos N, Martin AR, Jiang F, Fehlings MG. Intraoperative ultrasound in spine surgery: history, current applications, future developments. Quant Imaging Med Surg 2018; 8:261-267. [PMID: 29774179 DOI: 10.21037/qims.2018.04.02] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Mario Ganau
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Nikolaos Syrmos
- School of Medicine, Aristotle University of Thessaloniki, Macedonia, Greece
| | - Allan R Martin
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Fan Jiang
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Michael G Fehlings
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
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Vergara P, Barone DG. Minimally Invasive Excision of Thoracic Arachnoid Web. World Neurosurg 2017; 109:e81-e87. [PMID: 28951269 DOI: 10.1016/j.wneu.2017.09.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Arachnoid webs are rare intradural lesions that can cause direct spinal cord compression or alteration of the cerebrospinal fluid flow with syringomyelia. Surgery has been historically performed through wide-open laminectomies. The aim of this study is to prove the feasibility of minimally invasive techniques for the excision of arachnoid webs. METHODS A retrospective review of two cases of minimally invasive excision of thoracic arachnoid webs was performed. Surgery was undertaken through expandable tubular retractors. RESULTS Complete excision was achieved through the described approach, with minimal bony removal and soft tissue disruption. There were no intraoperative or perioperative complications. Both patients were mobilized early and discharged home within 24 hours after surgery. Postoperative imaging showed good re-expansion of the spinal cord, with no evidence of residual compression or tethering. CONCLUSIONS For symptomatic arachnoid webs, surgery remains the only definitive treatment. In expert hands, the excision of arachnoid webs can be achieved with tubular retractors and minimally invasive techniques.
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Affiliation(s)
- Pierluigi Vergara
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Clinical and Radiologic Outcomes After Fenestration and Partial Wall Excision of Idiopathic Intradural Spinal Arachnoid Cysts Presenting with Myelopathy. World Neurosurg 2017; 105:213-222. [PMID: 28578118 DOI: 10.1016/j.wneu.2017.05.136] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intradural spinal arachnoid cysts (ISACs) with associated neurologic deficits are encountered infrequently. Various management strategies have been proposed with minimal data on comparative outcomes. OBJECTIVE We describe the clinical and radiologic presentation as well as the outcomes of 14 surgically managed patients who presented with an ISAC and associated myelopathy. METHODS We retrospectively reviewed the clinical course of consecutive patients presenting with neurologic deficits associated with idiopathic ISACs at our institution. The diagnoses were based on preoperative magnetic resonance imaging studies followed by intraoperative and histopathological confirmation. RESULTS A total of 14 consecutive patients with ISACs (1 cervicothoracic, 12 thoracic, and 1 thoracolumbar) and associated myelopathy were identified. Syringomyelia was noted in 8 patients. All ISACs were treated with cyst fenestration and partial wall resection through a posterior approach. Preoperative neurologic symptoms were noted to be stable or improved in all patients starting at 6-week postoperative follow-up. The median (interquartile range) preoperative mJOA score was 13 (12.0-14.8), whereas the postoperative median score at a mean follow-up of 22 months (range 6-50 months) was 16 (14.0-17.0), which represents a median improvement (ΔmJOA) of 2.0 (1.3-3.0) (P < 0.001). Comparison of ΔmJOA scores between cases without and with associated syrinxes did not reveal a significant difference (P = 0.23). Postoperative magnetic resonance imaging scans revealed spinal cord re-expansion at the level of the ISAC in all cases and either complete or partial syrinx resolution in 7 of 8 cases. CONCLUSIONS Early treatment with fenestration and partial wall resection allows for cord decompression, syrinx resolution, and gradual resolution of myelopathic symptoms in most cases.
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