Treatment of Posttubercular Syringomyelia Not Responsive to Antitubercular Therapy: Case Report and Review of Literature

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

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

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.

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

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

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

Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis

OBJECTIVE

This case report describes the clinical features, complications, imaging characteristics, and management of postoperative spinal adhesive arachnoiditis.

CLINICAL FEATURES

A 54-year-old woman presented with right posterior thigh and leg pain after a lumbar spine fusion surgery to correct a degenerative spondylolisthesis of L3/4. Her pain was sharp and shooting and worsened with knee extension. A lumbar computed tomography myelogram demonstrated clumping and adhesion of the nerve rootlets in the cauda equina at the surgical fusion levels. Findings were consistent with spinal arachnoiditis.

INTERVENTION AND OUTCOME

The patient was treated with 2 sets of neural mobilization of the sciatic nerve with 15 repetitions each. Treatment was provided 2× per week for 3 weeks. The patient used the neural mobilization exercises at home and performed to tolerance. The patient's Oswestry Questionnaire was reduced significantly by 19% with decreased pain intensity of 2 points on the verbal analogue scale.

CONCLUSION

Neural mobilization was used successfully in the management of a patient with postoperative spinal arachnoiditis.

Posttubercular syringomyelia in HIV-infected patients: A report of 10 cases and literature review

OBJECTIVES

To describe the clinical presentation, spinal magnetic resonance imaging (MRI) findings and outcome of HIV-infected patients with tuberculosis (TB)-associated syringomyelia and to compare these findings between all HIV-infected and -uninfected cases published in the literature.

METHODS

A retrospective observational study conducted over a 12.5-year period at a public-sector referral hospital in South Africa. HIV-infected adults with neurological TB in whom MRI confirmed a syrinx were included. We searched PubMed to identify all published syringomyelia cases.

RESULTS

Ten patients were enrolled. Syringomyelia complicated neurological TB within four years of initial diagnosis in all patients (median: 21 months, range: 0-39) after initial diagnosis. Six patients were treated conservatively (TB treatment = 5, no treatment = 1); four improved, but only one was ambulant during follow-up. Four patients underwent syringoperitoneal shunting; three improved and one died three months later. Our literature review identified 50 additional cases (HIV-infected = 2, HIV-uninfected = 9, HIV status not documented = 39 [presumed HIV-uninfected]). Clinical and imaging findings and outcomes were similar between HIV-infected and -uninfected cases, except for time of presentation following neurological TB diagnosis, which was delayed (>4 years) in 46% of HIV-uninfected cases, compared to 8% of HIV-infected cases. Conclusions Syringomyelia is a disabling complication of neurological TB that usually presents early after neurological TB diagnosis in HIV coinfected patients.