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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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Bhatjiwale M, Bhatjiwale M. Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report. World J Surg Proced 2021; 11:1-9. [DOI: 10.5412/wjsp.v11.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/06/2021] [Accepted: 12/11/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mrudul Bhatjiwale
- Department of Neurosurgery, Narayana Health City, Bangalore 560099, Karnataka, India
- Neurological Science, Neuro Health Foundation, Mumbai 400091, India
| | - Mohinish Bhatjiwale
- Department of Neurosurgery, Rotary Medical Center, Mumbai 400068, India
- Department of Neurosurgery, Manav Kalyan Kendra & Navneet Hitech Hospitals, Mumbai 400068, India
- Department of Neurosurgery, Neuro Health Foundation, Mumbai 400091, India
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El Ouadih Y, Coll G, Haro Y, Chaix R. Resolution of isolated syringomyelia after removing thoracic disc herniation. Br J Neurosurg 2020; 34:196-199. [DOI: 10.1080/02688697.2018.1424321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Guillaume Coll
- Neurosurgery, Hopital Gabriel Montpied, Clermont-Ferrand, France
- Image-Guided Clinical Neurosciences and Connectomics (IGCNC), Axe thérapies guidées par l'image (TGI), CNRS, Sigma, Institut Pascal, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Yakouba Haro
- Neurosurgery, Hopital Gabriel Montpied, Clermont-Ferrand, France
| | - Remi Chaix
- Neurosurgery, Hopital Gabriel Montpied, Clermont-Ferrand, France
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Spontaneous regression of post-traumatic syringomyelia: A case report and literature review. J Clin Neurosci 2017; 44:249-253. [DOI: 10.1016/j.jocn.2017.06.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/21/2017] [Indexed: 11/22/2022]
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Adeleye AO, Ogbole GI. Clinical-radiological improvement following low-tech surgical treatment of an extensive cervical-medullary idiopathic syringomyelia in a low-resource African neurosurgical practice. Neurosurg Rev 2015; 38:579-83; discussion 583. [PMID: 25697142 DOI: 10.1007/s10143-015-0618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
Abstract
Surgical intervention is not so commonly deployed for idiopathic syringomyelia, even the symptomatic ones; is only undertaken, in the current era, after thorough clinical evaluation and extensive high-resolution neuroimaging; and is more assuredly performed, high-tech, in health facilities in the developed world with cutting edge logistic supports. In the practice environment of a low-resource African developing country, a 41-year-old young man recently presented in severe clinical-neurological deficit, Nurick grade 5, with an extensive cervical-medullary idiopathic syringomyelia. In spite of severe preoperative and intraoperative resource limitations, he successfully underwent spinal surgical decompression, fenestration of syrinx, and expansile duraplasty. He improved clinically postoperatively and achieved mobility, Nurick grade 3, before hospital discharge. He sustained this improvement, Nurick grade 3 to 2, 20 months post-op. He is now independent, needing only a walking stick to aid ambulation, and an MRI at this time showed only minimal focal post-op changes but total disappearance of the syrinx.
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Affiliation(s)
- Amos O Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, UCH, Ibadan, Nigeria,
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Soo TM, Sandquist L, Tong D, Barrett R. Surgical treatment of idiopathic syringomyelia: Silastic wedge syringosubarachnoid shunting technique. Surg Neurol Int 2014; 5:114. [PMID: 25101209 PMCID: PMC4123260 DOI: 10.4103/2152-7806.137536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/07/2014] [Indexed: 11/23/2022] Open
Abstract
Background: The underlying pathophysiology leading to syringomyelia is elusive with multiple flow-related theories constituting our current limited understanding of the disease process. Syringomyelia is associated with pathologies related to the disturbance of cerebral spinal fluid flow found in conditions such as Chiari I malformations, spinal malignancy, spinal cord tethering, trauma, or arachnoid adhesions. Our aim is to describe a unique surgical shunting technique used to treat refractory cases of idiopathic syringomyelia. Methods: Five patients, aged 22-50, presented with progressive neurologic symptoms associated with an idiopathic syrinx. All underwent decompressive laminectomy surgery with syringosubarachnoid shunting using the silastic wedge technique. Results: In five cases of idiopathic syringomyelia, clinical and radiographic follow up ranges from 3 to 36 months. Three patients have radiographic and clinical follow up greater than 24 months. All patients improved clinically and their symptoms have been stable. Conclusions: Shunting procedures for the syringomyelia disease spectrum have been criticized due to the inconsistent long-term outcomes. This surgical technique used to treat symptomatic idiopathic syringomyelia has been devised based on our intraoperative experience, surgical outcomes, and evaluation of the literature. The purpose of the wedges is to preserve patency of the communication between the syrinx cavity and the expanded subarachnoid space by preventing healing of the myelotomy edges and by maintaining an artificial conduit between the syrinx cavity and the subarachnoid space. Although short-term results are promising, continued long-term follow up is needed to determine the ultimate success of the silastic wedge shunting procedure.
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Affiliation(s)
- Teck M Soo
- Michigan Spine and Brain Surgeons, PLLC, Southfield, MI, USA
| | - Lee Sandquist
- Section of Neurosurgery, Department of Surgery, Providence Hospital and Medical Centers, Southfield and Novi, USA
| | - Doris Tong
- Michigan Spine and Brain Surgeons, PLLC, Southfield, MI, USA
| | - Ryan Barrett
- Michigan Spine and Brain Surgeons, PLLC, Southfield, MI, USA
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Clinical course of incidental syringomyelia without predisposing pathologies. J Clin Neurosci 2012; 19:665-8. [DOI: 10.1016/j.jocn.2011.07.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 07/08/2011] [Accepted: 07/12/2011] [Indexed: 11/19/2022]
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Roy AK, Slimack NP, Ganju A. Idiopathic syringomyelia: retrospective case series, comprehensive review, and update on management. Neurosurg Focus 2011; 31:E15. [DOI: 10.3171/2011.9.focus11198] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Object
A syrinx is a fluid-filled cavity within the spinal cord that can be an incidental finding or it can be accompanied by symptoms of pain and temperature insensitivity. Although it is most commonly associated with Chiari malformation Type I, the advancement of imaging techniques has resulted in more incidental idiopathic syringes that are not associated with Chiari, tumor, trauma, or postinfectious causes. The authors present a comprehensive review and management strategies for the idiopathic variant of syringomyelia.
Methods
The authors retrospectively identified 8 idiopathic cases of syringomyelia at their institution during the last 6 years. A PubMed/Medline literature review yielded an additional 38 articles.
Results
Two of the authors' patients underwent surgical treatment that included a combination of laminectomy, lysis of adhesions, duraplasty, and syrinx fenestration. The remaining 6 patients were treated conservatively and had neurologically stable outcomes. Review of the literature suggests that an etiology-driven approach is essential in the diagnosis and management of syringomyelia, although conservative management suffices for most cases. In particular, it is important to look at disturbances in CSF flow, as well as structural abnormalities including arachnoid webs, cysts, scars, and a diminutive posterior fossa.
Conclusions
The precise etiology for idiopathic syringomyelia (IS) is still unclear, although conceptual advances have been made toward the overall understanding of the pathophysiology of IS. Various theories include the cerebellar piston theory, intramedullary pulse pressure theory, and increased spinal subarachnoid pressure. For most patients with IS, conservative management works well. Continued progression of symptoms, however, could be approached using decompressive strategies such as laminectomy, lysis of adhesions, and craniocervical decompression, depending on the level of pathology. Management for patients with progressive neurological dysfunction and the lack of flow disturbance is unclear, although syringosubarachnoid shunting can be considered.
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Sponseller BA, Sponseller BT, Alcott CJ, Kline K, Hostetter J, Reinertson EL, Fales-Williams A. Syringohydromyelia in horses: 3 cases. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2011; 52:147-152. [PMID: 21532819 PMCID: PMC3022450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Syringomyelia and hydromyelia are cavitary lesions of the spinal cord that may be acquired or congenital. These lesions are not frequently reported in large animal species. The presenting complaints, clinical, gross pathological, and histopathologic findings of 2 cases of syringomyelia and 1 case of hydromyelia in horses are described.
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Affiliation(s)
- Brett A Sponseller
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa 50011, USA.
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Kato N, Tanaka T, Nagashima H, Arai T, Hasegawa Y, Tani S, Abe T. Syrinx disappearance following laminoplasty in cervical canal stenosis associated with Chiari malformation--case report. Neurol Med Chir (Tokyo) 2010; 50:172-4. [PMID: 20185889 DOI: 10.2176/nmc.50.172] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 50-year-old woman presented with nuchal pain, clumsiness in both hands, and gait disturbance. Cervical magnetic resonance (MR) imaging showed cervical canal stenosis at C3-C7 levels associated with a syrinx and cerebellar tonsillar herniation. The patient underwent C3-C7 laminoplasty. Her symptoms improved completely, and the patient was discharged 10 days after operation. Postoperative MR imaging showed disappearance of the syrinx. This case suggests that cerebellar tonsillar herniation may not cause syringomyelia. Posterior decompression, such as laminectomy and laminoplasty, without foramen magnum decompression may be an appropriate surgical strategy for diffuse cervical canal stenosis associated with syringomyelia below the narrow canal, even in the presence of co-existing Chiari malformation.
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Affiliation(s)
- Naoki Kato
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Kashiwa, Chiba
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