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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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Zhang P, Liu H, Sun Z, Guo Y, Wang G, Wang JJ. Ultrafine Flexible endoscope visualization to assist in the removal of a huge spinal extradural arachnoid cyst: a case report and literature review. World Neurosurg 2021; 159:130-133. [PMID: 34973437 DOI: 10.1016/j.wneu.2021.12.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Peihai Zhang
- Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing 102218 China.
| | - Huiting Liu
- Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing 102218 China
| | - Zhenxin Sun
- Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing 102218 China
| | - Yi Guo
- Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing 102218 China
| | - Guihuai Wang
- Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing 102218 China
| | - James Jin Wang
- Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing 102218 China
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Abstract
Cervical vertebral compressive myelopathy (CVCM) represents the most significant disease of the spinal cord in horses for which surgical treatment is described. Current surgical methods used include ventral interbody fusion with kerf cut cylinders and dorsal laminectomy. Polyaxial pedicle screw and rod constructs and ventral locking compression plating have been introduced in the treatment of equine CVCM and present promising alternative approaches to achieve ventral interbody fusion. Advancements in diagnostic imaging and endoscopy of the cervical vertebral canal may improve reliable preoperative identification of the exact locations of spinal cord compression in horses with CVCM to improve postoperative outcomes.
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Affiliation(s)
- Lynn Pezzanite
- Translational Medicine Institute, Department of Clinical Sciences, Colorado State University, 300 W Drake Road, Fort Collins, CO 80523, USA
| | - Jeremiah Easley
- Preclinical Surgical Research Laboratory, Department of Clinical Sciences, Colorado State University, 300 W Drake Road, Fort Collins, CO 80523, USA.
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4
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Stretching of roots contributes to the pathophysiology of radiculopathies. Joint Bone Spine 2018; 85:41-45. [DOI: 10.1016/j.jbspin.2017.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/05/2017] [Indexed: 12/26/2022]
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Shrauner B, Blikslager A, Davis J, Campbell N, Law M, Lustgarten M, Prange T. Feasibility and safety of lumbosacral epiduroscopy in the standing horse. Equine Vet J 2016; 49:322-328. [DOI: 10.1111/evj.12591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/09/2016] [Indexed: 12/13/2022]
Affiliation(s)
- B. Shrauner
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - A. Blikslager
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - J. Davis
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - N. Campbell
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - M. Law
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - M. Lustgarten
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - T. Prange
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
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Yörükoğlu AG, Tahta A, Akçakaya MO, Sabancı PA, Aras Y, Aydoseli A, Dolgun M, Sencer A, Hepgül K. Percutaneous Fully Endoscopic İnterlaminar Approach to the Filum Terminale: A Cadaveric Study. World Neurosurg 2016; 92:402-406. [PMID: 27241095 DOI: 10.1016/j.wneu.2016.05.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate the utility, safety, and feasibility of a novel endoscopic technique for the visualization and surgical manipulation of the filum terminale in fresh postmortem adult human cadavers. METHODS The filums from 18 fresh postmortem adult human cadavers were explored with a percutaneous fully endoscopic interlaminar approach. After the filum was identified and the nerve roots were dissected away from it, the filum was cut. A specimen was sent for histopathologic examination. RESULTS In 15 of 18 (83%) cadavers, the filum terminale could be visualized. A specimen for histopathologic examination was obtained from 11 of 15 (73%) visualized filums. Histopathologic examination revealed that 2 of them were fatty filums, 7 were normal filums, and 2 were peripheral nerves. CONCLUSIONS We have described a successful and feasible percutaneous fully endoscopic interlaminar approach to the filum terminale. This technique provides a smaller skin incision, narrow durotomy, and minimal tissue damage. Animal studies are necessary to prove the feasibility and safety of our method before clinical use.
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Affiliation(s)
| | - Alican Tahta
- Department of Neurosurgery, Iğdır State Hospital, Iğdır, Turkey
| | | | - Pulat Akın Sabancı
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Yavuz Aras
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydın Aydoseli
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Müge Dolgun
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Altay Sencer
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Kemal Hepgül
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
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Prange T, Shrauner BD, Blikslager AT. Epiduroscopy of the lumbosacral vertebral canal in the horse: Technique and endoscopic anatomy. Equine Vet J 2015; 48:125-9. [DOI: 10.1111/evj.12470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/14/2015] [Indexed: 11/29/2022]
Affiliation(s)
- T. Prange
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - B. D. Shrauner
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
| | - A. T. Blikslager
- College of Veterinary Medicine; North Carolina State University; Raleigh USA
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Chern JJ, Gordon AS, Naftel RP, Tubbs RS, Oakes WJ, Wellons JC. Intradural spinal endoscopy in children. J Neurosurg Pediatr 2011; 8:107-11. [PMID: 21721897 DOI: 10.3171/2011.4.peds10533] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial endoscopy in the treatment of hydrocephalus, arachnoid cysts, or brain tumors has gained wide acceptance, but the use of endoscopy for intradural navigation in the pediatric spine has received much less attention. The aim of the authors' present study was to analyze their experience in using spinal endoscopy to treat various pathologies of the spinal canal. The authors performed a retrospective review of intradural spinal endoscopic cases at their institution. They describe 4 representative cases, including an arachnoid cyst, intrinsic spinal cord tumor, holocord syrinx, and split cord malformation. Intradural spinal endoscopy was useful in treating the aforementioned lesions. It resulted in a more limited laminectomy and myelotomy, and it assisted in identifying a residual spinal cord tumor. It was also useful in the fenestration of a multilevel arachnoid cyst and in confirming communication of fluid spaces in the setting of a complex holocord syrinx. Endoscopy aided in the visualization of the spinal cord to ensure the absence of tethering in the case of a long-length Type II split spinal cord malformation. Conclusions Based on their experience, the authors found intradural endoscopy to be a useful surgical adjunct and one that helped to decrease morbidity through reduced laminectomy and myelotomy. With advances in technology, the authors believe that intradural endoscopy will begin to be used by more neurosurgeons for treating diseases of this anatomical region.
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Affiliation(s)
- Joshua J Chern
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA
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Endoscope-assisted surgery of spinal intradural adhesions in the presence of cerebrospinal fluid flow obstruction. Spine (Phila Pa 1976) 2011; 36:E773-9. [PMID: 21289584 DOI: 10.1097/brs.0b013e3181fb8698] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To investigate whether the adjunctive use of endoscopy of the subarachnoid space (arachnoscopy) can improve the success of microsurgery for spinal arachnoid adhesions. SUMMARY OF BACKGROUND DATA Intradural adhesions that obstruct pulsatile cerebrospinal fluid (CSF) flow are a typical spinal cause of syringomyelia. Phase-contrast magnetic resonance imaging (MRI) allows CSF flow obstructions to be reliably localized. The treatment of choice is the microsurgical removal of CSF flow obstructions caused by adhesions. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. In this study, we therefore investigated whether endoscopic assistance allows adhesions in the vicinity of the exposed area to be detected. METHODS From 2006 to 2009, a single neurosurgeon performed 27 consecutive microsurgical procedures with endoscopic assistance in 25 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. CSF flow was studied before and after surgery in all patients using phase-contrast MRI in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine. RESULTS In all 27 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MRI. In 25 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In six cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery.Postoperative MRI scans demonstrated free CSF flow in all patients and a decrease in syrinx size in six patients. CONCLUSION Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space, which would remain undetected by microscopy alone.
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Mauer UM, Gottschalk A, Kunz U, Schulz C. Arachnoscopy: a special application of spinal intradural endoscopy. Neurosurg Focus 2011; 30:E7. [DOI: 10.3171/2011.1.focus10291] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The microsurgical removal of obstructions to CSF flow is the treatment of choice in the surgical management of intradural arachnoid cysts. Cardiac-gated phase-contrast MR imaging is an effective tool for the primary diagnosis and localization of arachnoid cysts. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. The use of a thin endoscope allows surgeons to assess intraoperatively whether the exposure is wide enough.
Methods
Between 2006 and 2010, a single neurosurgeon performed 31 consecutive microsurgical procedures with endoscopic assistance in 28 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. The CSF flow was studied before and after surgery in all patients by using phase-contrast MR imaging in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine.
Results
In all 31 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MR imaging. In 29 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In 6 cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space that were not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery.
Conclusions
Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space that would remain undetected by microscopy alone.
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Prange T, Derksen FJ, Stick JA, Garcia-Pereira FL, Carr EA. Cervical vertebral canal endoscopy in the horse: intra- and post operative observations. Equine Vet J 2011; 43:404-11. [PMID: 21496080 DOI: 10.1111/j.2042-3306.2010.00310.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
REASONS FOR PERFORMING STUDY Despite modern medical diagnostic imaging, it is not possible to identify reliably the exact location of spinal cord compression in horses with cervical vertebral stenotic myelopathy (CVSM). Vertebral canal endoscopy has been successfully used in man and a technique for cervical vertebral canal endoscopy (CVCE) has been described in equine cadavers. OBJECTIVE To determine the feasibility and safety of CVCE in healthy mature horses. METHODS Six healthy mature horses were anaesthetised. A flexible videoendoscope was subsequently introduced via the atlanto-occipital space into the epidural space (epiduroscopy, Horses 1-3) or the subarachnoid space (myeloscopy, Horses 4-6) and advanced to the 8th cervical nerve. Neurological examinations were performed after surgery and lumbosacral cerebrospinal fluid (CSF) analysed in horses that had undergone myeloscopy. RESULTS All procedures were completed successfully and all horses recovered from anaesthesia. Anatomical structures in the epidural space (including the dura mater, nerve roots, fat and blood vessels) and subarachnoid space (including the spinal cord, blood vessels, arachnoid trabeculations, nerve roots and the external branch of the accessory nerve) were identified. During epiduroscopy, a significant increase in mean arterial pressure was recognised, when repeated injections of electrolyte solution into the epidural space were performed. In one horse of the myeloscopy group, subarachnoid haemorrhage and air occurred, resulting in transient post operative ataxia and muscle fasciculations. No complications during or after myeloscopy were observed in the other horses. CSF analysis indicated mild inflammation on Day 7 with values approaching normal 21 days after surgery. CONCLUSIONS Endoscopic examination of the epidural and subarachnoid space from the atlanto-occipital space to the 8th cervical nerve is possible and can be safely performed in healthy horses. POTENTIAL RELEVANCE Cervical vertebral canal endoscopy might allow accurate identification of the compression site in horses with CVSM and aid diagnosis of other lesions within the cervical vertebral canal.
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Affiliation(s)
- T Prange
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, MI, USA.
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PRANGE T, DERKSEN FJ, STICK JA, GARCIA-PEREIRA FL. Endoscopic anatomy of the cervical vertebral canal in the horse: A cadaver study. Equine Vet J 2010; 43:317-23. [DOI: 10.1111/j.2042-3306.2010.00170.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shimoji K, Ogura M, Gamou S, Yunokawa S, Sakamoto H, Fukuda S, Morita S. A new approach for observing cerebral cisterns and ventricles via a percutaneous lumbosacral route by using fine, flexible fiberscopes. J Neurosurg 2009; 110:376-81. [DOI: 10.3171/2007.12.17287] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
To establish a new method for the diagnosis of central nervous system diseases, the authors visualized the cerebral cisterns and ventricles via a percutaneous lumbosacral route by using newly developed fine, flexible fiberscopes.
Methods
Fine, flexible fiberscopes, 0.9 and 1.4 mm in diameter, were introduced up to the cerebral cisterns and ventricles through a percutaneous lumbosacral route in awake patients with chronic headache and/or neck pain or those undergoing spinal surgery and in whom MR imaging did not disclose any particular abnormalities in the brain. A lumbosacral subarachnoid puncture was made with a modified method of a continuous epidural block.
Results
In 25 of 31 patients tested, the cerebellomedullary and/or pontine/interpeduncular cisterns were easily and safely reached, and the brainstem structures were visualized. Advancement of the fiberscope beyond the spinal level was abandoned in 6 patients with adhesive spinal arachnoiditis, because the fiberscopes encountered resistance seemingly caused by arachnoid adhesions. Further advancement of the fiberscopes up to the fourth and third ventricles was successfully achieved in 2 patients. A number of arachnoid filaments were found in the cerebellomedullary cistern in 4 patients: 2 with chronic spinal arachnoiditis, 1 with a spinal arachnoid cyst, and 1 with posttraumatic pain syndrome. None of the patients reported pain or any major complication except a postspinal headache and light fever, which were encountered in 4 and 1 patient, respectively.
Conclusions
The approach to the supraspinal structures via the lumbosacral route by using a fine, flexible fiberscope may provide a new, minimally invasive, and safe way to observe the cerebral cisterns and/or brainstem regions.
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Affiliation(s)
- Koki Shimoji
- 1Department of Human Sciences, Ube Frontier University Graduate School, Ube, Yamaguchi
- 2Pain Control Institute, Shinjuku, Tokyo
- 3Department of Anesthesiology, Niigata University Graduate School of Medicine, Niigata; and
| | - Mai Ogura
- 4Department of Anesthesiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Sanae Gamou
- 4Department of Anesthesiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Seki Yunokawa
- 4Department of Anesthesiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hidetoshi Sakamoto
- 4Department of Anesthesiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Satoru Fukuda
- 4Department of Anesthesiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Shigeho Morita
- 4Department of Anesthesiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
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Aldrete JA. Arachnoiditis and Related Conditions. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50090-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Dulou R, Blondet E, Dutertre G, Delmas JM, De Soultrait F, Pernot P. Compression médullaire par kystes arachnoïdiens. Neurochirurgie 2006; 52:381-6. [PMID: 17088720 DOI: 10.1016/s0028-3770(06)71234-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Spinal arachnoid cysts are considered to be rare entities, intradural locations are even less common. We report two cases of patients (two women aged 77- and 21-year-old) who presented spinal cord compression by intradural arachnoid cysts. For the second patient, repeated surgical procedures were necessary to improve the neurological status. After presenting the case reports, we expose the pathophysiological mechanisms and clinical features, and the surgical difficulties of treating this rare cause of spinal cord compression.
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Affiliation(s)
- R Dulou
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Percy, 101, avenue Henri-Barbusse, 92141 Clamart.
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