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Akgun MY, Ates O, Akyoldas G, Tepebasili MA, Sasani M, Oktenoglu T, Ozer AF. Does long segment subarachnoido-subarachnoid shunt prevent posttraumatic and postinfectious spinal arachnoid cyst recurrence?: technical note and case series. Neurochirurgie 2024; 70:101555. [PMID: 38520969 DOI: 10.1016/j.neuchi.2024.101555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/15/2024] [Accepted: 03/19/2024] [Indexed: 03/25/2024]
Abstract
Syringomyelia associated with extensive spinal adhesive arachnoiditis (SAA) can be defined as a rare but progressive disease with potentially devastating clinical consequences. Diagnosis can be challenging due to the absence of specific clinical findings, confusion with other pathologies, and late imaging modalities. The treatment strategy for syringomyelia associated with extensive SAA should include direct drainage of the syringomyelia, and dissection of the adhesive arachnoid with expansive duraplasty. Hence, several approaches have been reported for arachnoid dissection and decompression of the subarachnoid space. The high risk of recurrence after the operation is one of the most challenging situations. First two cases were operated previously, and the cyst walls were removed and anastomosed to the intact subarachnoid space at the upper and lower ends by each other. However, in both cases, the cyst recurred after a short time and they were anastomosed again in our clinic. A subarachnoid-subarachnoid shunt was placed with a multi-hole silicone tube extending to the proximal and distal intact subarachnoid spaces and passing through the cyst removal area. In our third case, the shunt system we described was applied directly, and satisfactory results were obtained in the clinical follow-up of the patient. It has been demonstrated that subarachnoido-subarachnoid shunt is a very satisfactory treatment option for this type of pathology, which is difficult to follow and treat.
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Affiliation(s)
- Mehmet Yigit Akgun
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Ozkan Ates
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Goktug Akyoldas
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
| | | | - Mehdi Sasani
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Tunc Oktenoglu
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey
| | - Ali Fahir Ozer
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey; Spine Center, Koc University Hospital, Istanbul, Turkey; Bioengineering and Orthopaedic Surgery Colleges of Engineering and Medicine, University of Toledo, Toledo, OH, USA.
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Segura-Lozano MA, Carranza-Rentería O, Velázquez-Delgado G, Munguía-Rodríguez AG. Histochemical Analysis of Altered Arachnoid Tissue in Patients With Paroxysmal Trigeminal Neuralgia With Concomitant Continuous Pain. Cureus 2024; 16:e61502. [PMID: 38855490 PMCID: PMC11156573 DOI: 10.7759/cureus.61502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 06/11/2024] Open
Abstract
Background Trigeminal neuralgia (TN) is a craniofacial pain characterized by sudden onset, brief, severe, recurrent shooting pain within one or more branches of the trigeminal nerve (CN V). Based on its clinical presentation, TN may be classified as purely paroxysmal or paroxysmal with concomitant continuous pain (CCP), previously known as typical and atypical, respectively. Microvascular decompression (MVD) surgery for releasing the CN V from a neurovascular conflict is an effective and safe treatment for TN. During MVD of patients manifesting TN with CCP, the involvement of an abnormal arachnoid tissue is a common finding. The etiology and pathophysiology behind the appearance of this tissue are unknown; however, it is more commonly found in this variant of the disease. Methods From January 2015 to December 2016, a total of 330 patients diagnosed with TN were evaluated at our clinic. Among them, 31 individuals (9.4%) presented with paroxysmal TN with CCP, with 16 patients (51.6%) undergoing MVD. During surgery, samples of altered arachnoid tissue were collected from five patients and subjected to Hematoxylin-Eosin staining and immunohistochemistry for S100 and CD2 Results In a long-term follow-up, 80% of patients operated by DMV remains pain free. Analysis of biopsies revealed chronic fibrosis (n=4), hyperplasia of neurothelial cells (n=3), dystrophic calcifications (n=1). Immunohistochemistry was positive for S100 (n=3) and CD20 (n=3) inflammatory markers. Conclusion Chronic inflammation in the arachnoid tissue involved in paroxysmal TN with CCP could be a contributor to the pathophysiology of this variant of the disease.
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Gilbert V, Chakir S, Peeters JB, Hage GE, Labidi M, Jabre R, Chaalala C, Bojanowski MW. Craniovertebral and spinal adhesive arachnoiditis: a late complication of ruptured vertebral and posterior inferior cerebellar arteries aneurysms. Neurochirurgie 2024; 70:101535. [PMID: 38324943 DOI: 10.1016/j.neuchi.2024.101535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Adhesive arachnoiditis is a rare yet serious complication that may occur following subarachnoid hemorrhage (SAH). In this circumstance, it is mainly due to ruptured vertebral artery (VA) or posterior inferior artery (PICA) aneurysms. It disrupts cerebrospinal fluid (CSF) flow leading to complications such as spinal arachnoiditis, syringomyelia, trapped 4th ventricle, or a combination of these conditions. Evidence for effective treatment strategies is currently limited. We aimed to review the epidemiology, clinical characteristics, treatment, complications, outcomes, and prognosis of cranio-vertebral junction and spinal adhesive arachnoiditis resulting from ruptured VA and PICA aneurysms. METHODS This study involved a comprehensive literature review and complemented by our own case. We focused on adult cases of arachnoiditis, syringomyelia, and trapped 4th ventricle with SAH caused by ruptured VA or PICA aneurysms, excluding cases unrelated to these aneurysms and those with insufficient data. RESULTS The study included 22 patients, with a mean age of 52.4 years. Symptoms commonly manifest within the first year after SAH and timely diagnosis requires a high index of suspicion. Treatment approaches included lysis of adhesions and various shunt procedures. Most patients showed improvement post-treatment, though symptom recurrence is significant. CONCLUSION Adhesive arachnoiditis is a critical complication following SAH, most commonly from ruptured VA and PICA aneurysms. Early detection and individualized treatment based on the type of arachnoiditis and CSF flow impact are crucial for effective management. This study underscores the need for tailored treatment strategies and further research in this field.
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Affiliation(s)
- Valérie Gilbert
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Sara Chakir
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Jean-Baptiste Peeters
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Gilles El Hage
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Moujahed Labidi
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Roland Jabre
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada.
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4
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El-Ghandour NMF. Commentary: Thoracic Laminoplasty for Post-Traumatic Syrinx Fenestration with Duraplasty, Syringo-Subarachnoid, and Subarachnoid-Subarachnoid Shunts: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:475-476. [PMID: 38032209 DOI: 10.1227/ons.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
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5
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Her YF, McWilliams RT, Ovrom EA, Watson JC. Corticosteroid Therapy in Acute and Subacute Arachnoiditis - A Case Series. Int Med Case Rep J 2024; 17:235-240. [PMID: 38559495 PMCID: PMC10981380 DOI: 10.2147/imcrj.s445705] [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: 11/04/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
Arachnoiditis is difficult to treat. Patients are often left frustrated after many failed trials of conservative therapies without symptom resolution. Surgery may provide symptom relief for a short period of time, but their pain often returned. Herein, we present three cases of acute arachnoiditis following three different pain procedures: epidural blood patch, IDDS implant, and epidural steroid injection. The patients were diagnosed and treated with corticosteroids within 10 days of the procedure. Two patients were treated with the same oral steroid regiment, while the third patient was treated with both oral and IV steroid. All three patients had good outcomes at the completion of their steroid therapy. This case series may provide insight into treating acute and subacute arachnoiditis from pain interventions.
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Affiliation(s)
- Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | | | - Erik A Ovrom
- Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - James C Watson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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6
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Perillo T, Vitiello A, Carotenuto B, Perrotta M, Serino A, Manto A. Spontaneous epidural and subdural hematomas of the spine: Review of anatomy and imaging findings. Neuroradiol J 2024; 37:23-30. [PMID: 36908230 PMCID: PMC10863578 DOI: 10.1177/19714009231163553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Spontaneous epidural (SEH) and subdural hematomas (SSH) of the spine are a rare cause of spinal injury and morbidity. They often present in the emergency setting, though magnetic resonance imaging is the gold-standard for diagnosis. Knowledge of anatomy, and in particular of the dural layers of the spine, is crucial to understand the location of SEH and SSH and their relationship with spinal structure. In this pictorial review, we aim to explain imaging features of the SEH and SSH, and to rule out their main differential diagnosis.
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Affiliation(s)
- Teresa Perillo
- Department of Neuroradiology, “Umberto I” Hospital, ASL Salerno, Italy
| | - Alessio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Naples, Italy
| | | | - Marianna Perrotta
- Department of Neuroradiology, “Umberto I” Hospital, ASL Salerno, Italy
| | - Antonietta Serino
- Department of Neuroradiology, “Umberto I” Hospital, ASL Salerno, Italy
| | - Andrea Manto
- Department of Neuroradiology, “Umberto I” Hospital, ASL Salerno, Italy
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7
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Bansal K, Guha M, Gupta A. Spontaneous-Onset Delayed Spinal Arachnoiditis With Dorsal Cord Herniation in a 29-Year-Old Paraplegic Patient: A Case Report. Cureus 2023; 15:e51374. [PMID: 38292951 PMCID: PMC10825720 DOI: 10.7759/cureus.51374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
Spinal adhesive arachnoiditis is a rare occurrence with a diverse etiology. The clinical picture is not universal, and varying degrees of neurodeficit have been mentioned. Spontaneous spinal cord herniation or idiopathic spinal cord herniation occurs due to displacement of the cord through a dural or arachnoid defect. We report a case of a 29-year-old male paraplegic patient with a nontraumatic spinal cord injury (SCI) following surgery for an intradural extramedullary lesion at T10-T11 level who developed loss of truncal balance after two years of the index surgery. After a thorough clinical examination and MRI as well as other investigations, the patient was diagnosed as having spontaneous-onset delayed spinal arachnoiditis with dorsal cord herniation through the laminectomy window with effacement of neural tissue and ascending edema up to T6 level. A new-onset weakness or the development of an ascending loss of sensory level with a loss of truncal balance should alarm the therapist about some new pathology happening at the cord level in patients with SCI. In this regard, spinal adhesive arachnoiditis with or without cord herniation should always be suspected in a paraplegic patient with delayed-onset deterioration of neurology. Differential diagnoses like arachnoid web and arachnoid cysts should also be kept in mind.
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Affiliation(s)
- Kuldeep Bansal
- Spine Services, Indian Spinal Injuries Center, New Delhi, IND
| | - Mayukh Guha
- Spine Services, Indian Spinal Injuries Center, New Delhi, IND
| | - Anuj Gupta
- Spine Surgery, Max Superspeciality Hospital, New Delhi, IND
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8
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Andour H, Abide Z, Cherraqi A, Mouhassani M, En-Nafaa I, Fenni J, Lahkim M. Pain in the back after a brain trauma-The revelation of a spinal subdural hematoma: A case report with a literature review. SAGE Open Med Case Rep 2023; 11:2050313X231204771. [PMID: 37829351 PMCID: PMC10566262 DOI: 10.1177/2050313x231204771] [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: 01/15/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023] Open
Abstract
Traumatic spinal subdural hematoma is a rare condition mostly favored by an anticoagulation therapy, a traumatic lumbar puncture, a hematologic disease, or an epidural anesthesia. This pathological condition can be subtle or be at the origin of a compression of the spinal cord and the rootlets resulting in an irreversible damage if an emergent surgery is not performed. We report the case of a 45-year-old man who has been a victim of a brain trauma which resulted in a cerebral edema. A week later, the patient came to the emergency department for disabling abdominal pain, predominant in the back. An abdominal computed tomography was performed and showed an incidentally spontaneous hyperdensity in the spinal cord, which raised the suspicion of a spinal hematoma that has been confirmed through spine magnetic resonance imaging. In this case, we discuss the different subtypes of spinal hematoma. We recall the main differential diagnoses to help setting an accurate diagnosis and to not delay the adequate therapy that is most of the time emergent when indicated.
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Affiliation(s)
- Hajar Andour
- Radiology Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
| | - Zakaria Abide
- Radiology Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
| | - Amine Cherraqi
- Radiology Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
| | - Mohamed Mouhassani
- Neurosurgery Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
| | - Issam En-Nafaa
- Radiology Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
| | - Jamal Fenni
- Radiology Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
| | - Mohamed Lahkim
- Radiology Department, Military Hospital Mohamed V-Rabat, Rabat, Morocco
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9
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Tu YT, Chiang YH, Lin JH. Delta Cord as a Radiological Localization Sign of Postoperative Adhesive Arachnoiditis: A Case Report and Literature Review. Diagnostics (Basel) 2023; 13:2942. [PMID: 37761311 PMCID: PMC10529766 DOI: 10.3390/diagnostics13182942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Postoperative adhesive arachnoiditis is an inflammatory response of the spinal leptomeninges that occurs after surgery and results in scar formation in the avascular nature of the arachnoid layer. Clinical manifestations of postoperative adhesive arachnoiditis include pain, sensory deficits, motor dysfunction, reflex abnormalities, and bladder or bowel impairment. In magnetic resonance imaging scans, signs of postoperative adhesive arachnoiditis can vary; however, some indicators can assist surgeons in locating the lesion accurately and, thus, in planning effective surgical interventions. This paper reports the case of a 37-year-old man with postoperative adhesive arachnoiditis after two surgeries for Chiari I malformation. This case illustrates the progressive development of the "delta cord sign", which refers to the formation of a thick arachnoid band causing the spinal cord to adopt a triangular shape in the axial view. This phenomenon is accompanied by the sequential occurrence of syringomyelia. During intraoperative examination, we identified the presence of the delta cord sign, which had been formed by an arachnoid scar that tethered the dorsal spinal cord to the dura. This discovery enabled us to precisely pinpoint the location of the arachnoid scar and thus provided us with guidance that enabled us to avoid unnecessary exploration of unaffected structures during the procedure. Other localization signs were also reviewed.
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Affiliation(s)
- Yi-Ting Tu
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei City 110301, Taiwan; (Y.-T.T.); (Y.-H.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei City 110301, Taiwan
| | - Yung-Hsiao Chiang
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei City 110301, Taiwan; (Y.-T.T.); (Y.-H.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Neurosurgery, Department of Surgery, School of Medicine, Taipei Medical University, Taipei City 110301, Taiwan
| | - Jiann-Her Lin
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei City 110301, Taiwan; (Y.-T.T.); (Y.-H.C.)
- Taipei Neuroscience Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Neurosurgery, Department of Surgery, School of Medicine, Taipei Medical University, Taipei City 110301, Taiwan
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10
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Bee SWL, Hoe RHM, Goh AGW, Goh Y, Chan VEY, Yong C, Lim MC, Kee CK, Kei PL. Cauda equina thickening: an approach to MRI findings. Clin Radiol 2023:S0009-9260(23)00141-1. [PMID: 37179144 DOI: 10.1016/j.crad.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/15/2023] [Accepted: 04/05/2023] [Indexed: 05/15/2023]
Abstract
There are many causes of cauda equina (CE) thickening on neuroimaging of the lumbar spine. The imaging features of CE thickening for the various conditions often overlap and are non-specific to clinch a definite diagnosis. Hence, the imaging findings have to be discerned in accordance with the patient's presenting history, clinical examination findings, and results from electrophysiology and laboratory studies. In this review, the authors aim to supplement the existing literature on imaging findings of CE thickening with a diagnostic framework for clinical workup. The authors also aim to familiarise readers with the interpretation of CE thickening on magnetic resonance imaging (MRI) and would like to illustrate the normal variants and pitfalls that could be mistaken for abnormal results.
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Affiliation(s)
- S W L Bee
- Department of Diagnostic Imaging, National University Hospital, Singapore.
| | - R H M Hoe
- Department of Neurology, National Neuroscience Institute, Singapore
| | - A G W Goh
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Y Goh
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - V E Y Chan
- Department of Neuroradiology, National Neuroscience Institute, Singapore
| | - C Yong
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - M C Lim
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - C K Kee
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - P L Kei
- Department of Diagnostic Imaging, Ng Teng Fong General Hospital, Singapore
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11
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Multiple Genetic Loci Associated with Pug Dog Thoracolumbar Myelopathy. Genes (Basel) 2023; 14:genes14020385. [PMID: 36833311 PMCID: PMC9957375 DOI: 10.3390/genes14020385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Pug dogs with thoracolumbar myelopathy (PDM) present with a specific clinical phenotype that includes progressive pelvic limb ataxia and paresis, commonly accompanied by incontinence. Vertebral column malformations and lesions, excessive scar tissue of the meninges, and central nervous system inflammation have been described. PDM has a late onset and affects more male than female dogs. The breed-specific presentation of the disorder suggests that genetic risk factors are involved in the disease development. To perform a genome-wide search for PDM-associated loci, we applied a Bayesian model adapted for mapping complex traits (BayesR) and a cross-population extended haplotype homozygosity test (XP-EHH) in 51 affected and 38 control pugs. Nineteen associated loci (harboring 67 genes in total, including 34 potential candidate genes) and three candidate regions under selection (with four genes within or next to the signal) were identified. The multiple candidate genes identified have implicated functions in bone homeostasis, fibrotic scar tissue, inflammatory responses, or the formation, regulation, and differentiation of cartilage, suggesting the potential relevance of these processes to the pathogenesis of PDM.
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12
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Thejeel B, Geannette CS, Roytman M, Pisapia DJ, Chazen JL, Jawetz ST. Patterns of Intrathecal Ossification in Arachnoiditis Ossificans: A Retrospective Case Series. AJNR Am J Neuroradiol 2023; 44:228-234. [PMID: 36635055 PMCID: PMC9891321 DOI: 10.3174/ajnr.a7764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023]
Abstract
Arachnoiditis ossificans is an uncommon end-stage appearance of chronic adhesive arachnoiditis. Imaging features of arachnoiditis ossificans are characteristic and should be diagnosed to avoid unnecessary intervention and guide prognosis and management. In this case series, we retrospectively analyzed CT and MR imaging of 41 patients to identify common patterns of intrathecal ossification and present the common etiologies. Thirty-two patients had a confirmed history of spinal instrumentation, 7 were discovered on imaging without prior surgical history, 1 had a history of ankylosing spondylitis, and 1 had trauma. The most frequent site of ossification was at the conus and cauda equina. Four patterns of ossification were identified, including central, nerve root encasing, weblike, and peripheral. Arachnoiditis ossificans is an important, likely under-recognized consideration in patients who present with back pain. Diagnosis can be made readily on CT; MR imaging diagnosis is also possible but may be challenging.
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Affiliation(s)
- B Thejeel
- From the Department of Radiology and Diagnostic Imaging (B.T.), University of Alberta, Edmonton, Alberta, Canada
| | - C S Geannette
- Department of Radiology and Imaging (C.S.G., J.L.C., S.T.J.), Hospital for Special Surgery, New York, New York
| | - M Roytman
- Department of Radiology (M.R), New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York
| | - D J Pisapia
- Department of Pathology and Laboratory Medicine (D.J.P.), Weill Cornell Medicine, New York, New York
| | - J L Chazen
- Department of Radiology and Imaging (C.S.G., J.L.C., S.T.J.), Hospital for Special Surgery, New York, New York
| | - S T Jawetz
- Department of Radiology and Imaging (C.S.G., J.L.C., S.T.J.), Hospital for Special Surgery, New York, New York
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13
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Muacevic A, Adler JR, Medeiros F, Farid G, Santa Maria PE, Perret CM, Koester SW, Bertani R. Spinal Adhesive Arachnoiditis: A Literature Review. Cureus 2023; 15:e33697. [PMID: 36788823 PMCID: PMC9922032 DOI: 10.7759/cureus.33697] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Adhesive arachnoiditis (AA) is a rare inflammatory and scar-forming disease with several etiologies that may lead to incapacitating sequelae if not managed early. Nevertheless, as the onset of symptoms varies from days to years, the etiology is not often discovered. The disease is characterized by adhesions disrupting the cerebrospinal fluid flow and causing encapsulation and atrophy of the nerve root. Therefore, a range of clinical features may be present, including urinary, gastroenterology, dermatologic, and neurologic. In terms of diagnosis, magnetic resonance imaging is the gold standard showing pseudocysts with adherent and narrow nerve roots toward the center of the dural sac or peripherally cluster and narrow nerve roots with empty thecal sac. Despite its sensitivity and specificity, the imaging findings are not often associated with clinical manifestations, requiring treatment being based on anamneses and clinical findings. Nowadays, AA can be managed with pharmacological and non-pharmacological treatment, although none provides a completely satisfying result.
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14
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Sivasubramanian G, Kadakia S, Kim JM, Pervaiz S, Yan Y, Libke R. Spinal Arachnoiditis in Patients with Coccidioidomycosis Meningitis-Analysis of Clinical and Imaging Features. J Fungi (Basel) 2022; 8:1180. [PMID: 36354947 PMCID: PMC9697661 DOI: 10.3390/jof8111180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 06/28/2024] Open
Abstract
Background: Coccidioidomycosis meningitis (CM) is the most aggressive form of coccidioidomycosis, requiring lifelong antifungal treatment and often cerebrospinal fluid (CSF) diversion. Long-standing CM can be associated with spinal complications such as arachnoiditis. However, studies describing the frequency, clinical, and imaging characteristics of arachnoiditis in patients with CM are limited. Methods: We identified 133 patients with CM based on CSF culture, PCR, or serology between January 2010 and December 2020. Of these, 37 patients underwent spinal imaging. Data on demographics, risk factors, symptoms, antifungal therapy, surgical management, follow-up visits, adherence, serological trends, and imaging findings were reviewed. Results: Abnormal findings were observed in 30 of the 37 patients with CM who underwent spinal imaging. The imaging abnormalities noted in our study included leptomeningeal enhancement (53%), arachnoiditis (53%), syringomyelia (23%), cord signal abnormalities (10%), and osteomyelitis (7%). Of the 30 patients, 90% had symptoms, such as weakness, numbness, or urinary retention. The incidence of arachnoiditis in the present study was 12%. Higher initial CSF protein levels and intra cranial pressure were associated with a higher risk of developing arachnoiditis/syringomyelia. Management of CM was challenging, as evidenced by shunt failure (46%), medication non-compliance (57%), and lack of adequate follow-up (60%). Persistent disabilities were noted in 62% of the patients. Conclusions: Patients with CM develop spinal complications such as arachnoiditis, or syringomyelia. Many cases may go undetected due to lack of symptoms in early stages. CM management challenges such as shunt failure, lack of follow-up care, and medication noncompliance, were frequent.
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Affiliation(s)
| | - Saurin Kadakia
- Department of Internal Medicine, University of California, Fresno, CA 93701, USA
| | - Jani M. Kim
- Department of Infectious Disease, University of California, Fresno, CA 93701, USA
| | - Sarah Pervaiz
- Department of Infectious Disease, University of California, Fresno, CA 93701, USA
| | - Yueqi Yan
- HSRI Biostatistics and Data Support Core, University of California, Merced, CA 95343, USA
| | - Robert Libke
- Department of Infectious Disease, University of California, Fresno, CA 93701, USA
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Epstein NE, Agulnick MA. Perspective: Lumbar adhesive arachnoiditis (AA)/ Chronic AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Surg Neurol Int 2022; 13:507. [DOI: 10.25259/sni_943_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background:
Our hypothesis was that lumbar adhesive arachnoiditis (AA)/chronic lumbar AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Therefore, patients with these syndromes do not necessarily have to demonstrate significant radiographic abnormalities on myelograms, MyeloCT studies, and/or MR examinations. When present, typical AA/CAA findings may include; central or peripheral nerve root/cauda equina thickening/clumping (i.e. latter empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/Myelo-CT studies.
Methods :
We reviewed 3 articles and 7 clinical series that involved a total of 253 patients with AA/CAA to determine whether there was a significant correlation between these clinical syndromes, and myelographic, Myelo-CT, and/or MR imaging pathology.
Results:
We determined that patients with the clinical diagnoses of AA/CAA do not necessarily exhibit associated radiographic abnormalities. However, a subset of patients with AA/CAA may show the classical AA/CAA findings of; central or peripheral nerve root/cauda equina thickening/clumping (empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/ Myelo-CT studies.
Conclusion:
Patients with clinical diagnoses of AA/CAA do not necessary show associated neuroradiagnostic abnormalities on myelograms, Myelo-CT studies, or MR. Rather, the clinical syndromes of AA/CAA may exist alone without the requirement for radiolographic confirmation.
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Affiliation(s)
- Nancy E. Epstein
- Clinical Professor of Neurosurgery, School of Medicine, State University of NY at Stony Brook, and Editor-in-Chief Surgical Neurology International NY and ℅ Dr. Marc Agulnick 1122 Frankllin Avenue Suite 106, Garden City, NY 11530, USA,
| | - Marc A. Agulnick
- Assistant Clinical Professor of Orthopedics, NYU Langone Hospital, Long Island, NY, USA. 1122 Franklin Avenue Suite 106 Garden City, NY 11530
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16
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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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17
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Myelopathy caused by intrathecal remnants of oil-based contrast medium. J Orthop Sci 2022; 27:1159-1163. [PMID: 32111548 DOI: 10.1016/j.jos.2019.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 11/27/2019] [Accepted: 12/28/2019] [Indexed: 11/22/2022]
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18
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Nadeem SF, Baig AN, Tariq QUA, Shamim MS. Spinal arachnoiditis and syringomyelia: Review of literature with emphasis on postinfectious inflammation and treatment. Surg Neurol Int 2022; 13:299. [PMID: 35928312 PMCID: PMC9345109 DOI: 10.25259/sni_383_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Arachnoiditis refers to chronic inflammation of the arachnoid mater and subarachnoid space due to three major etiologies: chemical, mechanical, and postinfectious. As a rare disease with variable symptomatology and severity at presentation, arachnoiditis can be extremely debilitating with many complications, prominent among which is syringomyelia.
Methods:
We reviewed current literature concerning postinfectious spinal arachnoiditis and associated syringomyelia with emphasis on the treatment options that have been used to date and discuss their respective benefits and drawbacks.
Results:
It is critical to understand the natural history and potential complications of patient with postinfectious arachnoiditis. Surgical and medical treatments both have their own merits and demerits. Different surgical approaches have been employed with variable success rates.
Conclusion:
At present, no consensus exists regarding management of these patients due to the variable nature of the disease that affects treatment efficacy; however, surgical intervention in selected cases may be beneficial.
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Affiliation(s)
- Syed Faisal Nadeem
- Department of Neurosurgery, Medical College, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Ahmer Nasir Baig
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Qurat ul Ain Tariq
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
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19
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Kim JJ, Li C, Ammanuel SG, Elbayomy AM, Page PS, Ahmed AS. Candida Shunt Infection Causing Arachnoiditis and Hydrocephalus: A Case Report. Cureus 2022; 14:e23675. [PMID: 35510023 PMCID: PMC9060725 DOI: 10.7759/cureus.23675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 11/22/2022] Open
Abstract
Arachnoiditis is a relatively rare condition and can result in long-term chronic and debilitating complications if not diagnosed early and treated properly. However, diagnosis of arachnoiditis is rare and knowledge of potential causes of this condition is still sparse. Current known causes of arachnoiditis include infections, trauma, spinal tumors, and iatrogenic causes induced via neurological interventions. Here, we present a case of a 65-year-old female who presented with arachnoiditis caused by Candida albicans infection from a contaminated ventriculoperitoneal (VP) shunt, placed following the development of hydrocephalus from subarachnoid hemorrhage. During her initial assessment, the possibility of arachnoiditis was raised after spinal magnetic resonance imaging (MRI) due to leg weakness and spasms with bladder dysfunction. However, further workup was not pursued after a normal spinal angiogram and lack of constitutional symptoms. She presented six months later with symptoms of fever and lower abdominal pain. She was diagnosed with fungal arachnoiditis after a computerized tomography (CT) of the abdomen showed thickening of the fascia around the shunt catheter and fluid collections near the tip of the shunt in the abdominal cavity after hospitalization. The diagnosis was made after an ultrasound-guided tap of the same area revealed budding yeast and cerebrospinal fluid (CSF) showed growths of Candida albicans. Her shunt was removed, and she received intravenous (IV) antifungals and recovered. MRI should be considered with clinical presentations that are characteristic of arachnoiditis. Symptoms from fungal infections are usually dramatic; however, in some instances as in this case, they may follow a more progressive course. The patient should be extensively evaluated for infection, especially fungal, in interventions involving device placement even when minimally, but persistently, symptomatic.
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20
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Mastorakos P, Pomeraniec IJ, Bryant JP, Chittiboina P, Heiss JD. Flexible thecoscopy for extensive spinal arachnoiditis. J Neurosurg Spine 2022; 36:325-335. [PMID: 34598155 PMCID: PMC9382886 DOI: 10.3171/2021.4.spine21483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic adhesive spinal arachnoiditis (SA) is a complex disease process that results in spinal cord tethering, CSF flow blockage, intradural adhesions, spinal cord edema, and sometimes syringomyelia. When it is focal or restricted to fewer than 3 spinal segments, the disease responds well to open surgical approaches. More extensive arachnoiditis extending beyond 4 spinal segments has a much worse prognosis because of less adequate removal of adhesions and a higher propensity for postoperative scarring and retethering. Flexible neuroendoscopy can extend the longitudinal range of the surgical field with a minimalist approach. The authors present a cohort of patients with severe cervical and thoracic arachnoiditis and myelopathy who underwent flexible endoscopy to address arachnoiditis at spinal segments not exposed by open surgical intervention. These observations will inform subsequent efforts to improve the treatment of extensive arachnoiditis. METHODS Over a period of 3 years (2017-2020), 10 patients with progressive myelopathy were evaluated and treated for extensive SA. Seven patients had syringomyelia, 1 had spinal cord edema, and 2 had spinal cord distortion. Surgical intervention included 2- to 5-level thoracic laminectomy, microscopic lysis of adhesions, and then lysis of adhesions at adjacent spinal levels performed using a rigid or flexible endoscope. The mean follow-up was 5 months (range 2-15 months). Neurological function was examined using standard measures. MRI was used to assess syrinx resolution. RESULTS The mean length of syringes was 19.2 ± 10 cm, with a mean maximum diameter of 7.0 ± 2.9 mm. Patients underwent laminectomies averaging 3.7 ± 0.9 (range 2-5) levels in length followed by endoscopy, which expanded exposure by an average of another 2.4 extra segments (6.1 ± 4.0 levels total). Endoscopic dissection of extensive arachnoiditis in the dorsal subarachnoid space proceeded through a complex network of opaque arachnoidal bands and membranes bridging from the dorsal dura mater to the spinal cord. In less severely problematic areas, the arachnoid membrane was transparent and attached to the spinal cord through multifocal arachnoid adhesions bridging the subarachnoid space. The endoscope did not compress or injure the spinal cord. CONCLUSIONS Intrathecal endoscopy allowed visual assessment and safe removal of intradural adhesions beyond the laminectomy margins. Further development of this technique should improve its effectiveness in opening the subarachnoid space and untethering the spinal cord in cases of extensive chronic adhesive SA.
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Affiliation(s)
- Panagiotis Mastorakos
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - I. Jonathan Pomeraniec
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jean-Paul Bryant
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - John D. Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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21
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Karschnia P, Kaulen L, Thon N, Baehring JM. Clinical Reasoning: A 64-Year-Old Man With History of Meningitis Presenting With Proximal Weakness of the Arms. Neurology 2021; 98:208-213. [PMID: 34799459 DOI: 10.1212/wnl.0000000000013085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 64-year-old man presented for evaluation of proximally pronounced weakness of the arms with preserved facial and lower extremity strength. Symptoms slowly developed over the last two years, and the patient's history was notable for severe Listeria monocytogenes meningitis four years prior to presentation, which was adequately treated with antibiotics. On examination, symptoms clinically reassembled 'man-in-the-barrel' syndrome and localized to the cervicothoracic central cord. Blood analysis was unremarkable, and CSF analysis showed no recurrent or persistent infection. Spinal MRI revealed pockets of sequestered CSF from C3 to C4 and areas of CSF space effacement from C3 to T12. MRI findings were interpreted as cord tethering suggestive of adhesive arachnoiditis. CT myelogram showed insufficient contrast agent migration above T10 and contour irregularities of the conus medullaris, confirming the postulated pathomechanism of cord tethering. Final diagnosis was therefore cervicothoracic central cord damage due to cord tethering in the setting of postinfectious adhesive arachnoiditis following bacterial meningitis. The patient failed a course of pulsed methylprednisolone therapy, and symptoms progressed. Best supportive care was provided. The clinical presentation of adhesive arachnoiditis is variable, and advanced imaging techniques and invasive studies such as CT myelogram may be required to establish the diagnosis. Timely diagnosis is warranted as early surgical or medical therapy can improve symptoms.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurology, Yale School of Medicine, New Haven, CT.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT.,Department of Neurosurgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Leon Kaulen
- Department of Neurology, Yale School of Medicine, New Haven, CT.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Niklas Thon
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joachim M Baehring
- Department of Neurology, Yale School of Medicine, New Haven, CT .,Department of Neurosurgery, Yale School of Medicine, New Haven, CT
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22
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Assey EV, Sadiq AM, Swai MJ, Sadiq AM, Dekker MCJ. Idiopathic Arachnoiditis of the Cauda Equina: A Case Report from Tanzania. Case Rep Neurol 2021; 13:535-540. [PMID: 34720959 PMCID: PMC8460926 DOI: 10.1159/000518379] [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: 05/24/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022] Open
Abstract
Arachnoiditis is a rare clinical entity that usually presents with severe debilitating radiating pain that can pose a challenge in diagnosis especially in areas without appropriate imaging modalities. We present a 26-year-old male with progressive lower back pain with radiation to the lower extremities, aggravated by movement and touch. We diagnosed idiopathic arachnoiditis based on cerebrospinal fluid analysis and magnetic resonance imaging. He was managed with a 5-day course of methylprednisolone and analgesics with a good outcome. Severe back pain without a specific cause in a young patient should be investigated with proper imaging modalities and lumbar puncture if warranted to evaluate the cause.
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Affiliation(s)
- Emmanuel V Assey
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Abid M Sadiq
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Magreth J Swai
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Adnan M Sadiq
- Department of Radiology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Marieke C J Dekker
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
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23
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Hackert J, Maßmann L, Sure U, Forsting M, Kleinschnitz C, Pul R, Hagenacker T. Immunotherapies in chronic adhesive arachnoiditis - A case series and literature review. eNeurologicalSci 2021; 24:100350. [PMID: 34195394 PMCID: PMC8225987 DOI: 10.1016/j.ensci.2021.100350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/10/2021] [Accepted: 06/09/2021] [Indexed: 01/02/2023] Open
Abstract
Chronic spinal adhesive arachnoiditis (CSAA) is a rare condition with limited therapeutic options. Surgical treatment proves effective in approximately 60% of cases. Conservative treatment options have not been extensively investigated. Here, we report the course of the disease, analyze the effect of immune treatments in patients with CSAA who were treated in the University Hospital Essen between 2015 and 2020, and conduct a literature review. Three out of four patients showed no improvement after treatment with corticosteroids, methotrexate, or plasmapheresis. All non-responders suffered from CSAA for several years, while one patient who had a disease duration of less than one month fully recovered. It is necessary to verify whether treatment at an early stage of the disease is better than treatment after chronic adhesion manifestation, as it interrupts the development of adhesions and all subsequent complications. Surgical treatment of CSAA patients proves effective in approx. 60% of cases. High-dose steroid treatment may be effective in early stages of CSAA. Only conservative therapy cannot be recommended in long-standing CSAA.
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Affiliation(s)
- Jana Hackert
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Louisa Maßmann
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Ulrich Sure
- University Medicine Essen, Department of Neurosurgery and Spine Surgery, Hufelandstrasse 55, 45147 Essen, Germany
| | - Michael Forsting
- University Medicine Essen, Institute of Diagnostic and Interventional Radiology and Neuroradiology, Hufelandstrasse 55, 45147 Essen, Germany
| | - Christoph Kleinschnitz
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Refik Pul
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Tim Hagenacker
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
- Corresponding author.
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24
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Winn A, Martin A, Castellon I, Sanchez A, Lavi ES, Munera F, Nunez D. Spine MRI: A Review of Commonly Encountered Emergent Conditions. Top Magn Reson Imaging 2021; 29:291-320. [PMID: 33264271 DOI: 10.1097/rmr.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.
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Affiliation(s)
- Aaron Winn
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Adam Martin
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Ivan Castellon
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Allen Sanchez
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | | | - Felipe Munera
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Diego Nunez
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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25
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Epstein NE. Perspective: Early diagnosis and treatment of postoperative recurrent cerebrospinal fluid fistulas/ dural tears to avoid adhesive arachnoiditis. Surg Neurol Int 2021; 12:208. [PMID: 34084635 PMCID: PMC8168645 DOI: 10.25259/sni_317_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: 03/27/2021] [Accepted: 03/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Intraoperative traumatic cerebrospinal fluid (CSF) fistulas/dural tears (DT) occur in up to 8.7–9.5% of primary lumbar surgical procedures. Further, they recur secondarily in between 8.1% and 17% of cases. It is critical to diagnose and treat these recurrent lumbar DT early (i.e. within 3–4 weeks of the index surgery) to avoid the evolution of adhesive arachnoiditis (AA), and its’ permanent neurological sequelae. Methods: Postoperative lumbar CSF fistulas/DT should be diagnosed on postoperative MR scans, and confirmed on Myelo-CT studies if needed. They should be definitively treated/occluded early on (e.g. within 3–4 postoperative weeks) to avoid the evolution of AA which can be readily diagnosed on MR studies, and corroborated, if warranted, on Myelo-CT examinations. The most prominent MR/Myelo-CT findings include; nerve roots aggregated in the central thecal sac, nerve roots peripherally scarred/adherent to the surrrounding meningeal wall (“empty thecal sac sign”), soft tissue masses in the subarachnoid space, and/or multiple loculated/scarred compartments. Results: Percutaneous interventional procedures (i.e. epidural blood patches, injection of fibrin glue (FG)/fibrin sealants (FS)) are rarely effective for treating postoperative recurrent lumbar CSF fistulas. Rather, direct surgical occlusion is frequently warranted including the use of; an operating microscope, adequate surgical exposure, 7-0 Gore-Tex sutures, muscle/dural patch grafts or suture anchors, followed by the application of microfibrillar collagen, and fibrin sealant/glue. Conclusion: Lumbar AA most commonly results from the early failure to diagnose and treat recurrent postoperative CSF fistulas. Since the clinical course of lumbar AA is typically one of progressive neurological deterioration, avoiding its’ initial onset is key.
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Affiliation(s)
- Nancy E Epstein
- Department of Neurosurgery, School of Medicine, State University of New York at Stony Brook, N,Y., U.S.A
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26
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Matsushima S, Shimizu T, Baba A, Ojiri H. Physiological pseudo-thickened cauda equina associated with dural sac dilatation on magnetic resonance imaging. Neuroradiol J 2021; 34:401-407. [PMID: 33657903 DOI: 10.1177/1971400921998970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES In daily clinical practice, the assessment of the thickness of the cauda equina on lumbar spine magnetic resonance imaging is an important parameter. However, its relevance to the size of the dural sac in non-pathological conditions is unknown. To examine the relationship between the size of the dural sac and the apparent thickness of the cauda equina nerve root using lumbar spine magnetic resonance imaging in non-pathological conditions. METHODS We retrospectively measured the dural sac diameter and vertebral body diameter, counted the apparent number, and calculated total cross-sectional area of the cauda equina, dural sac ratio and the area of one apparent nerve root of cauda equina in 100 cases. Spearman's rank correlation coefficient (ρ) was used. RESULTS Dural sac ratio and diameter were positively correlated with the area of one apparent nerve root (ρ=0.77, P<0.001; ρ=0.74, P<0.001; respectively) and negatively correlated with the apparent number of cauda equina in a single cross-section (ρ=-0.63, P<0.001; ρ=-0.52, P<0.001; respectively). CONCLUSIONS A larger dural sac ratio and diameter was associated with an apparently thicker cauda equina and lower visible number. In a larger dural sac, the physiologically clumped and apparently thicker cauda equina should not be misdiagnosed as pathological.
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Affiliation(s)
- Satoshi Matsushima
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
| | - Tetsuya Shimizu
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
| | - Akira Baba
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
| | - Hiroya Ojiri
- Department of Radiology, The 12839Jikei University School of Medicine, Japan
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27
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El Homsi M, Gharzeddine K, Cuevas J, Arevalo-Perez J, Rebeiz K, Khoury NJ, Moukaddam H. MRI Findings of Arachnoiditis, Revisited. Is Classification Possible? J Magn Reson Imaging 2021; 54:904-909. [PMID: 33644967 DOI: 10.1002/jmri.27583] [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: 09/11/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Prior imaging studies characterizing lumbar arachnoiditis have been based on small sample numbers and have reported inconsistent results. PURPOSE To review the different imaging patterns of lumbosacral arachnoiditis, their significance, and clinical implications. STUDY TYPE Retrospective. POPULATION A total of 96 patients (43 women; average age 61.3 years) with imaging findings of arachnoiditis (postsurgical: N = 49; degenerative: N = 29; vertebral fracture: N = 6; epidural and subdural hemorrhage: N = 3, infectious: N= 1; other: N = 8) from January 2009 to April 2018. FIELD STRENGTH/SEQUENCE Sagittal and axial T2-weighted Turbo Spin Echo at 1.5 T and 3 T. ASSESSMENT Chart review was performed to assess the cause of arachnoiditis, and imaging was reviewed by two musculoskeletal and three neurology radiologists, blinded to the clinical data and to each other's imaging interpretation. Previous classification included a three-group system based on the appearance of the nerve roots on T2-weighted images. A fourth group was added in our review as "nonspecified" and was proposed for indeterminate imaging findings that did not fall into the classical groups. The presence/absence of synechiae/fibrous bands that distort the nerve roots and of spinal canal stenosis was also assessed. STATISTICAL TESTS The kappa score was used to assess agreement between readers for both classification type and presence/absence of synechiae. RESULTS Postsurgical (51%) and degenerative changes (30%) were the most common etiologies. About 7%-55% of arachnoiditis were classified as group 4. There was very poor classification agreement between readers (kappa score 0.051). There was also poor interreader agreement for determining the presence of synechiae (kappa 0.18) with, however, strong interreader agreement for the presence of synechia obtained between the most experienced readers (kappa 0.89). DATA CONCLUSION This study demonstrated the lack of consensus and clarity in the classification system of lumbar arachnoiditis. The presence of synechia has high interreader agreement only among most experienced readers and promises to be a useful tool in assessing arachnoiditis. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Karem Gharzeddine
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jordan Cuevas
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julio Arevalo-Perez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Karim Rebeiz
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nabil J Khoury
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hicham Moukaddam
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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Jurga S, Szymańska-Adamcewicz O, Wierzchołowski W, Pilchowska-Ujma E, Urbaniak Ł. Spinal adhesive arachnoiditis: three case reports and review of literature. Acta Neurol Belg 2021; 121:47-53. [PMID: 32833147 PMCID: PMC7937595 DOI: 10.1007/s13760-020-01431-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 07/03/2020] [Indexed: 01/30/2023]
Abstract
Spinal adhesive arachnoiditis is a rare pathology involving pia mater of the spinal cord and nerve roots. It can potentially lead to disability—many patients end up wheelchair-bound due to subsequent paraparesis. It is an infrequent but possible cause of lower extremities weakness in patients with a history of spinal surgery, epidural anaesthesia, myelography or spinal tumors. Three patients, one male and two females, admitted to our unit due to paraparesis presented at least one of the above mentioned risk factors. Each of them had a severe course of illness—progressive paresis of lower extremities. All above cases were diagnosed with spinal adhesive arachnoiditis confirmed with Magnetic Resonance Imaging (MRI) scan—the most sensitive and specific diagnostic tool. Despite conservative treatment and intensive rehabilitation none of the presented patients preserved the ability to mobilise independently. Considering spinal adhesive arachnoiditis in patients with paraparesis and history of typical risk factors should be included in clinical diagnostic procedure.
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Affiliation(s)
- Szymon Jurga
- Department of Neurology, University Hospital, Zielona Góra, Poland
| | | | | | | | - Łukasz Urbaniak
- Department of Neurology, University Hospital, Zielona Góra, Poland
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Abstract
PURPOSE OF REVIEW This article highlights both common structural causes of myelopathy, such as spondylotic disease, and infrequent but treatable causes, such as syringomyelia, spinal cord herniation, arachnoid cyst, arachnoid band and web, epidural lipomatosis, Hirayama disease, and arachnoiditis. RECENT FINDINGS Neuroimaging improvements and availability have uncovered many structural abnormalities in the spines and spinal cords of patients who were asymptomatic or minimally symptomatic. Recent published clinical series have improved our knowledge of the natural history of structural abnormalities and the risks of intervention versus conservative management. SUMMARY Myelopathy from a suspected structural cause is a common reason for neurologic consultation. Correlation between the history, examination, and imaging are especially important to determine whether intervention is necessary or conservative management is the best option.
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Abstract
PURPOSE OF REVIEW This article reviews the neuroimaging of disorders of the spinal cord and cauda equina, with a focus on MRI. An anatomic approach is used; diseases of the extradural, intradural-extramedullary, and intramedullary (parenchymal) compartments are considered, and both neoplastic and non-neoplastic conditions are covered. Differentiating imaging features are highlighted. RECENT FINDINGS Although T2-hyperintense signal abnormality of the spinal cord can have myriad etiologies, neuroimaging can provide specific diagnoses or considerably narrow the differential diagnosis in many cases. Intradural-extramedullary lesions compressing the spinal cord have a limited differential diagnosis and are usually benign; meningiomas and schwannomas are most common. Extradural lesions can often be specifically diagnosed. Disk herniations are the most commonly encountered mass of the epidural space. Cervical spondylotic myelopathy can cause a characteristic pattern of enhancement, which may be mistaken for an intrinsic myelopathy. A do-not-miss diagnosis of the extradural compartment is idiopathic spinal cord herniation, the appearance of which can overlap with arachnoid cysts and webs. Regarding intrinsic causes of myelopathy, the lesions of multiple sclerosis are characteristically short segment but can be confluent when multiple. Postcontrast MRI can be particularly helpful, including when attempting to differentiate the long-segment myelopathy of neurosarcoidosis and aquaporin-4 (AQP4)-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD) and when characterizing spinal cord tumors such as primary neoplasms and metastases. Spinal dural arteriovenous fistula is another do-not-miss diagnosis, with characteristic MRI features both precontrast and postcontrast. Tract-specific white matter involvement can be a clue for diseases such as subacute combined degeneration, paraneoplastic myelopathy, and radiation myelitis, whereas gray matter-specific involvement can suggest conditions such as cord infarct, viral myelitis, or myelin oligodendrocyte glycoprotein (MOG)-IgG associated disorder. SUMMARY Knowledge of the neuroimaging findings of the many causes of spinal cord and cauda equina dysfunction is critical for both neurologists and neuroradiologists. A structured approach to lesion compartmental location and imaging feature characterization is recommended.
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Grewal P, Hall JP, Jhaveri M, Dafer RM. Cerebral Vasculopathy and Spinal Arachnoiditis: Two Rare Complications of Ventriculitis Post Subarachnoid Hemorrhage. Cureus 2020; 12:e12241. [PMID: 33500861 PMCID: PMC7819455 DOI: 10.7759/cureus.12241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This report describes a case of subarachnoid hemorrhage complicated by ventriculitis and subsequent delayed cerebral vasospasm, severe chronic spinal arachnoiditis, and Froin syndrome. A 60-year-old woman presented with diffuse aneurysmal subarachnoid hemorrhage and underwent successful coil embolization of ruptured left anterior cerebral artery aneurysm. Her course was complicated by bacterial ventriculitis and acute hydrocephalus necessitating ventriculoperitoneal shunt placement. She returned ten weeks later with recurrent headaches; CT angiography showed diffuse cerebral vasospasm. Spine magnetic resonance imaging ordered due to concern for mass or other obstruction of the cerebrospinal fluid obstruction based on lumbar puncture results showed leptomeningeal enhancement with loculated cerebrospinal fluid collections along the spinal canal concerning for spinal arachnoiditis and septal adhesions. Lumbar puncture was consistent with Froin syndrome. She was treated with calcium-channel blockers. Follow up imaging showed resolution of vasospasm, but progression of the arachnoiditis. No surgical intervention was pursued as the patient had no symptoms concerning myelopathy. Aneurysmal subarachnoid hemorrhage and ventriculitis may lead to delayed reversible vasculopathy as well as arachnoiditis, with “dry tap” and Froin-like syndrome picture. Workup should be initiated in patients who develop persistent headaches or myelopathic changes to investigate these possibilities.
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Park C, Lee IS, Nam KH, Song YS, Lee TH, Han IH, Kim DH. Transiting Nerve Rootlet Abnormalities on MRI after Lumbar Laminectomy: Associations with Persistent Postoperative Pain. Korean J Radiol 2020; 22:225-232. [PMID: 32901462 PMCID: PMC7817636 DOI: 10.3348/kjr.2020.0194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/19/2020] [Accepted: 05/26/2020] [Indexed: 01/02/2023] Open
Abstract
Objective To determine whether changes in the transiting nerve rootlet or its surroundings, as seen on MRI performed after lumbar hemilaminectomy, are associated with persistent postoperative pain (PPP), commonly known as the failed back surgery syndrome. Materials and Methods Seventy-three patients (mean age, 61 years; 43 males and 30 females) who underwent single-level partial hemilaminectomy of the lumbar spine without postoperative complications or other level spinal abnormalities between January 2010 and December 2018 were enrolled. Two musculoskeletal radiologists evaluated transiting nerve rootlet abnormalities (thickening, signal alteration, distinction, and displacement), epidural fibrosis, and intrathecal arachnoiditis on MRI obtained one year after the operations. A spine surgeon blinded to the radiologic findings evaluated each patient for PPP. Univariable and multivariable analyses were used to evaluate the association between the MRI findings and PPP. Results The presence of transiting nerve rootlet thickening, signal alteration, and ill-distinction was significantly different between the patients with PPP and those without, for both readers (p ≤ 0.020). Conversely, the presence of transiting nerve rootlet displacement, epidural fibrosis, and intrathecal arachnoiditis was not significantly different between the two groups (p ≥ 0.128). Among the above radiologic findings, transiting nerve rootlet thickening and signal alteration were the most significant findings in the multivariable analyses (p ≤ 0.009). Conclusion On MRI, PPP was associated with transiting nerve rootlet abnormalities, including thickening, signal alterations, and ill-distinction, but was not associated with epidural fibrosis or intrathecal arachnoiditis. The most relevant findings were the nerve rootlet thickening and signal alteration.
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Affiliation(s)
- Chankue Park
- Department of Radiology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - In Sook Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea.
| | - Kyoung Hyup Nam
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - You Seon Song
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Tae Hong Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - In Ho Han
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Hwan Kim
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Formation of Adhesive Arachnoiditis with Epidural Fibrosis as a Cause of Repeated Surgical Interventions (Clinical Case). ACTA BIOMEDICA SCIENTIFICA 2020. [DOI: 10.29413/abs.2020-5.3.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The work presents a rare clinical case of adhesive arachnoiditis, which developed against the background of epidural fibrosis during repeated surgical interventions. The cicatricial adhesion in the epidural space is formed in 100% of cases after surgery and is a frequent cause of intraoperative complications during repeated surgical interventions (bleeding, damage to the spinal cord and the dura mater with subsequent outflow of cerebrospinal fluid) and, therefore, an unsatisfactory result of surgical treatment with the formation of constant pain of various intensity, pseudomeningocele, commissural arachnoiditis, etc. The cicatricial adhesion in the epidural space is the main reason for the development of failed back surgery syndrome (FBSS), which today is an important and unresolved problem in spinal surgery. The epidural, as well as the subdural and subarachnoid space of the operated spinal motor segment of the spinal canal can be involved in the cicatricial adhesion, as it is shown in our clinical example. In this regard, it is important to prevent the development of the cicatricial adhesion in the epidural space during primary spinal surgeries, since with the increase in life expectancy of the population and increase in surgical activity during spinal surgeries, the patient can be operated repeatedly. Consequently, the question arises of preventing the formation of the cicatricial adhesion in 100% of cases with each surgical intervention, since the formed cicatricial adhesion in the epidural space does not have effective methods of conservative and surgical treatment and worsens favorable and satisfactory forecasts of surgical treatment for repeated surgical interventions.
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Patel DM, Weinberg BD, Hoch MJ. CT Myelography: Clinical Indications and Imaging Findings. Radiographics 2020; 40:470-484. [DOI: 10.1148/rg.2020190135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Dhruv M. Patel
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
| | - Brent D. Weinberg
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
| | - Michael J. Hoch
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
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Parenti V, Huda F, Richardson PK, Brown D, Aulakh M, Taheri MR. Lumbar arachnoiditis: Does imaging associate with clinical features? Clin Neurol Neurosurg 2020; 192:105717. [PMID: 32062307 DOI: 10.1016/j.clineuro.2020.105717] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/02/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Lumbar arachnoiditis is a rare and debilitating neurologic disorder with multiple etiologies and a spectrum of imaging and clinical characteristics. Prior reports have anecdotally claimed that no association exists between findings of arachnoiditis observed on magnetic resonance imaging (MRI) and those assessed clinically. The purpose of this study was to determine if MRI features of lumbar arachnoiditis associate with the clinical findings of the disorder. PATIENTS AND METHODS Twenty eight patients with lumbar arachnoiditis reported on MRI between 2012 and 2018 were retrospectively identified. A variety of MRI and clinical features of lumbar arachnoiditis were cataloged for these patients based on common findings discovered through literature review. Imaging findings included cauda equina nerve root contour and thickening, adhesion location, level of involvement, enhancement, and Delamarter group. Clinical findings included demographics, etiology, symptom dynamics, and signs/symptoms. Fisher's exact tests were used to determine associations between the imaging and clinical features of lumbar arachnoiditis. RESULTS In general, MRI findings did not associate with the clinical features of lumbar arachnoiditis with a few exceptions. Most notably, confounding lumbar pathology was associated with symptom dynamics (p = 0.004) and nerve root contour was associated with motor and sensory symptoms (p = 0.01). The suspected arachnoiditis etiology of the majority of patients was either post-operative or post-infectious in nature. CONCLUSION MRI findings in lumbar arachnoiditis offer limited insight into the clinical presentation of the disorder.
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Affiliation(s)
- Vincent Parenti
- The George Washington University School of Medicine and Health Sciences, 2300 I St. NW, Washington, DC, 20052, USA.
| | - Fahimul Huda
- The George Washington University School of Medicine and Health Sciences, 2300 I St. NW, Washington, DC, 20052, USA; Department of Radiology, The George Washington University Hospital, 900 23rd St. NW, Washington, DC, 20037, USA.
| | - Perry K Richardson
- The George Washington University School of Medicine and Health Sciences, 2300 I St. NW, Washington, DC, 20052, USA; Department of Neurology, The George Washington University Hospital, 2150 Pennsylvania Ave. NW, Washington, DC, 20037, USA.
| | - Derek Brown
- Department of Biostatistics and Data Science, University of Texas Health Science Center, 1200 Pressler Street, Houston, TX, 77030, USA.
| | - Manek Aulakh
- The George Washington University School of Medicine and Health Sciences, 2300 I St. NW, Washington, DC, 20052, USA; Department of Radiology, The George Washington University Hospital, 900 23rd St. NW, Washington, DC, 20037, USA.
| | - M Reza Taheri
- The George Washington University School of Medicine and Health Sciences, 2300 I St. NW, Washington, DC, 20052, USA; Department of Radiology, The George Washington University Hospital, 900 23rd St. NW, Washington, DC, 20037, USA.
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Naito K, Yamagata T, Ohata K, Takami T. Safety and Efficacy of Syringoperitoneal Shunting with a Programmable Shunt Valve for Syringomyelia Associated with Extensive Spinal Adhesive Arachnoiditis: Technical Note. World Neurosurg 2019; 132:14-20. [PMID: 31465850 DOI: 10.1016/j.wneu.2019.08.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/10/2019] [Accepted: 08/14/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Although syringomyelia associated with extensive spinal adhesive arachnoiditis (SAA) can be a progressive disease that has potentially devastating clinical consequences, its surgical resolution has remained poorly defined. The aim of the present study was to verify the safety and efficacy of syringoperitoneal shunting for syringomyelia associated with extensive SAA. METHODS The present retrospective study included 15 patients who had undergone syringoperitoneal shunting with a programmable shunt valve for the diagnosis of syringomyelia associated with extensive SAA from October 2012 to June 2018. The shunt pressure was appropriately adjusted according to the postoperative sequential clinical condition and change in syringomyelia evaluated using magnetic resonance imaging. The average postoperative follow-up duration was 32.7 months. RESULTS No surgery-related complications such as shunt dysfunction or infection occurred during the follow-up period, except for 2 patients with minor issues with the shunt tube. The average shunt pressure at the last follow-up examination was 4.5 cm H2O. The findings from the clinical assessment suggested that the average grade on the sensory pain scale was 2.9 before surgery and had improved significantly to 2.5 at the most recent follow-up examination. Radiological analysis suggested that improvement of syringomyelia was noted in 14 of the 15 patients (93.3%), with no cases of radiological aggravation. No recurrence of syringomyelia developed during the follow-up period in the present study. CONCLUSION Syringoperitoneal shunting with a programmable shunt valve was safe and effective for clinical control of syringomyelia associated with extensive SAA. Long-term follow-up is mandatory to monitor for shunt dysfunction and mechanical trouble.
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Affiliation(s)
- Kentaro Naito
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toru Yamagata
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
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Marchesini N, Soda C, Ricci UM, Pinna G, Alessandrini F, Ghimenton C, Bernasconi R, Paolino G, Teli M. Giant intradural extramedullary spinal ependymoma, a rare arachnoiditis-mimicking condition: case report and literature review. Br J Neurosurg 2019:1-6. [PMID: 31213094 DOI: 10.1080/02688697.2019.1630551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and importance: Ependymomas are tumours arising from the ependymal cells lining the ventricles and the central canal of the spinal cord. They represent the most common intramedullary spinal cord tumour in adults and are very rarely encountered in an extramedullary location. Only 40 cases of intradural extramedullary (IDEM) ependymomas have been reported, all of which were diagnosed pre-operatively as IDEM ependymomas on contrast-enhanced MRI. Clinical presentation: We report a 23-year old male presenting with rapidly worsening signs and symptoms of spinal cord disease. A spinal MRI demonstrated a posterior multi-cystic dilatation extended between T1 and T12. Post-contrast sequences showed peri-medullar leptomeningeal enhancement and the diagnosis of spinal arachnoiditis was made. The patient underwent surgery and the spinal cord appeared circumferentially wrapped by an irregular soft tissue. The tissue was sub-totally removed and the pathological diagnosis was ependymoma WHO grade II. The patient experienced an excellent neurological recovery and no further treatments were administered. A small residue is now stable at 2.5 years follow-up. Conclusions: Giant IDEM ependymomas are rare entities and pre-operative diagnosis can be challenging in some cases. Surgery represents the main treatment option being resolutive in most cases.
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Affiliation(s)
- Nicolò Marchesini
- a Department of Neurosurgery , University of Verona , Verona , Italy
| | - Christian Soda
- b Department of Neurosurgery , AOUI Borgo Trento Hospital , Verona , Italy
| | | | - Giampietro Pinna
- b Department of Neurosurgery , AOUI Borgo Trento Hospital , Verona , Italy
| | - Franco Alessandrini
- c Department of Neuroradiology , AOUI Borgo Trento Hospital , Verona , Italy
| | - Claudio Ghimenton
- d Department of Pathology , AOUI Borgo Trento Hospital , Verona , Italy
| | | | - Gaetano Paolino
- e Department of Pathology , University of Verona , Verona , Italy
| | - Marco Teli
- f Department of Neurosurgery , Walton Centre NHS Foudation Trust , Liverpool , UK
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Eisenberg E, Goldman R, Schlag-Eisenberg D, Grinfeld A. Adhesive arachnoiditis following lumbar epidural steroid injections: a report of two cases and review of the literature. J Pain Res 2019; 12:513-518. [PMID: 30774420 PMCID: PMC6357879 DOI: 10.2147/jpr.s192706] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Lumbar epidural steroid injections (LESIs) are commonly used for managing lower back pain (LBP) and radicular pain. LESIs are generally considered safe with only rare serious complication. One very rare complication that is frequently cited in the literature is adhesive arachnoiditis. However, a literature search failed to detect even one published manuscript, clearly documenting LESI induced arachnoiditis. This article presents two patients who received a transforaminal L5–S1 and two L3–L4 interlaminar LESIs. Although the presented patients developed clear radiological (MRI) findings of arachnoiditis, they were not accompanied by any improvement or deterioration in their clinical condition. The article also reviews the literature on the prevalence, pathogenesis, diagnosis, and clinical features of adhesive arachnoiditis. Literature suggests that adhesive arachnoiditis following LESIs is a rare entity, which – as seen in our patients – has clear radiological characteristics but uncertain pathogenesis. It has a large spectrum of clinical presentation, ranging from an incidental finding to a serious neurological sequela. In at least some patients with adhesive arachnoiditis following LESI, the radiological and clinical findings may fail to correlate with each other. In light of the fact that LESI is one of the most commonly performed procedures for managing LBP, clinicians should be aware of this rare yet existing entity.
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Affiliation(s)
- Elon Eisenberg
- Pain Research Unit, Institute of Pain Medicine, Rambam Health Care Campus, Haifa, Israel, .,B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel,
| | | | | | - Anat Grinfeld
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
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Cornelson SM, Johnnie ED, Kettner NW. Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis. J Chiropr Med 2018; 17:283-288. [PMID: 30846922 PMCID: PMC6391232 DOI: 10.1016/j.jcm.2018.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
| | - Edward D. Johnnie
- Chiropractic Health Centers, Logan University, Chesterfield, Missouri
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Pierce JL, Donahue JH, Nacey NC, Quirk CR, Perry MT, Faulconer N, Falkowski GA, Maldonado MD, Shaeffer CA, Shen FH. Spinal Hematomas: What a Radiologist Needs to Know. Radiographics 2018; 38:1516-1535. [DOI: 10.1148/rg.2018180099] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer L. Pierce
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Joseph H. Donahue
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Nicholas C. Nacey
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Cody R. Quirk
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Michael T. Perry
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Nicholas Faulconer
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Gene A. Falkowski
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Michael D. Maldonado
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Catherine A. Shaeffer
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
| | - Francis H. Shen
- From the Departments of Radiology and Medical Imaging (J.L.P., J.H.D., N.C.N., C.R.Q., M.T.P., N.F., M.D.M., C.A.S.) and Orthopedic Surgery (G.A.F., F.H.S.), University of Virginia, 1215 Lee St, Charlottesville, VA 22908
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