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Hsiao PH, Lin ET, Chen HT, Lo YS. Complete Intradural Interbody Cage Migration in Lumbar Spine Surgery: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050956. [PMID: 37241188 DOI: 10.3390/medicina59050956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023]
Abstract
Background: Spinal fusion is a common surgery, in which vertebrae are fused to restore spinal stability and eliminate pain during movement. The use of an interbody cage facilitates spinal fusion. However, complete cage migration into the dura matter rarely occurs and can be challenging to manage. Case Presentation: A 44-year-old man presented at our spine center with a history of incomplete paraplegia and cauda equina syndrome that had lasted for 2 years and 4 months. This condition developed after he underwent six lumbar spine surgeries to address lower back pain and right-sided sciatica. A structural allograft kidney-shaped cage was found completely within the dura at the level of the L3 vertebra. Durotomy, cage retrieval, and pedicle screw fixation from the L2 to L4 vertebrae were performed. Numbness in both lower limbs markedly decreased within several days of the operation. After four months following the progressive physical therapy, the patient could partially control both urination and defecation. Five months postoperatively, he could stand with slight assistance. Conclusions: Complete intradural cage migration is a rare and serious complication. To the best of our knowledge, this is the first reported case with such a condition in the literature. Even if treatment is delayed, surgical intervention may salvage the remaining neurologic function and may even lead to partial recovery.
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Affiliation(s)
- Pang-Hsuan Hsiao
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung 404327, Taiwan
- Spine Center, China Medical University Hospital, No. 2, Xueshi Rd., North Dist., Taichung 404327, Taiwan
| | - Erh-Ti Lin
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung 404327, Taiwan
| | - Hsien-Te Chen
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung 404327, Taiwan
- Spine Center, China Medical University Hospital, No. 2, Xueshi Rd., North Dist., Taichung 404327, Taiwan
| | - Yuan-Shun Lo
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung 404327, Taiwan
- Spine Center, China Medical University Hospital, No. 2, Xueshi Rd., North Dist., Taichung 404327, Taiwan
- Department of Orthopedic Surgery, China Medical University Beigang Hospital, Yunlin 651012, Taiwan
- Graduate Institute of Precision Engineering, National Chung Hsing University, Taichung 402204, Taiwan
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Delhaas EM, Harhangi BS, van Doormaal PJ, Dinkelaar W, van Es AC, van Assema DM, Frankema SP, van der Lugt A, Huygen FJ. Restoration of rostral cerebrospinal fluid flow to solve treatment failure caused by obstruction in long-term intrathecal baclofen administration. J Spinal Cord Med 2021; 44:312-321. [PMID: 31418647 PMCID: PMC7952057 DOI: 10.1080/10790268.2019.1646476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objects: We describe five traumatic spinal cord injury (SCI) patients with an intrathecal baclofen administration (ITB) failure caused by a rostral CSF flow obstruction referred to our expert center between January 2014 and January 2019. We discuss the diagnostic workup, rostral CSF flow obstruction as the cause of the ITB failure and treatment.Methods: When we could not determine the cause of the ITB failure through the patient's history, physical spasticity examination, pump readout, absence of fluid in the pump reservoir during aspiration, or plain radiography, we performed pump catheter access port (computed tomography [CT]) myelography. When CT myelography did not reveal the diagnosis, we used scintigraphy. In an obstruction, we aimed for CSF flow restoration. In three cases, we conducted a laminectomy with microsurgical adhesiolysis. In two of these patients, we could not achieve CSF flow restoration; thus, we placed an intradural catheter bypass. Recently, in three patients, we applied a less invasive technique of percutaneous fenestration of the obstruction.Results: In one case, we performed a successful catheter replacement. In another case using surgical adhesiolysis, spasticity control was complete. In two cases, we could obtain improvement with an additional intradural bypass, followed by a percutaneous fenestration of the obstruction, resulting in further improved CSF flow restoration. In one case, percutaneous fenestration was the first line of treatment. In all cases with percutaneous fenestration, we experienced spasticity control.Conclusion: Preliminary results showed that the restoration of rostral CSF flow might result in an effective ITB treatment in patients with an intrathecal obstruction.
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Affiliation(s)
- Elmar M. Delhaas
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands,Correspondence to: Elmar M. Delhaas, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, P.O. Box 2040, Rotterdam, CA3000, The Netherlands.
| | - Biswadjiet S. Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter J. van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wouter Dinkelaar
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ad C.G.M. van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Danielle M.E. van Assema
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sander P.G. Frankema
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Frank J.P.M. Huygen
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Kleindienst A, Laut FM, Roeckelein V, Buchfelder M, Dodoo-Schittko F. Treatment of posttraumatic syringomyelia: evidence from a systematic review. Acta Neurochir (Wien) 2020; 162:2541-2556. [PMID: 32820376 PMCID: PMC7496040 DOI: 10.1007/s00701-020-04529-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/04/2020] [Indexed: 01/29/2023]
Abstract
Background Following spinal cord injury (SCI), the routine use of magnetic resonance imaging (MRI) resulted in an incremental diagnosis of posttraumatic syringomyelia (PTS). However, facing four decades of preferred surgical treatment of PTS, no clear consensus on the recommended treatment exists. We review the literature on PTS regarding therapeutic strategies, outcomes, and complications. Methods We performed a systematic bibliographic search on (“spinal cord injuries” [Mesh] AND “syringomyelia” [Mesh]). English language literature published between 1980 and 2020 was gathered, and case reports and articles examining syrinx due to other causes were excluded. The type of study, interval injury to symptoms, severity and level of injury, therapeutic procedure, duration of follow-up, complications, and outcome were recorded. Results Forty-three observational studies including 1803 individuals met the eligibility criteria. The time interval from SCI to the diagnosis of PTS varied between 42 and 264 months. Eighty-nine percent of patients were treated surgically (n = 1605) with a complication rate of 26%. Symptoms improved in 43% of patients postoperatively and in 2% treated conservatively. Stable disease was documented in 50% of patients postoperatively and in 88% treated conservatively. The percentage of deterioration was similar (surgery 16%, 0.8% dead; conservative 10%). Detailed analysis of surgical outcome with regard to symptoms revealed that pain, motor, and sensory function could be improved in 43 to 55% of patients while motor function deteriorated in around 25%. The preferred methods of surgery were arachnoid lysis (48%) and syrinx drainage (31%). Conclusion Even diagnosing PTS early in its evolution with MRI, to date, no satisfactory standard treatment exists, and the present literature review shows similar outcomes, regardless of the treatment modality. Therefore, PTS remains a neurosurgical challenge. Additional research is required using appropriate study designs for improving treatment options.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | | | - Verena Roeckelein
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | - Michael Buchfelder
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | - Frank Dodoo-Schittko
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
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Klimov V, Gulay Y, Clyde BL, Khamidov K. Under pressure: Syringo-subarachnoid shunting and syrinx cyst videoscopy. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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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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Giner J, Pérez López C, Hernández B, Gómez de la Riva Á, Isla A, Roda J. Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Neurosurgical untethering with or without syrinx drainage results in high patient satisfaction and favorable clinical outcome in post-traumatic myelopathy patients. Spinal Cord 2018; 56:873-882. [DOI: 10.1038/s41393-018-0094-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 12/16/2022]
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Microscope and Fiberscope-assisted Subarachnoid-Subarachnoid (S-S) Bypass: A Novel Surgical Technique to Reestablish Cerebrospinal Fluid Flow in Treating Dorsal Spinal Arachnoid Webs, Diagnosed by Cine-MRI. Clin Spine Surg 2018; 31:58-64. [PMID: 28719455 DOI: 10.1097/bsd.0000000000000569] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A "dorsal spinal arachnoid web" is the thickened arachnoid band on the surface of the spinal cord which disturbs the cerebrospinal fluid (CSF) flow, known as a rare cause of thoracic myelopathy. The ideal treatment is controversial because of the risk of readhesion after simple resection of the web. A subarachnoid-subarachnoid bypass is a method to reestablish CSF flow through a silicon tube between the cranial and caudal subarachnoid space. This method is reported to be useful for traumatic syringomyelia, adhesive arachnoiditis, etc. We applied this technique for arachnoid webs with the assistance of a microscope and fiberscope. After a dura incision, the thickened arachnoid web can be seen fluttering within the CSF flow inside the arachnoid space, which partitions the subarachnoid space into cranial and caudal parts. After opening the subarachnoid space and resection of the web under a microscope, the fiberscope is inserted toward the cranial and caudal directions to check for the presence of another arachnoid web. If another web is found, it is penetrated using a guiding wire. Then, a silicone tube is inserted into the cranial and caudal normal subarachnoid space. In this paper, we would like to introduce this technique.
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Cell Therapy as a New Approach to the Treatment of Posttraumatic Syringomyelia. World Neurosurg 2017; 107:1047.e5-1047.e8. [PMID: 28804041 DOI: 10.1016/j.wneu.2017.08.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/30/2017] [Accepted: 08/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cell transplantation with autologous bone marrow-derived mesenchymal stromal cells (MSCs) seems to be a therapeutic promise for patients with established spinal cord injury, achieving improvement in their quality of life, but there is no experience with the application of this type of cell therapy in patients suffering posttraumatic syringomyelia. OBJECTIVE To study the possible utility of cell therapy with autologous MSCs in posttraumatic syringomyelia. METHODS A 40-year-old man with complete paraplegia since 1991 as a consequence of a Th4 vertebral fracture showed a great posttraumatic syringomyelia that extended up to C2 vertebral level, without signs of recent worsening. Autologous MSCs (150 × 106) were injected into the syrinx, without drainage or aspiration. RESULTS One year after cell therapy, syrinx was reduced without collapse of cervical spinal cord. During the course of follow-up, clear clinical improvement was observed, mainly in sphincter dysfunction. CONCLUSIONS Injection of MSCs in the syrinx of posttraumatic syringomyelia is safe and is associated with clinical and neuroimaging improvement. The possibility of cell therapy as a new approach to posttraumatic syringomyelia, or even for idiopathic syringomyelia, is an open door that requires further study.
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Klimov VS, Gulay YS, Evsyukov AV, Moysak GI. [Syringosubarachnoid shunting in treatment of syringomyelia: a literature review and a clinical case report]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 81:58-65. [PMID: 28665389 DOI: 10.17116/neiro201781358-65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In the article, we describe a clinical case of syringomyelia associated with an Arnold-Chiari type 1 malformation, evaluate the efficacy of syringosubarachnoid shunting, and analyze the literature data of domestic and international researchers involved in investigation and treatment of the pathology. Application of syringosubarachnoid shunting in the described case resulted in a clinical improvement in the form of regression of paresis and hypoesthesia, which demonstrated the efficacy of the shunting technique for correction of the syringomyelia symptoms.
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Affiliation(s)
- V S Klimov
- Federal Neurosurgical Center, Novosibirsk, Russia
| | - Yu S Gulay
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A V Evsyukov
- Federal Neurosurgical Center, Novosibirsk, Russia
| | - G I Moysak
- Federal Neurosurgical Center, Novosibirsk, Russia
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Update on the pathophysiology and management of syringomyelia unrelated to Chiari malformation. Neurologia 2016; 34:318-325. [PMID: 27939111 DOI: 10.1016/j.nrl.2016.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/20/2016] [Accepted: 09/30/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Much has been published on syringomyelia related to Chiari malformation. In contrast, little is known about the condition when it is not associated with this malformation, but this presentation of syringomyelia constitutes a different entity and therefore requires specific management. We conducted a literature review to summarise the most accepted and widespread ideas about the pathophysiology, management and other aspects of syringomyelia unrelated to Chiari malformation. DEVELOPMENT We reviewed the most relevant literature on this condition, focusing on the pathophysiology, clinical presentation, diagnosis, and treatment. CONCLUSIONS Syringomyelia unrelated to Chiari malformation is a distinct entity that must be well understood to guarantee correct diagnosis, monitoring, and management. When the disease is suspected, a thorough study should be conducted to identify its aetiology. Treatment must aim to eliminate the cause of the disease; symptomatic treatment should remain a second-line option.
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Ghobrial GM, Dalyai RT, Maltenfort MG, Prasad SK, Harrop JS, Sharan AD. Arachnolysis or cerebrospinal fluid diversion for adult-onset syringomyelia? A Systematic review of the literature. World Neurosurg 2014; 83:829-35. [PMID: 24980802 DOI: 10.1016/j.wneu.2014.06.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 06/09/2014] [Accepted: 06/24/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To identify surgical practice patterns in the literature for nonpediatric syringomyelia by systematic review and to determine the following: 1) What is the best clinical practice of cerebrospinal fluid (CSF) diversion to maximize clinical improvement or to achieve the lowest recurrence rate? 2) Does arachnolysis, rather than CSF diversion, lead to prolonged times to clinical recurrence? METHODS A database search comprising PubMed, Cochrane Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Database of Systematic Reviews was conducted to find pertinent articles on postinfectious, posttraumatic, or idiopathic syringomyelia. RESULTS An advanced PubMed search in August 2012 yielded 1350 studies, including 12 studies meeting Oxford Centre for Evidence-Based Medicine criteria for level IV evidence as a case series, with a total of 410 patients (mean age, 39 years). Data on 486 surgeries were collected. Mean follow-up data were available for 10 studies, with a mean follow-up time of 62 months. On regression analysis, increased age had a significant correlation with a higher likelihood of having clinically significant recurrence on mean follow-up (P < 0.05). The use of arachnolysis in surgery was associated with a longer duration until clinically symptomatic recurrence (P = 0.02). Data on mortality were unavailable. The mean number of surgeries per patient across all studies was 1.20 (range, 0.95-2.00). CONCLUSIONS With postinfectious and posttraumatic etiologies, arachnolysis was the only surgical treatment to have a statistically significant effect on decreasing recurrence rates. More prospective, randomized, controlled studies are required to reach a clear consensus.
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Affiliation(s)
- George M Ghobrial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard T Dalyai
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mitchell G Maltenfort
- Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Srinivas K Prasad
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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