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Zarrin D, Goel K, Kim WJ, Holly LT, Batzdorf U. Chiari Type I Revision Decompressive Surgery Indications and Operative Technique: Experience in a Large Adult Cohort. World Neurosurg 2024; 185:e1074-e1085. [PMID: 38490446 DOI: 10.1016/j.wneu.2024.03.026] [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: 11/21/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Chiari malformation is characterized by inferior displacement of the cerebellar tonsils through the foramen magnum, frequently resulting in strain related headaches, and motor/sensory dysfunction. Chiari decompression technique varies significantly, possibly contributing to frequent revisions. We reviewed revision Chiari decompressions at our institution to determine the primary indications for revision and outcomes after revision. METHODS We retrospectively reviewed patients who underwent revision of Chiari decompression at our institution from 2005 to 2020. Demographics, indications for revision surgery, operative techniques, imaging findings, and preoperative/postoperative symptoms were collected. χ2 test was performed to determine statistical significance using a P < 0.05. Independent predictors of operative outcomes were identified. RESULTS A total of 46 patients (91% females, mean age 38.8 years) were included for analysis. The median time to revision surgery was 69.1 months (range 0-364 months) with headache (n = 37, 80%) being the most commonly recurring symptom. Large craniectomy (n = 28, 61%) was the most frequent indication for revision surgery. Thirty-two (70%) patients underwent cranioplasty, 20 (43%) required duraplasty, 15 (33%) required arachnoid dissection, and 15 (33%) required tonsillar reduction during revision surgery. Postrevision follow-up (at 8.9 ± 5.2 months average, range 1-18 months), revealed an average reduction in all Chiari-related symptoms relative to symptoms before the revision. CONCLUSIONS The most common indication for revision Chiari decompression was a large craniectomy resulting in cerebellar ptosis. We found that tonsillar reduction paired with modest craniectomy achieved near-complete resolution of symptoms with minimal complications. For patients with recurrent or persistent sequelae of Chiari malformation after decompression, revision may reduce symptom severity.
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Affiliation(s)
- David Zarrin
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Langston T Holly
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Ulrich Batzdorf
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA.
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2
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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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3
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Kovalenko RA, Osipova NV, Mineev VA, Mitrofanova LB. Symptomatic arachnoiditis ossificans associated with syringomyelia: a clinical case and a brief literature review. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2023. [DOI: 10.14531/ss2023.1.93-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Objective. To present a clinical case of arachnoiditis ossificans associated with syringomyelia and a brief literature review with an emphasis on its etiology, pathogenesis and methods of diagnosis and treatment.Material and Methods. A clinical case of a 68-year-old patient with symptomatic arachnoiditis ossificans is described. The diagnosis was established on the basis of the results of intraoperative biopsy, histological examination of the resected fragment and confirmed in the postoperative period using CT of the spinal cord, multislice CT myelography, etc. Analysis of the course of the pathology raised the following questions: diagnostic criteria and optimal tactics for treating this disease. A brief review of cases of arachnoiditis ossificans described in the literature for the period from 1982 to the present is given.Results. A review of cases of ossifying arachnoiditis described in the literature showed that today there is no single tactic for diagnosing and treating this disease. In most cases, the diagnosis is established intraoperatively (65 % of analyzed cases). At the preoperative stage, CT provides reliable visualization of ossification. When choosing therapy, it is necessary to be based on the severity of the clinical picture, the degree of ossification of the arachnoid membrane and the presence of concomitant pathology of the affected spinal cord department (such as syringomyelia).Conclusion. The presence of a growing neurological deficit should be considered an indication for surgical treatment of patients with arachnoiditis ossificans. The goals of surgery should include decompression of neural structures and restoration of normal cerebrospinal fluid circulation.
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Affiliation(s)
- R. A. Kovalenko
- Almazov National Medical Research Centre
2 Akkuratova str., St. Petersburg, 197341, Russia
| | - N. V. Osipova
- Pavlov First Saint Petersburg State Medical University
6–8 L’va Tolstogo str., St. Petersburg, 197022, Russia
| | - V. A. Mineev
- Almazov National Medical Research Centre
2 Akkuratova str., St. Petersburg, 197341, Russia
| | - L. B. Mitrofanova
- Almazov National Medical Research Centre
2 Akkuratova str., St. Petersburg, 197341, Russia
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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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5
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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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6
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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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7
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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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8
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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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9
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Rohdin C, Ljungvall I, Häggström J, Leijon A, Lindblad-Toh K, Matiasek K, Rosati M, Wohlsein P, Jäderlund KH. Thoracolumbar meningeal fibrosis in pugs. J Vet Intern Med 2020; 34:797-807. [PMID: 32003496 PMCID: PMC7096664 DOI: 10.1111/jvim.15716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 01/20/2020] [Indexed: 12/29/2022] Open
Abstract
Background Thoracolumbar myelopathies associated with spinal cord and vertebral column lesions, with a similar clinical phenotype, but different underlying etiologies, occur in pugs. Objectives To further characterize the clinical and neuropathological characteristics of pugs with longstanding thoracolumbar myelopathy. Animals Thirty client‐owned pure‐bred pugs with a history of more than a month of ataxia and paresis of the pelvic limbs, suggesting a myelopathy localized to the thoracolumbar spinal cord, were included in the study. Methods Prospective clinicopathological study. Included pugs underwent a complete neurological examination and gross and histopathologic postmortem studies with focus on the spinal cord. Computed tomography (n = 18), magnetic resonance imaging (n = 17), and cerebrospinal fluid analysis (n = 27) were performed before or immediately after death. Results Twenty male and 10 female pugs had a median age at clinical onset of 84 months (interquartile range, 66‐96). Affected pugs presented with a progressive clinical course and 80% were incontinent. There was circumferential meningeal fibrosis with concomitant focal, malacic, destruction of the neuroparenchyma in the thoracolumbar spinal cord in 24/30 pugs. Vertebral lesions accompanied the focal spinal cord lesion, and there was lympho‐histiocytic inflammation associated or not to the parenchymal lesion in 43% of the pugs. Conclusions and Clinical Importance Meningeal fibrosis with associated focal spinal cord destruction and neighboring vertebral column lesions were common findings in pugs with long‐standing thoracolumbar myelopathy.
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Affiliation(s)
- Cecilia Rohdin
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden.,Anicura Albano Small Animal Hospital, Danderyd, Sweden
| | - Ingrid Ljungvall
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Jens Häggström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Alexandra Leijon
- Department of Biomedical Sciences and Veterinary Public Health (BVF), Section of Pathology, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Kerstin Lindblad-Toh
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden.,Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kaspar Matiasek
- Section of Clinical and Comparative Neuropathology, Ludwig-Maximilians-Universität, Munich, Germany
| | - Marco Rosati
- Section of Clinical and Comparative Neuropathology, Ludwig-Maximilians-Universität, Munich, Germany
| | - Peter Wohlsein
- Department of Pathology, University of Veterinary Medicine, Hannover, Germany
| | - Karin Hultin Jäderlund
- Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences, Oslo, Norway
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10
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Heiss JD, Jarvis K, Smith RK, Eskioglu E, Gierthmuehlen M, Patronas NJ, Butman JA, Argersinger DP, Lonser RR, Oldfield EH. Origin of Syrinx Fluid in Syringomyelia: A Physiological Study. Neurosurgery 2019; 84:457-468. [PMID: 29618081 DOI: 10.1093/neuros/nyy072] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 02/13/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The origin of syrinx fluid is controversial. OBJECTIVE To elucidate the mechanisms of syringomyelia associated with cerebrospinal fluid pathway obstruction and with intramedullary tumors, contrast transport from the spinal subarachnoid space (SAS) to syrinx was evaluated in syringomyelia patients. METHODS We prospectively studied patients with syringomyelia: 22 with Chiari I malformation and 16 with SAS obstruction-related syringomyelia before and 1 wk after surgery, and 9 with tumor-related syringomyelia before surgery only. Computed tomography-myelography quantified dye transport into the syrinx before and 0.5, 2, 4, 6, 8, 10, and 22 h after contrast injection by measuring contrast density in Hounsfield units (HU). RESULTS Before surgery, more contrast passed into the syrinx in Chiari I malformation-related syringomyelia and spinal obstruction-related syringomyelia than in tumor-related syringomyelia, as measured by (1) maximum syrinx HU, (2) area under the syrinx concentration-time curve (HU AUC), (3) ratio of syrinx HU to subarachnoid cerebrospinal fluid (CSF; SAS) HU, and (4) AUC syrinx/AUC SAS. More contrast (AUC) accumulated in the syrinx and subarachnoid space before than after surgery. CONCLUSION Transparenchymal bulk flow of CSF from the subarachnoid space to syrinx occurs in Chiari I malformation-related syringomyelia and spinal obstruction-related syringomyelia. Before surgery, more subarachnoid contrast entered syringes associated with CSF pathway obstruction than with tumor, consistent with syrinx fluid originating from the subarachnoid space in Chiari I malformation and spinal obstruction-related syringomyelia and not from the subarachnoid space in tumor-related syringomyelia. Decompressive surgery opened subarachnoid CSF pathways and reduced contrast entry into syringes associated with CSF pathway obstruction.
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Affiliation(s)
- John D Heiss
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland
| | - Katie Jarvis
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland
| | - René K Smith
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland
| | - Eric Eskioglu
- Novant Health Neurosurgery Specialists, Charlotte, North Carolina
| | - Mortimer Gierthmuehlen
- Department of Neurosurgery, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Nicholas J Patronas
- Department of Radiology, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - John A Butman
- Department of Radiology, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Davis P Argersinger
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland
| | - Russell R Lonser
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland
| | - Edward H Oldfield
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland
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11
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Stretching of roots contributes to the pathophysiology of radiculopathies. Joint Bone Spine 2018; 85:41-45. [DOI: 10.1016/j.jbspin.2017.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/05/2017] [Indexed: 12/26/2022]
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12
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Yabe I, Matsushima M, Seki T, Sasaki H. A nationwide survey of familial syringomyelia in Japan. J Neurol Sci 2017; 381:128-129. [PMID: 28991663 DOI: 10.1016/j.jns.2017.08.3237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/31/2017] [Accepted: 08/21/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaaki Matsushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshitaka Seki
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hidenao Sasaki
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
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13
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Zuev AA, Lebedev VB, Pedyash NV, Epifanov DS, Levin RS. [Treatment of syringomyelia associated with adhesive arachnoiditis]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:39-47. [PMID: 28665387 DOI: 10.17116/neiro201781339-47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED The prevalence of syringomyelia (SM) caused by adhesive arachnoiditis (AA) is 2 to 4 cases per 100000 population. Surgical treatment of this pathology usually includes implantation of shunts into the cyst cavity or opening and drainage of the cavity. In this case, SM continues to progress in 72-100% of patients. Unsatisfactory outcomes of this surgical approach necessitate searching for other treatment options. PURPOSE To define the optimal amount of surgery for SM associated with AA and the criteria for assessment of surgery outcomes. MATERIAL AND METHODS The authors treated 47 SM patients in the period from 2010 to 2015. Of these, 34 (72.3%) patients underwent surgery; a total of 40 operations were performed. The patients' age ranged from 18 to 64 years (mean, 43.5 years). Tethering of the spinal cord was eliminated in 25 patients; 9 patients underwent cyst shunting. RESULTS Among operated patients, 5 patients had grade 1 arachnopathy, 13 patients had grade 2 arachnopathy, 12 patients had grade 3 arachnopathy, and 4 patients had grade 4 arachnopathy. The minimal postoperative follow-up period was 11 months. After shunting, the condition improved in 8 of 9 patients; in 7 patients, the condition returned to the baseline level within the first postoperative year; in 6 (66.7%) of these patients, the disease continued to progress. After surgical release of spinal cord tethering, satisfactory long-term results were achieved in 13 (86.6%) patients with grade 1-2 arachnopathy. In 3 (50%) patients with grade 3 arachnopathy, the condition was stabilized. Among patients with grade 4 arachnopathy, progression of the disease was stopped in 1 patient; the condition worsened in 2 (50%) patients. Among all the operated patients, complications developed in 7 patients. There were no lethal outcomes. CONCLUSIONS In grade 1-2 arachnopathy, progression of SM after release of spinal cord tethering occurs only in 13.4% of patients. Therefore, release of spinal cord tethering is recommended for these patients. In grade 3-4 arachnopathy, the rate of relapse after this surgery is more than 80%. Therefore, given the simplicity and a lower risk of complications of cyst shunting, this procedure is advisable for these patients.
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Affiliation(s)
- A A Zuev
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - V B Lebedev
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - N V Pedyash
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - D S Epifanov
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - R S Levin
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
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