Postoperative spinal adhesive arachnoiditis presenting with hydrocephalus and cauda equina syndrome

To our knowledge, the association between hydrocephalus and postoperative spinal adhesive arachnoiditis (SAA) has never been reported. Herein we describe an unusual case of a 45-year-old man with spinal adhesive arachnoiditis (SAA) who developed delayed-onset hypertensive hydrocephalus and cauda equina syndrome (CES) after multiple low-back surgeries. The patient's clinical presentation, imaging findings, surgical management, and the possible mechanisms are discussed in the light of the present literature.     

脊髓蛛网膜炎合并脊髓空洞的显微手术治疗

目的探讨脊髓蛛网膜炎合并脊髓空洞的显微手术治疗方法。方法回顾性分析经显微外科手术治疗的15例脊髓蛛网膜炎合并脊髓空洞病人的临床资料。根据脊髓蛛网膜炎症黏连的特点分为3型：I型（弥漫黏连型）10例,Ⅱ型（局限黏连型）3例,Ⅲ型（囊肿型）2例。I型行脊髓空洞一胸腔分流术,Ⅱ型行脊髓黏连松解术,Ⅲ型行囊肿探查切除术。结果术后症状明显改善13例,同术前2例。MRJ复查显示：脊髓空洞缩小12例,消失1例,同术前2例。13例术后随访8个月～3年,症状改善9例,同术前3例,加重1例。结论显微手术是治疗脊髓蛛网膜炎合并脊髓空洞的有效方法,根据分型选择合适的显微手术治疗方案,治疗效果较好。     

椎管内硬脊膜外蛛网膜囊肿的临床特点及手术治疗

目的 探讨椎管内硬脊膜外蛛网膜囊肿的临床表现、手术方法及疗效。方法 2005年1月至2015年1月手术治疗椎管内硬脊膜外蛛网膜囊肿28例,其中采用囊肿全切+交通孔封闭术治疗5例,囊肿部分切除+交通孔封闭术治疗17例,囊肿切开+带蒂竖脊肌置入缝合术治疗6例。结果 术后随访5~72个月,平均51.6个月;症状完全消失18例,明显改善8例,无明显变化2例;术后复查脊椎MRI,仅1例复发。2例囊肿长度16 cm左右,术后出现较明显的脊柱后突畸形。结论 椎管内硬脊膜外蛛网膜囊肿建议采用囊肿全切+交通孔封闭术;若术中无法行囊肿全切或难以找到交通孔,则采用囊肿部分切除+交通孔封闭术或囊肿切开+带蒂竖脊肌置入缝合术,也是有效的手术方式。     

Clinical experience with a pressure-adjustable valve SOPHY in the management of hydrocephalus

Seventy-four patients with hydrocephalus due to a variety of causes were treated with a cerebrospinal fluid (CSF) shunt, incorporating a recently developed pressure-adjustable valve SOPHY (PAVS). The PAVS may be changed percutaneously with the help of an externally applied magnet in order to select a high-, mediumor low-valve opening pressure, whenever the need for a change in pressure characteristics seems necessary to the neurosurgeon. The percutaneous pressure adjustment obviated up- or downgrading of a medium pressure position by surgical means in half of our patients during the follow-up time (up to 39 months; mean follow-up 16.7 months). In 66 patients (89%) decreased ventricle volume and improvement of the clinical sign of increased intracranial pressure were established. In 11 patients a valve or a catheter infection occurred; in 6 of these patients the valve had to be removed. Half of this group consisted of patients under 2 years of age. Significant technical complications related to the PAVS did not occur in our series but until a somewhat smaller PAVS is available, we cannot recommend its use in neonates or in small infants. In all other patients the PAVS is a very valuable instrument in the surgical management of hydrocephalus because it makes shunt revisions for inadequate valve pressure obsolete in individual patients.Part of this paper was presented at the XVI Annual Meeting of the International Society for Pediatric Neurosurgery, Rome 1988, and the 5th International Congress of the International Federation for Hydrocephalus and Spina Bifida, Antwerp 1989     

Cerebrospinal fluid shunt infection in children: efficiency of management protocol, rate of persistent shunt colonization, and significance of `off-antibiotics' trial

To evaluate the efficiency of our management protocol, 33 pediatric cases of bacteria-infected cerebrospinal fluid shunt were reviewed. The causative organism was staphylococcus in 23 patients. In 23 patients, shunt infection was managed according to the protocol. The complexity of the shunt system did not prolong hospitalization. Unchanged but externalized tubings showed persistent colonization despite adequate antibiotics in 10 of 21 patients. Staphylococcal infection was oxacillin-resistant in 7 of 19. The efficiency of an `off-antibiotics' trial was minimal. Further modification of the protocol is expected to enhance efficiency of the management. Received: 10 July 1998 Revised: 18 August 1998     

脊髓空洞症外科治疗新方法——脊神经后根分流术

采用脊神经后根行囊腔内引流治疗脊髓空洞症9例,经1～6年随访.疗效满意.该手术具有操作简便、引流可靠和术后神经组织损伤小等优点.     

Use of Doppler ultrasonography to detect an elusive communication of a spinal extradural arachnoid cyst

Spinal extradural arachnoid cysts are thought to be extradural arachnoid pouches that communicate with the intraspinal subarachnoid space through a small dural defect. The mainstay of current treatment is resection of the cyst wall followed by obliteration of the communicating pedicle. Despite its clinical importance, the communicating pedicle of the cyst is often elusive. The authors report a 57-year-old woman with an extradural arachnoid cyst with intractable back pain and progressive motor weakness. Preoperative imaging studies, including phase-contrast MRI, failed to identify the communicating pedicle. Intraoperative Doppler ultrasonography clearly demonstrated the pulsatile influx of cerebrospinal fluid into the cyst. A flap-like structure was also noted near the pedicle; this structure appeared to act as a one-way valve. Doppler ultrasonography may be a helpful adjunct for identifying the location of elusive communication in a spinal extradural arachnoid cyst.     

山莨菪碱对急性颈髓损伤后血浆及脑脊液中内皮素-1含量的影响

目的：研究山莨菪碱（654－2）对内皮素－1（ET－1）水平的影响。方法：用放免法（RIA）测定急性颈髓损伤患血浆及脑脊液中ET－1含量。结果：急性颈髓损伤后血浆及脑脊液ET－1明显升高，经山莨菪碱治疗组ET－1较创伤对照组明显下降。结论：急性颈髓损伤后神经元坏死可能与ET－1水平升高有关，山莨菪碱可通过降低ET－1水平而发挥对脊髓神经元的保护作用。     

Drainage of molecules from subarachnoid space to spinal nerve roots and peripheral nerve of the rat

The purpose of the present investigation was to find out if a compound injected into the spinal subarachnoid space, after having entered ventral and dorsal nerve roots, can be traced to the epineurial-perineurial sheaths and the endoneurium of peripheral nerves. This would indicate a centrifugal movement of substances from the cerebrospinal fluid along nerves; one route of drainage of cerebrospinal fluid which in the past has been widely discussed. In vivo studies were made using Evans blue-albumin and lanthanum chloride as tracers. Evans blue-albumin is macromolecular in size and emits a red fluorescence after exposure to ultraviolet light. Lanthanum ions are small and easily visible in the electron microscope. The tracers were injected into the cervical subarachnoid space and 15 min to 24 h later sampled from roots, dorsal root ganglia, proximal part of spinal nerves and the median nerves were taken and further processed for detection of tracers. Fluorescence microscopy from samples removed 15 min and 24 h after the injection of Evans blue-albumin showed a red fluorescence of low intensity in the endoneurium of nerve roots, ganglia and proximal spinal nerve. After 24 h also the median nerve elicited some fluorescence. The sheaths around these structures were also fluorescent. Lanthanum was detected between cell layers of the nerve root sheath as well as inside the nerve root parenchyma. In about 50% of the samples from dorsal root ganglia extracellular lanthanum was found in the capsule. The tracer was also found in the epineurium of 50% of the spinal nerves and occasionally in the perineurium. At 15 min, 6 h and 15 h lanthanum was often present in the endoneurium of the spinal nerve sample but always absent in the median nerve. At 24 h electron-dense particles identical to, and suspected to be, lanthanum was rarely seen also in the median nerve. The results show that substances in the cerebrospinal fluid can be transferred to other parts of the peripheral nervous system indicating a centrifugal spread, which may take place in [1] extracellular spaces of the sheaths covering roots, ganglia and nerve, and [2] endoneurial spaces in roots, ganglia and nerve after passage across the sheath surrounding spinal nerve roots. If absorption of tracer into the blood occurs following injection into the subarachnoid space, leaky blood vessels in ganglia and epineurium may add tracer molecules to the extra-cellular environment of the peripheral nervous system.Supported by grants from the Swedish Medical Research Council, project 12X-03020, Trygg Hansa, Svenska Sällskapet för Medicinsk Forskning, Söderbergs stiftelser, Thurings stiftelse, P. and A. Hedlunds stiftelse, Riksföreningen för Trafik och Polioskadade, Henning Larssons fond, Thyr och Thure Stenemarks och Ruth Trossbecks minnesfond and the Multipel Sclerosis Society of Sweden     

Evaluation of cerebrospinal fluid biomarkers in pediatric patients with spinal muscular atrophy

BackgroundSpinal muscular atrophy (SMA) is a rare neuromuscular disorder characterised by muscle weakness and muscle atrophy and classified into five known subtypes based on clinical features. The recent development of novel drugs to treat SMA has been encouraging, and nusinersen is the first drug approved to treat SMA.ObjectiveTo explore cerebrospinal fluid (CSF) biomarkers of SMA and investigate their relationship with symptoms and the treatment response in pediatric patients.MethodsWe analyzed the CSF levels of chitotriosidase 1 (CHIT1) and inflammatory cytokines (tumor necrosis factor [TNF]-α and interferon [INF]-γ) using enzyme-linked immunosorbent assays in pediatric SMA patients treated at Hiroshima University Hospital over 2 years.ResultsThis study analyzed pediatric SMA patients. While the CSF inflammatory cytokines (TNF-α and INF-γ) in these SMA children were unchanged, the CHIT1 levels decreased significantly from year 1 to 2 of treatment. We also found a trend toward an inverse correlation between the motor function score (HINE-2 scores) and CHIT1 level from year 1 to 2 of treatment.ConclusionsCHIT1 may be a CSF biomarker of the treatment response in pediatric SMA.     

An alternative approach for management of abdominal cerebrospinal fluid pseudocysts in children

Background Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. From the collected series, several features about the etiology and management become apparent. Retrospective data were obtained from 12 children treated with cerebrospinal fluid abdominal pseudocyst defined an alternative approach for management of these patients.Methods There were eight girls and four boys who ranged in age from 12 days to 18 years old (mean 7.7 months). The most frequent etiology of the hydrocephalus was Chiari type II malformation in six cases. Initial presentation with shunt malfunction was detected in nine cases. Abdominal distention and/or pain were the most frequent finding in our series (10/12). In only one case, infection was detected for all cerebrospinal fluid abdominal pseudocysts (8.3%). Ventriculoperitoneal shunt (VPS) externalization, antibiotics, and cyst aspiration was performed in 8/12 cases as initial management of abdominal pseudocyst. Ventriculoperitoneal shunt reinsertion in abdominal cavity and/or endoscopic third ventriculostomy (ETV) was performed as final management in 9/12. Ventriculoatrial shunt was used only in three cases. Recurrence of the abdominal cyst was observed in two cases.Discussion Based on the success rate (75%) in our series submitted to this management, a ventriculoperitoneal shunt can be safely reinserted in the majority of the patients. Endoscopic third ventriculostomy could be performed in selected cases as an alternative approach. Although infection has been reported as responsible for pseudocyst formation, it was only exceptionally found in our series.     

儿童后纵隔椎管肿瘤的分型和治疗

目的探讨小儿后纵隔椎管肿瘤的分型和手术方式,以提高对该病的认识及疗效。方法男12例,女11例,年龄5个月至6岁,平均(2.3±1.6)岁。术前均摄胸部X线光片、CT或MRI并进行分型:Ⅰ型5例;Ⅱ型6例;Ⅲ型11例;Ⅳ型1例;椎管内的肿瘤均位于硬膜外;术前依据分型选择适当的治疗方案。结果23例中良性11例,其中畸胎瘤1例、肠源性囊肿3例、神经节细胞瘤7例;恶性12例,其中恶性神经鞘瘤1例、节细胞性神经母细胞瘤1例、神经母细胞瘤10例。16例行椎管及纵隔同期手术,7例进行了分期手术。随访1-8年,17例有神经症状中的13例均不同程度改善或恢复正常。结论影像学检查结合临床表现是儿童后纵隔椎管肿瘤诊断、分型和确定手术方案的主要方法,神经外科和胸外科同期手术是治疗小儿后纵隔椎管肿瘤安全有效的方式。     

磁共振动态脑脊液流速测定技术在蛛网膜囊肿诊治中的应用

目的 探讨MRI动态脑脊液流速测定技术(MRI电影技术)对蛛网膜囊肿诊断及治疗的价值.方法 用普通MRI、CT对17例不同部位的蛛网膜囊肿患者进行平扫+增强,同时对其中的14例患者,应用MRI电影技术分别对蛛网膜囊肿内液体与蛛网膜下腔内脑脊液测速,并对所测得的结果进行统计学分析.结果 与沟通性蛛网膜囊肿不同,非沟通性蛛网膜囊肿内液体流速与蛛网膜下腔内脑脊液流速差异有统计学意义(P＜0.05),并于术中证实.结论 与普通MRI和CT对比,MRI电影技术可以无创性诊断蛛网膜囊肿是否与外界沟通,给手术治疗提供证据.     

Systematic Review and Meta-Analysis of Antibiotic-Impregnated Shunt Catheters on Anti-Infective Effect of Hydrocephalus Shunt

ObjectiveShunt infection is a common complication while treating hydrocephalus. The antibiotic-impregnated shunt catheter (AISC) was designed to reduce shunt infection rate. A meta-analysis was conducted to study the effectiveness of AISCs in reduction of shunt infection in terms of age, follow-up time and high-risk patient population. MethodsThis study reviewed literature from three databases including PubMed, EMBASE, and Cochrane Library (from 2000 to March 2019). Clinical studies from controlled trials for shunt operation were included in this analysis. A subgroup analysis was performed based on the patient’s age, follow-up time and high-risk population. The fixed effect in RevMan 5.3 software (Cochrane Collaboration) was used for this meta-analysis. ResultsThis study included 19 controlled clinical trials including 10105 operations. The analysis demonstrated that AISC could reduce the infection rate in shunt surgery compared to standard shunt catheter (non-AISC) from 8.13% to 4.09% (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.40–0.58; p=0.01; I²=46%). Subgroup analysis of different age groups showed that AISC had significant antimicrobial effects in all three groups (adult, infant, and adolescent). Follow-up time analysis showed that AISC was effective in preventing early shunt infections (within 6 months after implant). AISC is more effective in high-risk population (OR, 0.24; 95% CI, 0.14–0.40; p=0.60; I²=0%) than in general patient population. ConclusionThe results of meta-analysis indicated that AISC is an effective method for reducing shunt infection. We recommend that AISC should be considered for use in infants and high-risk groups. For adult patients, the choice for AISC could be determined based on the treatment cost.     

颅内蛛网膜囊肿临床诊断和手术治疗

报告２１例颅内蛛网膜囊肿（ＩＡＣ），对其临床表现、诊断、手术适应证、手术方法选择和术中注意事项进行了讨论。ＩＡＣ约占颅内占位性病变的０．８７％，最常见于外侧裂池。认为：ＣＴ、ＭＲＩ是最可靠的诊断方法。凡囊肿有颅内高压者，充分建立囊腔与周围脑池或腹腔之间的交通是手术成功的关键。     

Complications of ventriculosubgaleal shunts in infants and children

Introduction The ventriculosubgaleal shunt has been used for the temporary bypass of the normal cerebrospinal fluid (CSF) pathways. To date, a large series of complications from this procedure has not been elaborated upon in the literature.Patients and methods We retrospectively reviewed all such shunts (170) placed at our institution over the last 6 years and documented all complications from this procedure. The majority of patients operated upon were premature infants with intraventricular hemorrhage and subsequent hydrocephalus. This technique was used in a much smaller group of patients in whom the peritoneal cavities were not currently candidates for distal shunt implantation but would have been with time. Other patients in whom this technique was used were those with malignant brain tumors, intraventricular abscesses, chronic truncal wounds, chronic subdural hygromas, and meningitis.Results Complications from subgaleal shunting included infection (5.9%), intracranial hemorrhage (1.1%), and wound leakage (4.7%).Conclusions We believe the benefits afforded by ventriculosubgaleal shunting significantly outweigh the risks of the procedure and greatly ease the burden of care for this select population of children. Based on the literature and our own experience, the complications from this procedure are not excessive or extraordinarily unique compared with other neurosurgical CSF diversion techniques.     

椎管内硬脊膜外海绵状血管瘤的诊治

目的总结单纯椎管内硬脊膜外海绵状血管瘤的诊治经验。方法回顾性分析2006年2月至2009年3月经病理证实的7例单纯椎管内硬脊膜外海绵状血管瘤患者的临床表现、MRI特征和手术结果。结果 7例均表现为慢性双下肢麻木及无力,1例伴有神经根性症状;脊柱MRI显示6例病变位于胸椎,1例位于颈胸交界区;所有病变均达到手术全切,术后所有患者神经功能症状明显改善。结论单纯椎管内硬脊膜外海绵状血管瘤临床少见;主要表现为脊髓及神经根慢性受压而出现神经功能缺损症状及体征;脊柱MRI示病变位于硬脊膜外脊髓背侧或一侧,且有经相应椎间孔向外生长的趋势;手术切除病变较为容易,术后患者神经功能改善明显。     

Ossified thoracic spinal meningioma in childhood: A case report and review of the literature

Spinal ossified meningiomas are extremely rare. This is a report of a study on a 15-year-old boy with thoracic spinal ossified meningioma. The meningioma was resected totally. Histopathological examination revealed a transitional meningioma (psammomatous+meningothelial). Immunohistochemically, Ki 67 antibody was applied but no positive staining was present. The surgical and pathological aspects of spinal ossified meningiomas were reviewed.     

Bone marrow stromal cells infused into the cerebrospinal fluid promote functional recovery of the injured rat spinal cord with reduced cavity formation

The effects of bone marrow stromal cells (BMSCs) on the repair of injured spinal cord and on the behavioral improvement were studied in the rat. The spinal cord was injured by contusion using a weight-drop at the level of T8-9, and the BMSCs from the bone marrow of the same strain were infused into the cerebrospinal fluid (CSF) through the 4th ventricle. BMSCs were conveyed through the CSF to the spinal cord, where most BMSCs attached to the spinal surface although a few invaded the lesion. The BBB score was higher, and the cavity volume was smaller in the rats with transplantation than in the control rats. Transplanted cells gradually decreased in number and disappeared from the spinal cord 3 weeks after injection. The medium supplemented by CSF (250 microl in 3 ml medium) harvested from the rats in which BMSCs had been injected 2 days previously promoted the neurosphere cells to adhere to the culture dish and to spread into the periphery. These results suggest that BMSCs can exert effects by producing some trophic factors into the CSF or by contacting with host spinal tissues on the reduction of cavities and on the improvement of behavioral function in the rat. Considering that BMSCs can be used for autologous transplantation, and that the CSF infusion of transplants imposes a minimal burden on patients, the results of the present study are important and promising for the clinical use of BMSCs in spinal cord injury treatment.     

Treatment of refractory intracranial hypertension in a spina bifida patient by a concurrent ventricular and cisterna magna-to-peritoneal shunt

Case report A 20-year-old female born with a thoracic level myelomeningocele, Chiari II malformation, and hydrocephalus treated at birth developed clinical features of increased intracranial pressure (ICP) due to shunt malfunction. The patient became comatose. Her ICP remained high despite a functioning shunt and even after the ventricular catheter was exteriorized. Diagnostic imaging consistently demonstrated slit-like ventricles, a Chiari II malformation, and a tethered spinal cord. We attributed her neurological condition either to brainstem compression or increased ICP related to venous outlet obstruction at the foramen magnum.Outcome The patient improved rapidly after undergoing a Chiari II decompression and placement of a shunt from the cisterna magna and upper cervical subarachnoid space to the peritoneum connected by a Y connector to the ventricular catheter.Conclusion The complex hydrocephalus was effectively treated by this concurrent ventricular and cisterna magna-to-peritoneum shunt.