Utility of heavily T2-weighted MR myelography as the first step in CSF leak detection and the planning of epidural blood patches

Heavily T2-weighted MR myelography (HT2W-MRM) is emerging as an alternative approach for detection and follow up of CSF leaks. We aimed to assess epidural blood patch (EBP) treatment outcome when using HT2W-MRM as the primary modality for detecting CSF leak and planning EBP placement in routine clinical practice. Since 2018, patients at our institute suspected of having CSF leak, routinely HT2W-MRM instead of CT myelography to determine presence of the leak and identify the EBP target site. Fifty-nine consecutive patients suspected of having a CSF leak underwent HT2W-MRM. After excluding patients with subdural hematoma and poor image quality, 26 (10 men, 16 women; mean age 44.92 ± 12.6 years) patients were included in this study. Patients received EBP on the basis of HT2W-MRM assessments and clinical assessment. Imaging findings and clinical outcome were evaluated. CSF leak was identified in 21 patients (80.8%, 21/26) based HT2W-MRM. Most cases were graded on a confidence scale as CSF leak definitely (n = 13) or probably (n = 3) present. Successful clinical EBP treatment was achieved in 14 of 17 patients (82.4%) after first targeted EBP, and patient symptoms significantly improved after treatment (numerical rating score 6.4 before EBP, 1.3 after EBP, P < 0.001). HT2W-MRM based EBP are the rational and effective choices for CSF leak treatment in routine clinical practice.     

Imaging of thoracic and lumbar spinal extradural arachnoid cysts: report of two cases

Extradural arachnoid cysts are uncommon expanding lesions in the spinal canal which may communicate with the subarachnoid space. Usually in the lower thoracic spine, they may cause symptoms by compressing the spinal cord or nerve roots. We report cases of thoracic and lumbar arachnoid cysts studied by cystography, myelography, CT and MRI. These techniques showed extradural cystic lesions containing cerebrospinal fluid, with variable communication with the subarachnoid space, causing anterior displacement and flattening of the spinal cord. Received: 3 November 1995 Accepted: 16 April 1996     

胸腰椎外伤后脊髓损伤CT平扫的局限性

目的：探讨CT平扫诊断胸腰椎外伤后脊髓损伤的局限性。方法：收集近7a来48例胸腰椎外伤的CT平扫结果、X线片结果及临床资料，并进行对比分析。结果：48例胸腰椎外伤病人中椎体骨折73个，单发59个，多发14个，其中CT示碎骨入椎管内的有25处，血肿1处，附件骨折36处，X线片漏报附件骨折16处(44％)瘫痪病人11例，均经手术治疗，术中发现椎管内碎骨15处，血肿2处，脊髓挫伤或断裂10处。结论：CT平扫对椎体、附件骨折、椎管形态改变和碎骨片移位及明显的椎管内血肿的诊断，优于X线平片，但是对脊髓损伤的显示有局限性，建议胸腰椎外伤后瘫痪病人做脊髓造影(CTM)或磁共振成像(MRI)。     

Delayed occurrence of spinal arachnoiditis following a caudal block

Abstract

Context

Spinal arachnoiditis is a rare disease caused by fibrosis and adhesion of the arachnoid membrane due to chronic inflammation. The causes of arachnoiditis are infection, spinal surgery, intraspinal injection of steroid or myelography dye, and spinal anesthesia.

Method

Case report.

Findings

A 60-year-old woman presented with progressive weakness and sensory change of both legs and urinary symptoms. She had received a single caudal block 6 months before symptom onset. Magnetic resonance imaging of the thoraco-lumbar spine showed an intradural extramedullary tumor at the T5–T7 level. She underwent laminectomy and tumor resection. The pathological finding was arachnoiditis. After surgery, a rehabilitation program of strengthening exercises of both lower extremities and gait training was started. At 2-month follow-up, she was able to walk with orthoses and performed daily activities with minimal assistance.

Conclusion

Symptoms of spinal arachnoiditis occurred 6 months after a single caudal block in this woman. Clinicians should be aware of this possible delayed complication.     

Delayed occurrence of spinal arachnoiditis following a caudal block

Context

Spinal arachnoiditis is a rare disease caused by fibrosis and adhesion of the arachnoid membrane due to chronic inflammation. The causes of arachnoiditis are infection, spinal surgery, intraspinal injection of steroid or myelography dye, and spinal anesthesia.

Method

Case report.

Findings

A 60-year-old woman presented with progressive weakness and sensory change of both legs and urinary symptoms. She had received a single caudal block 6 months before symptom onset. Magnetic resonance imaging of the thoraco-lumbar spine showed an intradural extramedullary tumor at the T5–T7 level. She underwent laminectomy and tumor resection. The pathological finding was arachnoiditis. After surgery, a rehabilitation program of strengthening exercises of both lower extremities and gait training was started. At 2-month follow-up, she was able to walk with orthoses and performed daily activities with minimal assistance.

Conclusion

Symptoms of spinal arachnoiditis occurred 6 months after a single caudal block in this woman. Clinicians should be aware of this possible delayed complication.     

Influence of myelography on the developmental curve of auditory brainstem responses and hearing loss

Auditory threshold and auditory brainstem response studies were conducted in 50 patients before and after myelography. Analysis of amplitudes and latencies of auditory brainstem measurements demonstrated significant disorders of function of the cochlea and auditory pathway. The Jewett I wave showed a prolongation of latency from 1.92 to 1.98 ms using an average of all repetition rates. The Jewett III wave showed prolongation from 4.01 to 4.14 ms and the Jewett V wave prolongation from 6.01 to 6.16 ms. At the same time average amplitudes for Jewett III and V decreased. In most of the patients these disorders of function were found to be subclinical. However, 12 patients had changes ranging from a subjectively slight hearing loss to an audiometrically defined acute hearing loss. The reasons for these disorders could not be clarified. An open cochlear aqueduct through which perilymph can enter the subarachnoid space, leading to secondary endolymphatic hydrops, was suggested as the cause for the losses found. Changes in brainstem audiometry were also explained by changes in osmolality of inner ear fluids, leading to the development of an endolymphatic hydrops.     

Haemorrhagic necrosis of the grey matter of the spinal cord due to accidental injection of iopamidol in a patient with multiple neurofibromas; a clinico-pathological study

Summary Cervical laminectomy was performed in a 34-year-old man with multiple spinal neurofibromas because of a slowly progressive medullary compression. Four weeks later a rapid deterioration necessitated iopamidol myelography by left lateral cervical puncture at C2 level. Despite the establishment of adequate spinal fluid contact, resulting in imaging of the subarachnoid space, part of the contrast medium entered the spinal cord, thus delineating a syrinx from the upper cervical extending to the upper thoracic level. After the puncture the patient developed triplegia, involving the left arm and both legs and a paresis of the right arm. He died from aspiration pneumonia. Autopsy revealed haemorrhagic necrosis of the spinal grey matter. This adverse effect of myelography is argued to have been conditioned by the extreme immobility and displacement of the spinal cord due to the presence of multiple neurofibromas. The deterioration four weeks after the operation was probably caused by a further compression of the spinal cord.     

Myelography in patients with acquired immuno deficiency syndrome

Summary Neurological complications in patients with Acquired Immuno Deficiency Syndrome (AIDS) are frequent and in addition to central nervous system syndromes, involvement of the peripheral nervous system is increasingly seen. We evaluated the indications and results of myelographic examination in six AIDS-patients with signs of peripheral nervous system disease, out of 200 AIDS-patients with neurological complications. Five of these patients had a polyradiculopathy, with proven cytomegalovirus (CMV) infection in four cases. There were two abnormal myelographic examinations with findings of cauda equina nerve root involvement, both in patients with proven CMV-polyradiculopathy. These abnormal findings had no direct therapeutic consequences. Myelography is not essential for establishing the diagnosis, which is based on cerebrospinal fluid (CSF) analysis, but may be indicated to exclude a spinal cord or nerve root compressive lesion.     

脊髓造影辅助经皮椎板间孔内窥镜下髓核摘除术治疗L5/S1椎间盘突出症

目的:评估术中脊髓造影辅助经皮椎板间孔入路内窥镜下髓核摘除术治疗L<,5>/S<,1>椎间盘突出症的临床价值.方法:选择确诊为L5/S1单节段腰椎间盘突出症患者共40例,采用随机数字表的方法将患者分为A组和B组,每组各20例.A组在脊髓造影辅助下行经皮椎板间孔入路内窥镜下髓核摘除术,B组不实施脊髓造影操作,其它方法同A组.记录两组穿刺到目标椎间盘所需时间,一次性穿刺成功率,穿刺过程中神经根刺激症状和神经根、硬膜囊损伤发生率,脊髓造影相关的并发症.两组病例均随访6～12个月.采用疼痛VAS评分、Oswestry功能障碍指数(ODI)、改良的MacNab分级标准为疗效观察指标.结果:A组穿刺到目标椎间盘时间为9.67±1.45min,B组14.40±2.35min(P<0.01);A组一次性穿刺成功率95%(19/20例),B组60%(12/20例)(P<0.05);A组穿刺过程中神经根刺激症状发生率15%(3/20例),B组55%(11/20例)(P<0.05);A组无神经根和硬膜囊损伤发生,B组神经根和硬膜囊损伤各1例.按照改良MacNab疗效评定标准,A组优良率85%,B组优良率80%,两组无显著性差异(P>0.05).两组患者术后VAS和ODI评分较术前明显改善(P<0.05),但两组间比较无差异(P>0.05).A组中未见和脊髓造影相关并发症发生.结论:脊髓造影辅助经皮椎板间孔入路内窥镜下髓核摘除术治疗L<,5>/S<,1>椎间盘突出症的优点是减少目标椎间盘的穿刺时间,提高一次性穿刺成功率,降低并发症的发生率.     

腰椎间盘突出症的诊断问题──临床检查、脊髓造影、CT及MRI在诊断中所起的作用

本文分析了手术治疗的１５３例腰椎间盘突出症，指出临床检查是诊断本病的基础；各种影象学检查对术前准确定位和鉴别诊断是非常必要的，但是，其结果一定要与临床相结合，才有实际意义。同时讨论了脊髓造影、ＣＴ及ＭＲＩ检查的选择应用和应注意的问题。