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Rairan LG, Henriquez A, Diaz G, Mejía JA, Gomez D, Ramon JF, Hakim EJ. Unveiling the Current Understanding of Idiopathic Spinal Cord Herniation: A Systematic Review. Spine Surg Relat Res 2024; 8:225-234. [PMID: 38868787 PMCID: PMC11165495 DOI: 10.22603/ssrr.2023-0102] [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: 05/11/2023] [Accepted: 08/07/2023] [Indexed: 06/14/2024] Open
Abstract
Background Idiopathic spinal cord herniation (ISCH) is a rare condition that is characterized by ventral herniation of the spinal cord through a defect in the dura mater into the epidural space, with no identifiable cause. ISCH is frequently underdiagnosed, and the information available in case reports is limited. To provide an overview of the clinical manifestations and diagnosis of this condition, this study aims to conduct a review of reported cases of ISCH. Methods A literature review was carried out using seven databases. The search was conducted using the keywords "Idiopathic spinal cord herniation" OR "Idiopathic Ventral Spinal Cord Herniation" AND "Case report" OR "case series." Results A total of 92 relevant papers reporting 224 cases, besides the index case, were determined. Of the cases, 58.5% were females and the mean age was 50.7 (SD 13.2) years. Symptoms, diagnoses, and outcomes were similar between genders. The most common clinical signs included motor symptoms (82.6%), instability (61.3%), hypoesthesia (59.2%), and disturbance of thermal sensitivity (47.3%). Brown-Séquard syndrome was observed in 27.2% of the cases, and surgical treatment was employed in 89.7% of the cases. Conclusions ISCH is a pathology that is principally treated with surgical approach. This study provides valuable insights into the clinical manifestations and diagnosis of ISCH, which can aid in the early recognition and treatment of this rare condition.
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Affiliation(s)
- Luis Garcia Rairan
- Department of Neurosurgery, Universidad Nacional de Colombia, Bogotà, Colombia
| | | | - Gustavo Diaz
- Faculty of Medicine, Universidad El Bosque, Bogotá, Colombia
| | | | - Diego Gomez
- Department of Neurosurgery, Fundación Santa Fe, Bogotá, Colombia
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Adib SD, Schittenhelm J, Kurucz P, Hauser TK, Tatagiba M. Surgical management of syringomyelia associated with spinal arachnoid web: strategies and outcomes. Neurosurg Rev 2023; 46:152. [PMID: 37358703 PMCID: PMC10293323 DOI: 10.1007/s10143-023-02071-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
Spinal arachnoid web (SAW) is a rare disease entity characterized as band-like arachnoid tissue that can cause spinal cord compression and syringomyelia. This study aimed to analyze the surgical management of the spinal arachnoid web in patients with syringomyelia, focusing on surgical strategies and outcomes. A total of 135 patients with syringomyelia underwent surgery at our department between November 2003 and December 2022. All patients underwent magnetic resonance imaging (MRI), with a special syringomyelia protocol (including TrueFISP and CINE), and electrophysiology. Among these patients, we searched for patients with SAW with syringomyelia following careful analysis of neuroradiological data and surgical reports. The criteria for SAW were as follows: displacement of the spinal cord, disturbed but preserved CSF flow, and intraoperative arachnoid web. Patients were evaluated for initial symptoms, surgical strategies, and complications by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. Of the 135 patients, 3 (2.22%) fulfilled the SAW criteria. The mean patient age was 51.67 ± 8.33 years. Two patients were male, and one was female. The affected levels were T2/3, T6, and T8. Excision of the arachnoid web was performed in all cases. No significant change in intraoperative monitoring was noted. Postoperatively, none of the patients presented new neurological symptoms. The MRI 3 months after surgery revealed that the syringomyelia improved in all cases, and caliber variation of the spinal cord could not be detected anymore. All clinical symptoms improved. In summary, SAW can be safely treated by surgery. Even though syringomyelia usually improves on MRI and symptoms also improve, residual symptoms might be observed. We advocate for clear criteria for the diagnosis of SAW and a standardized diagnostic (MRI including TrueFISP and CINE).
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Affiliation(s)
- Sasan Darius Adib
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Jens Schittenhelm
- Department of Neuropathology, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Peter Kurucz
- Department of Neurosurgery, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Tran TDD, Vo PD, Truong TV, Ho TD. A case of neurosurgical treatment of thoracic dorsal arachnoid web. Surg Neurol Int 2023; 14:210. [PMID: 37404503 PMCID: PMC10316147 DOI: 10.25259/sni_398_2023] [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: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
Background Dorsal arachnoid webs constitute abnormal formations of arachnoid that tend to occur in the upper thoracic spine and can lead to spinal cord displacement. Patients typically present with back pain, sensory disturbances, and weakness. It may also obstruct the cerebrospinal fluid (CSF) flow, leading to syringomyelia. In magnetic resonance (MR) studies, the "scalpel sign" is a classical finding, and it may also be accompanied by syringomyelia attributed to CSF flow. Definitive surgical resection is the mainstay of treatment. Case Description A 31-year-old male presented with mild weakness in the right leg and diffuse lower extremity sensory changes. The MR showed the typical "scalpel sign" at the T7 level consistent with diagnosing a spinal arachnoid web. He underwent a T6-T8 laminotomy for lysis of the web and decompression of the thoracic cord. Postoperatively, his symptoms improved markedly. Conclusion Surgical resection is the treatment of choice when an arachnoid web is documented on an MR and correlates with the patient's clinical symptoms/signs.
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Affiliation(s)
- Tri Duc Duy Tran
- Department of Neurosurgery, Hoan My ITO Dong Nai Hospital, Bien Hoa, Vietnam
| | - Phong Duc Vo
- Department of Neurosurgery, Hoan My ITO Dong Nai Hospital, Bien Hoa, Vietnam
| | - Tri Van Truong
- Department of Neurosurgery, Vinmec Central Park International Hospital, Hochiminh, Vietnam
| | - Thi Duc Ho
- Department of Radiology, Hoan My ITO Dong Nai Hospital, Bien Hoa, Vietnam
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Bugdadi A, Herbrecht A, Alzahrani A, Aghakhani N, Parker F. Long-term outcome of surgical treatment for idiopathic spinal arachnoid web: A case series. Neurochirurgie 2023; 69:101455. [PMID: 37269747 DOI: 10.1016/j.neuchi.2023.101455] [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] [Received: 03/05/2023] [Revised: 05/09/2023] [Accepted: 05/16/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Spinal arachnoid web (SAW) is a rare condition of the spine with limited long-term follow-up data in the literature. The longest reported follow-up period was an average 3.2 years. The objective of this study is to report our long-term results of patients who underwent surgical treatment for symptomatic idiopathic SAW. METHODS We conducted a retrospective review of cases of idiopathic SAW that were operated between 2005-2020. We collected preoperative and last follow-up (LFU) data on motor force, sensory loss, pain, upper motor neuron (UMN) sign, gait disorder, sphincter dysfunction, syringomyelia, hyperintensity on T2-MRI, appearance of newer symptoms and number of reoperations. RESULTS Our study included 9 patients with a mean follow-up period of 3.6years (range 2-9.1years). The surgical intervention involved a standard centered laminectomy, durotomy and arachnoid lysis. At presentation, motor weakness was present in 77.8% of patients, sensory loss in 66.7%, pain in 88.9%, sphincter dysfunction in 33.3%, UMN sign in 22%, gait disorder 55.6%, syringomyelia in 55.6% and MRI T2 hyperintensity in 55.6% of patients. At LFU, there was an improvement in all symptoms and signs to varying degrees. No new neurological symptoms appeared postoperatively, and there was no recurrence during the follow-up period. CONCLUSION Our results demonstrate that the reported immediate and short-term favorable outcomes following arachnoid lysis for symptomatic SAW persist over a long-term period and the risk of readhesion-correlated neurological deterioration following conventional surgical intervention is low.
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Affiliation(s)
- Abdulgadir Bugdadi
- Department of Neurosurgery, Bicêtre University Hospital, Kremlin-Bicêtre, France; Department of Surgery, Faculty of Medicine, Umm Al Qura University, Makkah, Saudi Arabia.
| | - Anne Herbrecht
- Department of Neurosurgery, Bicêtre University Hospital, Kremlin-Bicêtre, France
| | - Abdullah Alzahrani
- Department of Neurosurgery, Bicêtre University Hospital, Kremlin-Bicêtre, France
| | - Nozar Aghakhani
- Department of Neurosurgery, Bicêtre University Hospital, Kremlin-Bicêtre, France
| | - Fabrice Parker
- Department of Neurosurgery, Bicêtre University Hospital, Kremlin-Bicêtre, France
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Arora V, Verma H, Kamal R, Lone NA. Dorsal arachnoid web: the ‘scalpel’ sign—a case report and differential diagnosis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00847-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Arachnoid web of the spine is a not so common lesion of the spinal cord. It is a band-like arachnoid tissue in the intradural extramedullary compartment that extends to the surface of the spinal cord, with a tendency to occur in the upper dorsal spine causing focal dorsal indentation of the cord that has been coined the ‘scalpel sign’. Patients usually present with progressive weakening and numbing of bilateral lower limb.
Case presentation
A 58-year-old man presented with difficulty in walking and weakness of right leg for 1 year, aggravated over the previous 2 months. There was no history of trauma or fever. Magnetic resonance imaging (MRI) of the dorsal spine was done which revealed a small syrinx within the cord at D4 vertebral level on right side. There was sharp dorsal indentation of the spinal cord and widening of the arachnoid space below this level. This appearance was similar to a surgical scalpel. The anterior subarachnoid space was preserved. On post-contrast images, no parenchymal or meningeal enhancement was detected. The patient was taken up for surgery as the symptoms further progressed. Laminectomy was done from D3 to D7 under general anesthesia, with release of arachnoid web and adhesions. Histology of the resected specimen revealed epithelial cells and fibrous tissue. No inflammatory or neoplastic cells were observed.
Conclusions
Thoracic arachnoid web is a rare entity, which if not treated can have devastating effects on a patient’s neurological function. Careful evaluation of radiological findings is important to avoid delay in diagnosis. Surgery is the only curative treatment and is known to have a favorable outcome.
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Krishnan P, Das S. Dorsal arachnoid web: A rare cause of syringomyelia and myelopathy. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:366-370. [PMID: 36333094 DOI: 10.1016/j.neucie.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/12/2021] [Indexed: 06/16/2023]
Abstract
Dorsal arachnoidal webs are condensations of arachnoidal tissue densely adherent to the pial surface of the posterior aspect of the dorsal spinal cord. Infrequently described in literature they disrupt the flow of CSF in the spinal subarachnoid space leading to syringomyelia and myelopathy. While there are several theories on their origin, the "scalpel sign" on magnetic resonance imaging is considered to be pathognomonic of this condition. An illustrative case of a 58 year old man with syringomyelia and dorsal cord indentation who presented with spastic paraparesis, gait instability, parasthesias and bilateral non radicular upper limb pain that resolved following excision of the web is described to highlight the importance of considering this diagnosis when cases of so called "idiopathic" syringomyelia are encountered.
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Affiliation(s)
- Prasad Krishnan
- Department of Neurosurgery, National Neurosciences Centre, Calcutta, India.
| | - Sayan Das
- Department of Radiology, Peerless Hospital, Calcutta, India
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Buntting CS, Ham Y, Teng KX, Dimou J, Gauden AJ, Nair G. Scalpel sign: Dorsal thoracic arachnoid web, thoracic arachnoid cyst and ventral cord herniation. Radiol Case Rep 2022; 17:3564-3569. [PMID: 35923346 PMCID: PMC9340144 DOI: 10.1016/j.radcr.2022.06.100] [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: 03/13/2022] [Revised: 06/26/2022] [Accepted: 06/29/2022] [Indexed: 12/01/2022] Open
Abstract
The “Scalpel sign” is a radiological sign which can be identified on magnetic resonance imaging and indicates dorsal compression of the spinal cord [1]. Prior descriptions of a “Scalpel sign” have been reported in the literature and the awareness and identification of this pathognomonic sign may aid in the rapid diagnosis and treatment of patients with dorsal arachnoid web, dorsal arachnoid cyst or ventral cord herniation. We describe 3 cases which highlight these rare conditions for which this sign is pathognomonic and summarize the pertinent literature related to these disorders [1,2].
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Affiliation(s)
| | - Yeji Ham
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - Ken X Teng
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - James Dimou
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - Andrew J Gauden
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - Girish Nair
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
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Cunha B, Rodrigues A, Gonçalves J, Conceição C. Imaging of intraspinal cystic lesions: A review. J Neuroimaging 2022; 32:1044-1061. [PMID: 35942824 DOI: 10.1111/jon.13037] [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: 06/18/2022] [Revised: 07/21/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022] Open
Abstract
Several distinct conditions present as cystic or pseudocystic lesions within the spinal canal. Some of the most common spinal cystic lesions include spinal meningeal cysts, juxtafacet cysts, dermoid/epidermoid cysts, nerve sheath tumors, and syringohydromyelia. Clinical presentation is usually nonspecific and imaging characteristics are frequently overlapping, which may pose a challenging presurgical diagnosis. We provide a pictorial review of cystic intraspinal lesions and discuss the main imaging features that can aid the neuroradiologist in the differential diagnosis. First, we propose a categorization of the lesions according to their location as extradural, intradural extramedullary, and intramedullary. This is a crucial initial step in the diagnostic workup and surgical planning. Second, for each of these locations, we organize the lesions according to their etiology: congenital and developmental disorders, degenerative disorders, traumatic or postsurgical collections, infectious conditions, neoplastic lesions, and other miscellaneous disorders. Finally, we summarize the clinical highlights and MR features that provide important insights for the differential diagnosis. MR is the technique of choice in presurgical evaluation and postsurgery follow-up. It provides accurate lesion localization and characterization and, most of the times, it will allow a confident differential diagnosis. High-resolution three-dimensional T2-weighted sequences and diffusion-weighted imaging can provide important hints in specific cases. Signal correlation with T1-weighted and fat-saturated sequences allows to differentiate true cystic lesions from hemorrhage or fat tissue.
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Affiliation(s)
- Bruno Cunha
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Alexandra Rodrigues
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal.,Unidade de Neurorradiologia, Hospital Central do Funchal, Funchal, Portugal
| | - João Gonçalves
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal.,Unidade de Neurorradiologia, Hospital Central do Funchal, Funchal, Portugal
| | - Carla Conceição
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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Thoracic spinal arachnoid web and syringomyelia with rostral expansion to the first cervical spinal cord level: Case report. Int J Surg Case Rep 2022; 96:107360. [PMID: 35779315 PMCID: PMC9284059 DOI: 10.1016/j.ijscr.2022.107360] [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: 05/09/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE A spinal arachnoid web is a rare pathology that has been associated with the development of syringomyelia. Syrinx expansion can occur, which can result in the development of new symptoms. In the current literature, the farthest rostral expansion of the associated syrinx has been to the C3 spinal level. CASE PRESENTATION We present a 49-year-old Hispanic male with a thoracic spinal arachnoid web and an associated syrinx spanning from C1 to T7 spinal level. The patient developed upper extremities radicular symptoms that worsened over time. He underwent surgical management with T6-8 laminectomy and excision of the web. Postoperative follow-up evaluations demonstrated progressive clinical improvement with eventual resolution of symptoms and syringomyelia. CLINICAL DISCUSSION Syringomyelia secondary to a thoracic spinal arachnoid web is a progressive disease that can expand rostrally to the C1 spinal level. The clinical presentation usually involves the lower extremities. However, if the upper thoracic or cervical spinal cord is involved, patients can also present symptoms in the upper extremities. Management usually involves surgical excision of the web in order to decompress the subarachnoid space and restore the normal cerebrospinal fluid (CSF) flow. CONCLUSION Our case suggests that syringomyelia secondary to a spinal arachnoid web may continuously expand with concomitant worsening of symptoms. However, surgical resection is curative with possible remission of symptoms and normalization of spinal anatomy.
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Nagashima Y, Nishimura Y, Ito H, Oyama T, Nishii T, Gonda T, Kato H, Saito R. Atypical radiographic case of arachnoid web without scalpel sign. Surg Neurol Int 2022; 13:108. [PMID: 35399890 PMCID: PMC8986712 DOI: 10.25259/sni_179_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/10/2022] [Indexed: 12/16/2022] Open
Abstract
Background:
Spinal arachnoid webs (SAW) occur when abnormally thickened bands of arachnoid membranes commonly located dorsal to the thoracic spine cause blockage of normal cerebrospinal fluid (CSF) flow, resulting in focal cord compression and myelopathy. The pathognomonic MR finding for SAW is the “positive scalpel sign” comprised of an enlarged dorsal CSF space with a normal ventral subarachnoid space. The main differential diagnostic consideration for SAW is idiopathic spinal cord herniation (ISCH); however, for ISCH, MR studies classically demonstrate ventral displacement of the spinal cord through an anterior dural defect. Here, we describe a 60-year-old female with an atypical SAW at the T3-T4 level (i.e., the preoperative MR failed to demonstrate the “positive scalpel sign”). Nevertheless, at surgery, intraoperative ultrasonography confirmed that SAW was present and was decompressed/marsupialized/removed.
Case Description:
A 60-year-old female presented with sensory impairment to both lower extremities. The thoracic MR images showed an enlarged dorsal CSF space at the T3-T4 level but without the “scalpel sign” suggesting “interruption” of CSF flow by thickened bands of focal dorsal arachnoidal tissues. Although the initial preoperative diagnosis was ISCH, intraoperative ultrasound (IOUS) confirmed the presence of a thickened arachnoid band, confirming the diagnosis of a SAW that was appropriately decompressed/resected.
Conclusion:
Correctly, establishing the preoperative diagnosis of a SAW based on MR imaging may sometimes be difficult as the typical “scalpel sign” may not be present in all patients. Notably, in cases like this one, IOUS may critically confirm the diagnosis of SAW thus leading to appropriate SAW decompression/removal.
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Delgardo M, Higgins D, McCormick KL, Reid P, Canoll P, McCormick PC. Clinical Characteristics, Outcomes, and Pathology Analysis in Patients With Dorsal Arachnoid Web. Neurosurgery 2022; 90:581-587. [PMID: 35290255 DOI: 10.1227/neu.0000000000001884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 11/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dorsal arachnoid webs (DAWs) are rare pathological abnormalities of the arachnoid layer of the spinal cord that can result in pain and myelopathy. OBJECTIVE To present clinical, imaging, and pathological characteristics of patients diagnosed with DAW, case illustrations, and a review of the literature. METHODS Seventeen cases of DAW between 2015 and 2019 at a tertiary medical center were retrospectively identified through a case log search. Patient characteristics, preoperative imaging, operative notes, and pathology reports were collected. Our main outcome assessed was postoperative resolution of symptoms. Odds ratios were used to determine associations between preoperative signs and symptoms with postoperative symptom resolution. RESULTS The mean age of the cohort was 50.5 years (IQR = 16) and presented primarily with back pain (64.7%). On imaging, all patients were found to have the "scalpel sign," and nearly half had a syrinx present (41.2%). All DAWs were located in the thoracic spine, with the most common location being the midthoracic (70.6%). The mean follow-up length for all patients was 4.3 months. There were no preoperative symptoms significantly associated with postoperative symptom resolution; however, a trend was noted with the presence of a preoperative syrinx. Pathology samples consistently demonstrated fibroconnective or collagenous tissue with no evidence of inflammation or neoplasm. CONCLUSION DAW is a rare pathology that can result in myelopathy or inappropriate interventions if misdiagnosed. Surgical intervention using laminectomy with intradural exploration should be considered in symptomatic patients with DAW because it is curative with a strong chance of preoperative symptom resolution with relatively low complication rates.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Dominique Higgins
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Kyle L McCormick
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Patrick Reid
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Paul C McCormick
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
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Harel E, Parker F, Tuleasca C. Letter: Spinal Arachnoid Webs: Presentation, Natural History, and Outcomes in 38 Patients. Neurosurgery 2022; 90:e81-e82. [PMID: 35006208 DOI: 10.1227/neu.0000000000001813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ethan Harel
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Fabrice Parker
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Centre Hospitalier Universitaire de Bicêtre, Service de Neurochirurgie, Le Kremlin-Bicêtre, France
| | - Constantin Tuleasca
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Université de Lausanne (Unil), Faculté de Biologie et de Médecine (FBM), Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
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Spinal arachnoid web-a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection: analysis of a multicenter patient population. Spine J 2022; 22:126-135. [PMID: 34175468 DOI: 10.1016/j.spinee.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal arachnoid web (SAW) is a rare condition characterized by focal thickening of the arachnoid membrane causing displacement and compression of the spinal cord with progressive symptoms and neurological deficits. Recent reports and clinical experience suggest that SAW is a distinct entity with specific radiological findings and treatment strategies distinguishable from other arachnopathies and potential differential diagnoses. PURPOSE To better define the diagnostic and clinical features, treatment options and outcomes of surgically treated SAW. STUDY DESIGN Multicentric retrospective cohort study. PATIENT SAMPLE Twelve cases of SAW surgically treated at three different centers. OUTCOME MEASURES Self-reported and neurological outcome measurements (pain, sensory-motor deficits, vegetative dysfunctions) were assessed at follow-up timepoints. METHODS Retrospective review of prospectively collected data on all patients surgically treated for SAW from three participating neurosurgical centers between 2014 and 2020. Clinicopathological data, including neurological presentation, radiological and histological findings and outcome data were analyzed. RESULTS Twelve radiologically and surgically confirmed cases of SAW were analyzed. Mean patient age was 54.7 [±12.7], 67% were male. All SAWs were located in the posterior thoracic dural sac. On magnetic resonance imaging (MRI), the "scalpel sign" - a characteristic focal dorsal indentation of the spinal cord resembling a scalpel blade - was identified in all patients. A focal intramedullary syrinx was present in 83%. Preoperative clinical symptoms included signs of myelopathy, pain, weakness and sensory loss, most commonly affecting the trunk/upper back or lower extremities. Laminectomy or laminoplasty with intradural excision of the SAW was the surgical treatment of choice in all cases. Intraoperative ultrasound was valuable to visualize the cerebrospinal fluid (CSF) flow obstruction, confirm the SAW location before dura incision and to control adequacy of resection. After surgery, sensory loss and weakness in particular showed significant improvement. CONCLUSIONS The present study comprises the largest series of surgically treated SAW, underscoring the unique clinical, radiographic, histopathological, and surgical findings. We want to emphasize SAW being a distinct entity of spinal arachnopathy with a favorable long-term outcome if diagnosed correctly and treated surgically. Intraoperative ultrasound aids visualizing the SAW before dural incision, as well as verifying restored CSF flow after resection.
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14
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Lim EJ, Leong NWL, Ho CL. Distinguishing Intramedullary Spinal Cord Neoplasms from Non-Neoplastic Conditions by Analyzing the Classic Signs on MRI in the Era of AI. Curr Med Imaging 2021; 18:797-807. [PMID: 34856911 DOI: 10.2174/1573405617666211202102235] [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: 07/23/2021] [Revised: 09/23/2021] [Accepted: 10/10/2021] [Indexed: 11/22/2022]
Abstract
Intramedullary lesions can be challenging to diagnose given the wide range of possible pathologies. Each lesion has unique clinical and imaging features, which are best evaluated on magnetic resonance imaging. Radiological imaging is unique with rich, descriptive patterns and classic signs-which are often metaphorical. In this review, we present a collection of classic MRI signs, ranging from neoplastic to non-neoplastic lesions, within the spinal cord. The differential diagnosis (DD) of intramedullary lesions can be narrowed down by careful analysis of the classic signs and pattern of involvement in the spinal cord. Furthermore, the signs are illustrated memorably with emphasis on the pathophysiology, mimics and pitfalls. Artificial intelligence (AI) algorithms, particularly deep learning, have made remarkable progress in image recognition tasks. The classic signs and related illustrations can enhance a pattern recognition approach in diagnostic radiology. Deep learning can potentially be designed to distinguish neoplastic from non-neoplastic processes by pattern recognition of the classic MRI signs.
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Affiliation(s)
- Ernest Junrui Lim
- NUS Yong Loo Lin School of Medicine, NUHS Tower Block, 1E Kent Ridge Road, Level 11. Singapore
| | - Natalie Wei Lyn Leong
- NUS Yong Loo Lin School of Medicine, NUHS Tower Block, 1E Kent Ridge Road, Level 11. Singapore
| | - Chi Long Ho
- Sengkang General Hospital, 110, Sengkang Eastway . Singapore
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Ruella M, Marco Del Pont F, Martin A, María Giovannini SJ, Centeno TR, Cervio A. Scalpel Sign in Spine Pathology: Presentation in 3 Different Rare Diagnoses. World Neurosurg 2021; 157:e77-e87. [PMID: 34587520 DOI: 10.1016/j.wneu.2021.09.093] [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: 07/05/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The scalpel sign is a radiological finding observed on sagittal magnetic resonance imaging and computed tomography myelography corresponding to an indentation in the dorsal aspect of the spinal cord resembling a surgical scalpel blade. It is said to be a pathognomonic imaging discovery linked to dorsal arachnoid webs. However, other spine-related conditions may mimic dorsal arachnoid webs on magnetic resonance imaging, such as spinal arachnoid cysts or ventral spinal cord herniation, leading to misdiagnosis. METHODS A retrospective review was performed of cases involving 3 different diagnoses at our institution in the last 5 years that shared in common the characteristic focal dorsal indentation of the spinal cord. RESULTS Of 7 cases identified, all but 1 were treated and confirmed intraoperatively. All lesions were located at the dorsal spinal cord. Magnetic resonance imaging was the study of choice for evaluation. Clinical manifestations included back pain and lower extremity numbness and weakness together with compressive myelopathy signs and urinary symptoms. Mean follow-up was 16.8 months with satisfactory postoperative results. CONCLUSIONS Isolated radiological presentation of the scalpel sign is not sufficient to distinguish between dorsal arachnoid webs, arachnoid cysts, and ventral herniation of the spine. However, awareness of its importance is relevant for accurate curative surgical planning.
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Affiliation(s)
- Mauro Ruella
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina.
| | | | - Aguilar Martin
- Department of Neuroradiology, FLENI, Buenos Aires, Argentina
| | | | | | - Andres Cervio
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
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16
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Dorsal arachnoid web: A rare cause of syringomyelia and myelopathy. Neurocirugia (Astur) 2021. [DOI: 10.1016/j.neucir.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Andrews JP, Chan AK, Mummaneni PV. Decompression of a Dorsal Arachnoid Web of the Spine: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E143. [PMID: 33289532 DOI: 10.1093/ons/opaa327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/05/2020] [Indexed: 11/13/2022] Open
Abstract
Arachnoid webs of the spine are a relatively rare entity with unique radiological findings, most notably the scalpel-sign on sagittal magnetic resonance imaging (MRI).1-4 To date there have been no videographic descriptions of the surgical treatment for this clinical entity. We present the case of a patient with progressive myelopathy and MRI showing a cervical and thoracic syrinx with a sharp transition point at the level of the T5 vertebral body. On computed tomography myelogram, there was preserved cerebrospinal fluid (CSF) in the ventral subarachnoid space-this space is often interrupted in ventral cord herniation, and preserved in dorsal arachnoid webs.5 A laminectomy with intradural excision of arachnoid web was offered and the patient consented for the procedure. Preoperatively, a fiducial screw was placed at T5. A T4-6 laminectomy was performed. A clearly compressive arachnoid web was encountered on exposure. Bands were dissected under an operating microscope, restoring normal CSF flow. Ventral dural defect was ruled out by passing a delicot beneath the cord and withdrawing it on the contralateral side. The patient did well and has shown improvement in myelopathic symptoms at 1- and 3-mo follow-up. Arachnoid webs of the spine can be treated effectively with a prudent, stepwise approach, and careful microsurgical technique. The neurosurgeon should consult closely with their neuroradiology colleagues to rule out other entities prior to the operation, such as ventral cord herniations, which can mimic dorsal arachnoid webs radiologically and clinically. We have received informed consent of the patient to submit this video.
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Ghosh R, Velagapudi L, Montenegro TS, Hines K, Gonzalez GA, Mahtabfar A, Prasad S, Jallo J, Sharan A, Heller J, Harrop J. Operative versus Nonoperative Management of Idiopathic Spinal Cord Herniation: Effect on Symptomatology and Disease Progression. World Neurosurg 2021; 152:e149-e154. [PMID: 34033961 DOI: 10.1016/j.wneu.2021.05.046] [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: 03/27/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Idiopathic spinal cord herniation (ISCH) is a rare pathology characterized by extravasation of the spinal cord through a dural defect. The optimal algorithm for choosing operative or nonoperative management is not well elucidated, partially because of the rarity of this pathology. We present the largest single-center series of ISCH and compare operative treatment to conservative management. METHODS A retrospective case series of all patients evaluated for treatment of ISCH at our institution between 2010 and 2019 was conducted. Demographic variables, presenting symptoms, and imaging characteristics were assessed for all patients. For patients who underwent operative treatment, surgical approach, postoperative course, and discharge outcomes were recorded. Follow-up notes were reviewed for status of symptoms and functional capabilities, which were synthesized into Odom's criteria score. RESULTS Sixteen patients met the inclusion criteria for this study, 8 of whom underwent operative treatment. No significant differences were found between operative and nonoperative groups with regard to demographic variables or pathology characteristics. Odom's criteria scores for the operative cohort were 12.5% (1 of 8) Excellent, 62.5% (5 of 8) Good, 12.5% (1 of 8) Fair, and 12.5% (1 of 8) Poor. Odom's criteria scores for the nonoperative cohort were 16.7% (1 of 6) Excellent, 33.3% (2 of 6) Good, 16.7% (1 of 6) Fair, and 33.3% (2 of 6) Poor. There was no significant difference between Odom's criteria score distribution between the operative and nonoperative groups at latest follow up (P = 0.715). CONCLUSIONS Conservative management of spinal cord herniation is an option that does not preclude symptomatic improvement in patients with idiopathic spinal cord herniation.
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Affiliation(s)
- Ritam Ghosh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thiago S Montenegro
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Glenn A Gonzalez
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aria Mahtabfar
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Srinivas Prasad
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joshua Heller
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Agarwal V, Shah LM, Parsons MS, Boulter DJ, Cassidy RC, Hutchins TA, Jamlik-Omari Johnson, Kendi AT, Khan MA, Liebeskind DS, Moritani T, Ortiz AO, Reitman C, Shah VN, Snyder LA, Timpone VM, Corey AS. ACR Appropriateness Criteria® Myelopathy: 2021 Update. J Am Coll Radiol 2021; 18:S73-S82. [PMID: 33958120 DOI: 10.1016/j.jacr.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 01/22/2023]
Abstract
Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Vikas Agarwal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, Vice Chair of Education, Department of Radiology, University of Pittsburgh Medical Center, Program Director, Neuroradiology Fellowship, University of Pittsburgh Medical Center.
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah, Chair, Committee on Appropriateness Criteria, Co-Chair, Neurological Imaging Panel, member of the ACR Commission on Neuroradiology
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky, American Academy of Orthopaedic Surgeons, Evidence Based Guideline Committee, North American Spine Society
| | | | | | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapies, Mayo Clinic Rochester
| | | | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology, President of SVIN
| | | | | | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina, North American Spine Society
| | - Vinil N Shah
- University of California San Francisco, San Francisco, California
| | - Laura A Snyder
- Barrow Neurological Institute, Phoenix, Arizona, Neurosurgery expert
| | - Vincent M Timpone
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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20
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Strong MJ, North RY, Yee TJ, Oppenlander ME. Commentary: Decompression of a Dorsal Arachnoid Web of the Spine: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E144-E145. [PMID: 33294934 DOI: 10.1093/ons/opaa359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J Strong
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Robert Y North
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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21
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YAMAMOTO A, FUJIMOTO M, AOKI K, SUZUKI Y, MIZUNO M, SUZUKI H. A Dorsal Arachnoid Web of the Cervical Spine: A Case Report. NMC Case Rep J 2021; 8:281-286. [PMID: 35079476 PMCID: PMC8769406 DOI: 10.2176/nmccrj.cr.2020-0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Atsushi YAMAMOTO
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi FUJIMOTO
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kazuaki AOKI
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yume SUZUKI
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masaki MIZUNO
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
- Department of Minimum-Invasive Neurospinal Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hidenori SUZUKI
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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22
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Nada A, Mahdi E, Mahmoud E, Cousins J, Ahsan H, Leiva-Salinas C. Multi-modality imaging evaluation of the dorsal arachnoid web. Neuroradiol J 2020; 33:508-516. [PMID: 33135580 PMCID: PMC7788682 DOI: 10.1177/1971400920970919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Dorsal arachnoid web (DAW) is a rare intradural abnormality which is associated with progressive myelopathy. Our objective was to review multi-modality imaging techniques demonstrating the scalpel sign appearance in evaluation of DAW. METHODS We retrospectively reviewed various imaging modalities of patients found to have DAW at our institution during January 2015 to February 2020. Five patients underwent surgical decompression with pathological correlation. The remaining patients were presumptively diagnosed based on the characteristic finding of scalpel sign. Clinical data were evaluated and correlated to imaging findings. All imaging modalities demonstrated the characteristic scalpel sign. RESULTS Sixteen patients (10 females, and six males) with multi-imaging modalities were evaluated. Their mean age was 52 year (range 23-74 years). Fifteen patients underwent conventional spine MRI. Further high-resolution MR imaging techniques, e.g. 3D T2 myelographic sequence, were utilized with two patients. MRI spine CSF flow study was performed to evaluate the flow dynamic across the arachnoid web in one patient. Eight patients were evaluated with CT myelogram. Syrinx formation was discovered in seven (44%) patients; five (71%) of them underwent surgical resection and decompression. Two patients underwent successful catheter-directed fenestration of the web with clinical improvement. We found a statically significant positive correlation between the degree of cord displacement and compression with syrinx formation (r = 0.55 and 0.65 with p-value of 0.03 and 0.009, respectively). CONCLUSION DAW has characteristic scalpel sign independent of imaging modality. Multi-modality imaging evaluation of DAW is helpful for evaluation and surgical planning.
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Affiliation(s)
- A Nada
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - E Mahdi
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - E Mahmoud
- Department of Diagnostic and Interventional Radiology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - J Cousins
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - H Ahsan
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
| | - C Leiva-Salinas
- Department of Radiology, University of Missouri Health Care, Columbia, MO, USA
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23
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Diagnosis and Surgical Treatment of Thoracic Dorsal Arachnoid Web: A Report of Two Cases. Case Rep Orthop 2020; 2020:8816598. [PMID: 33005467 PMCID: PMC7509563 DOI: 10.1155/2020/8816598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction An arachnoid web (AW) is a relatively rare disease and shows clinical symptoms and radiological findings similar to those of an arachnoid cyst (AC) or spinal cord herniation (SCH). Since the operative procedures for an AW are generally different from those intrathecal disorders, correct preoperative differential diagnosis is important. The purposes of this study were to report the usefulness of magnetic resonance imaging (MRI) and computed tomography (CT) myelography for diagnosing AW and to show the histological findings and clinical results. Case Description. Two patients, a 79-year-old man and a 43-year-old woman, are presented. The primary diagnoses were AC with ossification of the ligamentum flavum and epidural hematoma, respectively, in previous hospitals. They were finally diagnosed by the characteristic MRI and CT myelogram finding called the “scalpel sign.” Histological findings showed epithelial cells and fibrous tissue derived from arachnoid tissues and microcalcifications. After surgery, the scalpel sign has vanished, and aggravation of their symptoms was prevented. Conclusion An AW is refractory, but early detection by MRI and CT myelography and early treatment improve outcomes after surgery.
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24
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Zakhari N, Nguyen T, Omaiche S, Chakraborty S. Posterior spinal cord indentation: imaging findings and clinical outcome. Clin Radiol 2020; 75:615-621. [DOI: 10.1016/j.crad.2020.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
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Bhatia K, Madhavan A, Coutinho C, Mathur S. Idiopathic spinal cord herniation. Clin Radiol 2020; 75:721-729. [PMID: 32499121 DOI: 10.1016/j.crad.2020.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 04/28/2020] [Indexed: 11/28/2022]
Abstract
Idiopathic spinal cord herniation is a rare but important and increasingly recognised cause of myelopathy seen in the thoracic spine. The factors that contribute to the aetiology of the condition and of the dural defect through which the cord herniates remain under debate. We discuss the clinical features and proposed pathophysiology of the condition, and illustrate key imaging findings on MRI, fluoroscopy and computed tomography (CT) myelography to establish the diagnosis, and discuss relevant differential diagnoses. Awareness and recognition of the condition is key as surgical intervention can improve outcomes for patients.
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Affiliation(s)
- K Bhatia
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK.
| | - A Madhavan
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - C Coutinho
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - S Mathur
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK.
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26
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Nozawa S, Fushimi K, Iwai C, Ishizuka K, Akiyama H. Repetitive distortion of the spinal cord owing to a pulsating arachnoid cyst: case illustration. J Neurosurg Spine 2019; 32:61-62. [PMID: 31561233 DOI: 10.3171/2019.7.spine19660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/12/2019] [Indexed: 11/06/2022]
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27
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Tuleasca C, Ducos Y, Levivier M, Parker F, Aghakhani N. Letter to the Editor. Arachnoid webs: preoperative differential diagnosis and surgical exploration. J Neurosurg Spine 2019; 31:919-921. [PMID: 31470403 DOI: 10.3171/2019.6.spine19671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Constantin Tuleasca
- 1Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Centre Hospitalier Universitaire de Bicêtre, Service de Neurochirurgie, Le Kremlin-Bicêtre, France
- 2Sorbonné Université, Faculté de Médecine, Paris, France
- 3Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- 4Université de Lausanne (Unil), Faculté de Biologie et de Médecine (FBM), Lausanne, Switzerland
- 5Signal Processing Laboratory (LTS 5), Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Yohan Ducos
- 1Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Centre Hospitalier Universitaire de Bicêtre, Service de Neurochirurgie, Le Kremlin-Bicêtre, France
| | - Marc Levivier
- 3Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- 4Université de Lausanne (Unil), Faculté de Biologie et de Médecine (FBM), Lausanne, Switzerland
| | - Fabrice Parker
- 1Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Centre Hospitalier Universitaire de Bicêtre, Service de Neurochirurgie, Le Kremlin-Bicêtre, France
| | - Nozar Aghakhani
- 1Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Sud, Centre Hospitalier Universitaire de Bicêtre, Service de Neurochirurgie, Le Kremlin-Bicêtre, France
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28
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Fam MD, Woodroffe RW, Helland L, Noeller J, Dahdaleh NS, Menezes AH, Hitchon PW. Spinal arachnoid cysts in adults: diagnosis and management. A single-center experience. J Neurosurg Spine 2019; 29:711-719. [PMID: 30265227 DOI: 10.3171/2018.5.spine1820] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/22/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVEAdult spinal arachnoid cysts (SACs) are rare entities of indistinct etiology that present with pain or myelopathy. Diagnosis is made on imaging studies with varying degrees of specificity. In symptomatic cases, the standard treatment involves surgical exploration and relief of neural tissue compression. The aim of this study was to illustrate features of SACs in adults, surgical management, and outcomes.METHODSThe authors searched medical records for all SACs in adults in the 10-year period ending in December 2016. Radiology and pathology reports were reviewed to exclude other spine cystic disorders. Recurrent or previously treated patients were excluded. Demographic variables (age, sex) and clinical presentation (symptoms, duration, history of infection or trauma, and examination findings) were extracted. Radiological features were collected from radiology reports and direct interpretation of imaging studies. Operative reports and media were reviewed to accurately describe the surgical technique. Finally, patient-reported outcomes were collected at every clinic visit using the SF-36.RESULTSThe authors' search identified 22 patients with SACs (mean age at presentation 53.5 years). Seventeen patients were women, representing an almost 3:1 sex distribution. Symptoms comprised back pain (n = 16, 73%), weakness (n = 10, 45%), gait ataxia (n = 11, 50%), and sphincter dysfunction (n = 4, 18%). The mean duration of symptoms was 15 months. Seven patients (32%) exhibited signs of myelopathy. All patients underwent preoperative MRI; in addition, 6 underwent CT myelography. SACs were located in the thoracic spine (n = 17, 77%), and less commonly in the lumbar spine (n = 3, 14%) and cervical/cervicothoracolumbar region (n = 2, 9%). Based on imaging findings, the cysts were interpreted as intradural SACs (n = 11, 50%), extradural SACs (n = 6, 27%), or ventral spinal cord herniation (n = 2, 9%); findings in 3 patients (14%) were inconclusive. Nineteen patients underwent surgical treatment consisting of laminoplasty in addition to cyst resection (n = 13, 68%), ligation of the connecting pedicle (n = 4, 21%), or fenestration/marsupialization (n = 2, 11%). Postoperatively, patients were followed up for an average of 8.2 months (range 2-30 months). Postoperative MRI showed complete resolution of the SAC in 14 of 16 patients. Patient-reported outcomes showed improvement in SF-36 parameters. One patient suffered a delayed wound infection.CONCLUSIONSIn symptomatic patients with imaging findings suggestive of spinal arachnoid cyst, surgical exploration and complete resection is the treatment of choice. Treatment is usually well tolerated, carries low risks, and provides the best chances for optimal recovery.
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Affiliation(s)
- Maged D Fam
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Royce W Woodroffe
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Logan Helland
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Jennifer Noeller
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Nader S Dahdaleh
- 2Department of Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Arnold H Menezes
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Patrick W Hitchon
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
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Sharma P, Soin P, Elbanan M, Kochar PS. Understanding Idiopathic Spinal Cord Herniation - A Comprehensive Review of Imaging and Literature. J Clin Imaging Sci 2019; 9:22. [PMID: 31448173 PMCID: PMC6702865 DOI: 10.25259/jcis-25-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022] Open
Abstract
Idiopathic spinal cord herniation (ISCH) is displacement of spinal cord through a dural or arachnoidal defect. Most patients present with back pain or myelopathy, paresthesia, and sensory or motor weakness. Imaging findings include anterior displacement of the cord with possible kink, no filling defect on CT myelography, and no restricted diffusion/mass lesion on magnetic resonance imaging. Abrupt kink in the spinal cord or widened cerebrospinal fluid (CSF) space can be caused by a variety of reasons. The differential considerations include arachnoid web, intradural extramedullary epidermoid or arachnoid cyst, abscess or cystic schwannoma. We discuss the features, imaging, differentials, and treatment of ISCH as a rare cause of such kink in the cord. While reading such cases, a radiologist should include the location, segments involved, cord signal abnormality, visible defect, scalpel sign or C–sign, ventral cord kink, nuclear trail sign, the ventral CSF space preservation, or obliteration and the type.
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Affiliation(s)
- Pranav Sharma
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Priti Soin
- Department of Pathology and Laboratory Medicine, Weill Cornell College of Medicine, New York, USA
| | - Mohamed Elbanan
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Puneet Singh Kochar
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
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Sadek AR, Nader-Sepahi A. Spinal Arachnoid Cysts: Presentation, management and pathophysiology. Clin Neurol Neurosurg 2019; 180:87-96. [DOI: 10.1016/j.clineuro.2019.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 11/29/2022]
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Nisson PL, Hussain I, Härtl R, Kim S, Baaj AA. Arachnoid web of the spine: a systematic literature review. J Neurosurg Spine 2019; 31:175-184. [PMID: 31003220 DOI: 10.3171/2019.1.spine181371] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/31/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE An arachnoid web of the spine (AWS) is a rare and oftentimes challenging lesion to diagnose, given its subtle radiographic findings. However, when left untreated, this lesion can have devastating effects on a patient's neurological function. To date, only limited case reports and series have been published on this topic. In this study, the authors sought to better describe this lesion, performing a systematic literature review and including 2 cases from their institution's experience. METHODS A systematic literature search was performed in September 2018 that queried Ovid MEDLINE (1946-2018), PubMed (1946-2018), Wiley Cochrane Library: Central Register of Controlled Trials (1898-2018), and Thompson Reuters Web of Science: Citation Index (1900-2018), per PRISMA guidelines. Inclusion criteria specified all studies and case reports of patients with an AWS in which any relevant surgery types were considered and applied. Studies on arachnoid cysts and nonhuman populations, and those that did not report patient treatments or outcomes were excluded from the focus review. RESULTS A total of 19 records and 2 patients treated by the senior authors were included in the systematic review, providing a total of 43 patients with AWS. The mean age was 52 years (range 28-77 years), and the majority of patients were male (72%, 31/43). A syrinx was present in 67% (29/43) of the cases. All AWSs were located in the thoracic spine, and all but 2 (95%) were located dorsally (1 ventrally and 1 circumferentially). Weakness was the most frequently reported symptom (67%, 29/43), followed by numbness and/or sensory loss (65%, 28/43). Symptoms predominated in the lower extremities (81%, 35/43). It was found that nearly half (47%, 20/43) of patients had been experiencing symptoms for 1 year or longer before surgical intervention was performed, and 35% (15/43) of reports stated that symptoms were progressive in nature. The most commonly used surgical technique was a laminectomy with intradural excision of the arachnoid web (86%, 36/42). Following surgery, 91% (39/43) of patients had reported improvement in their neurological symptoms. The mean follow-up was 9.2 months (range 0-51 months). CONCLUSIONS AWS of the spine can be a debilitating disease of the spine with no more than an indentation of the spinal cord found on advanced imaging studies. The authors found this lesion to be reported in twice as many males than females, to be associated with a syrinx more than two-thirds of the time, and to only have been reported in the thoracic spine; over 90% of patients experienced improvement in their neurological function following surgery.
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Affiliation(s)
- Peyton L Nisson
- 1University of Arizona, College of Medicine, Tucson, Arizona; and
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Ibrahim Hussain
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Roger Härtl
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Samuel Kim
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
| | - Ali A Baaj
- 2Department of Neurosurgery, Weill Cornell Brain and Spine Center, New York, New York
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Hirai T, Taniyama T, Yoshii T, Mizuno K, Okamoto M, Inose H, Yuasa M, Otani K, Shindo S, Nakai O, Okawa A. Clinical Outcomes of Surgical Treatment for Arachnoid Web: A Case Series. Spine Surg Relat Res 2018; 3:43-48. [PMID: 31435550 PMCID: PMC6690113 DOI: 10.22603/ssrr.2018-0027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/10/2018] [Indexed: 12/01/2022] Open
Abstract
Introduction We describe 5 patients who underwent operative treatment for arachnoid web (AW) and discuss the postoperative clinical outcome in each case. AW is an extremely rare disease that causes cord compression and syringomyelia in the thoracic spine. To date, 14 cases only of AW have been reported, and the effect of surgical intervention on clinical and radiologic outcomes is unknown. Methods Five patients who underwent surgical treatment for AW were retrospectively reviewed. The clinical outcomes were evaluated using the thoracic Japanese Orthopaedic Association (T-JOA) score. Preoperative and postoperative images were reviewed. Results All the patients presented with spastic gait and numbness in the lower extremities. Two patients also presented with bladder-bowel dysfunction (BBD). AW, or the so-called “scalpel” sign, was seen dorsally in the thoracic spine on magnetic resonance imaging in all the patients. Syringomyelia adjacent to the web was observed in 4 patients. Fenestration and web resection without instrumentation was performed in all the cases. Overall, significant improvement was seen in locomotion and the total T-JOA score postoperatively. However, numbness in the lower extremities improved in 2 patients but was unchanged in 3 cases. BBD was ameliorated in 1 patient but remained unchanged in the other patient. Conclusions Our experience suggests that surgical treatment, including the another patient and resection of the web, can correct the flow dynamics of cerebrospinal fluid and allow neurologic recovery, in particular locomotion, in patients with AW.
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Affiliation(s)
- Takashi Hirai
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Taniyama
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichi Mizuno
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Mikio Okamoto
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masato Yuasa
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuyuki Otani
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Shigeo Shindo
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Osamu Nakai
- Department of Orthopedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Wu OC, Kasliwal MK. Letter to the Editor. Radiographic differentiation of idiopathic spinal cord herniation versus dorsal arachnoid webs. J Neurosurg Spine 2018; 29:120-121. [DOI: 10.3171/2017.11.spine171194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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