Obliterative arachnoiditis complicating lumbar spinal stenosis

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Filum Terminale Arteriovenous Fistula Coexisting with a Large L2-L3 Disc Sequestration and Associated Diffuse Lumbar Arachnoiditis

The authors describe a case of filum terminale arteriovenous fistula (FTAVF) in association with a large L2–L3 disc sequestration and diffuse lumbar arachnoiditis. A 64-year-old male manifested with chronic back pain and gait difficulty. Magnetic resonance imaging (MRI) of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T9. There was a large disc sequestration came from L2–L3 disc herniation. In addition, thickening, clumping, and enhancement of the entire cauda equina were noted, probably representing arachnoiditis. MR angiography (MRA) and spinal angiography confirmed FTAVF at the level of L5. The patient underwent laminectomy with lysis adhesions and obliteration of the fistula. His postoperative course was uneventful. MRI and MRA of the thoracolumbar spine obtained 4 months after surgery revealed complete obliteration of the fistula and significant resolution of spinal cord congestion. Enhancement of the cauda equina roots was no longer visible. Interestingly, the significant resorption of the sequestrated disc was documented on MRI. The formation of the FTAVF in the present study may result from severe spinal canal stenosis caused by a large disc sequestration blocking the rostral venous drainage of the fistula, or chronic inflammation, and adhesions of the caudal nerve roots from lumbar arachnoiditis. It seems that FTAVF may be of acquired origin by this evidence.

Risk Factors for Postsurgical Foot Complaints One Year Following Degenerative Lumbar Spinal Surgery

MINI: Postsurgical foot complaints occurred frequently in 853 degenerative lumbar surgeries (prevalence, 20.6%; n = 176). Risk factor analysis showed that the incidence of postsurgical foot complaint was significantly higher in patients with preoperative foot symptoms (adjusted odds ratio, 5.532) and in those with preoperative sensory deficits on the leg (adjusted odds ratio, 1.904).

STUDY DESIGN

Retrospective.

OBJECTIVE

To investigate the prevalence and risk factors of postsurgical foot complaints (PFCs) following spinal surgery by using a modified pain drawing (PD) instrument.

SUMMARY OF BACKGROUND DATA

Although many patients report nonspecific foot symptoms with various clinical presentation, there is not a well defined diagnostic criterion. PDs are essential for measuring spinal surgery outcomes. We created a modified patient-physician communication-based PD instrument to overcome the limitations of the previous system.

METHODS

We included 853 consecutive patients who underwent decompression with or without fusion. PFCs were defined as sensory foot symptoms, including ambiguous sensations that were not clearly due to spinal pathology. Patients who complained of postoperative foot symptoms at more than two consecutive visits were assigned to the PFC group. The remaining patients were assigned to the asymptomatic group. We collected medical records using our PD instrument and compared variables between the two groups.

RESULTS

In total, 176 (20.6%) of the 853 patients had PFCs. The duration of preoperative leg pain was significantly longer in the PFC group than in the asymptomatic group (2.8 vs. 2.2 years; P = 0.048). The proportions of preoperative foot symptoms (82.9% vs. 43.3%) and sensory deficits on the leg (48.6% vs. 27%) were significantly greater in the PFC group than in the asymptomatic group (P < 0.001). Multivariable logistic regression analysis revealed two independent risk factors: the presence of preoperative foot symptoms (adjusted odds ratio, 5.532) and preoperative sensory deficits on the leg (adjusted odds ratio, 1.904).

CONCLUSION

PFCs occurred frequently after degenerative lumbar spinal surgery (prevalence, 20.6%). Based on our data using PD instrument, it can help reduce the incidence of PFCs if patients are informed and educated that preoperatively existing foot symptom and sensory deficits on the leg are significant risk factors for PFC development.

LEVEL OF EVIDENCE

4.

Recurrent arachnoid cysts secondary to spinal adhesive arachnoiditis successfully treated with a ventriculoperitoneal shunt

Spinal adhesive arachnoiditis (SAA) with cyst formation secondary to infectious meningitis is a rare clinical entity. These cysts can compress the spinal cord and cause neurologic decline. We present a case of a patient who underwent resection for an intradural schwannoma which was complicated post-operatively by bacterial meningitis and development of several recurrent thoracic arachnoid cysts. After two separate thoracic decompressions with lysis of intradural adhesions, a permanent ventriculoperitoneal shunt (VPS) was eventually placed with complete recovery of his symptoms. Our review of the literature showed that CSF shunts have previously been successfully used to treat spinal fluid collections. Although there are many factors to consider when treating these patients, CSF diversion may be beneficial for similar SAA presentations in order to simultaneously treat and prevent recurrence of symptoms.

Surgical radio-frequency epiduroscopy technique (R-ResAblator) and FBSS treatment: preliminary evaluations

Failed back surgery syndrome represents a heterogeneous situation that suggests a fibrosis or neuroinflammatory genesis. The social cost related to this issue are enormous. Several surgical techniques have been applied to FBSS patients with controversial effectiveness. In 1998 we evaluated the efficiency and limits of epiduroscopy treatment; it proved to be effective in 75% of cases, but in 45% of cases it needed to be repeated after 12 months. Therefore we subjected 14 patients, who had previously experienced a short temporary benefit by using a traditional epiduroscopic approach, to a new epiduroscopy fibrolysis using a radio-frequency device named "R-Resablator Epiduroscopy". Clinical evaluation was performed before myeloscopy and after 1-3-6 months. After myeloscopy, 93% of patients reported a general improvement. Among the latter, pain was reduced by 90% in 8 patients, by 60-70% in 5, and by less than 30% in 1.

CONCLUSION

It can be concluded that RF-Epiduroscopy offers greater therapeutic benefit than traditional epiduroscopy or other surgical techniques. Furthermore, RF-Epiduroscopy is more easily performed and repeated.

Pathology of lumbar nerve root compression. Part 1: Intraradicular inflammatory changes induced by mechanical compression

STUDY DESIGN

This study is to investigate the intraradicular inflammation induced by mechanical compression using in vivo model.

OBJECTIVES

The relationship between the intraradicular edema and nerve fiber degeneration induced by mechanical compression was determined in the nerve root.

SUMMARY OF BACKGROUND DATA

Recently some studies reported that mechanical compression increased microvascular permeability of the endoneurial capillaries and resulted in an intraradicular inflammation. These changes may be an important factor of the pathogenesis of radiculopathy. However, the natural courses of the intraradicular inflammation after mechanical compression are still poorly understood.

METHODS

In dogs, laminectomy was performed at L7 and the seventh nerve root was exposed to compression at 7.5 gram force (gf) clipping power. The animals were evaluated at 1 and 3 weeks after clipping. After the appropriate period of nerve root compression, Evans blue albumin (EBA) was injected intravenously. The nerve root sections were divided into two groups. The sections were used to investigate the status of the blood-nerve barrier function under the fluorescence microscope. The other sections were used for light and transmission electron microscopic study.

RESULTS

After 1 and 3 weeks, intraradicular edema was observed not only at the site of compression but also in the peripheral zone of a compressed anterior root and in the central zone of a compressed posterior root. The evidence of active Wallerian degeneration was also seen in the area of intraradicular edema. In addition, the nerve roots showing Wallerian degeneration were infiltrated by inflammatory cells, such as macrophages and mast cells.

CONCLUSIONS

Inflammatory reaction, such as Wallerian degeneration, breakdown of blood-nerve barrier and appearance of macrophage, may be deeply involved in radiculitis arising from mechanical compression, and these factors seem to be important in the manifestation of radiculopathy.

Symptomatic lumbar spinal arachnoiditis: fact or fallacy?

It is generally accepted that chronic adhesive lumbar arachnoiditis is a cause of symptoms, notably back pain and/or pain (of almost any type, not necessarily 'anatomical') in the lower limbs, although there is no clearly defined clinical pattern which is clearly associated with this syndrome. There is no doubt that arachnoiditis occurs as a pathological and radiological entity due to a number of causes. In the view of the present authors, the nexus between the pathology and radiology on the one hand, and the patients' symptoms on the other hand, has not been demonstrated with any degree of scientific rigor.

Patterns of chronic adhesive arachnoiditis following Myodil myelography: the significance of spinal canal stenosis and previous surgery

109 patients who had undergone Myodil myelography on at least one occasion were identified. The patterns of lumbar nerve root distribution in this group were examined using magnetic resonance imaging. The relationship between these patterns and the presence of spinal stenosis or previous surgery was investigated. Chronic adhesive arachnoiditic nerve root patterns were seen in 68 patients and were classified into three groups according to Delemarter et al. Central clumping of nerve roots (type 1) and complete opacification of the thecal sac (type 3), extending over at least one vertebral level, were significantly related to spinal stenosis at an adjacent level (p < 0.0001). Peripheral adhesion of nerve roots to the theca (type 2) was significantly related to previous surgery at the level of abnormality (p < 0.00005). Only a single case of arachnoiditic nerve root patterns was seen in the absence of stenosis or previous surgery. We conclude that chronic adhesive arachnoiditis is significantly related to previous Myodil myelography in the presence of spinal stenosis or previous surgery but that Myodil alone rarely produces these changes.

Does degenerative disease of the lumbar spine cause arachnoiditis? A magnetic resonance study and review of the literature

The magnetic resonance appearances in 165 patients with symptoms suggestive of degenerative lumbar spine disease were reviewed. The aim of the study was to evaluate the relationship between abnormalities of nerve root distribution and degenerative disease of the lumbar spine in the absence of other known risk factors for arachnoiditis. Central clumping of nerve roots was present in 16 patients (9.7%) and was associated with spinal stenosis at one of the affected levels in all (p < 0.001). Spinal stenosis was present in 44 patients giving an incidence of abnormal nerve root distribution of 36% in this group. Nerve root clumping occurred in association with pure spinal stenosis (10 cases), stenosis secondary to disc prolapse (four cases) and degenerative spondylolisthesis (two cases). Nerve root clumping was confined to one vertebral level in nine cases and extended over two to four levels in seven. In five of the latter spinal stenosis was present at multiple levels. The appearance of nerve root clumping described here may result entirely from mechanical apposition of nerve roots but is indistinguishable from the central pattern of nerve root adhesions which occurs in adhesive lumbar arachnoiditis. No abnormalities of nerve root distribution were seen in association with any indicator of degenerative disk disease in the absence of stenosis. We have been unable to demonstrate the previously reported relationship between lumbar disk degeneration and arachnoiditis and discuss this with a critical review of the literature. Abnormal central clumping of nerve roots as described in arachnoiditis may occur in association with spinal stenosis in the absence of other risk factors although the cause for this appearance remains unexplained. Arachnoiditis-like changes extending over more than one vertebral level are rare (7%) except in the presence of spinal stenosis at multiple levels (29%). Awareness of this appearance may avoid a possibly incorrect diagnosis of arachnoiditis in the presence of a treatable stenosis.

Spinal cord stimulation in 112 patients with epi-/intradural fibrosis following operation for lumbar disc herniation

A total of 112 patients with epi-/intradural fibrosis following operation for lumbar disc herniation were treated by spinal cord stimulation. Lumbosacral spinal fibrosis is seen particularly often after extensive and repeated operations. Radicular pain responds better to stimulation than back pain. A favourable long-term effect on radicular pain has been observed in 67% of patients treated by epidural implantation, the corresponding average follow-up period being 4 1/2 years. 40% of these patients needed less analgesics after the operation, while 25% of them showed an improved fitness for work. Among about 5,000 patients who underwent surgical treatment for lumbar disc herniation, an indication for spinal cord stimulation was found in 1.5%. By comparison, the frequency of the "last resort" procedure of microsurgical cordotomy was 0.3%. We no longer use other ablative methods like extirpation of spinal ganglia.

Chronic spinal arachnoiditis following intracranial subarachnoid haemorrhage

A 54-year-old woman presented with progressive gait imbalance and increased urinary frequency, associated with spinal arachnoiditis. The symptoms started after the occurrence of communicating hydrocephalus as a sequel of subarachnoid haemorrhage (SAH), and were initially attributed to post-SAH vasospasm, decompensating hydrocephalus and/or periventricular leuko-encephalopathy. Further clinical deterioration led to the diagnosis of thoracic spinal arachnoiditis, as a second complication of SAH.

A fibrinolytic defect in chronic back pain syndromes

Blood fibrinolytic activity was measured in 18 subjects with severe chronic back pain and 18 age and sex matched controls. The patients showed evidence of defective fibrinolysis--namely, significant prolongation of the euglobulin clot-lysis time, reduction in fibrin-plate lysis-area and plasminogen levels, and increase in levels of the fibrinolytic inhibitors, alpha 2 antiplasmin and alpha 2 macroglobulin. This defect could be associated with fibrin deposition and scar formation and be responsible for the development and/or perpetuation of chronic inflammation and scarring at sites of damage in the spine. Enhancement of fibrinolytic activity may offer a new approach to the management of these back problems, and a double-blind controlled trial is in progress.

Spinal arachnoiditis: disease or coincidence?

In 86% of 63 patients with spinal arachnoiditis the localization was lumbosacral, and in 14% it was cervical or thoracic. The most important aetiological factor was the combination of one or more myelographies with one or more operations. It is remarkable that in most patients with lumbosacral arachnoiditis the clinical picture did not show new or typical signs of arachnoiditis, but was the same as before the arachnoiditis had developed. In only 20% of patients with lumbosacral arachnoiditis, and in all patients with cervical or thoracic arachnoiditis, did new signs and symptoms occur concomitantly with and due to the development of the arachnoiditis. The results of this retrospective study suggest that lumbosacral arachnoiditis is a coincidental finding in the majority of cases, without clinical consequences.