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BMJ Neurology Open 2022To assess the knowledge, attitudes and practices of healthcare professionals regarding the diagnosis and management of spontaneous intracranial hypotension (SIH).
OBJECTIVE
To assess the knowledge, attitudes and practices of healthcare professionals regarding the diagnosis and management of spontaneous intracranial hypotension (SIH).
METHODS
We performed a cross-sectional, web-based survey of multiple healthcare professional groups in the UK from June to August 2021. There were 227 respondents to the survey, including 62 general practitioners, 39 emergency medicine physicians, 38 neurologists, 35 radiologists, 20 neurosurgeons, 18 anaesthetists and 15 headache nurse specialists. The majority of the respondents were at the consultant level and all worked in the UK National Health Service.
RESULTS
Few general practitioners or emergency medicine physicians had ever been involved in the care of a patient with SIH or received teaching about SIH. Only 3 of 62 (4.8%) general practitioners and 1 of 39 (2.5%) emergency medicine physicians were confident in recognising the symptoms of SIH. Most neurologists were confident in recognising SIH and performed MRI of the brain as a first-line investigation, although there was variability in the urgency of the request, whether contrast was given or MRI of the spine organised at the same time. Most said they never or rarely performed lumbar puncture for diagnosis of SIH. Most neuroradiologists, but few general radiologists, were confident in interpreting imaging of patients with suspected SIH. Lack of access to epidural blood patching, personnel able to perform myelography, and established management pathways were identified by many respondents as barriers to the treatment of SIH.
CONCLUSIONS
We have identified a lack of awareness of SIH among non-specialists, several barriers to optimal treatment of SIH and a variation in current management pathways. The results highlight the need for education of healthcare professionals about SIH and the development of clinical practice guidelines to enable delivery of optimal and equitable care for patients with SIH.
PubMed: 36110926
DOI: 10.1136/bmjno-2022-000347 -
Neuroradiology Mar 2022CSF-venous fistulas - initially described in 2014 - are a significant cause of spontaneous intracranial hypotension. Dynamic lateral decubitus digital subtraction and/or...
CSF-venous fistulas - initially described in 2014 - are a significant cause of spontaneous intracranial hypotension. Dynamic lateral decubitus digital subtraction and/or CT myelography typically show a hyperdense paraspinal vein. In case of a central drainage toward the internal vertebral venous plexus, it is the "hyperdense basivertebral vein" which should be searched for carefully.
Topics: Brachiocephalic Veins; Cerebrospinal Fluid Leak; Fistula; Humans; Intracranial Hypotension; Myelography
PubMed: 35106631
DOI: 10.1007/s00234-022-02908-x -
Orthopaedics & Traumatology, Surgery &... Apr 2023Previous studies reported that spinal nerve edema on magnetic resonance myelography (MRM) and leg pain at rest were specifically observed in symptomatic lumbar foraminal...
BACKGROUND
Previous studies reported that spinal nerve edema on magnetic resonance myelography (MRM) and leg pain at rest were specifically observed in symptomatic lumbar foraminal stenosis patients. However, the correlation between leg pain at rest and spinal nerve edema in symptomatic foraminal stenosis has not been reported.
HYPOTHESIS
The purpose of this prospective study is to reveal a correlation between leg pain at rest and spinal nerve edema focusing on the pathophysiology of symptomatic foraminal stenosis.
PATIENTS AND METHODS
Clinical findings and MRM findings were surveyed among 30 patients with symptomatic foraminal stenosis diagnosed by MR imaging (MRI) and selective nerve root block. Comparisons of patient characteristics and clinical findings between the prevalence and absence groups of spinal nerve edema on MRM were analyzed. A correlation between the visual analogue scale (VAS) for leg pain at rest and the spinal edema ratio calculated as maximum intensity value of the affected spinal nerve/maximum intensity value of the asymptomatic side from region of interest (ROI) made on MRM was evaluated.
RESULTS
Twenty symptomatic foraminal stenosis cases (67%) showed the affected spinal nerve edema on MRM. The prevalence and VAS of leg pain at rest were significantly higher in the presence of spinal nerve edema group (95% and 67.0±36.4, respectively). The correlation coefficient between the VAS for leg pain at rest (53.0±33.6) and the spinal nerve edema ratio (1.3±0.3) was 0.647 (p<0.01).
DISCUSSION
Our study revealed the substantial correlation found between the spinal nerve edema ratio on MRM and the VAS for leg pain at rest in symptomatic foraminal stenosis. The correlation between spinal nerve edema and leg pain at rest has potential to clarify the pathology of symptomatic foraminal stenosis.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Constriction, Pathologic; Spinal Stenosis; Prospective Studies; Leg; Lumbar Vertebrae; Spinal Nerves; Pain; Magnetic Resonance Imaging; Edema
PubMed: 34666199
DOI: 10.1016/j.otsr.2021.103119 -
Spine Surgery and Related Research Mar 2023Although thoracic spondylotic myelopathy (TSM) without ossification or disc disorder has been associated with some dynamic factors in the thoracolumbar area, a detailed...
INTRODUCTION
Although thoracic spondylotic myelopathy (TSM) without ossification or disc disorder has been associated with some dynamic factors in the thoracolumbar area, a detailed investigation is yet to be published. Thus, in this study, we investigated the segmental motion and sagittal alignment of the thoracolumbar area in patients with and without TSM.
METHODS
Patients with TSM who were treated from 2013 to 2020 were enrolled in this study. The non-TSM group consisted of sex- and age-matched patients with spinal disorders other than TSM. Segmental mobility from T10-L2 during passive maximum flexion and extension following myelography and the sagittal cobb angles of T10-L1 and L1-L5 in the standing position were measured using multidetector computed tomography (CT). The mobility of each segment was set as the difference in the angles between the two positions.
RESULTS
In total, 10 patients (8 males and 2 females, mean age 65.8 years) with TSM and 20 without TSM were enrolled. The most stenotic level was observed at T10-T11 in four cases and T11-T12 in six. The average mobility at this segment in the TSM group (5.8°) was significantly greater than that in the non-TSM group (2.1°) (p<0.001). In the TSM group, the cobb angles of T10-L1 and L1-L5 were 2.3° and 17.4° of lordosis, respectively, which differed significantly from those in the non-TSM group, which were 8° of kyphosis and 32.2° of lordosis, respectively (p<0.001 and p=0.001, respectively).
CONCLUSIONS
Compared with those without TSM, patients with TSM were found to have greater segmental mobility at the most stenotic level, thoracolumbar lordosis, and decreased lumbar lordosis.
PubMed: 37041875
DOI: 10.22603/ssrr.2022-0123 -
Clinical Medicine (London, England) May 2021A robust treatment paradigm for spontaneous intracranial hypotension has yet to be agreed upon. We present retrospective data from the patient cohort at our UK regional...
A robust treatment paradigm for spontaneous intracranial hypotension has yet to be agreed upon. We present retrospective data from the patient cohort at our UK regional neurosciences centre from 2010-2020 and describe our locally developed treatment pathway.Seventy-three patients were identified: 31 men and 42 women; mean age was 42 years. The majority presented with a headache of variable duration, and most had positive imaging. Very few patients (7%) responded to conservative treatment. Sixty-six underwent epidural blood patching, with 39 (59%) having a good response. Twenty-three patients underwent myelography and targeted treatment (injection of fibrin sealant at the leak site), with 13 (57%) showing a good response. One patient had successful surgery. The relapse rate after response to epidural blood patching was 10%, and after response to targeted treatment was 23%. Most patients who relapsed responded to repeated treatments.The outcome data for our diverse patient cohort shows the success of a staged approach to treatment. Relapse rates are low, and surgery is only rarely required. We use these data to inform our discussions with patients, and present them here to enable other centres to develop robust investigation and treatment paradigms of their own.
Topics: Adult; Blood Patch, Epidural; Female; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Male; Neurosciences; Retrospective Studies; United Kingdom
PubMed: 34001579
DOI: 10.7861/clinmed.2020-0791 -
Surgical Neurology International 2022Our hypothesis was that lumbar adhesive arachnoiditis (AA)/chronic lumbar AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Therefore,... (Review)
Review
BACKGROUND
Our hypothesis was that lumbar adhesive arachnoiditis (AA)/chronic lumbar AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Therefore, patients with these syndromes do not necessarily have to demonstrate significant radiographic abnormalities on myelograms, MyeloCT studies, and/or MR examinations. When present, typical AA/CAA findings may include; central or peripheral nerve root/cauda equina thickening/clumping (i.e. latter empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/Myelo-CT studies.
METHODS
We reviewed 3 articles and 7 clinical series that involved a total of 253 patients with AA/CAA to determine whether there was a significant correlation between these clinical syndromes, and myelographic, Myelo-CT, and/or MR imaging pathology.
RESULTS
We determined that patients with the clinical diagnoses of AA/CAA do not necessarily exhibit associated radiographic abnormalities. However, a subset of patients with AA/CAA may show the classical AA/CAA findings of; central or peripheral nerve root/cauda equina thickening/clumping (empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/ Myelo-CT studies.
CONCLUSION
Patients with clinical diagnoses of AA/CAA do not necessary show associated neuroradiagnostic abnormalities on myelograms, Myelo-CT studies, or MR. Rather, the clinical syndromes of AA/CAA may exist alone without the requirement for radiolographic confirmation.
PubMed: 36447842
DOI: 10.25259/SNI_943_2022 -
Acta Neurologica Belgica Feb 2021Spinal adhesive arachnoiditis is a rare pathology involving pia mater of the spinal cord and nerve roots. It can potentially lead to disability-many patients end up... (Review)
Review
Spinal adhesive arachnoiditis is a rare pathology involving pia mater of the spinal cord and nerve roots. It can potentially lead to disability-many patients end up wheelchair-bound due to subsequent paraparesis. It is an infrequent but possible cause of lower extremities weakness in patients with a history of spinal surgery, epidural anaesthesia, myelography or spinal tumors. Three patients, one male and two females, admitted to our unit due to paraparesis presented at least one of the above mentioned risk factors. Each of them had a severe course of illness-progressive paresis of lower extremities. All above cases were diagnosed with spinal adhesive arachnoiditis confirmed with Magnetic Resonance Imaging (MRI) scan-the most sensitive and specific diagnostic tool. Despite conservative treatment and intensive rehabilitation none of the presented patients preserved the ability to mobilise independently. Considering spinal adhesive arachnoiditis in patients with paraparesis and history of typical risk factors should be included in clinical diagnostic procedure.
Topics: Adult; Arachnoiditis; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Muscle Weakness; Thoracic Vertebrae; Tissue Adhesions
PubMed: 32833147
DOI: 10.1007/s13760-020-01431-1 -
BMJ Case Reports Dec 2020Transient spinal shock is a previously unreported complication of intrathecal contrast. A 63-year-old man presented with the chief complaint of worsening back pain....
Transient spinal shock is a previously unreported complication of intrathecal contrast. A 63-year-old man presented with the chief complaint of worsening back pain. Computed topography of lumbar spine without contrast showed a lytic lesion. After international normalized ratio (INR) correction, patient was sent for CT myelogram. After intrathecal contrast injection, the patient dropped his blood pressure profoundly and developed clinical manifestations of spinal shock. Emergent intravenous bolus fluids were initiated resulting in improvement in blood pressure. Patient's spinal shock resolved within hours. CT myelogram was normal except previously known lytic lesion. It was concluded that the transient shock was most likely due to contrast injection. We believe that this is the first reported case of transient spinal shock following CT myelogram using water-soluble iodinated non-ionic contrast agent administered intrathecally.
Topics: Back Pain; Contrast Media; Humans; Injections, Spinal; Iohexol; Male; Middle Aged; Myelography; Remission, Spontaneous; Shock; Spinal Cord; Tomography, X-Ray Computed
PubMed: 33370945
DOI: 10.1136/bcr-2020-237610 -
AJNR. American Journal of Neuroradiology May 2020CSF-venous fistula is an important treatable cause of spontaneous intracranial hypotension that is often difficult to detect using traditional imaging techniques....
CSF-venous fistula is an important treatable cause of spontaneous intracranial hypotension that is often difficult to detect using traditional imaging techniques. Herein, we describe the technical aspects and diagnostic performance of MR myelography when used for identifying CSF-venous fistulas. We report 3 cases in which the CSF-venous fistula was occult on CT myelography but readily detected using MR myelography.
Topics: Adult; Cerebrospinal Fluid Leak; Contrast Media; Female; Fistula; Gadolinium; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Male; Middle Aged; Myelography; Tomography, X-Ray Computed; Veins
PubMed: 32354709
DOI: 10.3174/ajnr.A6521 -
Regional Anesthesia and Pain Medicine Jun 2022Lumbar puncture (LP) may be challenging for patients with scoliosis and other conditions following previous posterior fusion and instrumentation from thoracic to sacral...
BACKGROUND
Lumbar puncture (LP) may be challenging for patients with scoliosis and other conditions following previous posterior fusion and instrumentation from thoracic to sacral levels. Interventional radiologists have described CT approaches to transforaminal LP. We hypothesized that combined C-arm fluoroscopy and ultrasound could be a feasible approach to transforaminal LP for interventional pain physicians and regional anesthesiologists.
METHODS
With institutional review board approval, we reviewed medical records and imaging of six patients with spinal muscular atrophy and prior spine fusion. Non-cutting needles of 24 or 25 gage were advanced through 20-gage introducers. Prior imaging guided selection of a preferred side and spinal level. Initial procedures were performed in the interventional radiology suite. Subsequent procedures were performed in an operating room (OR). We report on technical success and complications and describe a case using this approach for spinal anesthesia.
RESULTS
Six patients underwent a total of 54 transforaminal LPs, including 51 for administration of the antisense oligonucleotide nusinersen, 2 for myelography, and 1 for spinal anesthesia; 45 of these procedures were performed using OR C-arm fluoroscopy and ultrasound. Transient paresthesias and short-term headaches occurred; none required intervention. No other complications were noted.
CONCLUSIONS
Transforaminal LP appears technically feasible for patients with full-spine fusions using a straight-needle approach with combined fluoroscopy and ultrasound guidance. Larger case series and prospective studies may better define the success rates, risks, and benefits of this approach relative to alternative approaches to intrathecal access for patients with previous long-segment posterior spine fusions.
Topics: Anesthesia, Spinal; Fluoroscopy; Humans; Muscular Atrophy, Spinal; Prospective Studies; Spinal Puncture
PubMed: 35321920
DOI: 10.1136/rapm-2021-103242