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Cureus Feb 2023Pseudomeningoceles are a well-known potential postoperative complication of spinal and cranial surgeries that can occur after lumbar decompression and posterior fossa...
Pseudomeningoceles are a well-known potential postoperative complication of spinal and cranial surgeries that can occur after lumbar decompression and posterior fossa surgeries. They are often caused by incidental durotomies but may also occur as a result of dural puncture during diagnostic testing. This report describes a 59-year-old male that developed a recurrent pseudomeningocele after an L4 laminectomy for severe lumbar spinal stenosis that was ultimately treated with an epidural blood patch (EBP). His preoperative condition greatly improved, but he developed a pseudomeningocele that did not resolve after applying ice and light pressure. The patient subsequently underwent a wound exploration where no dural defect was identified. During this exploration, the dura was reinforced with dural onlays and sealant. Unfortunately, the patient developed another pseudomeningocele within a short interval. It was then suspected that the post-laminectomy site provided a space for the dural punctures from previous CT myelography to leak cerebrospinal fluid (CSF) into. The patient subsequently underwent ultrasound (US)-guided aspiration of the pseudomeningocele and EBP injections at the levels where his preoperative myelography was performed. The success of the EBP indicates that the previous CT myelography was the likely cause of the pseudomeningocele. Recurrent spinal pseudomeningoceles with no evidence of incidental durotomy may be caused by dural puncture from myelography. In such cases, EBP to the area that the previous myelography was performed can resolve the pseudomeningocele.
PubMed: 37007384
DOI: 10.7759/cureus.35600 -
Neurorehabilitation and Neural Repair Apr 2023Sufficient and timely spinal cord decompression is a critical surgical objective for neurological recovery in spinal cord injury (SCI). Residual cord compression may be...
Cerebrospinal Fluid Pressure Dynamics as a Bedside Test in Traumatic Spinal Cord Injury to Assess Surgical Spinal Cord Decompression: Safety, Feasibility, and Proof-of-Concept.
BACKGROUND
Sufficient and timely spinal cord decompression is a critical surgical objective for neurological recovery in spinal cord injury (SCI). Residual cord compression may be associated with disturbed cerebrospinal fluid pressure (CSFP) dynamics.
OBJECTIVES
This study aims to assess whether intrathecal CSFP dynamics in SCI following surgical decompression are feasible and safe, and to explore the diagnostic utility.
METHODS
Prospective cohort study. Bedside lumbar CSFP dynamics and cervical MRI were obtained following surgical decompression in N = 9 with mostly cervical acute-subacute SCI and N = 2 patients with non-traumatic SCI. CSFP measurements included mean CSFP, cardiac-driven CSFP peak-to-valley amplitudes (CSFPp), Valsalva maneuver, and Queckenstedt's test (firm pressure on jugular veins, QT). From QT, proxies for cerebrospinal fluid pulsatility curve were calculated (ie, relative pulse pressure coefficient; RPPC-Q). CSFP metrics were compared to spine-healthy patients. computer tomography (CT)-myelography was done in 3/8 simultaneous to CSFP measurements.
RESULTS
Mean age was 45 ± 9 years (range 17-67; 3F), SCI was complete (AIS A, N = 5) or incomplete (AIS B-D, N = 6). No adverse events related to CSFP assessments. CSFP rise during QT was induced in all patients [range 9.6-26.6 mmHg]. However, CSFPp was reduced in 3/11 (0.1-0.3 mmHg), and in 3/11 RPPC-Q was abnormal (0.01-0.05). Valsalva response was reduced in 8/11 (2.6-23.4 mmHg). CSFP dynamics corresponded to CT-myelography.
CONCLUSIONS
Comprehensive bedside lumbar CSFP dynamics in SCI following decompression are safe, feasible, and can reveal distinct patterns of residual spinal cord compression. Longitudinal studies are required to define critical thresholds of impaired CSFP dynamics that may impact neurological recovery and requiring surgical revisions.
Topics: Humans; Adolescent; Young Adult; Adult; Middle Aged; Aged; Prospective Studies; Feasibility Studies; Cerebrospinal Fluid Pressure; Spinal Cord Injuries; Decompression, Surgical; Spinal Cord
PubMed: 36919616
DOI: 10.1177/15459683231159662 -
AJNR. American Journal of Neuroradiology Apr 2023CSF-venous fistula can be diagnosed with multiple myelographic techniques; however, no prior work has characterized the time to contrast opacification and the duration... (Review)
Review
BACKGROUND AND PURPOSE
CSF-venous fistula can be diagnosed with multiple myelographic techniques; however, no prior work has characterized the time to contrast opacification and the duration of visualization. The purpose of our study was to evaluate the temporal characteristics of CSF-venous fistula on digital subtraction myelography.
MATERIALS AND METHODS
We reviewed the digital subtraction myelography images of 26 patients with CSF-venous fistulas. We evaluated how long the CSF-venous fistula took to opacify after contrast reached the spinal level of interest and how long it remained opacified. Patient demographics, CSF-venous fistula treatment, brain MR imaging findings, CSF-venous fistula spinal level, and CSF-venous fistula laterality were recorded.
RESULTS
Eight of the 26 CSF-venous fistulas were seen on both the upper- and lower-FOV digital subtraction myelography, for a total of 34 CSF-venous fistula views evaluated on digital subtraction myelography. The mean time to appearance was 9.1 seconds (range, 0-30 seconds). Twenty-two (84.6%) of the CSF-venous fistulas were on the right. The highest fistula level was C7, while the lowest was T13 (13 rib-bearing vertebral bodies). The most common CSF-venous fistula levels were T6 (4 patients) followed by T8, T10, and T11 (3 patients each). The mean age was 58.3 years (range, 31.7-87.6 years). Sixteen patients were women (61.5%).
CONCLUSIONS
This is the first study to report the temporal characteristics of CSF-venous fistulas using digital subtraction myelography. We found that on average, the CSF-venous fistula appeared 9.1 seconds (range, 0-30 seconds) after intrathecal contrast reached the spinal level.
Topics: Humans; Female; Middle Aged; Male; Myelography; Cerebrospinal Fluid Leak; Spine; Magnetic Resonance Imaging; Fistula; Intracranial Hypotension
PubMed: 36894299
DOI: 10.3174/ajnr.A7809 -
Global Spine Journal Mar 2023Technical Report.
STUDY DESIGN
Technical Report.
OBJECTIVE
Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine.
METHODS
In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect.
RESULTS
The patient had complete resolution of his preoperative symptoms after primary repair.
CONCLUSIONS
In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.
PubMed: 36869642
DOI: 10.1177/21925682231161303 -
Clinical Neuroradiology Sep 2023The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging...
BACKGROUND AND PURPOSE
The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging (MRI) comprises dynamic digital subtraction myelography (dDSM) in prone position for leak detection. Dynamic computed tomography (CT) myelography (dCT-M) in prone position follows if the leak is not unequivocally located. A drawback of dCT‑M is a high radiation dose. This study evaluates the diagnostic needs of dCT-M examinations and measures to reduce radiation doses.
METHODS
Frequency, leak sites, length and number of spiral acquisitions, DLP and effective doses of dCT‑M were retrospectively recorded in patients with ventral dural tears.
RESULTS
Of 42 patients with ventral dural tears, 8 underwent 11 dCT‑M when the leak was not unequivocally shown on digital subtraction myelography. The median number of spiral acquisitions was 4 (range 3-7) and the mean effective radiation dose 30.6 mSv (range 13.1-62.16 mSv) mSv. Five of eight leaks were located in the upper thoracic spine (range C7/Th1-Th2/3). Bolus tracking of intrathecal contrast agent in dCT‑M was used to limit the number and length of spiral acquisitions.
DISCUSSION
A dCT‑M in prone position to localize a ventral dural tear is needed in every fifth patient with a SLEC on MRI. It is typically needed when the leak is located in the upper thoracic spine and when patients have broad shoulders. Measures to reduce the radiation dose include bolus tracking or to repeat the DSM with adjusted positioning of patient.
Topics: Humans; Intracranial Hypotension; Myelography; Cerebrospinal Fluid Leak; Retrospective Studies; Tomography, X-Ray Computed; Magnetic Resonance Imaging; Radiation Dosage
PubMed: 36867243
DOI: 10.1007/s00062-023-01269-z -
Arquivos de Neuro-psiquiatria Feb 2023Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically...
BACKGROUND
Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT).
OBJECTIVE
To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward.
METHODS
Review of the medical files of three patients and description of clinical and surgical outcomes.
RESULTS
Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up.
CONCLUSION
The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.
Topics: Humans; Female; Adolescent; Young Adult; Adult; Intracranial Hypotension; Brazil; Cerebrospinal Fluid Leak; Magnetic Resonance Imaging; Headache; Venous Thrombosis; Delivery of Health Care
PubMed: 36863400
DOI: 10.1055/s-0042-1758752 -
Advances in Radiation Oncology 2023The management of patients with advanced solid malignancies increasingly uses stereotactic body radiation therapy (SBRT). Advanced cancer patients are at risk for...
PURPOSE
The management of patients with advanced solid malignancies increasingly uses stereotactic body radiation therapy (SBRT). Advanced cancer patients are at risk for developing leptomeningeal metastasis (LM), a fatal complication of metastatic cancer. Cerebrospinal fluid (CSF) is routinely collected during computed tomography (CT) myelography for spinal SBRT planning, offering an opportunity for early LM detection by CSF cytology in the absence of radiographic LM or LM symptoms (subclinical LM). This study tested the hypothesis that early detection of tumor cells in CSF in patients undergoing spine SBRT portends a similarly poor prognosis compared with clinically overt LM.
METHODS AND MATERIALS
We retrospectively analyzed clinical records for 495 patients with metastatic solid tumors who underwent CT myelography for spinal SBRT planning at a single institution from 2014 to 2019.
RESULTS
Among patients planned for SBRT, 51 (10.3%) developed LM. Eight patients (1.6%) had subclinical LM. Median survival with LM was similar between patients with subclinical versus clinically evident LM (3.6 vs 3.0 months, = .30). Patients harboring both parenchymal brain metastases and LM (29/51) demonstrated shorter survival than those with LM alone (2.4 vs 7.1 months, = .02).
CONCLUSIONS
LM remains a fatal complication of metastatic cancer. Subclinical LM detected by CSF cytology in spine SBRT patients has a similarly poor prognosis compared with standardly detected LM and warrants consideration of central nervous system-directed therapies. As aggressive local therapies are increasingly used for metastatic patients, more sensitive CSF evaluation may further identify patients with subclinical LM and should be evaluated prospectively.
PubMed: 36845624
DOI: 10.1016/j.adro.2022.101154 -
AJNR. American Journal of Neuroradiology Mar 2023
Topics: Humans; Myelography; Tomography, X-Ray Computed
PubMed: 36822824
DOI: 10.3174/ajnr.A7726 -
Spinal extradural arachnoid cysts: A novel formation mechanism and dural defect location technology.Heliyon Jan 2023The formation mechanism of spinal extradural arachnoid cysts (SEACs) remains unclear. There are several hypotheses for the formation of SEACs, but none of them can fully...
PURPOSE
The formation mechanism of spinal extradural arachnoid cysts (SEACs) remains unclear. There are several hypotheses for the formation of SEACs, but none of them can fully explain its pathological findings and surgical procedures. In this study, we retrospectively analyzed the cases of SEACs, aiming to clarify the formation mechanism of SEACs. In addition, we summarize a concise method for locating dural defects preoperatively and formulate a putative explanation of this method.
METHODS
The clinical data of 14 patients with SEACs underwent surgery in our hospital from January 2017 to December 2021 were retrospectively analyzed.
RESULTS
Fourteen patients were identified during the study period. The cysts all spanned the T12/L1 segment, and dural defects were also located at the T12/L1 level (2 cases not recorded) as well as the middle or the upper-middle level of the cysts. Nine cases were treated with total cyst excision, 2 cases were treated with dural defect closure only, and 3 cases were treated with total cyst excision and dural defect closure. Histopathological examination demonstrated that the cyst wall contained both the arachnoid epithelial and compact fibrous connective tissue. The symptoms were relieved in all patients, and no recurrence was observed.
CONCLUSIONS
According to intraoperative and pathological findings, the dural outer layer cyst (DOLC) is a more reasonable hypothesis about SEACs formation. When CT myelography or cinematic MRI cannot determine the location of the dural defect preoperatively, it can be located according to the middle level of the SEACs with high accuracy.
PubMed: 36820184
DOI: 10.1016/j.heliyon.2023.e12969 -
BMC Musculoskeletal Disorders Feb 2023It is an ongoing debate whether fusion surgery is superior to non-operative treatment for non-specific low back pain (LBP) in terms of patient outcome. Further, the...
BACKGROUND
It is an ongoing debate whether fusion surgery is superior to non-operative treatment for non-specific low back pain (LBP) in terms of patient outcome. Further, the evidence for how signs of intervertebral disc (IVD) degeneration on magnetic resonance imaging (MRI) correlate with patient outcome is insufficient. Longitudinal studies of low back pain (LBP) patients are thus of interest for increased knowledge. The aim of this study was to investigate long-term MRI appearance in LBP patients 11-14 years after discography.
METHODS
In 2021, 30 LBP patients who had same-day discography and MRI in 2007-2010 were asked to undergo MRI (Th12/L1-L5/S1), complete visual analog scale (VAS), Oswestry Disability Index (ODI) and EuroQol-5 Dimension (EQ5D) questionnaires. Patients who had fusion surgery before the follow-up were compared with those without such surgery. MRIs were evaluated on Pfirrmann grade, endplate classification score (EPS), and High Intensity Zones (HIZ). For each disk it was noted if injected at baseline or not.
RESULTS
Of 17 participants (6 male;mean age 58.5 years, range 49-72), 10 (27 disks) had undergone fusion surgery before the follow-up. No differences in VAS, ODI, or EQ5D scores were found between patients with and without surgery (mean 51/32/0.54 vs. 50/37/0.40, respectively; 0.77 > p < 0.65). Other than more segments with EPS ≥ 4 in the surgery group (p < 0.05), no between-group differences were found in longitudinal change in MRI parameters. Of 75 non-fused disks, 30 were injected at baseline. Differences were found between injected and non-injected disks at both baseline and follow-up for Pfirrmann grade and HIZ, and at follow-up for EPS (0.04 > p < 0.001), but none for progression over time (0.09 > p < 0.82).
CONCLUSIONS
Other than more endplate changes in the surgery group, no differences in longitudinal change of MRI parameters were established between LBP patients treated with or without fusion surgery in the studied cohort. The study also highlights the limited progress of degenerative changes, which may be seen over a decade, despite needle puncture and chronic LBP.
Topics: Humans; Male; Middle Aged; Aged; Low Back Pain; Intervertebral Disc Degeneration; Magnetic Resonance Imaging; Longitudinal Studies; Myelography; Lumbar Vertebrae
PubMed: 36814225
DOI: 10.1186/s12891-023-06242-y