-
Regional Anesthesia and Pain Medicine Apr 2024Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of...
BACKGROUND
Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak.
CASE PRESENTATION
We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension.
CONCLUSIONS
A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.
Topics: Humans; Intracranial Hypotension; Blood Patch, Epidural; Cerebrospinal Fluid Leak; Punctures; Post-Dural Puncture Headache; Iatrogenic Disease; Uridine Diphosphate
PubMed: 38388018
DOI: 10.1136/rapm-2023-105197 -
Journal of the Korean Society of... Jan 2024Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and... (Review)
Review
Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.
PubMed: 38362391
DOI: 10.3348/jksr.2023.0151 -
Frontiers in Neurology 2024Acquired prolapse of the cerebellar tonsils in spontaneous intracranial hypotension (SIH) patients is rare. This study aims to evaluate neuroimaging changes of acquired...
BACKGROUND
Acquired prolapse of the cerebellar tonsils in spontaneous intracranial hypotension (SIH) patients is rare. This study aims to evaluate neuroimaging changes of acquired prolapse of the cerebellar tonsils below the foramen magnum in SIH patients due to spontaneous spinal cerebrospinal fluid leakage, which was treated by targeted epidural blood patches (EBP).
METHODS
We retrospectively reviewed clinical and neuroimaging characteristics of 5 cases of SIH with acquired prolapse of the cerebellar tonsils that received targeted EBP in our institution from January 2013 to December 2016.
RESULTS
Of these SIH patients, all of them suffered from an orthostatic headache. Initial cranial MRI demonstrated descent of the cerebellar tonsils ≥5 mm. Intrathecal gadolinium-enhanced spinal MR myelography and/or spinal MR hydrography were performed to evaluate the level of spinal cerebrospinal fluid leakage. Symptoms were alleviated in all 5 patients after two ( = 4), or three ( = 1) targeted EBP during hospitalization. Follow-up cranial MRI revealed that the descent of cerebellar tonsils was reversed after EBP treatment.
CONCLUSION
Acquired tonsillar herniation can occur in patients with SIH and spinal cerebrospinal fluid leakage. Symptoms of these patients may be resolved and radiologic findings may be reversed after EBP treatment.
PubMed: 38327627
DOI: 10.3389/fneur.2024.1309718 -
Radiology Case Reports Apr 2024Dorsal arachnoid webs are uncommon, and of uncertain etiology. We present a case in which imaging findings of a dorsal arachnoid web were identified at the level of a...
Dorsal arachnoid webs are uncommon, and of uncertain etiology. We present a case in which imaging findings of a dorsal arachnoid web were identified at the level of a known prior gunshot injury where a retained bullet was lodged adjacent to the spine, without associated penetrating injury to the spine, suggesting blunt post-traumatic etiology.
PubMed: 38292796
DOI: 10.1016/j.radcr.2024.01.004 -
Child's Nervous System : ChNS :... Apr 2024Spontaneous intracranial hypotension may result in debilitating postural headaches and severe neurological symptoms due to secondary cerebellar sagging. The most common... (Review)
Review
Spontaneous intracranial hypotension may result in debilitating postural headaches and severe neurological symptoms due to secondary cerebellar sagging. The most common cause is the cerebrospinal fluid (CSF) leak within the spinal canal. Although previously reported in only a few cases, also paraspinal lymphatic malformations causing vertebral bone destruction may occasionally result in CSF leak to these pathological formations. Here, we present a case of a 9-year-old girl with generalized lymphatic anomaly (GLA) presenting with severe postural headache. Radiological imaging revealed a typical feature of cerebellar sagging. Myelography localized the CSF leakage into vertebral bodies of C7 and Th1, which both were partly involved in pathological paravertebral masses of known lymphatic anomaly, and from there along the right C8 nerve root sleeve into the anomaly. As the C8-nerve root could not be ligated due to the risk of significant neurological injury, we attempted image-guided targeted percutaneous epidural placement of a blood patch directly into the foramen at the affected level. The procedure resulted in obliteration of the fistula and regression of cerebellar sagging, with significant relief of symptoms. Although it is an extremely rare coincidence, patients with paraspinal lymphatic malformations may develop intraspinal CSF leak into these pathological formations. The present case report suggests that besides a direct surgical obliteration of the fistula and sacrificing the nerve root, a targeted percutaneous epidural blood patch may be a possible alternative in the case of a functionally important nerve root.
Topics: Child; Female; Humans; Blood Patch, Epidural; Cerebrospinal Fluid Leak; Fistula; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography
PubMed: 38236406
DOI: 10.1007/s00381-024-06287-x -
International Journal of Surgery Case... Feb 2024Schwannoma, a benign nerve sheath tumor originating from Schwann cells, can migrate within the spine due to various factors, impacting surgical planning. Unforeseen...
INTRODUCTION
Schwannoma, a benign nerve sheath tumor originating from Schwann cells, can migrate within the spine due to various factors, impacting surgical planning. Unforeseen movement complicates treatment, and it is considered a very rare tumor.
CASE PRESENTATION
A 24-year-old woman complained of persistent back pain and was examined at a neurosurgery clinic. Initial MRI found a spinal lesion that later moved, leading to two surgeries. The diagnosis was a Schwannoma, confirmed by examining the tissue under a microscope, showing characteristic features of a Schwannoma, specifically Antoni type A with recent hemorrhage.
DISCUSSION
Schwannoma, a rare nerve cell tumor, often migrates within the spine due to its lack of attachment within the dura. The tumor's movement can be triggered by various factors like nerve root laxity, pressure changes, body positioning, or medical procedures. A case study discussed a woman with back pain; her tumor migrated between two MRI scans, showcasing a common migration pattern. Lower back pain commonly manifests as a primary symptom in most cases. Imaging techniques such as myelography and intraoperative ultrasound assist in locating and managing these mobile tumors, advocating for their utilization to minimize surgical complications.
CONCLUSION
Reported a rare mobile thoracolumbar schwannoma from nerve sheath cells. Its mobility complicates surgery; precise imaging like intraoperative MRI and ultrasound are crucial for localization, preventing complications.
PubMed: 38219519
DOI: 10.1016/j.ijscr.2024.109266 -
Cureus Dec 2023Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the... (Review)
Review
Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the degeneration of the cervical spine due to various processes such as disc ageing, osteophyte formation, ligament hypertrophy or ossification, as well as coexisting congenital anomalies. This article provides an overview of the literature on DCM and considers areas of focus for future research. A patient with DCM can present with a variety of symptoms ranging from mild hand paraesthesia and loss of dexterity to a more severe presentation of gait disturbance and loss of bowel/bladder control. Hoffman's sign and the inverted brachioradialis reflex are also important signs of this disease. The gold standard imaging modality is MRI which can identify signs of degeneration of the cervical spine. Other modalities include dynamic MRI, myelography, and diffusion tensor imaging. One important scoring system to aid with the diagnosis and categorisation of the severity of DCM is the modified Japanese Orthopaedic Association score. This considers motor, sensory, and bowel/bladder dysfunction, and categorises patients into mild, moderate, or severe DCM. DCM is primarily treated with surgery as this can halt disease progression and may even allow for neurological recovery. The surgical approach will depend on the location of degeneration, the number of cervical levels involved and the pathophysiological process. Surgical approach options include anterior cervical discectomy and fusion, corpectomy, or posterior approach (laminectomy ± fusion). Conservative management is also considered for some patients with mild or non-progressive DCM or for patients where surgery is not an option. Conservative treatment may include physical therapy, traction, or neck immobilisation. Future recommendations include research into the prevalence rate of DCM and if there is a difference between populations. Further research on the benefit of conservative management for patients with mild or non-progressive DCM would be recommended.
PubMed: 38213348
DOI: 10.7759/cureus.50387 -
Diagnostics (Basel, Switzerland) Dec 2023The accurate preoperative identification of decompression levels is crucial for the success of surgery in patients with multi-level lumbar spinal stenosis (LSS). The...
BACKGROUND
The accurate preoperative identification of decompression levels is crucial for the success of surgery in patients with multi-level lumbar spinal stenosis (LSS). The objective of this study was to develop machine learning (ML) classifiers that can predict decompression levels using computed tomography myelography (CTM) data from LSS patients.
METHODS
A total of 1095 lumbar levels from 219 patients were included in this study. The bony spinal canal in CTM images was manually delineated, and radiomic features were extracted. The extracted data were randomly divided into training and testing datasets (8:2). Six feature selection methods combined with 12 ML algorithms were employed, resulting in a total of 72 ML classifiers. The main evaluation indicator for all classifiers was the area under the curve of the receiver operating characteristic (ROC-AUC), with the precision-recall AUC (PR-AUC) serving as the secondary indicator. The prediction outcome of ML classifiers was decompression level or not.
RESULTS
The embedding linear support vector (embeddingLSVC) was the optimal feature selection method. The feature importance analysis revealed the top 5 important features of the 15 radiomic predictors, which included 2 texture features, 2 first-order intensity features, and 1 shape feature. Except for shape features, these features might be eye-discernible but hardly quantified. The top two ML classifiers were embeddingLSVC combined with support vector machine (EmbeddingLSVC_SVM) and embeddingLSVC combined with gradient boosting (EmbeddingLSVC_GradientBoost). These classifiers achieved ROC-AUCs over 0.90 and PR-AUCs over 0.80 in independent testing among the 72 classifiers. Further comparisons indicated that EmbeddingLSVC_SVM appeared to be the optimal classifier, demonstrating superior discrimination ability, slight advantages in the Brier scores on the calibration curve, and Net benefits on the Decision Curve Analysis.
CONCLUSIONS
ML successfully extracted valuable and interpretable radiomic features from the spinal canal using CTM images, and accurately predicted decompression levels for LSS patients. The EmbeddingLSVC_SVM classifier has the potential to assist surgical decision making in clinical practice, as it showed high discrimination, advantageous calibration, and competitive utility in selecting decompression levels in LSS patients using canal radiomic features from CTM.
PubMed: 38201362
DOI: 10.3390/diagnostics14010053 -
The Indian Journal of Radiology &... Jan 2024Spontaneous intracranial hypotension (SICH) is the emerging cause of orthostatic headache as it has been better recognized in recent years. SICH happens due to spinal... (Review)
Review
Spontaneous intracranial hypotension (SICH) is the emerging cause of orthostatic headache as it has been better recognized in recent years. SICH happens due to spinal cerebrospinal fluid (CSF) leak; however, the manifestations are predominantly cranial and hence imaging in SICH includes brain and spine. There are few characteristic brain imaging features to be concerned about to diagnose SICH in patients with vague symptoms or low clinical suspicion. Spine screening is recommended in these patients to assess spinal CSF leaks. While neuroradiologists play a significant role from the time of diagnosis to treatment of SICH, there is a need for all the general radiologists to be aware of the condition. Computed tomography myelogram and digital subtraction myelogram are performed for diagnostic and therapeutic management of SICH. There is a known risk for SICH recurrence in patients with sagittal longitudinal epidural collection and hence, targeted blood patch should be used instead of blind patch. Most importantly, slow mobilization is recommended following the patch to avoid recurrence.
PubMed: 38106851
DOI: 10.1055/s-0043-1774301 -
Medicine Dec 2023Lumbar epidural analgesia is the gold standard for labor pain control. However, misplacement of epidural catheters into the subdural space may inadvertently happen....
RATIONALE
Lumbar epidural analgesia is the gold standard for labor pain control. However, misplacement of epidural catheters into the subdural space may inadvertently happen. Unrecognized subdural administration of local anesthetics could result in serious consequences, including high spinal and brainstem blocks. This case report describes a case where subdural epidural catheter placement was recognized early but labor pain was adequately managed by dosage titration of subdural analgesia.
PATIENT CONCERNS
This case report describes a 29-year-old primiparous pregnant woman who was admitted to our obstetric unit for labor induction at the gestational age of 38 weeks. An epidural catheter was inserted via the L2-3 intervertebral space using the standard loss of resistance to air technique.
DIAGNOSES
The parturient experienced weakness in the lower extremities and numbness in the upper extremities within 15 minutes after administration of 5 mL of 2% v/v lidocaine as a loading dose and systolic blood pressure also dropped by 25%.
INTERVENTIONS
The dose regimen (a mixture of 0.1% ropivacaine and 4 μg/mL fentanyl) for patient-controlled analgesia was given with bolus doses of 0.1 mL per demand and lockout intervals of 20 minutes. The analgesic effects were adequately maintained below the T8 dermatome for more than 12 hours without hypotensive episodes or obvious signs of neurological deficits. Computed tomographic myelography was performed by instillation of a nonionic iodinated contrast medium via the epidural catheter on postpartum day 2 for imaging confirmation of catheter placement in the extradural space.
LESSONS
Early recognition that epidural catheters for neuraxial analgesia have been inserted into the subdural space is important for the prevention of high spinal blocks. Subdural analgesia could still be achieved by careful clinical assessment and titration of low analgesic doses. This report also presents important and clear serial computed tomographic images of catheter placement in the thoracic-lumbar subdural spaces and the extent of volume spread in the subdural space following administration of contrast medium.
Topics: Pregnancy; Female; Humans; Infant; Adult; Subdural Space; Labor Pain; Anesthetics, Local; Analgesia, Epidural; Analgesics; Catheters; Analgesia, Obstetrical; Labor, Obstetric
PubMed: 38050308
DOI: 10.1097/MD.0000000000036000