SpineClinical features and pathomechanisms of syringomyelia associated with spinal arachnoiditis
Introduction
Adhesive spinal arachnoiditis is a chronic inflammatory process in the pia-arachnoid of the spinal cord. Several factors such as spinal surgery, myelography, or meningitis are known to cause adhesive arachnoiditis. In the literature, spinal arachnoiditis can be divided into 2 entities according to the etiology and clinical features. Lumbar or lumbosacral adhesive arachnoiditis is usually related to lumbar disc diseases [6], [9], [27], and radicular pain due to involvement of the cauda equina is a main symptom. By contrast, spinal arachnoiditis at the cervicothoracic level is characterized by slowly progressive myelopathy due to degenerative changes of the spinal cord [2], [16], [17]. Syringomyelia is a common intramedullary lesion in cervicothoracic spinal arachnoiditis [4], [21]. Disturbance of cerebrospinal fluid (CSF) flow around the spinal cord is considered to produce syringomyelia [5], [19]. However, the exact mechanisms of syrinx formation have not been clarified.
In the present study, we retrospectively analyzed the clinical course and radiological findings of syringomyelia in patients with spinal arachnoiditis who underwent surgical treatment in our institutes. The purpose of this study was to understand the clinical features and pathomechanisms of syringomyelia with spinal arachnoiditis and to provide the current choices of surgical treatment.
Section snippets
Materials
Fifteen consecutive patients were reviewed. They underwent surgical treatment of syringomyelia due to spinal arachnoiditis in our institutes between 1982 and 2000. There were 6 men and 9 women aged 32 to 65 years (mean, 46.9 years). The causes of spinal arachnoiditis were meningitis in 9 patients (tuberculous meningitis 6, unknown organism 3), spinal surgery (thoracic laminectomy for spinal tumor) in 2 patients, and unknown in 4 patients. Conventional myelography or computed
Clinical course
All patients showed tetraparesis (13 patients) or paraparesis (2 patients) on admission. Eleven patients were not ambulatory. Five patients showed complete motor and sensory paralysis of legs. Interval from the initial onset of paraparesis to admission to our hospital ranged from 1 to 33 years (mean, 16.3 years). The clinical courses can be divided into 2 patterns (Table 1). Five patients (cases 1-5: meningitis 4, spinal surgery 1) showed acute onset of paraparesis followed by gradual
Pathomechanisms of syringomyelia
Several authors [4], [16], [19], [21], [25], [28] proposed that the initial stage of syringomyelia in spinal arachnoiditis would be intramedullary cystic degeneration caused by ischemia due to circulatory disturbance in the pia-arachnoid. The blockage of CSF pathways around the spinal cord contribute to formation of the intramedullary cystic cavities [3]. Experimental studies indicated that the disturbed CSF flow around the spinal cord had an important role in the development of syringomyelia.
Conclusions
This study demonstrates clinical and radiological characteristics of syringomyelia associated with spinal arachnoiditis. The syrinx originated from the thoracic levels where severe adhesion of the subarachnoid space was present. The pathomechanisms of syringomyelia may be based on the increased interstitial fluid of the spinal cord at the level of arachnoiditis. Shunting procedures were effective in some population of the patients. Decompression procedures of the spinal subarachnoid space may
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2021, eNeurologicalSciCitation Excerpt :Additional surgical procedures include cyst fenestration, intradural exploration, syrinx drainage, shunt placement, duraplasty, myelotomy, intraventricular drain placement, discectomy, and anterior fusion. In the field of shunt placement, various types of shunts have been implanted, i.e., cystoperitoneal cystopleural, cystosubarachnoid, ventriculoperitoneal, etc. [24,58]. Surgical treatment of adhesive arachnoiditis seems to be effective in the short term, but the long-term outcome proved unsatisfactory.
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