- Email: [email protected]
Surgical management of syringomyelia associated with spinal adhesive arachnoiditis
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Journal of Clinical Neuroscience (2001) 8(1), 40–42 © 2001 Harcourt Publishers Ltd DOI: 10.1054/jocn.2000.0731, available online at http://www.idealibrary.com on
Technical note
Surgical management of syringomyelia associated with spinal adhesive arachnoiditis Kenji Ohata1 MD, Takeo Gotoh1 MD, Yasuhiro Matsusaka1 MD, Michiharu Morino1 MD, Naohiro Tsuyuguchi1 MD, Bassem Sheikh1 MD, Yuichi Inoue2 MD, Akira Hakuba1 MD Departments of 1Neurosurgery and 2Radiology, Osaka City University Medical School, 1-5-7 Asahi-machi, Abeno-ku, Osaka 545-8586, Japan
Summary The authors describe a new surgical technique to minimise the postoperative recurrence of adhesion after microlysis of adhesion to treat syringomyelia associated with spinal adhesive arachnoiditis. A 47 year old male presented with numbness of the lower extremities and urinary disturbance and was demonstrated to have a case of syringomyelia from C1 to T2 which was thought to be secondary to adhesive spinal arachnoiditis related to a history of tuberculous meningitis. Following meticulous microlysis of the adhesions, maximal expansion of a blocked subarachnoid space was performed by expansive duraplasty with a Gore-Tex surgical membrane, expansive laminoplasty and multiple tenting sutures of the Gore-Tex graft. Postoperatively, the syringomyelia had been completely obliterated and improvement of the symptoms had been also achieved. The technique described may contribute to improvement of the surgical outcome following arachnoid dissection by maintaining continuity of the reconstructed subarachnoid space. © 2001 Harcourt Publishers Ltd Keywords: adhesive arachnoiditis, arachnoid dissection, expansive duraplasty, expansive laminoplasty, syringomyelia, tuberculosis, surgical technique
INTRODUCTION In the treatment of syringomyelia associated with spinal adhesive arachnoiditis, several authors have proposed the technique of lysis of adhesion to resolve the major pathogenic factors responsible for syrinx initiation and propagation: cord tethering and blockage of the subarachnoid space caused by adhesion.1–6 Surgical outcome by arachnoid dissection, however, is limited by the risk of surgical damage to the cord and postoperative recurrence of adhesions.7–10 We report a new surgical technique developed to prevent the recurrence of adhesions and in order to maintain continuity of the reconstructed spinal subarachnoid space following arachnoid dissection. CASE REPORT A 47 year old male was admitted with the complaint of numbness of the left hand which had developed 6 years previously with a slow progressive course and extended to all extremities during the following 5.5 years. Urinary disturbance developed over the last 6 months. In the following 4 months micturition was possible only by suprapubic compression with a resultant residual volume. The patient was catheterised in another institute because of urinary retention 2 months before admission. There was no past history of spinal injury, previous spinal operation or myelography, but there was a history of pulmonary tuberculosis complicated by meningitis 28 years earlier. On admission, the patient was fully conscious. Mild weakness of the fingers of both hands with muscle atrophy was found. Deep tendon reflexes in both extremities were exaggerated. Hypalgesia was found below the level of T4 on both sides without any sacral sparing. Sphincter tone was depressed.
Urodynamic study revealed a spastic bladder. Magnetic resonance imaging (MRI) showed syringomyelia from C2 to T2 without an enhanced lesion. The subarachnoid space on the dorsal side of the cord between C3 and C7 was absent, suggesting arachnoiditis at the same level (Fig. 1). Operation The patient was positioned in the semiprone park bench position lying on the right side. A midline skin incision with muscle separation was made to expose C1 down to T4. Laminotomies from C2 down to T3 were performed, then a midline dural incision was made from C3 down to T3 without opening the arachnoid membrane. As the arachnoid membrane incision was made in the midline, its edges were taken with the dural edges using a 6-0 suture and anchored laterally to the paraspinal tissues together with the dura (Figs 2 and 3). Opening of the arachnoid membrane, lysis of adhesions and lateral anchoring of the dura and arachnoid were performed in a stepwise manner. Adhesive arachnoiditis was found dorsal to the dentate ligament extending from C4 down to T3.
Received 28 August 1998 Accepted 21 March 2000 Correspondence to: Kenji Ohata MD, Department of Neurosurgery, Osaka City University Medical School, 1-5-7 Asahi-machi, Abeno-ku, Osaka 545-8586, Japan. Tel.: ;81 6 645 2157; Fax: ;81 6 647 8065; E-mail: [email protected]
40
Fig. 1 Preoperative MR images. Left and centre: sagittal T1-weighted (left) and T2-weighted (centre) images showing a syrinx from C2 to T2 and obliteration of the subarachnoid space dorsal to the spinal cord from C3 to C7. Right: axial T1-weighted image at the level of C7 demonstrating a large syrinx with a septum inside.
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Arachnoiditic syringomyelia 41
Fig. 2 Schematic drawing of the surgical procedures. A: laminotomy. B: anchoring of the dura mater together with the arachnoid to the paraspinal tissues on either side during the process of arachnoid dissection. C: expansive duraplasty with a Gore-Tex membrane, expansive laminoplasty with a miniplate, and multiple tenting sutures of the Gore-Tex membrane. Fig. 4 Post operative MR images one and a half years after the operation. Left and centre: sagittal T1-weighted (left) and T2-weighted (centre) images showing obliteration of the syrinx and a wide reconstructed subarachnoid space. Right: axial T2-weighted image at C7 demonstrating the flattened spinal cord floating in enlarged subarachnoid space.
tenting sutures to expand the Gore-Tex graft were performed (Figs 2 and 3). Lastly, the wound was closed anatomically in layers.
Postoperative course Within the first postoperative year, gradual improvement of bladder function was noticed. No retention of urine remained and no further urinary catheterisation was needed. The patient returned to the initial level as he was able to void by suprapubic compression. In addition, there was subjective improvement of the numbness. Follow up MRI revealed complete disappearance of the syrinx and expansion of the subarachnoid space (Fig. 4). During the one and a half year follow up period, recurrence of syringomyelia was not observed either neurologically or radiologically.
DISCUSSION
Fig. 3 Intraoperative photograph. Upper: Dura mater and arachnoid membrane anchored together to the paraspinal tissues. Arachnoid dissection was performed between C5 and C7. Moderate adhesions were observed at the T1 and T2 (left side of photo) while adhesions were mild above the C4 level (right side of photo). Lower: Expansive duraplasty with the Gore-Tex membrane and expansive laminoplasty with a miniplate were completed at the C4 level. Multiple tenting sutures of the Gore-Tex membrane were performed.
Extensive but not severe adhesions were found at three vertebral levels from C6 down to T1 (Fig. 3). Microscopically, the adhesions were dissected and the cord was untethered with great care to preserve the cord and the vessels. After cleaning the subarachnoid space, an elliptical shaped Gore-Tex (polytetrafluoroethylene) surgical membrane, 2 cm in width and 10 cm in length, was prepared to make an expansive dural flap. A watertight closure was made using a continuous 6-0 suture. Furthermore, a fibrin glue soaked collagen sponge (Helistat, Cola-Tec) was applied along the suture line to reinforce the watertight closure. Expansive laminoplasties were performed at C4 and C7, using their laminae and spinous processes. Next, 7 mm lengths of the spinous processes were resected and sutured on one side of the laminae by nylon through small drill holes. These laminae and spinous processes were tightly fixed together using titanium miniplates. Multiple © 2001 Harcourt Publishers Ltd
In the treatment of syringomyelia associated with spinal adhesive arachnoiditis, the primary target should be the adhesion and not the syrinx, in order to resolve the initial pathological factor responsible for pathogenesis and progression of the latter. Maximal enlargement of the reconstructed subarachnoid space by expansive duraplasty using a Gore-Tex surgical membrane and expansive laminoplasty following microlysis of the adhesions, presented herein, might help to achieve this treatment concept by contributing to the prevention of recurrent scarring. The surgical treatment of syringomyelia associated with spinal adhesive arachnoiditis has been directed toward the drainage of syrinx by myelotomy or by shunting with good short term results.2,3,11,12 Recent studies, however, have revealed an unsatisfactory long term prognosis with high rates of syrinx recurrence.3,4 Hence, several approaches for arachnoid dissection and decompression of the subarachnoid space have been reported.2–5 Edgar and Quail reported excellent results in 150 patients with post-traumatic arachnoid scarring using arachnoid dissection followed by a generous dural graft consisting mainly of fascia lata, anchored laterally to the paraspinal tissues to prevent recurrent adhesion.2 Sgouros and Williams performed expansion of subarachnoid space in post-traumatic syringomyelia by laminectomy, dissection of arachnoid scarring and leaving the dura opened to create a surgical meningocele.13 However, leaving the dura open may create the risk of postoperative cerebrospinal fluid (CSF) leakage. In addition, the escape of proteinaceous fluid from paraspinal muscles can cause recurrence of arachnoid adhesions.2 Although at this presentation no laboratory confirmation of tuberculous meningitis could be obtained, a cause of the adhesive arachnoiditis is highly suggested by the history of tuberculous Journal of Clinical Neuroscience (2001) 8(1), 40–42
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meningitis. Few cases of syringomyelia associated with tuberculous spinal adhesive arachnoiditis have been reported;4,14,15 all of these cases were treated by drainage procedures with an unsatisfactory outcome. As far as the literature has been reviewed, our case is the first case of syringomyelia associated with tuberculous spinal adhesive arachnoiditis which was successfully treated with arachnoid dissection and reconstruction of the subarachnoid space. Experience with a Gore-Tex membrane is still evolving. Good results in the prevention of adhesive pericarditis following heart surgery have been obtained by many cardiac surgeons.16,17,18 Inoue et al. used this membrane to prevent cord retethering following myelomeningocele repair and achieved good results in the intermediate follow up periods, ranging from 23 months to 7 years, without any postoperative readhesion.18 We should emphasise the role of the Gore-Tex membrane in preventing or at least in minimising the readhesion. Nevertheless, long term follow up results should be considered before evaluating the role of this membrane. The surgical damage to the spinal cord during arachnoid dissection as well as postoperative recurrence of scarring basically depend on the degree of arachnoiditis.7,9 Klekamp et al. reported achievement of clinical stability by arachnoid dissection and decompression with duraplasty in 83% of cases with focal arachnoiditis extending less than two vertebral levels (Klekamp grading I and II), but in cases with extensive arachnoiditis over two vertebral levels (Klekamp grading III and IV) the results were poor (17% achievement of clinical stability).3 In our case, despite being graded as IV, the adhesions were not severe and were located dorsally and not circumferentially around the cord, which might explain the satisfactory outcome. Based on the experience of meticulous microlysis of adhesion and duraplasty by fascia lata or lyophilised dura in our previous cases of syringomyelia associated with adhesive arachnoiditis, it was thought that technical improvement could be best achieved by using a technique that could prevent adhesions.19 In our case presented here, we used a Gore-Tex membrane for the graft supported by expansive laminoplasty and a tenting suture over the graft; this may be the optimal approach for managing syringomyelia associated with adhesive arachnoiditis.
2. 3.
4. 5. 6.
7. 8.
9. 10. 11. 12. 13. 14. 15. 16.
17.
18.
19.
Edgar R, Quail P. Progressive post-traumatic cystic and non-cystic myelopathy. Br J Neurosurg 1994; 8: 7–22. Klekamp J, Batzdore U, Samii M, Bothe HW. Treatment of syringomyelia associated with arachnoid scarring caused by arachnoiditis or trauma. J Neurosurg 1997; 86: 233–240. Sgouros S, Williams BW. A critical appraisal of drainage in syringomyelia. J Neurosurg 1995; 82: 1–10. Tatara N. Experimental syringomyelia in rabbits and rats after localized spinal arachnoiditis. No To Shinkei 1992; 44: 1115–1125 (Jpn). Tobimatsu Y, Nihei R, Kimura T, Suyama T, Kimura H, Tobimatsu H, Shirakawa T. A quantitative analysis of cerebrospinal fluid flow in posttraumatic syringomyelia. Paraplegia 1995; 33: 203–207. Guyer DW, Wiltse LL, Eskay ML, Guyer BH. The long-range prognosis of arachnoiditis. Spine 1989; 14: 1332–1341. Jenik F, Tekle-Haimanot R, Hamory BH. Non-traumatic adhesive arachnoiditis as a cause of spinal cord syndrome. Investigation of 507 patients. Paraplegia 1981; 19: 140–154. Shaw MDM, Russell JA, Grossart KW. The changing pattern of spinal arachnoiditis. J Neurol Neurosurg Psychiatry 1978; 41: 97–107. Wilkinson HA, Schumann N. Results of surgical lysis of lumbar adhesive arachnoiditis. Neurosurgery 1979; 4: 401–409. Alvisi C, Cerisoli M. Long-term results of the surgical treatment of syringomyelia. Acta Neurochir 1984; 71: 133–140. Barbaro NM, Wilson CB, Gutin PH, Edwards MS. Surgical treatment of syringomyelia. J Neurosurg 1983; 61: 531–538. Sgouros S, Williams BW. Management and outcome of posttraumatic syringomyelia. J Neurosurg 1996; 85: 197–205. Caplan LR, Norohna AB, Amico LL. Syringomyelia and arachnoiditis. J Neurol Neurosurg Psychiatry 1990; 53: 1016–1113. Suzuki M, Davis C, Symon L, Gentili F. Syringoperitoneal shunt for treatment of cord cavitation. J Neurol Neurosurg Psychiatry 1985; 48: 620–627. Harada Y, Imai Y, Kurosawa H, Hoshino S, Nakano K. Long-term results of the clinical use of an expanded polytetrafluorethylene surgical membrane as a pericardial substitute. J Thorac Cardiovascular Surg 1988; 96: 811–815. Minale C, Nikol S, Hollweg G, Mittermayer C, Messmer BJ. Clinical experience with expanded polytetrafluoroethylene Gore-Tex surgical membrane for pericardial closure: a study of 110 cases. J Cardiac Surg 1988; 3: 193–201. Inoue HK, Kobayashi S, Ohbayashi K, Kohgo H, Nakagawa M. Treatment and prevention of tethered and retethered spinal cord using a Gore-Tex surgical membrane. J Neurosurg 1994; 80: 686–693. Hakuba A, Ijichi H, Nagai K, Ohata K, Branco Soares Jr S. Surgical treatment for syringomyelia associated with adhesive spinal arachnoiditis. In: Tamaki N (ed) Annual Report of the Research Committee on Prevention and Treatment of Spinal Dysfunction Associated with Intractable Syringomyelia and Spina Bifida, Research Grant (8B-5) for Nervous and Mental Disorders from the Ministry of Health and Welfare, 1997: 41–47 (Jpn).
REFERENCES 1. Cho KH, Iwasaki Y, Imamura H, Hida K, Abe H. Experimental model of posttraumatic syringomyelia: the role of adhesive arachnoiditis in syrinx formation. J Neurosurg 1994; 80: 133–139.
Journal of Clinical Neuroscience (2001) 8(1), 40–42
© 2001 Harcourt Publishers Ltd
12/9/00 11:44 AM
Page 40
Journal of Clinical Neuroscience (2001) 8(1), 40–42 © 2001 Harcourt Publishers Ltd DOI: 10.1054/jocn.2000.0731, available online at http://www.idealibrary.com on
Technical note
Surgical management of syringomyelia associated with spinal adhesive arachnoiditis Kenji Ohata1 MD, Takeo Gotoh1 MD, Yasuhiro Matsusaka1 MD, Michiharu Morino1 MD, Naohiro Tsuyuguchi1 MD, Bassem Sheikh1 MD, Yuichi Inoue2 MD, Akira Hakuba1 MD Departments of 1Neurosurgery and 2Radiology, Osaka City University Medical School, 1-5-7 Asahi-machi, Abeno-ku, Osaka 545-8586, Japan
Summary The authors describe a new surgical technique to minimise the postoperative recurrence of adhesion after microlysis of adhesion to treat syringomyelia associated with spinal adhesive arachnoiditis. A 47 year old male presented with numbness of the lower extremities and urinary disturbance and was demonstrated to have a case of syringomyelia from C1 to T2 which was thought to be secondary to adhesive spinal arachnoiditis related to a history of tuberculous meningitis. Following meticulous microlysis of the adhesions, maximal expansion of a blocked subarachnoid space was performed by expansive duraplasty with a Gore-Tex surgical membrane, expansive laminoplasty and multiple tenting sutures of the Gore-Tex graft. Postoperatively, the syringomyelia had been completely obliterated and improvement of the symptoms had been also achieved. The technique described may contribute to improvement of the surgical outcome following arachnoid dissection by maintaining continuity of the reconstructed subarachnoid space. © 2001 Harcourt Publishers Ltd Keywords: adhesive arachnoiditis, arachnoid dissection, expansive duraplasty, expansive laminoplasty, syringomyelia, tuberculosis, surgical technique
INTRODUCTION In the treatment of syringomyelia associated with spinal adhesive arachnoiditis, several authors have proposed the technique of lysis of adhesion to resolve the major pathogenic factors responsible for syrinx initiation and propagation: cord tethering and blockage of the subarachnoid space caused by adhesion.1–6 Surgical outcome by arachnoid dissection, however, is limited by the risk of surgical damage to the cord and postoperative recurrence of adhesions.7–10 We report a new surgical technique developed to prevent the recurrence of adhesions and in order to maintain continuity of the reconstructed spinal subarachnoid space following arachnoid dissection. CASE REPORT A 47 year old male was admitted with the complaint of numbness of the left hand which had developed 6 years previously with a slow progressive course and extended to all extremities during the following 5.5 years. Urinary disturbance developed over the last 6 months. In the following 4 months micturition was possible only by suprapubic compression with a resultant residual volume. The patient was catheterised in another institute because of urinary retention 2 months before admission. There was no past history of spinal injury, previous spinal operation or myelography, but there was a history of pulmonary tuberculosis complicated by meningitis 28 years earlier. On admission, the patient was fully conscious. Mild weakness of the fingers of both hands with muscle atrophy was found. Deep tendon reflexes in both extremities were exaggerated. Hypalgesia was found below the level of T4 on both sides without any sacral sparing. Sphincter tone was depressed.
Urodynamic study revealed a spastic bladder. Magnetic resonance imaging (MRI) showed syringomyelia from C2 to T2 without an enhanced lesion. The subarachnoid space on the dorsal side of the cord between C3 and C7 was absent, suggesting arachnoiditis at the same level (Fig. 1). Operation The patient was positioned in the semiprone park bench position lying on the right side. A midline skin incision with muscle separation was made to expose C1 down to T4. Laminotomies from C2 down to T3 were performed, then a midline dural incision was made from C3 down to T3 without opening the arachnoid membrane. As the arachnoid membrane incision was made in the midline, its edges were taken with the dural edges using a 6-0 suture and anchored laterally to the paraspinal tissues together with the dura (Figs 2 and 3). Opening of the arachnoid membrane, lysis of adhesions and lateral anchoring of the dura and arachnoid were performed in a stepwise manner. Adhesive arachnoiditis was found dorsal to the dentate ligament extending from C4 down to T3.
Received 28 August 1998 Accepted 21 March 2000 Correspondence to: Kenji Ohata MD, Department of Neurosurgery, Osaka City University Medical School, 1-5-7 Asahi-machi, Abeno-ku, Osaka 545-8586, Japan. Tel.: ;81 6 645 2157; Fax: ;81 6 647 8065; E-mail: [email protected]
40
Fig. 1 Preoperative MR images. Left and centre: sagittal T1-weighted (left) and T2-weighted (centre) images showing a syrinx from C2 to T2 and obliteration of the subarachnoid space dorsal to the spinal cord from C3 to C7. Right: axial T1-weighted image at the level of C7 demonstrating a large syrinx with a septum inside.
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Arachnoiditic syringomyelia 41
Fig. 2 Schematic drawing of the surgical procedures. A: laminotomy. B: anchoring of the dura mater together with the arachnoid to the paraspinal tissues on either side during the process of arachnoid dissection. C: expansive duraplasty with a Gore-Tex membrane, expansive laminoplasty with a miniplate, and multiple tenting sutures of the Gore-Tex membrane. Fig. 4 Post operative MR images one and a half years after the operation. Left and centre: sagittal T1-weighted (left) and T2-weighted (centre) images showing obliteration of the syrinx and a wide reconstructed subarachnoid space. Right: axial T2-weighted image at C7 demonstrating the flattened spinal cord floating in enlarged subarachnoid space.
tenting sutures to expand the Gore-Tex graft were performed (Figs 2 and 3). Lastly, the wound was closed anatomically in layers.
Postoperative course Within the first postoperative year, gradual improvement of bladder function was noticed. No retention of urine remained and no further urinary catheterisation was needed. The patient returned to the initial level as he was able to void by suprapubic compression. In addition, there was subjective improvement of the numbness. Follow up MRI revealed complete disappearance of the syrinx and expansion of the subarachnoid space (Fig. 4). During the one and a half year follow up period, recurrence of syringomyelia was not observed either neurologically or radiologically.
DISCUSSION
Fig. 3 Intraoperative photograph. Upper: Dura mater and arachnoid membrane anchored together to the paraspinal tissues. Arachnoid dissection was performed between C5 and C7. Moderate adhesions were observed at the T1 and T2 (left side of photo) while adhesions were mild above the C4 level (right side of photo). Lower: Expansive duraplasty with the Gore-Tex membrane and expansive laminoplasty with a miniplate were completed at the C4 level. Multiple tenting sutures of the Gore-Tex membrane were performed.
Extensive but not severe adhesions were found at three vertebral levels from C6 down to T1 (Fig. 3). Microscopically, the adhesions were dissected and the cord was untethered with great care to preserve the cord and the vessels. After cleaning the subarachnoid space, an elliptical shaped Gore-Tex (polytetrafluoroethylene) surgical membrane, 2 cm in width and 10 cm in length, was prepared to make an expansive dural flap. A watertight closure was made using a continuous 6-0 suture. Furthermore, a fibrin glue soaked collagen sponge (Helistat, Cola-Tec) was applied along the suture line to reinforce the watertight closure. Expansive laminoplasties were performed at C4 and C7, using their laminae and spinous processes. Next, 7 mm lengths of the spinous processes were resected and sutured on one side of the laminae by nylon through small drill holes. These laminae and spinous processes were tightly fixed together using titanium miniplates. Multiple © 2001 Harcourt Publishers Ltd
In the treatment of syringomyelia associated with spinal adhesive arachnoiditis, the primary target should be the adhesion and not the syrinx, in order to resolve the initial pathological factor responsible for pathogenesis and progression of the latter. Maximal enlargement of the reconstructed subarachnoid space by expansive duraplasty using a Gore-Tex surgical membrane and expansive laminoplasty following microlysis of the adhesions, presented herein, might help to achieve this treatment concept by contributing to the prevention of recurrent scarring. The surgical treatment of syringomyelia associated with spinal adhesive arachnoiditis has been directed toward the drainage of syrinx by myelotomy or by shunting with good short term results.2,3,11,12 Recent studies, however, have revealed an unsatisfactory long term prognosis with high rates of syrinx recurrence.3,4 Hence, several approaches for arachnoid dissection and decompression of the subarachnoid space have been reported.2–5 Edgar and Quail reported excellent results in 150 patients with post-traumatic arachnoid scarring using arachnoid dissection followed by a generous dural graft consisting mainly of fascia lata, anchored laterally to the paraspinal tissues to prevent recurrent adhesion.2 Sgouros and Williams performed expansion of subarachnoid space in post-traumatic syringomyelia by laminectomy, dissection of arachnoid scarring and leaving the dura opened to create a surgical meningocele.13 However, leaving the dura open may create the risk of postoperative cerebrospinal fluid (CSF) leakage. In addition, the escape of proteinaceous fluid from paraspinal muscles can cause recurrence of arachnoid adhesions.2 Although at this presentation no laboratory confirmation of tuberculous meningitis could be obtained, a cause of the adhesive arachnoiditis is highly suggested by the history of tuberculous Journal of Clinical Neuroscience (2001) 8(1), 40–42
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meningitis. Few cases of syringomyelia associated with tuberculous spinal adhesive arachnoiditis have been reported;4,14,15 all of these cases were treated by drainage procedures with an unsatisfactory outcome. As far as the literature has been reviewed, our case is the first case of syringomyelia associated with tuberculous spinal adhesive arachnoiditis which was successfully treated with arachnoid dissection and reconstruction of the subarachnoid space. Experience with a Gore-Tex membrane is still evolving. Good results in the prevention of adhesive pericarditis following heart surgery have been obtained by many cardiac surgeons.16,17,18 Inoue et al. used this membrane to prevent cord retethering following myelomeningocele repair and achieved good results in the intermediate follow up periods, ranging from 23 months to 7 years, without any postoperative readhesion.18 We should emphasise the role of the Gore-Tex membrane in preventing or at least in minimising the readhesion. Nevertheless, long term follow up results should be considered before evaluating the role of this membrane. The surgical damage to the spinal cord during arachnoid dissection as well as postoperative recurrence of scarring basically depend on the degree of arachnoiditis.7,9 Klekamp et al. reported achievement of clinical stability by arachnoid dissection and decompression with duraplasty in 83% of cases with focal arachnoiditis extending less than two vertebral levels (Klekamp grading I and II), but in cases with extensive arachnoiditis over two vertebral levels (Klekamp grading III and IV) the results were poor (17% achievement of clinical stability).3 In our case, despite being graded as IV, the adhesions were not severe and were located dorsally and not circumferentially around the cord, which might explain the satisfactory outcome. Based on the experience of meticulous microlysis of adhesion and duraplasty by fascia lata or lyophilised dura in our previous cases of syringomyelia associated with adhesive arachnoiditis, it was thought that technical improvement could be best achieved by using a technique that could prevent adhesions.19 In our case presented here, we used a Gore-Tex membrane for the graft supported by expansive laminoplasty and a tenting suture over the graft; this may be the optimal approach for managing syringomyelia associated with adhesive arachnoiditis.
2. 3.
4. 5. 6.
7. 8.
9. 10. 11. 12. 13. 14. 15. 16.
17.
18.
19.
Edgar R, Quail P. Progressive post-traumatic cystic and non-cystic myelopathy. Br J Neurosurg 1994; 8: 7–22. Klekamp J, Batzdore U, Samii M, Bothe HW. Treatment of syringomyelia associated with arachnoid scarring caused by arachnoiditis or trauma. J Neurosurg 1997; 86: 233–240. Sgouros S, Williams BW. A critical appraisal of drainage in syringomyelia. J Neurosurg 1995; 82: 1–10. Tatara N. Experimental syringomyelia in rabbits and rats after localized spinal arachnoiditis. No To Shinkei 1992; 44: 1115–1125 (Jpn). Tobimatsu Y, Nihei R, Kimura T, Suyama T, Kimura H, Tobimatsu H, Shirakawa T. A quantitative analysis of cerebrospinal fluid flow in posttraumatic syringomyelia. Paraplegia 1995; 33: 203–207. Guyer DW, Wiltse LL, Eskay ML, Guyer BH. The long-range prognosis of arachnoiditis. Spine 1989; 14: 1332–1341. Jenik F, Tekle-Haimanot R, Hamory BH. Non-traumatic adhesive arachnoiditis as a cause of spinal cord syndrome. Investigation of 507 patients. Paraplegia 1981; 19: 140–154. Shaw MDM, Russell JA, Grossart KW. The changing pattern of spinal arachnoiditis. J Neurol Neurosurg Psychiatry 1978; 41: 97–107. Wilkinson HA, Schumann N. Results of surgical lysis of lumbar adhesive arachnoiditis. Neurosurgery 1979; 4: 401–409. Alvisi C, Cerisoli M. Long-term results of the surgical treatment of syringomyelia. Acta Neurochir 1984; 71: 133–140. Barbaro NM, Wilson CB, Gutin PH, Edwards MS. Surgical treatment of syringomyelia. J Neurosurg 1983; 61: 531–538. Sgouros S, Williams BW. Management and outcome of posttraumatic syringomyelia. J Neurosurg 1996; 85: 197–205. Caplan LR, Norohna AB, Amico LL. Syringomyelia and arachnoiditis. J Neurol Neurosurg Psychiatry 1990; 53: 1016–1113. Suzuki M, Davis C, Symon L, Gentili F. Syringoperitoneal shunt for treatment of cord cavitation. J Neurol Neurosurg Psychiatry 1985; 48: 620–627. Harada Y, Imai Y, Kurosawa H, Hoshino S, Nakano K. Long-term results of the clinical use of an expanded polytetrafluorethylene surgical membrane as a pericardial substitute. J Thorac Cardiovascular Surg 1988; 96: 811–815. Minale C, Nikol S, Hollweg G, Mittermayer C, Messmer BJ. Clinical experience with expanded polytetrafluoroethylene Gore-Tex surgical membrane for pericardial closure: a study of 110 cases. J Cardiac Surg 1988; 3: 193–201. Inoue HK, Kobayashi S, Ohbayashi K, Kohgo H, Nakagawa M. Treatment and prevention of tethered and retethered spinal cord using a Gore-Tex surgical membrane. J Neurosurg 1994; 80: 686–693. Hakuba A, Ijichi H, Nagai K, Ohata K, Branco Soares Jr S. Surgical treatment for syringomyelia associated with adhesive spinal arachnoiditis. In: Tamaki N (ed) Annual Report of the Research Committee on Prevention and Treatment of Spinal Dysfunction Associated with Intractable Syringomyelia and Spina Bifida, Research Grant (8B-5) for Nervous and Mental Disorders from the Ministry of Health and Welfare, 1997: 41–47 (Jpn).
REFERENCES 1. Cho KH, Iwasaki Y, Imamura H, Hida K, Abe H. Experimental model of posttraumatic syringomyelia: the role of adhesive arachnoiditis in syrinx formation. J Neurosurg 1994; 80: 133–139.
Journal of Clinical Neuroscience (2001) 8(1), 40–42
© 2001 Harcourt Publishers Ltd