Mastorakos Panagiotis, Pomeraniec I Jonathan, Bryant Jean-Paul, Chittiboina Prashant, Heiss John D
1Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.
2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and.
J Neurosurg Spine. 2021 Oct 1;36(2):325-335. doi: 10.3171/2021.4.SPINE21483. Print 2022 Feb 1.
Chronic adhesive spinal arachnoiditis (SA) is a complex disease process that results in spinal cord tethering, CSF flow blockage, intradural adhesions, spinal cord edema, and sometimes syringomyelia. When it is focal or restricted to fewer than 3 spinal segments, the disease responds well to open surgical approaches. More extensive arachnoiditis extending beyond 4 spinal segments has a much worse prognosis because of less adequate removal of adhesions and a higher propensity for postoperative scarring and retethering. Flexible neuroendoscopy can extend the longitudinal range of the surgical field with a minimalist approach. The authors present a cohort of patients with severe cervical and thoracic arachnoiditis and myelopathy who underwent flexible endoscopy to address arachnoiditis at spinal segments not exposed by open surgical intervention. These observations will inform subsequent efforts to improve the treatment of extensive arachnoiditis.
Over a period of 3 years (2017-2020), 10 patients with progressive myelopathy were evaluated and treated for extensive SA. Seven patients had syringomyelia, 1 had spinal cord edema, and 2 had spinal cord distortion. Surgical intervention included 2- to 5-level thoracic laminectomy, microscopic lysis of adhesions, and then lysis of adhesions at adjacent spinal levels performed using a rigid or flexible endoscope. The mean follow-up was 5 months (range 2-15 months). Neurological function was examined using standard measures. MRI was used to assess syrinx resolution.
The mean length of syringes was 19.2 ± 10 cm, with a mean maximum diameter of 7.0 ± 2.9 mm. Patients underwent laminectomies averaging 3.7 ± 0.9 (range 2-5) levels in length followed by endoscopy, which expanded exposure by an average of another 2.4 extra segments (6.1 ± 4.0 levels total). Endoscopic dissection of extensive arachnoiditis in the dorsal subarachnoid space proceeded through a complex network of opaque arachnoidal bands and membranes bridging from the dorsal dura mater to the spinal cord. In less severely problematic areas, the arachnoid membrane was transparent and attached to the spinal cord through multifocal arachnoid adhesions bridging the subarachnoid space. The endoscope did not compress or injure the spinal cord.
Intrathecal endoscopy allowed visual assessment and safe removal of intradural adhesions beyond the laminectomy margins. Further development of this technique should improve its effectiveness in opening the subarachnoid space and untethering the spinal cord in cases of extensive chronic adhesive SA.
慢性粘连性脊髓蛛网膜炎（SA）是一种复杂的疾病过程，可导致脊髓拴系、脑脊液流动受阻、硬膜内粘连、脊髓水肿，有时还会引发脊髓空洞症。当病变局限或累及少于3个脊髓节段时，该疾病对开放手术治疗反应良好。而超过4个脊髓节段的广泛性蛛网膜炎预后则要差得多，因为粘连清除不彻底，术后瘢痕形成和再次拴系的倾向更高。可弯曲神经内镜能够以微创方式扩大手术视野的纵向范围。作者报告了一组患有严重颈段和胸段蛛网膜炎及脊髓病的患者，他们接受了可弯曲内镜检查，以处理开放手术未暴露的脊髓节段的蛛网膜炎。这些观察结果将为后续改善广泛性蛛网膜炎治疗的努力提供参考。
在3年时间（2017 - 2020年）里，对10例进行性脊髓病患者进行了评估并针对广泛性SA进行治疗。7例患者患有脊髓空洞症，1例有脊髓水肿，2例有脊髓变形。手术干预包括2至5个节段的胸椎椎板切除术、显微镜下粘连松解，然后使用刚性或可弯曲内镜对相邻脊髓节段进行粘连松解。平均随访时间为5个月（范围2至15个月）。使用标准方法检查神经功能。采用MRI评估脊髓空洞的消退情况。
脊髓空洞的平均长度为19.2±10 cm，平均最大直径为7.0±2.9 mm。患者平均接受了长度为3.7±0.9（范围2至5）个节段的椎板切除术，随后进行内镜检查，内镜检查平均又额外扩大了2.4个节段的暴露范围（总共6.1±4.0个节段）。在背侧蛛网膜下腔对广泛性蛛网膜炎进行内镜下分离时，要穿过从硬脊膜背侧延伸至脊髓的不透明蛛网膜带和膜的复杂网络。在问题不太严重的区域，蛛网膜是透明的，通过跨越蛛网膜下腔的多灶性蛛网膜粘连附着于脊髓。内镜未对脊髓造成压迫或损伤。
鞘内内镜检查能够对椎板切除边缘以外的硬膜内粘连进行可视化评估并安全清除。这项技术的进一步发展应能提高其在广泛性慢性粘连性SA病例中开放蛛网膜下腔和解除脊髓拴系的有效性。
