Wang Timothy Y, Tabarestani Troy Q, Mehta Vikram A, Kranz Peter G, Gray Linda L, Brooks Kelli, Brown David A, Fernandez-Moure Joseph S, Schwab Joseph, Than Khoi D
Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA.
Duke University School of Medicine, Durham, NC, USA.
J Spine Surg. 2023 Jun 30;9(2):201-208. doi: 10.21037/jss-22-89. Epub 2023 Apr 4.
Enterothecal fistulas are pathological connections between the gastrointestinal system and subarachnoid space. These rare fistulas occur mostly in pediatric patients with sacral developmental anomalies. They have yet to be characterized in an adult born without congenital developmental anomaly yet must remain on the differential diagnosis when all other causes of meningitis and pneumocephalus have been ruled out. Good outcomes rely on aggressive multidisciplinary medical and surgical care, which are reviewed in this manuscript.
A 25-year-old female with history of a sacral giant cell tumor resected via anterior transperitoneal approach followed by posterior L4-pelvis fusion presented with headaches and altered mental status. Imaging revealed that a portion of small bowel had migrated into her resection cavity and created an enterothecal fistula resulting in fecalith within the subarachnoid space and florid meningitis. The patient underwent a small bowel resection for fistula obliteration, and subsequently developed hydrocephalus requiring shunt placement and two suboccipital craniectomies for foramen magnum crowding. Ultimately, her wounds became infected requiring washouts and instrumentation removal. Despite a prolonged hospital course, she made significant recovery and at 10-month following presentation, she is awake, oriented, and able to participate in activities of daily living.
This is the first case of meningitis secondary to enterothecal fistula in a patient without a previous congenital sacral anomaly. Operative intervention for fistula obliteration is the primary treatment and should be performed at a tertiary hospital with multidisciplinary capabilities. If recognized quickly and appropriately treated, there is a possibility of good neurological outcome.
肠鞘瘘是胃肠道系统与蛛网膜下腔之间的病理性连接。这些罕见的瘘管大多发生在患有骶骨发育异常的儿科患者中。在没有先天性发育异常的成年人中尚未对其进行特征描述，但当排除了所有其他脑膜炎和气颅病因时，仍必须将其列入鉴别诊断。良好的治疗效果依赖于积极的多学科医疗和手术治疗，本文对此进行了综述。
一名25岁女性，有经前路经腹手术切除骶骨巨细胞瘤并随后进行L4 - 骨盆后路融合的病史，出现头痛和精神状态改变。影像学检查显示一部分小肠移入了她的切除腔并形成了肠鞘瘘，导致蛛网膜下腔内有粪石和严重的脑膜炎。患者接受了小肠切除术以闭塞瘘管，随后出现脑积水，需要放置分流管，并因枕骨大孔受压进行了两次枕下颅骨切除术。最终，她的伤口感染，需要冲洗并取出器械。尽管住院时间延长，但她仍取得了显著恢复，在就诊后10个月，她清醒、定向力正常，能够参与日常生活活动。
这是首例在没有既往先天性骶骨异常的患者中由肠鞘瘘继发脑膜炎的病例。闭塞瘘管的手术干预是主要治疗方法，应在具备多学科能力的三级医院进行。如果能迅速识别并得到适当治疗，有可能获得良好的神经功能预后。
