Flexible thecoscopy for extensive spinal arachnoiditis.
Flexible thecoscopy for extensive spinal arachnoiditis.
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DOI：
10.3171/2021.4.spine21483
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发表时间：
2022-02-01
影响因子：
2.8
通讯作者：
Heiss, John D.
中科院分区：
文献类型：
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作者：
Mastorakos, Panagiotis;Pomeraniec, I. Jonathan;Bryant, Jean-Paul;Chittiboina, Prashant;Heiss, John D.
关键词：
慢性粘连性脊髓蛛网膜炎（SA）是一种复杂的疾病过程，可导致脊髓栓系、脑脊液血流阻塞、硬膜内粘连、脊髓水肿，有时还会出现脊髓空洞。当病变局限于局灶性或局限于少于3个脊柱节段时，对开放性手术入路反应良好。更广泛的蛛网膜炎延伸超过4个脊柱节段，预后更差，因为粘连的清除不充分，术后瘢痕和再栓的倾向更高。灵活的神经内窥镜可以以极简的方法扩展手术视野的纵向范围。作者介绍了一组患有严重颈、胸蛛网膜炎和脊髓病的患者，他们接受了柔性内窥镜检查，以治疗未通过开放手术干预暴露的脊柱节段的蛛网膜炎。这些观察结果将为后续改进广泛性蛛网膜炎的治疗提供信息。在3年（2017-2020）期间，对10例进行性脊髓病患者进行了广泛SA的评估和治疗。脊髓空洞7例，脊髓水肿1例，脊髓变形2例。手术干预包括2- 5节段胸椎板切除术，显微镜下的粘连松解，然后在刚性或柔性内窥镜下对相邻脊柱节段的粘连松解。平均随访5个月（2-15个月）。采用标准方法检查神经功能。MRI评估鼻咽癌消退。注射器平均长度为19.2±10 cm，平均最大直径为7.0±2.9 mm。患者接受平均3.7±0.9（范围2-5）个水平的椎板切除术，然后进行内窥镜检查，平均增加2.4个额外的节段（总共6.1±4.0个水平）。在背侧蛛网膜下腔的广泛蛛网膜炎的内镜下解剖，通过从硬脑膜背侧到脊髓的不透明蛛网膜带和膜的复杂网络进行。在问题不太严重的区域，蛛网膜是透明的，并通过多灶蛛网膜粘连桥接蛛网膜下腔与脊髓相连。内窥镜没有压迫或损伤脊髓。鞘内内窥镜检查可对椎板切除术边缘以外的硬膜内粘连进行视觉评估和安全切除。该技术的进一步发展应提高其在广泛慢性粘连性SA病例中打开蛛网膜下腔和解开脊髓的有效性。
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.