Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:1770   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
 Table of Contents    
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 3  |  Page : 250-252
Post traumatic arachnoiditis ossificans


Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India

Click here for correspondence address and email

Date of Web Publication14-Aug-2012
 

   Abstract 

Arachnoiditis ossificans is a rare chronic disorder characterized by the presence of calcification/ ossification of the spinal arachnoid. We describe the computed tomography (CT) and magnetic resonance imaging (MRI) findings of arachnoiditis ossificans as sequelae to trauma in a 30-year-old patient. This imaging diagnosis becomes important to alert the clinician as most of them can be treated by conservative management.

Keywords: Arachnoiditis ossificans, CT, MRI

How to cite this article:
Kumaran SP, Gupta K, Maddali A, Viswamitra S. Post traumatic arachnoiditis ossificans. J Emerg Trauma Shock 2012;5:250-2

How to cite this URL:
Kumaran SP, Gupta K, Maddali A, Viswamitra S. Post traumatic arachnoiditis ossificans. J Emerg Trauma Shock [serial online] 2012 [cited 2019 Aug 24];5:250-2. Available from: http://www.onlinejets.org/text.asp?2012/5/3/250/99701



   Introduction Top


Arachnoiditis ossificans represents chronic arachnoiditis characterized by calcification and/or ossification. [1] Unlike adhesive arachnoiditis, arachnoiditis ossificans can be treated with surgery [2] in patients with severe or deteriorating symptoms. However, surgery remains a controversial treatment option because excision of the dural calcification and microsurgical neurolysis is technically difficult, particularly when multiple nerve roots are involved and even if surgical removal of the intrathecal ossification is possible, the clinical outcome is generally poor. We analyze the clinical symptoms, radiological findings, and treatment options in a patient diagnosed of post traumatic arachnoiditis ossificans with a brief review of literature.


   Case Report Top


A 21-year-old male who sustained an injury in a fall from a tree 2 years back, presented with history of chronic progressive low back pain and left foot drop. There was no evidence of myelopathy. Higher mental functions, tone, power of the limbs were normal. There were no other neurological deficits. Radiograph of LS-spine showed only burst fracture of L4 vertebra. Non-contrast CT revealed a burst fracture of L4 vertebra with mild posterior retropulsion. There were intrathecal ossifications in the spinal canal extending from L4-S2 level with nerve roots exiting through the ossifications. These features are suggestive of arachnoiditis ossificans [Figure 1] a-d.
Figure 1: (a) Non-contrast sagittal CT shows a burst fracture of L4 vertebra with mild posterior retropulsion. (b, c and d): Non-contrast axial CT showing intrathecal ossifications in the spinal canal extending from L4-S2 level with nerve roots exiting through the ossifications

Click here to view


MRI was also done to see if there was any associated clumping of nerve roots/any associated pathology. MRI showed the burst fracture of L4 vertebra. On T1 images, the intrathecal ossification was hyperintense on T1 images and hypointense on T2 images [Figure 2]a and b. There was no clumping of nerve roots at any level. Since the patient declined surgery, conservative management for pain and physiotherapy was offered.
Figure 2: (a and b): Sagittal MRI sWequences show the intrathecal ossification, which is hyperintense on T1 images (arrows) and hypointense on T2 images

Click here to view



   Discussion Top


Arachnoiditis ossificans is an unusual chronic meningeal inflammatory process that typically affects adults [3] and is thought to be sequelae of end-stage adhesive arachnoiditis. Kaufman and Dunsmore [4] in 1971 coined the term arachnoiditis ossificans. Till 1998, only 46 cases were reported in the world literature [2] with only a handful of cases reported after that. To our knowledge, until now no cases have been reported from the Indian subcontinent, which describe the CT and MRI findings in arachnoiditis ossificans. Most of these patients present with neurological deficits like inability to walk due to lower limb weakness, although some of them may be asymptomatic. [1]

Prior trauma, as in this case, is a rarely reported cause for arachnoiditis ossificans. Surgery, subarachnoid hemorrhage, myelography (particularly using oil-based contrast agents), and spinal anesthesia have been more commonly implicated as causative factors of arachnoiditis ossificans. [1]

Osseous metaplasia associated with chronic inflammation is probably the most likely cause, with arachnoiditis ossificans representing end-stage chronic arachnoiditis, as suggested by Kaufman and Dunsmore. [1] They found chronic fibroblastic proliferative change to the leptomeninges associated with osseous metaplasia in all the cases they reviewed. They also suggested that vascular shunting or pressure effects might contribute to the development of the disorder, possibly complicated by bleeding into the abnormal tissues. [1] Various other mechanisms proposed for the development of the ossification include intradural hematoma, which organizes and ossifies the seeded bone fragments. [1]

In our case, the burst fracture of L4 vertebral body shows posterior cortical breech, and thus the seeded bony fragments might have resulted in chronic inflammatory reaction over a period of two years, which led to arachnoiditis ossificans for which the patient presented with the history of progressive neurological deficit.

Unenhanced CT is sensitive to diagnose this disorder and is also useful to evaluate the full extension of the ossified mass if surgical intervention is needed. On MR imaging, the findings could be minimal. There can be nerve root clumping, which is best demonstrated on axial T2-weighted images. The arachnoid calcification is difficult to identify using MRI because of their variable signal intensities. They can be hypointense or hyperintense in T1-weighted images and in T2-weighted images, and the calcifications or ossifications can vary from hypointense to hyperintense. Thus, it is important to verify the arachnoid ossification by CT scan, if arachnoiditis ossificans is suspected in the MRI scan. MR appearances of arachnoiditis ossificans has gained more significance because of the decline in the use of CT with corresponding rise in the use of MR imaging for the assessment of low back pain by the present day radiologist. MRI is also important to assess associated pathologic conditions like arachnoid cysts, intramedullary cysts and syringomyelia. [5] Conventional radiographs rarely show the abnormality unless it is extensive, and thus CT is the imaging modality of choice.

The best treatment strategy for arachnoiditis ossificans has still not been established. If the symptoms are mild, the outcome with conservative management is good and the patients become symptom-free over a period of time. In patients with severe or deteriorating symptoms, surgery is often performed. [6]

Excision of the dural calcification and microsurgical neurolysis is technically difficult, especially when multiple nerve roots are involved. Even if the surgical removal of the intrathecal ossification is possible, the clinical result reported is generally poor. [7]

Procedures such as decompressive laminectomies, anterior fusion, and foraminotomies are recommended and good results have been reported. [7] Only 50% of patients managed with surgical intervention showed improvement in the cases reported in the literature. [8] Treatment decisions are also based on the location and morphology of the calcifications and in relation to compression of the spinal cord or nerve roots. [2]


   Conclusion Top


Arachnoiditis ossificans is a rare entity. CT is the imaging modality of choice to evaluate the full extension of the ossified mass. MRI is needed to assess associated pathologic conditions, clumping of nerve roots and to differentiate a compressive mass lesion which simulates arachnoiditis ossificans. If the symptoms are mild, conservative management is recommended. In patients with severe or deteriorating symptoms, surgery is often performed and even with surgical removal, the clinical outcome is generally poor.

 
   References Top

1.Frizzell B, Kaplan P, Dussault R, Sevick R. Arachnoiditis Ossificans MR Imaging Features in Five Patients. AJR Am J Roentgenol 2001;177:461-4.  Back to cited text no. 1
[PUBMED]    
2.Lucchesi AC, White WL, Heiserman JE, Flom RA. Review of arachnoiditis ossificans with a case report. BNI Q 1998;14:4  Back to cited text no. 2
    
3.Junewick J, Culver SK. Arachnoiditis ossificans in a pediatric patient. Pediatr Radiol 2010;40:228.  Back to cited text no. 3
[PUBMED]    
4.Kaufman AB, Dunsmore RH. Clinicopathological considerations in spinal meningeal calcification and ossification. Neurology 1971;21:1243-8.  Back to cited text no. 4
[PUBMED]    
5.Braz A, Gonçalves C, Diogo C, Reis FC. Arachnoiditis ossificans. Acta Med Port 2003;16:183-4.  Back to cited text no. 5
    
6.Jaspan T, Preston BJ, Mulholland RC, Webb JK. The CT appearances of arachnoiditis ossificans. Spine (Phila Pa 1976) 1990;15:148-51.  Back to cited text no. 6
    
7.Chan CC, Lau PY, Sun LK, Lo SS. Arachnoiditis ossificans. Hong Kong Med J 2009;15:146-8.  Back to cited text no. 7
[PUBMED]    
8.Domenicucci M, Ramieri A, Passacantilli E, Russo N, Trasimeni G, Delfini R. Spinal arachnoiditis ossificans: Report of three cases. Neurosurgery 2004;55:985.  Back to cited text no. 8
[PUBMED]    

Top
Correspondence Address:
Sunitha P Kumaran
Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.99701

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 Arachnoiditis Ossificans After Revision Adolescent Idiopathic Scoliosis Surgery
Wajeeh R. Bakhsh,Addisu Mesfin,Keith H. Bridwell
Spine. 2013; 38(18): E1166
[Pubmed] | [DOI]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed3029    
    Printed114    
    Emailed1    
    PDF Downloaded14    
    Comments [Add]    
    Cited by others 1    

Recommend this journal