gms | German Medical Science

Background: Intraspinal epidural empyema or abscess can result in postinflammatory arachnoiditis. One of the complications of spinal arachnoiditis are meningeal septal compartments with circulation disturbances of the cerebrospinal fluid. These cysts might grow in size due to a valve mechanisms with impaires back flow of the CSF from the cyst to the spinal canal. This increases the intracystic pressure and thus might cause neurological symptoms.

Aim: Case report about progressive development of postinflammatory polyseptal intraspinal meningeal cysts with progressive neurological deterioration with partial relief by lumbar and thoracic peritoneal shunts.

Case presentation: Female, 29 y. Sept. 2015: after diagnosis of degenerative disc disease with L5 pain periradicular infiltration, followed by an iatrogenic abscess of the right psoas muscle with an intraspinal multilevel empyema and meningitis. Surgical evacuation of the epidural abscess at level T12 to L 4. Psoas abscess was treated with CT guided drainage and antibiotic therapy. In MRI postinflammatory intradural cystic compartment T12 to L2; March 2016: complaints about radicular pain and paresthesia L5 right side with L5 paresis and bilateral numb feet; surgical sequesterectomy and nucleotomy L4/5 in addition to intradural fenestration of the postinflammatory arachnoidal cyst at T12/L1 through a right sided approach. Slight improvement of paresthesia. April 2016: progressive paresis of foot extension bilaterally. In MRI unchanged size of the cystic compartment from T12 to L2 and in addition new multiple cysts C7-T5. Surgical fenestration at these levels without significant subjective improvement. In the electrophysiological examination tibial nerve evoked potentials (SEP) showed bilateral increased latency indicating a functional damage to the spinocortical tract. Because of persistent pain in the legs, numbness in both feet and gait disturbances a navigated lumboperitoneal shunt was implanted in May 2016. This resulted in a significant relief of the pain and improvement of gait disturbances. October 2016: the pt. complained of increasing radiating pain in both arms from the shoulder to the fingers. MRI spine showed regression of the thoracolumbar drained cystic compartment, but an unchanged intramedullary myelopathic pathology from C7 to T5. In the electrophysiological study at C7/C8 level signs of a neurogenic damage. Based on the neurological deterioration another cervico- and thoraco-peritoneal Shunt was implanted.

Summary: Postinflammatory cysts of the meninges at different spinal levels may cause progressive subjective impairment, sensory disturbances and even paresis. MRI can demonstrate the cysts and electrophysiological studies the functional impairment. Spino-peritoneal shunts may decrease size of the cysts and improve functional capacity.