Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Surg Proced. Dec 30, 2021; 11(1): 1-9
Published online Dec 30, 2021. doi: 10.5412/wjsp.v11.i1.1
Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report
Mrudul Bhatjiwale, Mohinish Bhatjiwale
Mrudul Bhatjiwale, Department of Neurosurgery, Narayana Health City, Bangalore 560099, Karnataka, India
Mrudul Bhatjiwale, Neurological Science, Neuro Health Foundation, Mumbai 400091, India
Mohinish Bhatjiwale, Department of Neurosurgery, Rotary Medical Center, Mumbai 400068, India
Mohinish Bhatjiwale, Department of Neurosurgery, Manav Kalyan Kendra & Navneet Hitech Hospitals, Mumbai 400068, India
Mohinish Bhatjiwale, Department of Neurosurgery, Neuro Health Foundation, Mumbai 400091, India
Author contributions: The two authors contributed equally to this manuscript; Bhatjiwale Mo contributed to the novel surgical technique and case management as well as the writing of the manuscript; Bhatjiwale Mr designed, proofread, and also contributed to the writing of the manuscript; both authors have read and approved the final manuscript.
Informed consent statement: The patient involved in this case report has provided full informed written consent prior to the surgery.
Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mrudul Bhatjiwale, MBBS, Surgeon, Neurological Science, Neuro Health Foundation, 006, D-31, Neuro Health Foundation Clinic, Yogi Nagar, Borivali West, Mumbai 400091, India. mbhatjiwale@gmail.com
Received: June 26, 2021
Peer-review started: June 26, 2021
First decision: September 2, 2021
Revised: September 6, 2021
Accepted: December 7, 2021
Article in press: December 7, 2021
Published online: December 30, 2021
Processing time: 186 Days and 22.7 Hours
Abstract
BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

Keywords: Syringomyelia; Tubercular; Arachnoiditis; Adhesiolysis; Minimally invasive; Cerebrospinal fluid; Case report

Core Tip: Theco-thecal bypass technique was envisaged to achieve a long lasting zero net pressure difference via free flow of cerebrospinal fluid above and below the level of spinal subarachnoid adhesions with minimal handling of the spinal cord and avoidance of extensive adhesiolysis that is associated with a high rate of re-adhesions and failure. This surgical technique involves a valve-less shunt conduit connecting the subarachnoid space above and below the level of adhesions and thereby abolishing the trans-mural pressure gradient causing the syringomyelia, leading to a drastic clinical improvement, as elaborated in this case report.