Intrathecal Hyaluronidase in the Management of Spinal Block due to Tuberculous Spinal Arachnoiditis

ABSTRACT

Despite the appropriate chemotherapy and the use of steroids, spinal arachnoiditis, as a complication of tuberculous meningitis, is not uncommon in developing countries. The various methods of treatment previously undertaken have been unsatisfac.ory due to their serious side effects and/or doubtful therapeutic value. The proteolytic enzyme, hyaluronidase, by virtue of its action of hydrolysing the glucosaminidic bonds of hyaluronic acid and other mucopolysaccharides of the ground substance, offers a promising mode of treatment. This report describes the effectiveness of intrathecal injections of hyaluronidase in a patient with spinal block due to spinal tuberculous arachnoiditis. Despite the antituberculous regimen combined with steroid therapy, paraparesis and sensory changes developed in a 25-year-old female patient diagnosed with tuberculous meningitis. At that time, the CSF protein level was 6500mg%, and the myelogram and MRI showed a definite block of the CSF flow in the subarachnoid space from the second to the ninth thoracic level. After the 5 intrathecal hyaluronidase injections with the interval of two weeks(total 7500 unit), the neurological deficits were markedly improved to a nearly normal state and the CSF protein converted from 6500mg% to 128mg%. The thoracic myelogram showed improvement of passage of the contrast media through the right lateral column. Thus this case may provide the therapeutic role of hyalironidase as an adjunvant in the management of spinal arachnoiditis complicating Tb meningitis for which no satisfactory treatment exist.