Pseudomeningocele nerve root entrapment after lumbar discectomy

Incidental Durotomy Repair in Lumbar Spine Surgery: Institutional Experience and Review of Literature

STUDY DESIGN

: Retrospective Chart Review.

OBJECTIVES

Incidental durotomies (IDs) are common spine surgery complications. In this study, we present a review on the most commonly utilized management strategies, report our institutional experience with case examples, and describe a stepwise management algorithm.

METHODS

A retrospective review was performed of the electronic medical records of all patients who underwent a thoracolumbar or lumbar spine surgery between March 2017 and September 2019. Additionally, a literature review of the current management approaches to treat IDs and persistent postoperative CSF leaks following lumbar spine surgeries was performed.

RESULTS

We looked at 1133 patients that underwent posterior thoracolumbar spine surgery. There was intraoperative evidence of ID in 116 cases. Based on our cohort and the current literature, we developed a progressive treatment algorithm for IDs that begins with a primary repair, which can be bolstered by dural sealants or a muscle patch. If this fails, the primary repair can be followed by a paraspinal muscle flap, as well as a lumbar drain. If the patient cannot be weaned from temporary CSF diversion, the final step in controlling postoperative leak is longterm CSF diversion via a lumboperitoneal shunt. In our experience, these shunts can be weaned once the patient has no further clinical or radiographic signs of CSF leak.

CONCLUSIONS

There is no standardized management approach of IDs and CSF leaks in the literature. This article intends to provide a progressive treatment algorithm and contribute to the development process of a treatment consensus.

Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis

BACKGROUND

An incidental durotomy (IDT) is a frequent complication of spinal surgery. The conventional management involving a period of flat bed rest is highly debatable. Indeed, there are scanty data and no consensus regarding the need or ideal duration of post-operative bed rest following IDT.

OBJECTIVE

To systematically evaluate the literature regarding the outcomes of mobilization within 24 h and after 24 h following IDT in open lumbar or thoracic surgery with respect to the length of hospital stay, minor and major complications.

METHODS

A systematic review of the literature using PubMed, Embase and Cochrane and dating up until September 2022 was undertaken following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support.

RESULTS

Out of 532 articles, 6 studies met the inclusion criteria (1 Level-I, 4 level-III and 1 Level-IV evidence) and were analyzed. Overall, 398 patients of mean age 59.9 years were mobilized within 24 h. The average length of stay (LOS) for this group was 5.7 days. Thirty-four patients (8.5%) required reoperation while the rate of minor complications was 25.4%. Additionally, 265 patients of mean age 63 years with IDT were mobilized after 24 h. The average LOS was 7.8 days. Twenty patients (7.54%) required reoperation while the rate of minor complications was 55%. Meta-analysis comparing early to late mobilization, showed a significant reduction in the risk of minor complications and shorter overall LOS due to early mobilization, but no significant difference in major complications and reoperation rates.

CONCLUSIONS

Although early mobilization after repaired incidental dural tears in open lumbar and thoracic spinal surgery has a similar major complication/ reoperation rates compared to late mobilization, it significantly decreases the risk of minor complications and length of hospitalization.

Efficacy and Safety of Subfascial Epidural Drainage Protocol After Intraoperative Durotomy in Posterior Thoracic and Lumbar Spine Surgery: Reoperation Prevention and Outcomes Among Drained and Undrained Cohorts

BACKGROUND

Persistent cerebrospinal fluid (CSF) egress after durotomy in posterior thoracic or lumbar spine surgery may cause devastating complications. Persistent CSF leaks may require reoperation, which confers additional cost and morbidity.

OBJECTIVE

To evaluate the efficacy of our subfascial epidural drainage protocol in the setting of durotomy to prevent reoperation.

METHODS

A retrospective cohort study of drained and undrained cohorts was completed to identify factors associated with reoperation for persistent CSF leak-related symptoms. The efficacy and safety of this 7-day subfascial epidural drainage protocol was assessed by comparing reoperation incidence, perioperative complications, rehabilitation necessity, and readmissions.

RESULTS

In total, 156 patients underwent subfascial epidural drainage, and 14 were not drained. Subfascial drainage for up to 7 days was associated with a significantly lower incidence of reoperation than no drainage (3.3% vs 14%, respectively; P = .03). Perioperative complication incidence was similar between cohorts (12.8% vs 21.4%, respectively; P = .37), and length of stay was unchanged regardless of drainage (median 7 days). Subfascial drainage conferred a nearly 2-fold relative risk reduction in inpatient rehabilitation requirement (RR 0.55) and 3-fold relative risk reduction in 30-day (RR 0.31) and 90-day readmission (RR 0.36). Factors associated with reoperation among drained patients included drainage longer than 7 days, tobacco use, age younger than 50 years, and longer segment operations. Revision spine surgery was associated with reoperation among undrained patients.

CONCLUSION

When followed after durotomy, our subfascial epidural drainage protocol results in fewer reoperations than in an undrained cohort without prohibitive cost and no added morbidity.

Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?: 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks.

SUMMARY OF BACKGROUND DATA

Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty.

METHODS

It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups-study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests.

RESULTS

The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups.

CONCLUSION

Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries.

LEVEL OF EVIDENCE

4.

Management of Giant Sacral Pseudomeningocele in Revision Spine Surgery

BACKGROUND

Giant pseudomeningoceles are an uncommon complication of spine surgery. Surgical management and extirpation can be difficult, and guidelines remain unclear.

METHODS

Here, we present a 56-year-old female patient with a history of grade III L5-S1 spondylolisthesis who was treated with 2 prior spine surgeries. The patient was treated with bone grafting for pseudarthrosis and instrumentation from L4 to ilium. After unsuccessful intraoperative and postoperative cerebrospinal fluid drainage and dural repair, the patient presented to the emergency room with debilitating positional headaches.

RESULTS

The patient underwent dural repair with bovine pericardial patch inlay sutured with 7-0 prolene, blood patch, and a dural sealant. Plastic surgery performed a layered closure, using acellular dermal matrix over the dural closure. The bilateral paraspinal flaps were advanced medially to cover the entirety of the acellular dermal matrix, and the fasciocutaneous flaps were then advanced to the midline for a watertight closure. At 3-month follow-up, the patient was headache free and had returned to her activities of daily living.

CONCLUSIONS

We conclude that early consultation with plastic surgery can be greatly beneficial to effectively extirpate dead space and resolve giant sacral pseudomeningoceles, especially if there is concern of persistent cerebrospinal fluid leakage due to relatively immobile avascular soft tissue as a result of prior revision surgery.

Surgical management of a retropharyngeal pseudomeningocele: Case report

•

Retropharyngeal pseudomeningocele is a rare condition, which is usually detected weeks after trauma.

•

Early recognition and accurate diagnosis might help avoiding management delay and late intervention.

•

As surgical management is considered to be the definitive management, multidisciplinary management involving a team of Otolaryngology and Neurosurgery skull base surgeons is essential to achieve optimal outcomes.

Introduction

Retropharyngeal pseudomeningocele is a very rare form of pseudomeningocele, that is known to be associated with cervical trauma. Identifying such pathology can be challenging leading to delayed management.

Case presentation

We report a case of post-traumatic retropharyngeal pseudomeningocele that was managed surgically in a 21-year-old gentleman with poly-trauma injuries due to a motor vehicle accident. After 10 weeks since the traumatic event, magnetic resonance imaging (MRI) and computerised tomography (CT) scan showed evidence of bilateral atlanto-occipital dislocation and a fluid collection of 8 × 4 × 2 cm in the retropharyngeal space. The patient was found to have dysphagia and muffled voice with difficult visualisation of the vocal cords upon examination. After a multidisciplinary team decision, the patient underwent cerebrospinal fluid (CSF) leak management, pseudomeningocele resection and dural defect repair with shunting conducted by the Neurosurgery and Otolaryngology. Postoperative assessments and patient's symptoms, at 9 months follow-up, were satisfactory and reassuring.

Discussion

It’s believed that conservative management with bed rest, elevation of bed head and acetazolamide is the initial step in management. As an alternative measure, shunting of the CSF had led to resolution of the collection. However, surgical removal of the collection and direct dural defect repair have been suggested in the literature but needed to be properly studied.

Conclusion

Early recognition of this condition is important to avoid management delay. With a multidisciplinary approach, surgical management can be safe and an acceptable option for retropharyngeal pseudomeningocele.

Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review

BACKGROUND

Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series.

METHODS

The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient.

RESULTS

This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up.

CONCLUSIONS

This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.

Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management

Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.

Early mobilisation does not increase the complication rate from unintended lumbar durotomy

BACKGROUND

Unintended durotomy is a well-recognised complication of lumbar spine surgery. Reported complications include headaches, intracranial haematomata, pseudomeningocoele and infection. Methods of intraoperative repair vary and although post-operative flat bed rest is advocated by some, there is no consensus on duration. We reviewed a series of unintended durotomies that occurred in our institution and reviewed them to compare management strategies and outcome.

METHODS

A retrospective analysis was conducted of adult patients who experienced an unintended durotomy during surgery for lumbar degenerative disease in our neurosurgical unit over a 15-month period. Post-operative complications were followed up for a minimum of 3 months.

RESULTS

1125 patients underwent elective or emergency decompressive lumbar spine surgery. 45 (4%) dural tears were identified; all were repaired intra-operatively with suturing, Tisseal thrombin glue or both. Absence of leakage was confirmed on Valsalva manoeuvre for all cases, before wound closure. 28 patients were mobilised within 24 hrs of surgery, 16 patients between 24-48 hours and 1 patient after 48 hours. Seven patients (16%) with a dural tear experienced a complication. There was no statistically significant relationship between time to post-operative mobilisation and complication rate (p = .76). There was a significantly longer inpatient stay when patients were on bed rest for longer (2 tailed test significant at the 2% level).

CONCLUSION

Duration of post-operative bed rest was not related to complication rate but led to delays in discharge. We did not find evidence that early mobilisation lead to increased likelihood of complications.

Clinical and Magnetic Resonance Imaging Characteristics of Postfenestration Optic Nerve Sheath Pseudomeningoceles

PURPOSE

The clinical significance of postoperative pseudomeningocele formation following optic nerve sheath fenestration (ONSF) has not been fully characterized. A literature review identifies 9 previously published cases the authors believe demonstrate pseudomeningocele formation and approximately 19 other similar findings that were either transient or less defined blebs. This study was undertaken to more clearly define the clinical, radiographic, and histopathologic features associated with this entity.

METHODS

Sixteen-year, single-center, retrospective chart review of all ONSF cases performed by 2 surgeons. Clinical data, intracranial pressure, radiographic imaging, and histopathology of clinically detected pseudomeningoceles after ONSF were reviewed.

RESULTS

Eighty-six eyes in 57 patients underwent ONSF (28 unilateral, 12 bilateral sequential, 17 bilateral simultaneous). Forty-nine of 57 patients had elevated intracranial pressure preoperatively (41 idiopathic intracranial hypertension, 4 venous thrombosis, 2 meningitis, 1 arteriovenous malformation, and 1 sarcoid). In 32 patients undergoing postoperative imaging, 4 eyes (4.7%) in 4 patients developed well-defined pseudomeningoceles, of which 3 were symptomatic and 2 required surgical revision. Each pseudomeningocele developed in the setting of elevated preoperative intracranial pressure (350, 360, 430, 500 mm H20). Magnetic resonance imaging and/or computed tomography revealed sharply demarcated fluid-filled sacs adjacent to the optic nerve. The contents of these sacs were hypointense on T1-weighted imaging, hyperintense on T2-weighting, variably enhanced with contrast, and hypointense on fluid attenuated inversion recovery, and were thus consistent with cerebrospinal fluid. Histopathologic analysis of one of these outpouchings demonstrated an acellular, fibrocollagenized lining consistent with pseudomeningocele. Three eyes in 3 additional patients had less well-defined findings on imaging interpreted as bleb-like or cyst-like change.

CONCLUSIONS

Pseudomeningoceles following ONSF may be asymptomatic or may cause symptomatic orbital mass effect and rarely visual loss, amendable to surgical excision. Post-ONSF pseudomeningoceles are identified on computed tomography or magnetic resonance imaging to occur at the locations of fenestration sites and contain cerebrospinal fluid communicating with the subdural space that may act as a "filtration" bleb in some cases. Imaging findings may represent a spectrum spanning intraorbital cerebrospinal fluid leakage, partial walling off of bleb, or fully developed cysts. Resection of optic nerve pseudomeningoceles is considered in symptomatic cysts or eyes with papilledema that fails to improve.

Lumbar pseudomeningocele presenting as decerebrate rigidity-A rare case entity

INTRODUCTION

Spinal pseudomeningoceles are extradural collections of cerebrospinal fluid that result following a breach in the dural-arachnoid layer and is reported as one of the complications of lumbar disc surgery. Although they are often self subsiding and asymptomatic, they may occasionally cause low-back pain, headaches, and even nerve root entrapment. The purpose of this case report is to present an unreported presentation of pseudomeningocele PRESENTATION OF CASE: A 34 year obese male presented one month post lumbar discectomy with symptoms suggestive of raised intra cranial pressure presenting as repetitive decerebrate rigidity and altered sensorium lasting for few minutes when there is pressure on the pseudomeningocele sac and subsiding with change in position of the patient. He underwent surgical repair of the dural tear and was improved symptomatically with no recurrence of symptoms at five years follow up.

DISCUSSION

Radiological investigation helped in ruling out the other causes of decerebrate rigidity and the possible mechanism of development of such symptom in pseudomeningocele is discussed.

CONCLUSION

To the best of our knowledge, this is the first reported case of pseudomeningooele presenting as decerebrate rigidity. Spinal pseudomeningocele can present in varied ways and earliest detection is the key to avoid such complications.

Repair of giant postlaminectomy pseudomeningocele with fast-resorbing polymer mesh: technical report of 2 cases

Pseudomeningocele is a rare but well-known complication of lumbar spine surgery, which arises in 0.068%-0.1% of individuals in large series of patients undergoing laminectomy and in up to 2% of patients with postlaminectomy symptoms. In symptomatic pseudomeningoceles, surgical reexploration and repair of the dural defect are typically necessary. Whereas the goals of pseudomeningocele repair, which are extirpation of the pseudomeningocele cavity and elimination of extradural dead space, can typically be achieved by primary closure performed using nonabsorbable sutures, giant pseudomeningoceles (> 8 cm) can require more elaborate repair in which fibrin glues, dural substitute, myofascial flaps, or all of the above are used. The authors present 2 cases of postsurgical symptomatic giant pseudomeningoceles that were repaired using a fast-resorbing polymer mesh-supported reconstruction technique, which is described here for the first time.

Repair of Inaccessible Ventral Dural Defect in Thoracic Spine: Double Layered Duraplasty

We propose a double layered (intradural and epidural patch) duraplasty that utilizes Lyoplant and Duraseal. We examined a 47-year-old woman after decompression for thoracic ossification of posterior longitudinal ligament was performed in another hospital. On postoperative day 7, she complained of weakness in both legs. Postoperative magnetic resonance imaging (MRI) showed cerebrospinal fluid (CSF) collection with cord compression. In the operative field, we found 2 large dural defects on the ventral dura mater. We performed a conventional fat graft with fibrin glue. However, the patient exhibited neurologic deterioration, and a postoperative MRI again showed CSF collection. We performed dorsal midline durotomy and inserted a intradural and epidural Lyoplant patch. She immediately experienced diminishing back pain postoperatively. Her visual analog scale and motor power improved markedly. Postoperative MRIs performed at 2 and 16 months showed no spinal cord compression or CSF leakage to the epidural space. We describe a new technique for double layered duraplasty. Although we do not recommend this technique for all dural repairs, double-layered duraplasty may be useful for repairing large inaccessible dural tears in cases of persistent CSF leakage refractory to conventional management.

Neurogenic Shock Immediately following Posterior Lumbar Interbody Fusion: Report of Two Cases

Study Design Case report. Objective To present two cases of neurogenic shock that occurred immediately following posterior lumbar interbody fusion (PLIF) and that appeared to have been caused by the vasovagal reflex after dural injury and incarceration of the cauda equina. Case Report We present two cases of neurogenic shock that occurred immediately following PLIF. One patient had bradycardia, and the other developed cardiac arrest just after closing the surgical incision and opening the drainage tube. Cardiopulmonary resuscitation was performed immediately, and the patients recovered successfully, but they showed severe motor loss after awakening. The results of laboratory data, chest X-ray, electrocardiogram, computed tomography, and echocardiography ruled out pulmonary embolism, hemorrhagic shock, and cardiogenic shock. Although the reasons for the postoperative shock were obscure, reoperation was performed to explore the cause of paralysis. At reoperation, a cerebrospinal fluid collection and the incarceration of multiple cauda equina rootlets through a small dural tear were observed. The incarcerated cauda equina rootlets were reduced, and the dural defect was closed. In both cases, the reoperation was uneventful. From the intraoperative findings at reoperation, it was thought that the pathology was neurogenic shock via the vasovagal reflex. Conclusion Incarceration of multiple cauda equina rootlets following the accidental dural tear by suction drainage caused a sudden decrease of cerebrospinal fluid pressure and traction of the cauda equina, which may have led to the vasovagal reflex.

Incidence and treatment of delayed symptoms of CSF leak following lumbar spinal surgery

PURPOSE

Dural tear (DT) resulting in cerebrospinal fluid (CSF) leak is a common complication of spinal surgery. Most cases of DT are recognised and addressed intraoperatively; however, a small percentage of cases may present at a later stage with delayed symptoms of CSF leak, either due to an unrecognised intraoperative DT or as a result of a de novo delayed DT. Apart from few reports describing delayed symptomatic CSF leaks, most studies tend not to separate intraoperatively recognised DTs from delayed symptomatic CSF leaks. To our knowledge, there are no long-term studies describing specifically the incidence and management of this complication. The aim of this study is to determine the incidence of late presentation of dural tear (LPDT) following lumbar spinal surgery, its treatment, associated complications and clinical outcomes from long-term follow-up in a consecutive series of patients.

METHODS

A retrospective review was conducted on 2052 consecutive patients who underwent spinal surgery by two spinal surgeons from 2000 to 2005 and 2007 to 2013 at two institutions.

RESULTS

A total of 2052 patient records were reviewed. Seventeen patients (0.83%) were found to have LPDT, unrecognised intraoperatively. Fifteen patients required surgical intervention, one patient was treated with insertion of a subarachnoid drain and only one patient settled with conservative measures. Out of the 15 patients who underwent surgery, two patients required another operation and 2 patients were treated with a subarachnoid drain. At 9 months mean follow-up, there was no significant difference in outcome in cases with LPDT compared to those without.

CONCLUSION

A delayed symptomatic presentation of DT unrecognised intraoperatively is a specific complication that needs to be recognised and treated appropriately. A high suspicion and vigilance can help discover and address delayed CSF leaks with no long-term sequelae.

Cost analysis of incidental durotomy in spine surgery

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To characterize the consequences of an incidental durotomy with regard to perioperative complications and total hospital costs.

SUMMARY OF BACKGROUND DATA

There is a paucity of data regarding how an incidental durotomy and its associated complications may relate to total hospital costs.

METHODS

The Nationwide Inpatient Sample database was queried from 2008 to 2011. Patients who underwent cervical or lumbar decompression and/or fusion procedures were identified, stratified by approach, and separated into cohorts based on a documented intraoperative incidental durotomy. Patient demographics, comorbidities (Charlson Comorbidity Index), length of hospital stay, perioperative outcomes, and costs were assessed. Analysis of covariance and multivariate linear regression were used to assess the adjusted mean costs of hospitalization as a function of durotomy.

RESULTS

The incidental durotomy rate in cervical and lumbar spine surgery is 0.4% and 2.9%, respectively. Patients with an incidental durotomy incurred a longer hospitalization and a greater incidence of perioperative complications including hematoma and neurological injury (P < 0.001). Regression analysis demonstrated that a cervical durotomy and its postoperative sequelae contributed an additional adjusted $7638 (95% confidence interval, 6489-8787; P < 0.001) to the total hospital costs. Similarly, lumbar durotomy contributed an additional adjusted $2412 (95% confidence interval, 1920-2902; P < 0.001) to the total hospital costs. The approach-specific procedural groups demonstrated similar discrepancies in the mean total hospital costs as a function of durotomy.

CONCLUSION

This analysis of the Nationwide Inpatient Sample database demonstrates that incidental durotomies increase hospital resource utilization and costs. In addition, it seems that a cervical durotomy and its associated complications carry a greater financial burden than a lumbar durotomy. Further studies are warranted to investigate the long-term financial implications of incidental durotomies in spine surgery and to reduce the costs associated with this complication.

LEVEL OF EVIDENCE

3.

Traumatic dural tears: what do we know and are they a problem?

BACKGROUND CONTEXT

Iatrogenic dural tears are common complications encountered in spine surgery with known ramifications. There is little information, however, with respect to the implications and complications of traumatic dural tears.

PURPOSE

To describe the demographics and characteristics of traumatically acquired dural tears and evaluate the complication rate associated with traumatic dural tears in patients who have undergone surgical treatment for spine injuries.

STUDY DESIGN

Retrospective review of a single Level I trauma center to identify patients with traumatic dural tears between January 1, 2003 and December 31, 2009.

PATIENT SAMPLE

The sample comprises 187 patients with traumatic dural tears identified from 1,615 patients who underwent operative management of their traumatic injury.

OUTCOME MEASURES

The outcome measures consisted of a description of the location and nature of dural tears and associated fracture patterns and neurologic status as well as an assessment of complications attributable to the traumatic dural tear.

METHODS

No funding was received or used in this study. In total, 1,615 operatively managed spine injuries over a 7-year period were reviewed to identify 187 patients with traumatic dural tears. Operative reports were reviewed to assess location and description of injury as well as type of repair, if done. Associated spinal cord injuries as well as fracture level, patterns, and complications were recorded. Postoperative records were assessed focusing on complications related to the traumatic dural tears.

RESULTS

Traumatic dural tears were identified in 9.1% (67/739) of cervical, 9.9% (45/452) of thoracic, and 17.6% (75/424) of lumbosacral spine fractures. Among the patients, 82.3% (154/187) had a formal dural repair. Fracture patterns included burst (AO Type A3) 26.2% (49/187), flexion distraction (AO Type B) 16% (30/187), and fracture dislocations (AO Type C) 36.4% (68/187). A complete neurologic injury was noted in 48.7% (91/187) of the patient population, whereas no neurologic injury was noted in 17.1% (32/187). Two patients (1%) developed a persistent cerebral spinal fluid leak that necessitated an irrigation and debridement with exploration and closure of the cerebral spinal fluid tear. Two patients (1%) developed a pseudomeningocele; one required a return to the operating room for irrigation and debridement, and the other suspected of having developed meningitis was treated with intravenous antibiotics. Among the patients, 2.1% (4/187) were noted to have a complication directly related to a traumatic dural tear.

CONCLUSIONS

Traumatic dural tears occurred in 11.6% of patients with operatively managed traumatic spine injuries at a regional Level 1 trauma center. In total, 83% had a neurologic injury and 49% had complete spinal cord injuries. Patients with traumatically induced dural tears have a low likelihood of developing a complication attributable to the dural tear.

Safety of spinal decompression using an ultrasonic bone curette compared with a high-speed drill: outcomes in 337 patients

Object

Unintended durotomies are a common complication of spine surgery and are often correlated with increased postoperative morbidity. Recently, ultrasonic bone curettes have been introduced in spine surgery as a possible alternative to the conventional high-speed drill, offering the potential for greater bone-cutting precision and less damage to surrounding soft tissues. To date, however, few studies have investigated the safety and efficacy of the ultrasonic bone curette in reducing the rates of incidental durotomy compared with the high-speed drill.

Methods

The authors retrospectively reviewed the records of 337 consecutive patients who underwent posterior cervical or thoracic decompression at a single institution between January 2009 and September 2011. Preoperative pathologies, the location and extent of spinal decompression, and the use of an ultrasonic bone curette versus the high-speed drill were noted. The rates of incidental durotomy, as well as hospital length of stay (LOS) and perioperative outcomes, were compared between patients who were treated using the ultrasonic bone curette and those treated using a high-speed drill.

Results

Among 88 patients who were treated using an ultrasonic bone curette and 249 who were treated using a high-speed drill, 5 (5.7%) and 9 (3.6%) patients had an unintentional durotomy, respectively. This finding was not statistically significant (p = 0.40). No patients in either cohort experienced statistically higher rates of perioperative complications, although patients treated using an ultrasonic bone curette tended to have a longer hospital LOS. This difference may be attributed to the fact that this series contained a statistically higher number of metastatic tumor cases (p < 0.0001) in the ultrasonic bone curette cohort, likely increasing the LOS for that patient population. In 13 patients, the dural defect was repaired intraoperatively. No patients who experienced an incidental durotomy had new-onset or permanent neurological deficits postoperatively.

Conclusions

The safety and efficacy of ultrasonic bone curettes in spine surgery has not been well established. This study shows that the ultrasonic bone curette has a similar safety profile compared with the high-speed drill, although both are capable of causing iatrogenic dural tears during spine surgery.

Transdural Nerve Rootlet Entrapment in the Intervertebral Disc Space through Minimal Dural Tear : Report of 4 Cases

Four patients underwent lumbar surgery. In all four patients, the dura was minimally torn during the operation. However, none exhibited signs of postoperative cerebrospinal fluid leakage. In each case, a few days after the operation, the patient suddenly experienced severe recurring pain in the leg. Repeat magnetic resonance imaging showed transdural nerve rootlets entrapped in the intervertebral disc space. On exploration, ventral dural tears and transdural nerve rootlet entrapment were confirmed. Midline durotomy, herniated rootlet repositioning, and ventral dural tear repair were performed, and patients' symptoms improved after rootlet repositioning. Even with minimal dural tearing, nerve rootlets may become entrapped, resulting in severe recurring symptoms. Therefore, the dural tear must be identified and repaired during the first operation.

Entrapment of the fifth lumbar spinal nerve by advanced osteophytic changes of the lumbosacral zygapophyseal joint: a case report

A 54-year-old female patient had a 6-year history of backache and left sciatica. Five years earlier, she had undergone surgery in another hospital for left L4-5 disc herniation. Computed tomography revealed the ossified wall that enclosed the left L5 nerve root. There were also osteophytic changes in the left L5-S zygapophyseal joint. These osteophytes developed rostrally, along the left L5 nerve root, throug h the intervertebral foramina. We performed decompression surgery for the left L5 nerve root, and surgery resulted in symptomatic relief. We experienced a rare clinical presentation of osteophytic formation, with a specific configuration in relation to the nerve root. Surgeons should be aware of entrapment of the lumbar spinal nerve by advanced osteophytic changes occurring in the zygapophyseal joint after lumbar surgery.

Postlaminectomy lumbar pseudomeningocele with nerve root entrapment: a case report with review of literature

Pseudomeningocele is a rare but well-recognized complication of lumbar surgery. Most of the patients tolerate the presence of the cyst well, however, some present with back pain and spinal claudication, presumably due to neural compression. We report a case who presented with radicular symptoms and signs after disk surgery. The cause of his pain was nerve root herniation into large pseudomeningocele. The diagnosis was made by magnetic resonance imaging. The patient underwent surgery for the pseudomeningocele with reduction in the nerve root into the dural canal and primary closure of the dural defect. Postoperative results were gratifying.

Incidental durotomy after spinal surgery: a prospective study in an academic institution

Object

Incidental durotomies (IDs) are an unfortunate but anticipated potential complication of spinal surgery. The authors surveyed the frequency of IDs for a single spine surgeon and analyzed the major risk factors as well as the impact on long-term patient outcomes.

Methods

The authors conducted a prospective review of elective spinal surgeries performed over a 15-year period. Any surgery involving peripheral nerve only, intradural procedures, or dural tears due to trauma were excluded from analysis. The incidence of ID was categorized by surgery type including primary surgery, revision surgery, and so forth. Incidence of ID was also examined in the context of years of physician experience and training. Furthermore, the incidence and types of sequelae were examined in patients with an ID.

Results

Among 3000 elective spinal surgery cases, 3.5% (104) had an ID. The incidence of ID during minimally invasive procedures (3.3%) was similar, but no patients experienced long-term sequelae. The incidence of ID during revision surgery (6.5%) was higher. There was a marked difference in incidence between cervical (1.3%) and thoracolumbar (5.1%) cases. The incidence was lower for cases involving instrumentation (2.4%). When physician training was examined, residents were responsible for 49% of all IDs, whereas fellows were responsible for 26% and the attending for 25%. Among all of the cases that involved an ID, 7.7% of patients went on to experience a neurological deficit as compared with 1.5% of those without an ID. The overall failure rate of dural repair was 6.9%, and failure was almost 3 times higher (13%) in revision surgery as compared with a primary procedure (5%).

Conclusions

The authors established a reliable baseline incidence for durotomy after spine surgery: 3.5%. They also identified risk factors that can increase the likelihood of a durotomy, including location of the spinal procedure, type of procedure performed, and the implementation of a new procedure. The years of physician training or resident experience did not appear to be a major risk for ID.

Polyethylene glycol hydrogel spinal sealant (DuraSeal Spinal Sealant) as an adjunct to sutured dural repair in the spine: results of a prospective, multicenter, randomized controlled study

STUDY DESIGN

A prospective, multicenter, randomized, two-arm, single-blind, investigational device exemption pivotal study.

OBJECTIVE

To assess the efficacy and the safety of a polyethylene glycol (PEG) hydrogel spinal sealant (DuraSeal Spinal Sealant) as an adjunct to sutured dural repair compared with standard of care methods (control) to obtain a watertight dural closure in patients undergoing an intentional durotomy during spinal surgery.

SUMMARY OF BACKGROUND DATA

If a watertight dural closure is not achieved, cerebrospinal fluid leak with associated complications may occur. The PEG hydrogel spinal sealant is an Food and Drug Administration (FDA)-approved adjunct to sutured dural repair in spine surgery. This synthetic, absorbable hydrogel sealant works in the presence of fluid, conforms to irregular surfaces, and demonstrates strong adherence and compliance to tissue, without interfering with underlying tissue visibility.

METHODS

A total of 158 patients were treated at 24 centers after they were randomized on the basis of an approximately 2:1 ratio (sealant:control); 102 received the PEG hydrogel spinal sealant and 56 received standard care. The primary end point was intraoperative watertight closure. Secondary end points included evaluations of postoperative cerebrospinal fluid leak, infection, and wound healing.

RESULTS

Patients treated with the PEG hydrogel spinal sealant had a significantly higher rate of watertight closure than the control (100% vs. 64.3%, P < 0.001). No statistical differences were seen in postoperative cerebrospinal fluid leak, infection, and wound healing. No neurologic deficits were seen attributable to the sealant.

CONCLUSION

The PEG hydrogel spinal sealant evaluated in this study is safe and effective for providing watertight closure when used as an adjunct to sutured dural repair during spinal surgery. This readily available tool is superior to other standard of care technologies commonly used to achieve intraoperative watertight dural closure.

Incidence of Unintended Durotomy in Spine Surgery Based on 108 478 Cases

BACKGROUND:

Unintended durotomy is a common complication of spinal surgery. However, the incidences reported in the literature vary widely and are based primarily on relatively small case numbers from a single surgeon or institution.

OBJECTIVE:

To provide spine surgeons with a reliable incidence of unintended durotomy in spinal surgery and to assess various factors that may influence the risk of durotomy.

METHODS:

We assessed 108 478 surgical cases prospectively submitted by members of the Scoliosis Research Society to a deidentified database from 2004 to 2007.

RESULTS:

Unintended durotomy occurred in 1.6% (1745 of 108 478) of all cases. The incidence of unintended durotomy ranged from 1.1% to 1.9% on the basis of preoperative diagnosis, with the highest incidence among patients treated for kyphosis (1.9%) or spondylolisthesis (1.9%) and the lowest incidence among patients treated for scoliosis (1.1%). The most common indication for spine surgery was degenerative spinal disorder, and among these patients, there was a lower incidence of durotomy for cervical (1.0%) vs thoracic (2.2%; P = .01) or lumbar (2.1%, P &lt; .001) cases. Scoliosis procedures were further characterized by etiology, with the highest incidence of durotomy in the degenerative subgroup (2.2% vs 1.1%; P &lt; .001). Durotomy was more common in revision compared with primary surgery (2.2% vs 1.5%; P &lt; .001) and was significantly more common among elderly (&gt; 80 years of age) patients (2.2% vs 1.6%; P = .006). There was a significant association between unintended durotomy and development of a new neurological deficit (P &lt; .001).

CONCLUSION:

Unintended durotomy occurred in at least 1.6% of spinal surgeries, even among experienced surgeons. Our data provide general benchmarks of durotomy rates and serve as a basis for ongoing efforts to improve safety of care.

Spinal nerve root herniation into a pseudomeningocele associated with lumbar spondylolysis: a case report

A 38-year-old man presented with low back pain and sciatica on the left side. Magnetic resonance imaging showed spinal nerve root herniation into a pseudomeningocele associated with lumbar spondylolysis. After closure of the dural defect, the sciatic pain was relieved and subsequently the patient was able to return to work.

Management of giant pseudomeningoceles after spinal surgery

Background

Pseudomeningoceles are a rare complication after spinal surgery, and studies on these complex formations are few.

Methods

Between October 2000 and March 2008, 11 patients who developed symptomatic pseudomeningoceles after spinal surgery were recruited. In this retrospective study, we reported our experiences in the management of these complex, symptomatic pseudomeningoceles after spinal surgery. A giant pseudomeningocele was defined as a pseudomeningocele >8 cm in length. We also evaluated the risk factors for the formation of giant pseudomeningoceles.

Results

All patients were treated successfully with a combined treatment protocol of open revision surgery for extirpation of the pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage. Surgery-related complications were not observed. Recurrence of pseudomeningocele was not observed for any patient at a mean follow-up of 16.5 months. This result was confirmed by magnetic resonance imaging.

Conclusions

We conclude that a combined treatment protocol involving open revision surgery for extirpation of pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage is safe and effective to treat giant pseudomeningoceles.

Cauda equina entrapment in a pseudomeningocele after lumbar schwannoma extirpation

Incidental or intentional durotomy causing cerebrospinal fluid (CSF) leakage, leading to the formation of a pseudomeningocele is a known complication in spinal surgery. Herniation of nerve roots into such a pseudomeningocele is very rare, but can occur up to years after initial durotomy and has been described to cause permanent neurologic deficit. However, cauda equina fiber herniation and entrapment into a pseudomeningocele has not been reported before. Here, we present a case of symptomatic transdural cauda equina herniation and incarceration into a pseudomeningocele, 3 months after extirpation of a lumbar Schwannoma. A 59-year-old man, who previously underwent intradural Schwannoma extirpation presented 3 months after surgery with back pain, sciatica and loss of bladder filling sensation caused by cauda equina fiber entrapment into a defect in the wall of a pseudomeningocele, diagnosed with magnetic resonance imaging. On re-operation, the pseudomeningocele was resected and the herniated and entrapped cauda fibers were released and replaced intradurally. The dura defect was closed and the patient recovered completely. In conclusion, CSF leakage can cause neurological deficit up to years after durotomy by transdural nerve root herniation and subsequent entrapment. Clinicians should be aware of the possibility of this potentially devastating complication. The present case also underlines the importance of meticulous dura closure in spinal surgery.

Cervical pseudomeningocele due to occult hydrocephalus

STUDY DESIGN

Case report with a brief review of the literature.

OBJECTIVE

To describe a rare clinical presentation of post-traumatic hydrocephalus (PTH) in a child who sustained a complete cervical spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

The incidence of PTH can be as high as 30% in cases of pediatric SCI and traumatic brain injury. Presentation may include gait disturbance, altered mental status, or incontinence. To our knowledge, this is the first documentation of PTH presenting as a postsurgical pseudomeningocele.

METHODS

An 8-year-old girl involved in a motor vehicle accident sustained a C2-C3 fracture dislocation resulting in a complete SCI. She was initially treated with C2-C3 sublaminar wiring and halo placement. At postoperative week 6, the patient underwent drainage of a posterior cervical pseudomeningocele and repair of a small dural leak at C2-C3. She subsequently exhibited signs of altered mental status, and computed tomography scan revealed a significant hydrocephalus.

RESULTS

Emergent ventriculostomy was performed, and was converted to a ventriculo-peritoneal shunt 2 days later. The patient's neurologic status markedly improved, and she continues to do well at 2 months after surgery.

CONCLUSION

PTH presenting as a pseudomeningocele is extremely rare. In a patient with polytrauma and concomitant traumatic brain injury, the spine surgeon should consider hydrocephalus as a potential cause for a postsurgical pseudomeningocele, even several months after initial injury.

Sciatica in the female patient: anatomical considerations, aetiology and review of the literature

The principal author was confronted few years ago with the case of a 38-year-old woman with a 5-month history of ill-defined L5 sciatic pain that was referred to an orthopaedic department for investigation and eventual surgical treatment for what was suspected to be herniated disc-related sciatica. Removal of her enlarged uterus found unexpectedly close to the sacroiliac joint upon lumbar MRI abolished her symptoms. Review of the literature showed that the lumbosacral trunk is vulnerable to pressure from any abdominal mass originating from the uterus and the ovaries. Physiological processes in the female patient and gynaecological diseases may be the source of sciatica, often not readily searched for, leading to fruitless investigations and surgical treatments. The aim of the paper is to highlight gynaecological and obstetrical causes of sciatica and sciatica-like symptoms. To prevent unproductive expenses and morbidity, a thorough gynaecological examination should be done even though neurological examination may be suggestive of a herniated intervertebral disc, and the cyclic pattern of pain related to menses should be routinely asked for.

Entrapped spinal nerve roots in a pseudomeningocoele as a complication of previous spinal surgery

Pseudomeningocele is a rare but well recognised complication of lumbar surgery (microdiscectomy and laminectomy). Most of the patients tolerate the presence of the cyst well, however some present with back pain and spinal claudication, presumably due to neural compression. We report a case who presented following three operations (microdiscectomy, laminectomy and excision of a pseudomeningocele) with symptoms of spinal claudication and bilateral radicular pain. The cause of her pain was evident only at operation and was due to herniation of nerve roots through the dural defect.

Etiologies of failed back surgery syndrome

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To report the epidemiologic data of nonsurgical and surgical etiologies of failed back surgery syndrome (FBSS) from two outpatient spine practices.

SUMMARY OF BACKGROUND DATA

FBSS has been offered as a diagnosis, but this is an imprecise term encompassing a heterogeneous group of disorders that have in common pain symptoms after lumbar surgery. The current literature primarily diagnoses for the various etiologies of FBSS from a surgical perspective. To our knowledge, there is no study that investigates the myriad of surgical and nonsurgical diagnoses from a nonsurgical perspective.

METHODS

Specific inclusion and exclusion criteria were developed for a list of 42 nonsurgical and surgical differential diagnoses of FBSS. The determination of which category, surgical or nonsurgical, each diagnosis was placed into depended upon the categorization of those diagnoses in previously published literature on FBSS. Each of the authors reviewed the definitions, and they came to a unanimous agreement on each diagnosis' inclusion and exclusion criteria. Data extraction was then carried out in each of the two involved institutions by using the key words discectomy, laminectomy, and fusion to identify all the patients who had any combination of low back, buttock, or lower extremity pain after lumbar discectomy surgery. These charts were then individually reviewed to extract epidemiologic data.

RESULTS

A total of 267 charts were reviewed. One hundred and ninety-seven (197) charts had a complete workup. Of these, 11 (5.6%) had an unknown etiology, and 186 had a known diagnosis. Twenty-three (23) various diagnoses were identified. There was approximately an equal distribution between the incidences of nonsurgical and surgical diagnoses; 44.4% had nonsurgical diagnoses and 55.6% had surgical diagnoses. The most common diagnoses identified were spinal stenosis, internal disc disruption syndrome, recurrent/retained disc, and neural fibrosis.

CONCLUSION

FBSS is a syndrome consisting of a myriad of surgical and nonsurgical etiologies. Approximately one half of FBSS patients have a surgical etiology. Approximately 95% of patients can be provided a specific diagnosis.

Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique

STUDY DESIGN

Retrospective review of 110 patients undergoing spinal dural repair and regeneration using an onlay, suture-free, 3-dimensional-collagen matrix graft (DuraGen) over an 8-year period (1995-2003).

OBJECTIVES

Technique appraisal of collagen matrix to repair spinal dura following incidental durotomy, spinal tumor surgery, and trauma.

SUMMARY OF BACKGROUND DATA

Traditional methods of spinal dural repair following incidental durotomy involve tedious attempts at primary watertight suture with a 5% to 10% failure rate. Dural injury occurs after trauma, or dural excision may be required after tumor resection. Collagen matrix is a newer development in collagen sponge.

METHODS

The clinical and demographic data included diagnosis, type and site of surgery, infection risk, size of defect, use of lumbar drains, closed suction subfascial drains, and adverse events. The primary endpoints of graft failure were cerebrospinal fluid leak and pseudomeningocele formation. Neurosurgical wound infection rates were determined.

RESULTS

Collagen matrix was used (n = 110) in the following conditions: degenerative (69), pseudomeningocele formation repair (4), tumors (14), trauma (13), and congenital (5). There were 15 cervical (10 anterior), 21 thoracic (3 anterior), and 71 lumbar (all posterior) surgeries. Fibrin glue was used in 7.3%, subfascial drains in 82%, and lumbar drainage in 2.7%. Overall, cerebrospinal fluid leaks occurred in 2.7%. The 2 pseudomeningocele formations (3.2%) resolved at 3 months. There were 2 wound infections. In the subgroup with incidental durotomy (n = 69), failure of cerebrospinal fluid containment occurred in 4.3% [1 cerebrospinal fluid leak (1.4%), 2 pseudomeningocele formations (2.9%)].

CONCLUSIONS

Collagen matrix was successful in cerebrospinal fluid containment in > 95% of patients requiring dural repair following anterior and posterior spinal surgery. Subfascial drains were safe. Routine lumbar drains are not required but are recommended for repair of established pseudomeningocele formations.

Spinal pseudomeningoceles and cerebrospinal fluid fistulas

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are rare extradural collections of CSF that result following a breach in the dural-arachnoid layer. They may occur due to an incidental durotomy, during intradural surgery, or from trauma or congenital abnormality. The majority are iatrogenic and occur in the posterior lumbar region following surgery. Although they are often asymptomatic, they may cause low-back pain, headaches, and even nerve root entrapment. Leakage of CSF from the wound may cause a fistulous tract, which is a conduit for infection and should be repaired immediately. Diagnosis can be confirmed on clinical examination or imaging studies including magnetic resonance imaging, computerized tomography myelography, and radionuclide myelography. Treatment must be specific to each patient because the timing, size, symptoms, and location of the dural breach all affect the choice of therapy. Nonsurgical methods may be used, but more frequently operative repair is required. In this article, the authors review the diagnosis and treatment of spinal pseudomeningoceles and CSF fistulas.

Lumbar myofascial flap for pseudomeningocele repair

Object

Initial management for lumbar pseudomeningoceles entails the closed external drainage of cerebrospinal fluid (CSF) with or without blood patch application. The presence of longstanding pseudomeningoceles and those associated with nonmicroscopic dural tears can be more problematic. Additionally the failure of nonoperative measures may necessitate surgery. Ideally the procedure should involve repairing the dural defect, removing the encapsulated cavity of the pseudomeningocele, and obliterating the extraspinal dead space to minimize the recurrence of the problem.

Methods

The authors describe a technique performed in 12 patients with large (> 5-cm-diameter) pseudomeningoceles referred for management following the failure of less aggressive measures. Diagnosis was based on symptoms of lumbar wound swelling, postural headaches, back and leg pain, and was confirmed by imaging studies. In all patients subarachnoid CSF drainage and initial operative attempts to obliterate the pseudomeningocele had failed. They were treated between July 1990 and July 1998. The cause of the pseudomeningoceles was lumbar discectomy (four patients), lumbar decompression (one patient), lumbar decompression and placement of instrumentation (five patients), and intradural procedures (two patients). Their mean age was 47.9 years (range 20–67 years), and they presented at a mean of 5.5 months postoperatively (range 3 weeks–37 months). In all cases there was a satisfactory repair of the pseudomeningocele, dead space obliteration, and long-term symptomatic resolution.

Conclusions

Lumbar myofascial advancement for this problem is a useful technique in cases of symptomatic pseudomeningoceles. This technique requires the medial advancement of the musculofascial units of the paravertebral muscles for a layered closure over the exposed spinal canal with obliteration of the pseudomeningocele.

Evaluation and treatment of dural tears in lumbar spine surgery: a review

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.

Anterior dural laceration caused by thoracolumbar and lumbar burst fractures

A retrospective review of the records of 60 patients with thoracolumbar and lumbar burst fractures was undertaken to document the incidence and evaluate the sequelae of dural injuries found during anterior procedures. In the entire series, six (10%) patients each had a preexisting vertically oriented dural tear. All patients with anterior dural lacerations were male and had associated neurologic deficits. In all six patients, preoperative computed tomography showed an asymmetrically retropulsed bone fragment. Dural tears were repaired primarily. A postoperative cerebrospinal fluid leak developed into the chest cavity of one patient, who was treated successfully with subarachnoid drainage. In patients with anterior dural laceration, primary repair is warranted and can be performed more easily after intraoperative correction of kyphosis. Subarachnoid drainage may be effective in cases of continued postoperative anterior cerebrospinal fluid leakage before repeated operation is considered.

Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas

Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are uncommon extradural collections of CSF that may result from inadvertent tears in the dural-arachnoid layer, traumatic injury, or may be congenital in origin. Most pseudomeningoceles are iatrogenic and occur in the posterior lumbar region following surgery. The true incidence of iatrogenic pseudomeningoceles following laminectomy or discectomy is unknown; however, the authors of several published reports suggest that the incidence of lumbar pseudomeningoceles following laminectomy or discectomy is between 0.07% and 2%. Pseudomeningoceles are often asymptomatic, but patients may present with recurrence of low-back pain, radiculopathy, subcutaneous swelling, or with symptoms of intracranial hypotension. Very rarely, they present with delayed myelopathy. Although magnetic resonance imaging is the neurodiagnostic study of choice, computerized tomography myelography and radionuclide myelographic study may be helpful diagnostic tools in some cases. Analysis of suspect fluid for Beta2 transferrin may be a useful adjunctive study. Treatment options include close observation for spontaneous resolution, conservative measures such as bed rest and application of an epidural blood patch, lumbar subarachnoid drainage, and definitive surgical repair.