Traumatic anterior cervical pseudomeningocele causing intracranial hypotension successfully treated with blood patch: case report

Cerebrospinal Fluid Refill Test as a Novel Diagnostic Tool for Cerebrospinal Fluid Hypovolemia: Preliminary Result

OBJECTIVE

Cerebrospinal fluid (CSF) hypovolemia presents with orthostatic headaches due to CSF leakage. However, a direct association between the lack of CSF and clinical symptoms has not been found. CSF hypovolemia can be improved by refilling CSF. Therefore, we assessed the validity of a CSF refill test.

METHODS

From November 2019 to August 2021, we included 10 patients (≥18 years old) with potential CSF hypovolemia, clear orthostatic headaches, and a CSF opening pressure <10 cmH₂O. In the CSF refill test, 10 mL of artificial CSF was injected intrathecally. The primary outcome was improvement in orthostatic headache assessed using a visual analog scale (VAS), while the secondary outcomes were the 10-m walk time and adverse events. When the symptoms temporarily improved after intrathecal injection, the patients underwent radiologic imaging to identify the CSF leak, and an epidural blood patch was proposed accordingly.

RESULTS

All patients showed post-test improvements in the VAS score (median [interquartile range], pretest 63.0 [50.3-74.3] vs. post-test 1.5 [0.0-26.0]). The 10-m walk time also significantly improved (9.5 [8.5-10.2] s vs. 8.2 [7.9-8.7] s). One patient experienced temporary right leg numbness associated with a lumbar puncture. After radiologic investigation, 9 patients underwent epidural blood patches, of which 6 were completely cured, and 3 revealed partial improvement.

CONCLUSIONS

The cerebrospinal fluid (CSF) refill test was safe and effective in demonstrating the direct association between the lack of CSF and clinical symptoms and may help predict the outcome of an epidural blood patch.

Management of postoperative cervical pseudomeningocele with percutaneous aspiration and epidural blood patch

INTRODUCTION

While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine.

METHODS

A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed.

RESULTS

In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery.

CONCLUSION

Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Anterior cervical pseudomeningocele causing syncope after spinal surgery: A case report

INTRODUCTION AND IMPORTANCE

Pseudomeningocele formation from incidental durotomy is a known risk in spine surgery. We present a case of incidental durotomy leading to anterior neck pseudomeningocele, compressing the carotid body (CB) resulting in syncopal episodes. To our knowledge, this is the first case report implicating syncopal episodes to CB compression via a pseudomeningocele.

CASE PRESENTATION

A mid sixty-year-old patient with history of obesity, hypertension, and diabetes presented with gait impairment and hand weakness. Ossification of posterior longitudinal ligament (OPLL) was diagnosed with computed tomography imaging (CT) and magnetic resonance imaging (MRI). Elective surgery was completed with an anterior and posterior approach for decompression and fusion. Hospital course (San Jose, CA, USA) was complicated by respiratory depression and incomplete tetraplegia. On post-operative day (POD) six, CT revealed anterolateral soft tissue neck swelling; subsequent CT and MRI showed fluid collection expansion, with associated syncopal episodes on POD thirty-nine. Despite interventional radiology drainage, the fluid collection and symptoms returned five days later. The patient ultimately underwent durotomy revision and repair with muscle patch.

CLINICAL DISCUSSION

This case highlights the challenges in managing anterior cervical dural tears resulting in pseudomeningocele. Risk factors include anterior cervical corpectomy and decompression, as well as an underlying diagnosis of OPLL. Untreated dural tears may develop into pseudomeningoceles which can contribute to life-threatening outcomes.

CONCLUSION

This case report presents the serious consequences of incidental durotomy, the unique post-surgical complication of syncope due to compression of the CB from a pseudomeningocele, and the challenges of managing a persistent pseudomeningocele.

Posttraumatic Retropharyngeal Pseudomeningocele—A Case Report

A retropharyngeal pseudomeningocele after cervical vertebral fracture dislocation is an extremely rare complication and often associated with hydrocephalus. It usually presents with respiratory difficulty and dysphagia, sometimes as an incidental finding in radiological study. We reported a case of 45-year-old female patient who had posttraumatic lower cervical prevertebral retropharyngeal pseudomeningocele, found as an incidental finding in a routine radiological workup. Patient underwent ACDF but expired 2 weeks postoperatively due to respiratory failure. Although the prognosis of retropharyngeal pseudomeningocele depends upon the severity of initial trauma, early recognition and management can prevent enlargement of cyst and development of respiratory difficulty and dysphagia.

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.