Spinal pseudomeningoceles and cerebrospinal fluid fistulas

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.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

OBJECTIVE

Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

METHODS

This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

RESULTS

Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

CONCLUSIONS

Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery

OBJECTIVE

Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion.

METHODS

All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group.

RESULTS

There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups.

CONCLUSIONS

For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.

An In Vitro Study of Chitosan-Coated Bovine Pericardium as a Dural Substitute Candidate

Defects in the dura matter can be caused by head injury, and many cases require neurosurgeons to use artificial dura matter. Bovine pericardium is an option due to its abundant availability, adjustable size and characteristics, and because it has more collagen than porcine or equine pericardia. Nevertheless, the drawback of bovine pericardium is that it has a higher inflammatory effect than other synthetic dura matters. Chitosan has been shown to have a strong anti-inflammatory effect and has good tensile strength; thus, the idea was formulated to use chitosan as a coating for bovine pericardium. This study used decellularized bovine pericardial membranes with 0.5% sodium dodecyl sulphate and coatings containing chitosan at concentrations of 0.25%, 0.5%, 0.75%, and 1%. An FTIR test showed the presence of a C=N functional group as a bovine pericardium-chitosan bond. Morphological tests of the 0.25% and 0.5% chitosan concentrations showed standard pore sizes. The highest tensile strength percentage was shown by the membrane with a chitosan concentration of 1%. The highest degradation rate of the membrane was observed on the 7th and 14th days for 0.75% and 1% concentrations, and the lowest swelling ratio was observed for the 0.25% concentration. The highest level of cell viability was found for 0.75% chitosan. The bovine pericardium membrane with a 0.75% concentration chitosan coating was considered the optimal sample for use as artificial dura matter.

Predictors of Cerebrospinal Fluid Leak Following Dural Repair in Spinal Intradural Surgery

OBJECTIVE

We aim to compare the effectiveness of dural closure techniques in preventing cerebrospinal fluid (CSF) leaks following surgery for intradural lesions and seek to identify additional factors associated with CSF leaks. Surgical management of spinal intradural lesions involves durotomy which requires a robust repair to prevent postoperative CSF leakage. The ideal method of dural closure and the efficacy of sealants has not been established in literature.

METHODS

We performed a retrospective analysis of all intradural spinal cases performed at a tertiary spine centre from 1 April 2015 to 29 January 2020 and collected data on patient bio-profile, dural repair technique, and CSF leak rates. Multivariate analysis was performed to identify predictors for postoperative CSF leak.

RESULTS

A total of 169 cases were reported during the study period. There were 15 cases in which postoperative CSF leak was reported (8.87%). Multivariate analysis demonstrated that patient age (odds ratio [OR], 0.942; 95% confidence interval [CI], 0.891-0.996), surgical indication listed in the "others" category (OR, 44.608; 95% CI, 1.706-166.290) and dural closure with suture, sealant and patch (OR, 22.235; 95% CI, 2.578-191.798) were factors associated with CSF leak. Postoperative CSF leak was associated with the risk of surgical site infection with a likelihood ratio of 8.704 (χ² (1) = 14.633, p < 0.001).

CONCLUSION

Identifying predictors for CSF leaks can assist in the counselling of patients with regard to surgical risk and expected postoperative recovery.

Surgical management of an ossified giant lumbar pseudomeningocele: A case report

BACKGROUND

Pseudomeningoceles (PMs) are infrequent complications of spine surgery resulting from incidental durotomy and subsequent extravasation of cerebrospinal fluid. Giant PMs (GPMs), defined as ≥8 cm in major diameter, are rarely reported in the literature and present a challenge due to a lack of clear guidelines for surgical management.

CASE DESCRIPTION

Here, the authors discuss the successful surgical management of a 25.3 cm lumbar GPM that became calcified 3 years following an initial T10-S2 laminectomy with instrumented fusion performed at an outside-hospital.

CONCLUSION

This report focuses on the successful 3-year delayed surgical intervention for the management of an ossified GPM.

Cranial meningioma with bone involvement: surgical strategies and clinical considerations

BACKGROUND

Intracranial meningioma with bone involvement and primary intraosseous meningioma is uncommon. There is currently no consensus for optimal management. This study aimed to describe the management strategy and outcomes for a 10-year illustrative cohort, and propose an algorithm to aid clinicians in selecting cranioplasty material in such patients.

METHODS

A single-centre, retrospective cohort study (January 2010-August 2021). All adult patients requiring cranial reconstruction due to meningioma with bone involvement or primary intraosseous meningioma were included. Baseline patient and meningioma characteristics, surgical strategy, and surgical morbidity were examined. Descriptive statistics were performed using SPSS v24.0. Data visualisation was performed using R v4.1.0.

RESULTS

Thirty-three patients were identified (mean age 56 years; SD 15) There were 19 females. Twenty-nine patients had secondary bone involvement (88%). Four had primary intraosseous meningioma (12%). Nineteen had gross total resection (GTR; 58%). Thirty had primary 'on-table' cranioplasty (91%). Cranioplasty materials included pre-fabricated polymethyl methacrylate (pPMMA) (n = 12; 36%), titanium mesh (n = 10; 30%), hand-moulded polymethyl methacrylate cement (hPMMA) (n = 4; 12%), pre-fabricated titanium plate (n = 4; 12%), hydroxyapatite (n = 2; 6%), and a single case combining titanium mesh with hPMMA cement (n = 1; 3%). Five patients required reoperation for a postoperative complication (15%).

CONCLUSION

Meningioma with bone involvement and primary intraosseous meningioma often requires cranial reconstruction, but this may not be evident prior to surgical resection. Our experience demonstrates that a wide variety of materials have been used successfully, but that pre-fabricated materials may be associated with fewer postoperative complications. Further research within this population is warranted to identify the most appropriate operative strategy.

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.

The Management of Recurrent Post-myelography Lumbar Pseudomeningocele With Epidural Blood Patch

Pseudomeningoceles are a well-known potential postoperative complication of spinal and cranial surgeries that can occur after lumbar decompression and posterior fossa surgeries. They are often caused by incidental durotomies but may also occur as a result of dural puncture during diagnostic testing. This report describes a 59-year-old male that developed a recurrent pseudomeningocele after an L4 laminectomy for severe lumbar spinal stenosis that was ultimately treated with an epidural blood patch (EBP). His preoperative condition greatly improved, but he developed a pseudomeningocele that did not resolve after applying ice and light pressure. The patient subsequently underwent a wound exploration where no dural defect was identified. During this exploration, the dura was reinforced with dural onlays and sealant. Unfortunately, the patient developed another pseudomeningocele within a short interval. It was then suspected that the post-laminectomy site provided a space for the dural punctures from previous CT myelography to leak cerebrospinal fluid (CSF) into. The patient subsequently underwent ultrasound (US)-guided aspiration of the pseudomeningocele and EBP injections at the levels where his preoperative myelography was performed. The success of the EBP indicates that the previous CT myelography was the likely cause of the pseudomeningocele. Recurrent spinal pseudomeningoceles with no evidence of incidental durotomy may be caused by dural puncture from myelography. In such cases, EBP to the area that the previous myelography was performed can resolve the pseudomeningocele.

Spinal pseudomeningocele closure: capsulofascial interposition technique

INTRODUCTION

The development of a spinal pseudomeningocele is a complication of dural repair or reconstruction that carries significant morbidity for pediatric patients. In addition to cerebrospinal fluid (CSF) hypotension and positional headaches, CSF leaking into the extradural space increases the risk for incisional breakdown, meningitis, and cosmetic deformity. Spinal pseudomeningocele management is challenging, and reported techniques range from local wound revisions/exploration to shunt placement for permanent CSF diversion.

METHODS

At our institution, we have recently implemented a multidisciplinary approach of capsulofascial interposition for the surgical repair of the symptomatic spinal pseudomeningocele with a combined neurosurgery-plastic surgery team. To our knowledge, this technique has not previously been characterized, and we describe the technical aspects of this surgery here.

RESULTS

Among 10 patients treated with this technique, none required reoperation or developed infections following pseudomeningocele closure; 2 patients received postoperative transfusions; and 2 patients underwent CSF diversion procedures.

CONCLUSION

We propose that this capsulofascial interposition technique should be employed in the surgical treatment of symptomatic spinal pseudomeningoceles.

Meningitis due to intra-abdominal cerebrospinal fluid fistula following gunshot wound successfully treated with antibiotics and blood patch: A case report and literature review

Background:

Penetrating spinal cord injury (PSCI) represents an average of 5.5% of all SCIs among civilians in the United States. The formation of a cerebrospinal fluid (CSF) fistula following PSCI occurs in approximately 9% of cases. Intra-abdominal CSF fistulae are rarely reported.

Case Description:

We present the case of a 28-year-old Caucasian female who suffered a single gunshot wound to the abdomen with a missile fragment lodged within the left L2 pedicle and transverse process without obvious canal compromise. The patient developed bacterial meningitis 13 days after the initial injury, treated with IV antibiotics. CT myelogram demonstrated intra-abdominal ventral CSF fistula from the left L2–L3 neuroforamen. The patient was successfully treated with fluoroscopy-guided dorsal autologous blood patch graft.

Conclusion:

This case highlights a rare complication of PSCI successfully managed with the use of a blood patch graft.

Successful treatment of intractable pseudomeningocele with FXIII deficiency by surgery and FXIII replacement therapy: A case report

Pseudomeningocele is an extradural cystic collection of cerebrospinal fluid (CSF) and is rare and typically asymptomatic. However, pseudomeningocele is sometimes associated with symptoms. Whether symptomatic pseudomeningocele is best treated conservatively or surgically remains controversial. Factor XIII (FXIII) is a blood coagulation factor that also promotes fibroblast proliferation during wound healing. Although treatment of postsurgical CSF leakage with FXIII has been reported, there have been no reports on surgical treatment and FXIII replacement therapy of pseudomeningocele with FXIII deficiency. We report a case of pseudomeningocele with FXIII deficiency that was successfully treated by surgery and FXIII replacement therapy. The patient presented with symptoms of intracranial hypotension syndrome that had started a few months after laminectomy for thoracic ossification of the ligamentum flavum 2 years earlier. Magnetic resonance imaging and delayed computed tomography myelography confirmed a diagnosis of pseudomeningocele. Epidural blood patch treatment was performed twice but did not result in improvement. Furthermore, the FXIII level decreased to 56%, so the patient was also diagnosed as having acquired FXIII deficiency. We elected to treat the patient by surgery with FXIII replacement therapy. The dural injury was repaired using an artificial dura mater patch, fibrin glue, and polyglycolic acid sheets. The FXIII level was 74%–135% during the perioperative period. The patient had a good postoperative course. Postoperative magnetic resonance images showed resolution of the pseudomeningocele. There was no recurrence during 6 months of follow-up. Perioperative FXIII replacement may be a useful treatment for pseudomeningocele with FXIII deficiency.

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Pseudomeningocele is an extradural cystic collection of cerebrospinal fluid.

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Whether symptomatic pseudomeningocele is best treated remains controversial.

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Factor XIII is a blood coagulation factor that also promotes fibroblast proliferation.

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There have been no reports on surgical treatment and FXIII replacement therapy of pseudomeningocele with FXIII deficiency.

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We report a case of pseudomeningocele treated by surgery and FXIII replacement therapy.

Clinical and Patient-reported Outcomes After Posterior Versus Transforaminal Lumbar Interbody Fusion-A Propensity Score-matched Cohort Study on 422 Patients with 2-year Follow-up

STUDY DESIGN

This was a dual-center study over an eight-year period on patients undergoing single level fusion surgery with either posterior- (PLIF) or transforaminal lumbar interbody fusion (TLIF). We analyzed prospectively collected pre- and postoperative data from the national Danish surgical spine database (DaneSpine).

OBJECTIVE

The aim of this study was to compare clinical and patient-reported outcome (PRO) 2 years after TLIF or PLIF in patients with symptomatic lumbar mechanical disc degeneration.

SUMMARY OF BACKGROUND DATA

PLIF and TLIF are well-described techniques for treating lumbar mechanical disc degeneration but whether the theoretical differences between the two techniques translate to different clinical outcomes is unknown.

METHODS

The primary outcome was Oswestry Disability Index (ODI) score at 2-year follow-up. Secondary outcome measures were scores on the European Quality of Life-5 Dimensions (EQ-5D) and visual analog scale (VAS) and the rate of intraoperative complications. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on preoperative factors including age, sex, back and leg pain, ODI, EQ-5D, and previous spine surgery.

RESULT

The matched cohort included 211 patients in each cohort. There was no significant difference between the groups in the mean score on the ODI at two years (PLIF: 33 ± 20 vs. TLIF: 35 ± 20, P = 0.328). We found no statistically significant differences in EQ-5D score (0.54 ± 0.35 vs. 0.51 ± 0.34, P = 0.327), VAS score for back pain (47 ± 32 vs. 48 ± 29, P = 0.570) or leg pain (42 ± 33 vs. 41 ± 32, P = 0.936) between the PLIF and TLIF groups, respectively, at 2-year follow-up. Dural tears occurred in 9.5% in the PLIF group and 1.9% in the TLIF group (P = 0.002) corresponding to a relative risk of 5.0 (95% CI 1.7-14.4).

CONCLUSION

We found no significant difference in PRO at 2-year follow-up between PLIF and TLIF for the treatment of lumbar disc degeneration. PLIF is associated with a five times higher risk of dural tears.Level of Evidence: 3.

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.

Pseudomeningocele-a rare complication following thoracic spinal decompression surgery: clinical features, treatment guidelines, technical notes, and evaluation of results

PURPOSE

Pseudomeningocele (PMC) is a rare complication following thoracic spinal decompression surgery. The aim of this study is to assess the clinical features and treatment of PMC and provide the technical notes with revision surgery.

METHODS

Between January 2010 and December 2019, patients who developed PMC after posterior thoracic surgery were enrolled. An additional 25 patients who suffered cerebrospinal fluid leakage (CSFL) but did not develop PMC in the same period were randomly selected. General data, intra-operative factors, CSFL position, cost, modified Japanese Orthopaedic Association (mJOA) scores, patient satisfaction, and clinical features were recorded and compared between the two groups.

RESULTS

Eighteen patients were diagnosed with PMC after thoracic spinal surgery. The average length, width, and depth were 16.25 ± 5.73 cm, 6.96 ± 3.61 cm and 4.39 ± 2.2 cm, respectively. The most common symptom was neurological deficits following incision problems and headache. Compared with the control group, the PMC group showed a longer duration of initial surgery, greater estimated blood loss, an increased rate of CSFL on the ventral side, reduced mJOA scores, and lower patient satisfaction at the final follow-up.

CONCLUSION

PMC is a rare complication of thoracic surgery with an incidence of 1.12%. PMC typically occurs at the upper and lower thoracic spine, resulting in increased health care costs, poorer neurological recovery, and a lower rate of patient satisfaction. The management of PMC should be individualized depending on diagnosis time and symptoms.

Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series

BACKGROUND

Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear.

OBJECTIVE

To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS.

METHODS

A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma.

RESULTS

A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported.

CONCLUSION

Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.

Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch

BACKGROUND

Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time.

METHODS

A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele.

RESULTS

Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m², respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months.

CONCLUSIONS

This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.

The Effect of Adding Modified Chitosan on the Strength Properties of Bacterial Cellulose for Clinical Applications

Currently, several materials for the closure of the dura mater (DM) defects are known. However, the long-term results of their usage reveal a number of disadvantages. The use of antibiotics and chitosan is one of the major trends in solving the problems associated with infectious after-operational complications. This work compares the mechanical properties of samples of bacterial nanocellulose (BNC) impregnated with Novochizol™ and vancomycin with native BNC and preserved and native human DM. An assessment of the possibility of controling the mechanical properties of these materials by changing their thickness has been performed by statistical analysis methods. A total of 80 specimens of comparable samples were investigated. During the analysis, the results obtained, the factor of Novochizol™ addition has provided a statistically significant impact on the strength properties (Fisher Criteria p-value 0.00509 for stress and 0.00112 for deformation). Moreover, a stronger relationship between the thickness of the samples and their ultimate load was shown: R2=0.236 for BNC + Novochizol™ + vancomycin, compared to R2=0.0405 for native BNC. Using factor analysis, it was possible to show a significant effect of modified chitosan (Novochizol™) on the ultimate stress (p-value = 0.005).

Spontaneous Resolution of Postoperative Giant Frontal Pseudomeningocele

Cranial pseudomeningoceles are abnormal extradural collections of cerebrospinal fluid. Postoperative giant cranial pseudomeningoceles have been rarely reported in the literature and have no specific treatment guidelines. The optimal management strategy for this condition differs among authors, varying from conservative approach to surgical intervention. A spontaneous resolution of postoperative giant frontal pseudomeningocele is reported. A 41-year-old female presented a pseudomeningocele 3 weeks after a right frontal meningioma surgical resection. The pseudomeningocele progressed during the first 1.5-month postoperatively despite percutaneous aspiration and compressive bandage, it then shrank spontaneously and was completely resolved at the 15^th month since the surgery. Nonoperative treatment with a close follow-up could be a good option for asymptomatic giant pseudomeningoceles, resulting in a spontaneous resolution.

Repair of Delayed Meningeal Cyst after Spinal Surgery with Paraspinal Muscle Flap under Microscope

BACKGROUND

Delayed meningeal cyst (DMC) is a rare complication after spinal surgery that is often ignored by clinicians, and its in-depth research is infrequent. In particular, no consensus has been reached about its surgical treatment. We found that patients with a DMC failed after conservative treatment, epidural blood patch, subarachnoid drainage, and initial attempts to eliminate the meningeal cyst. Therefore, we introduce the application of a paraspinal muscle flap repair under a microscope for the treatment of DMC.

METHODS

In this study, 13 patients who were repaired by a paraspinal muscle flap under a microscope for DMC from January 2007 to January 2017 were retrospectively reviewed. Their ages were 18-68 years old (mean age 48.7 years). The course of the disease ranged from 3 weeks to 28 months after the operation for the primary disease, with an average of 10.6 months. Length >5 cm was called a large DMC and length >8 was called a giant DMC. By analyzing the effect of surgical treatment, we summarized the treatment experience of DMC and evaluated the risk factors for the formation of DMC.

RESULTS

All patients were treated with paraspinal muscle flap repair under a microscope, and they healed well after the operation. There was no cerebrospinal fluid leakage or other operation-related complication. The mean follow-up was 16.5 months. Reexamination of the spine MRI showed no recurrence of the DMC.

CONCLUSIONS

The application of paraspinal muscle flap under a microscope combined with glue, bedrest, and CSF drain, was an effective option for the patients with DMC.

Compressive cervicothoracic pseudomeningocele as a rare manifestation of idiopathic intrathecal hypotension after past trauma: a review

PURPOSE

Spontaneous intracranial or intrathecal hypotension (SIH) is an underdiagnosed phenomenon predominantly presenting with low cerebrospinal fluid (CSF) pressure and postural headache in the setting of CSF leak. Extrathecal CSF collections causing compression of the spinal cord or nerve roots present an even rarer subset of this disease. We aim to describe this pathology in a comprehensive manner while illustrating with a case of our own.

METHODS

We present a literature review on spinal idiopathic pseudomeningoceles and their neurological implications illustrated with a case of an anterior compressive pseudomeningocele between C2 and D7. Further investigations through a myelography and myelo-CT were able to postulate a CSF leak through a discogenic osteophytic microspur at the level C5-C6.

RESULTS

Spinal manifestations are uncommon in cases of idiopathic or spontaneous CSF leak, occurring in about 6% of patients, but myelopathy and radiculopathy involving all spinal segments do occur. In contrast to the cranial complaints, the spinal manifestations usually are not positional and are caused by mass effect from an extradural CSF collection.

CONCLUSION

The utility of multiple imaging modalities such as dynamic myelography and the use of epidural blood patches and fibrin glue polymers should be explored, and surgery is an option if the symptoms persist despite other measures.

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.

Nerve root entrapment with pseudomeningocele after percutaneous endoscopic lumbar discectomy: A case report

Context: Pseudomeningocele is a relatively uncommon postoperative complication of spine surgery. Although the condition tends to be asymptomatic and self-limiting, it may cause radicular pain and neurological defect due to herniation of the nerve root or the spinal cord. Its pathophysiology remains unclear. Only few cases with intraoperative photos have been reported. Finding: We present a case of pseudomeningocele with nerve root entrapment after percutaneous endoscopic lumbar discectomy (PELD). A 52-year-old man had undergone PELD for sciatic pain and showed good postoperative recovery. Unfortunately, he was readmitted for progressive right leg pain at six weeks after the surgery. After the failure of conservative therapy, he received PELD again to explore the surgical site. Intraoperatively, a pseudomeningocele-containing nerve root, herniating through a small defect in the dural sac, was identified. During the dissection process, the pseudomeningocele was broken, which led to entrapment of the nerve root. Thereafter, the microsurgical technique was adopted to relocate the nerve root into the thecae sac and to repair the dural tear by non-resorbable suture. Conclusion: To our knowledge, this case report is the first documented instance of identification of a pseudomeningocele under an endoscope, and provides insights into the transformation of a pseudomeningocele into a cerebrospinal fluid fistula with nerve root entrapment. For neurological deficit caused by pseudomeningocele following PELD, operative revision by the microsurgery technique is the appropriate strategy.

Consensus on Implants in Infections After Spine Surgery

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 9 focused on implants questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Pseudomeningocele after biportal endoscopic spine surgery: A case report

Background

Biportal endoscopic spinal surgery (BESS) was recently introduced and became prevalent fast. Incidental dural tear (IDT) could happen as one of the common complications even in endoscopic spine surgery.

Case description

A 45-year old male underwent discectomy by BESS. IDT sized about 15mm at the dorsal surface of dura occurred during the laminotomy procedure with an osteotome. Revision surgery was planned for assuming that the IDT is small enough to be sealed with a patch.

Conclusion

Revision surgery using BESS for a small-sized IDT could be reasonable alternative treatment to preserve the soft tissue, the primary purpose of MISS.

Watertightness of wound closure in lumbar spine-a comparison of different techniques

BACKGROUND

Since a primary watertight dural suture after incidental durotomies has a failure rate of 5-10%, a watertight closure technique of the overlying layers (fascia, subcutis and skin) is essential. The purpose of this cadaveric study was to find the most watertight closure technique for fascia, subcutis and skin.

METHODS

Different suturing techniques were tested for each layer in a sheep cadaveric model by measuring the leakage pressure. The specimens were mounted on a pressure chamber connected to a manometer and a water tube system. Subsequently, the leakage was over-sewed with a cross stitch and the experiment was repeated.

RESULTS

Cross stitch suturing [median =180 mbar (43; 660)] performed best compared to continuous [median =16 mbar (6; 52)] (P=0.003) but not to single knot [median =118 mbar (21; 387)] (P=1.0) or locking stitch suturing [median =109 mbar (3; 149)] (P=0.93) for fascia closure. Continuous suture [median =9 mbar (3; 14)] resulted in a higher leakage pressure than single knot [median =1 mbar (1; 6)] (P=0.017) for subcutaneous closure. No significant differences were found between intracutaneous, Donati-continuous, single knot and locking stitch for skin closures (P=0.075). However, the Donati-continuous stitch closure resulted in higher pressures in tendency. Over-sewing increased median leakage pressure from 8.0 to 11.0 mbar (P=0.068) and from 4.0 to 13.0 mbar (P=0.042) for single knot and for locking stitch skin closures, respectively.

CONCLUSIONS

Cross stitches for the fascia, continuous suturing technique for the subcutis and Donati-continuous stitch for the skin resulted in the most watertight closure within this experimental setting. If leakage occurs, over-sewing might relevantly improve the watertightness of the wound.

Hydrocephalic Attack-An Uncommon Complication of Spine Surgery: A Case Series and Review of Literature

BACKGROUND

Spinal pseudomeningocele refers to an abnormal accumulation of cerebrospinal fluid (CSF) in a fibrous sac without arachnoid lining that occurs mostly as a result of an accidental dural opening. When accidental dural openings are found intraoperatively, they should be repaired to prevent further complications. Sometimes inadequately dealt dural openings, unnoticed, or postoperative dural openings may produce complications.

CASE DESCRIPTION

Three patients had complications as a result of spine surgery and presented several days after the surgery with episodic symptoms of raised intracranial pressure, including headache, opisthotonos, altered breathing patterns, and altered sensorium. These symptoms increased whenever pressure was applied on the operated area suggesting hydrocephalic attacks. All 3 patients had a giant pseudomeningocele at the operated area, a complication that resulted from the spine surgery. Magnetic resonance imaging CSF flow study revealed hyperdynamic flow and increase in absolute stroke volume across the cerebral aqueduct when constant pressure was applied on the pseudomeningocele sac.

CONCLUSIONS

Usually pseudomeningoceles are asymptomatic, and if symptomatic, the common presentations are local swelling, back pain, radiculopathy, and orthostatic headache. To our knowledge, this is the first article in the literature reporting the uncommon presentation of hydrocephalic attacks in 3 cases subsequent to CSF backflow from the sac, confirmed with MRI CSF flow study. This case series emphasizes rare presentations can result from transiently increased intracranial pressure related to postoperative pseudomeningocele in spine surgeries.

Dural tear is associated with an increased rate of other perioperative complications in primary lumbar spine surgery for degenerative diseases

Prospective case-control study.This study used a prospective multicenter database to investigate whether dural tear (DT) is associated with an increased rate of other perioperative complications.Few studies have had sufficient data accuracy and statistical power to evaluate the association between DT and other complications owing to a low incidence of occurrence.Between 2012 and 2017, 13,188 patients (7174 men and 6014 women) with degenerative lumbar diseases underwent primary lumbar spine surgery. The average age was 64.8 years for men and 68.7 years for women. DT was defined as a tear that was detected intraoperatively. Other investigated intraoperative surgery-related complications were massive hemorrhage (>2 L of blood loss), nerve injury, screw malposition, cage/graft dislocation, surgery performed at the wrong site, and vascular injury. The examined postoperative surgery-related complications were dural leak, surgical-site infection (SSI), postoperative neurological deficit, postoperative hematoma, wound dehiscence, screw/rod failure, and cage/graft failure. Information related to perioperative systemic complications was also collected for cardiovascular diseases, respiratory diseases, renal and urological diseases, cerebrovascular diseases, postoperative delirium, and sepsis.DTs occurred in 451/13,188 patients (3.4%, the DT group). In the DT group, dural leak was observed in 88 patients. After controlling for the potentially confounding variables of age, sex, primary disease, and type of procedure, the surgery-related complications that were more likely to occur in the DT group than in the non-DT group were SSI (odds ratio [OR] 2.68) and postoperative neurological deficit (OR 3.27). As for perioperative systemic complications, the incidence of postoperative delirium (OR 3.21) was significantly high in the DT group.This study demonstrated that DT was associated with higher incidences of postoperative SSI, postoperative neurological deficit, and postoperative delirium, in addition to directly DT-related dural leak.

Incidental durotomy in the pediatric spine population

OBJECTIVESpine surgery is less common in children than adults. These surgeries, like all others, are subject to complications such as bleeding, infection, and CSF leak. The rate of incidental durotomy in the pediatric population, and its associated complications, has scarcely been reported in the literature.METHODSThis is a retrospective chart review of all pediatric patients operated on at Wake Forest Baptist Health from 2012 to 2017 who underwent spine surgeries. The authors excluded any procedures with intended durotomy, such as tethered cord release or spinal cord tumor resection.RESULTSFrom 2012 to 2017, 318 pediatric patients underwent surgery for a variety of indications, including adolescent idiopathic scoliosis (51.9%), neuromuscular scoliosis (27.4%), thoracolumbar fracture (2.83%), and other non-fusion-related indications (3.77%). Of these patients, the average age was 14.1 years, and 71.0% were female. There were 6 total incidental durotomies, resulting in an overall incidence of 1.9%. The incidence was 18.5% in revision operations, compared to 0.34% for index surgeries. Comparison of the revision cohort to the durotomy cohort revealed a trend toward increased length of stay, operative time, and blood loss; however, the trends were not statistically significant. The pedicle probe was implicated in 3 cases and the exact cause was not ascertained in the remaining 3 cases. The 3 durotomies caused by pedicle probe were treated with bone wax; 1 was treated with dry Gelfoam application and 2 were treated with primary repair. Only 1 patient had a persistent leak postoperatively that eventually required wound revision.CONCLUSIONSIncidental durotomy is an uncommon occurrence in the pediatric spinal surgery population. The majority occurred during placement of pedicle screws, and they were easily treated with bone wax at the time of surgery. Awareness of the incidence, predisposing factors, and treatment options is important in preventing complications and disability.

Intraoperative Cerebrospinal Fluid Leak in Extradural Spinal Tumor Surgery

Objective

Patients with extradural spine tumors are at an increased risk for intraoperative cerebrospinal fluid (CSF) leaks and postoperative wound dehiscence due to radiotherapy and other comorbidities related to systemic cancer treatment. In this case series, we discuss our experience with the management of intraoperative durotomies and wound closure strategies for this complex surgical patient population.

Methods

We reviewed our recent single-center experience with spine surgery for primarily extradural tumors, with attention to intraoperative durotomy occurrence and postoperative wound-related complications.

Results

A total of 105 patients underwent tumor resection and spinal reconstruction with instrumented fusion for a multitude of pathologies. Twelve of the 105 patients (11.4%) reviewed had intraoperative durotomies. Of these, 3 underwent reoperation for a delayed complication, including 1 epidural hematoma, 1 retained drain, and 1 wound infection. Of the 93 uncomplicated index operations, there were a total of 9 reoperations: 2 for epidural hematoma, 3 for wound infection, 2 for wound dehiscence, and 2 for recurrent primary disease. One patient was readmitted for a delayed spinal fluid leak. The average length of stay for patients with and without intraoperative durotomy was 7.3 and 5.9 days, respectively, with a nonsignificant trend for an increased length of stay in the durotomy cases (p=0.098).

Conclusion

Surgery for extradural tumor resections can be complicated by CSF leaks due to the proximity of the tumor to the dura. When encountered, a variety of strategies may be employed to minimize subsequent morbidity.

Challenges of Managing Patients with Symptomatic Large Traumatic Cervical Pseudomeningoceles

BACKGROUND

Traumatic cervical pseudomeningoceles (TCPs) occur secondary to traction of the cervical nerve roots resulting in violation of the dura. Surgical repair is not necessary in most cases because pseudomeningoceles have a high propensity to spontaneously resolve with conservative management alone. Currently, there are a limited number of cases of large TCPs (large is defined as ≥6 cm in greatest diameter), and there is no established guideline for the management of such lesions.

CASE DESCRIPTION

We describe the cases of 2 young men in their 20s who were involved in a motor vehicle accident. Both patients suffered a brachial plexus injury and developed large TCPs. Patient 1 was treated surgically for TCP using a combined intra-/extradural approach using a fascia lata graft. Patient 2 was ultimately treated nonsurgically because a spontaneous resolution of the pseudomeningocele was achieved over the period of 7 months after the accident. Both patients underwent brachial plexus repair surgery consisting of spinal accessory nerve transfer to the suprascapular nerve and intercostal nerve transfer to the musculocutaneous nerve.

CONCLUSIONS

Disease progression of TCPs is a dynamic process, and even large lesions may spontaneously resolve without surgical intervention. When surgery is indicated, a definitive dural repair using a fascia lata graft to cover the dural tear intra- and extradurally is an effective method. Surgery must be planned carefully on a case-by-case basis, and close follow-up with thorough physical examination and serial imaging is critical to monitor disease progression.

Incidental durotomy during total en bloc spondylectomy

BACKGROUND CONTEXT

The incidence of incidental durotomy (ID) during total en bloc spondylectomy (TES) tends to be higher than that during other spinal surgeries because of the peculiarities of TES, including its highly invasive nature, epidural tumor extension, and use in patients who often have complicated medical backgrounds. However, there have been no detailed reports on ID associated with TES.

PURPOSE

The study aimed to investigate ID during TES in detail.

STUDY DESIGN

This is a retrospective review of prospectively collected data.

PATIENT SAMPLE

The study included 105 consecutive patients with spinal tumor who underwent TES between May 2010 and February 2015 (59 men, 46 women; mean age, 54.0 years [range, 14-75 years] at the time of surgery).

OUTCOME MEASURES

Outcome measures included the incidence, risk factors, anatomical location, intraoperative maneuvers, and postoperative course of ID associated with TES.

MATERIALS AND METHODS

Medical and operative records and imaging findings were reviewed. Univariate analysis and multivariable stepwise logistic regression models were used to identify independent risk factors for ID.

RESULTS

Incidental durotomy occurred in 18 (17.1%) of the 105 patients. The univariate and multivariate analyses demonstrated that older age (adjusted odds ratio [aOR], 6.09; 95% confidence interval [CI], 1.17-31.76; p=.03), radiotherapy (RT) history (aOR, 5.31; 95% CI, 1.46-19.49; p=.01), and revision surgery (aOR, 19.42; 95% CI, 3.46-109.14; p<.01) were independent risk factors for ID. Incidental durotomy was more likely to occur during dissection of tumor tissues in proximity to the nerve root. Although all of the ID cases were primarily sutured and covered with polyglycolic acid mesh and fibrin glue spray, eight cases required additional intervention because of intractable postoperative cerebrospinal fluid leakage. Six of these eight had a history of RT.

CONCLUSIONS

Our results may help better identify high-risk patients for ID during TES, which may aid surgeons with optimal surgical decision making and in counseling patients on perioperative complications.

Effective Repair of Dural Tear Using Bioabsorbable Sheet With Fibrin Glue

STUDY DESIGN

Basic science.

OBJECTIVE

This study aimed to compare the techniques of surgical repair of dural tear using bioabsorbable material and fibrin glue.

SUMMARY OF BACKGROUND DATA

Cerebrospinal fluid (CSF) leakage caused by dural tear can often be difficult to manage even after repair when the same materials are used in a similar manner.

METHODS

Burst pressure was measured for repaired porcine dura with holes of different diameters using spray of combined fibrinogen and thrombin solution (fibrin spray) alone as a control and the 5-mm hole following different methods using fibrinogen and thrombin solutions plus polyglactin 910 sheet (PGS). For group 1, fibrinogen was applied on the dura followed by PGS and thrombin. For group 2, thrombin was followed by PGS and fibrinogen. For group 3, fibrinogen was followed by PGS and fibrin spray. For group 4, thrombin was followed by PGS and fibrin spray. Microscopic observation was conducted for each specimen.

RESULTS

Repair using fibrin spray alone was successful for the 0.3-mm diameter pinhole (breakdown pressure: 27.8 ± 8.6 mmHg), but was not able to cover the 2.7- and 5-mm holes. For a 5-mm diameter hole, the breakdown pressure was 54.4 ± 38.8 mmHg in group 1, 26.3 ± 19.4 mmHg in group 2, 147.7 ± 65.0 mmHg in group 3, and 35.5 ± 23.4 mmHg in group 4 (P < 0.001). There was little fibrin glue in the burst layer between the dural surface and PGS with thrombin on the dural surface (group 2 and group 4).

CONCLUSION

Suppression of excessive CSF leakage could be successful by performing several cycles of the group 1 method (fibrinogen was applied on the dura followed by PGS and thrombin), followed by the group 3 method (fibrinogen was applied on the dura followed by PGS and fibrin spray), with thrombin solution wash each time.

LEVEL OF EVIDENCE

4.

Spontaneous pseudomeningocele associated with lumbar spondylolisthesis: A case report and review of the literature

Background:

Pseudomeningocele, an extradural collection of cerebrospinal fluid (CSF), has only been rarely reported to occur spontaneously in conjunction with isthmic spondylolisthesis (with lysis) in the lumbar spine.

Case Description:

A 68-year-old male presented with low back pain and neurogenic claudication of several years duration without any history of trauma, epidural spine injections, or spine surgery. Lumbosacral magnetic resonance imaging (MRI) revealed a grade-I L4–L5 isthmic spondylolisthesis with spinal canal narrowing and a posterior paravertebral collection consistent with CSF. The patient underwent a spinal decompression consisting of a complete L4 and partial L5 laminectomy, a bilateral L4–L5 instrumented fusion (due to the lysis defect), and closure of the CFS fistula. The histology analysis was compatible with a pseudomeningocele.

Conclusion:

Lumbar isthmic spondylolisthesis may lead to changes in the elastic properties of the underlying dura mater. Rarely, this may lead to meningeal tears and formation of a pseudomeningocele. Historically, one must always check for a prior epidural injection that could have resulted in this complication. Additionally, as most likely the case here, the lysis defect was responsible for the foraminal dural laceration resulting in the pseudomeningocele.

Pseudomeningocele Aspiration and Blood Patch Effectively Treats Positional Headache Associated With Postoperative Lumbosacral Pseudomeningocele

STUDY DESIGN

Retrospective chart review with limited prospective follow-up survey.

OBJECTIVE

To evaluate the efficacy and safety of blood patch injection for the treatment of positional headaches caused by postoperative lumbosacral pseudomeningoceles.

SUMMARY OF BACKGROUND DATA

Pseudomeningocele is one of the most common complications after posterior lumbosacral spinal surgery. Common treatments include bedrest, abdominal binder use, subarachnoid lumbar drainage, and surgical re-exploration for durotomy closure. To date, only small case reports support the use of epidural blood patch injection for symptomatic pseudomeningocele treatment.

METHODS

A retrospective chart review analyzed the outcomes and complications of 19 consecutive patients who underwent blood patch injection, with and without pseudomeningocele aspiration, for symptomatic postoperative lumbosacral pseudomeningoceles between 2009 and 2015. An attempt was made to survey patients by phone regarding satisfaction.

RESULTS

As of last follow-up (average time = 22.3 months), 16 patients (84%) experienced headache resolution after blood patch injection and did not require further treatment of their pseudomeningocele. In addition to symptomatic improvement, 12 of the 16 successful patients had imaging, which demonstrated pseudomeningocele resolution. Persistent pseudomeningoceles were demonstrated on imaging among all three unsuccessful patients.

CONCLUSION

Pseudomeningocele aspiration followed by blood patch is an effective treatment for symptomatic postoperative lumbosacral pseudomenigocele. This is a minimally invasive alternative to surgical re-exploration with durotomy closure. Injections are most effective when performed early after pseudomeningocele development.

LEVEL OF EVIDENCE

4.

How to address cerebrospinal fluid leakage following ossification of the posterior longitudinal ligament surgery

BACKGROUND

Primary dural repair in ossification of posterior longitudinal ligament (OPLL) surgery via anterior is challenging because of limited space. Based on several years of our experiences, we present our concept for addressing cerebrospinal fluid (CSF) leakage following dural tear during anterior OPLL surgery.

METHODS

We reviewed the medical records of 65 patients who underwent anterior OPLL surgery from 2003 to 2014. We included 7 patients whose operation records described dural tear followed by CSF leakage. Primary dural repair could not be performed in 6 patients because of ragged tear and limited space. We managed them with our own strategy: simple cover with an artificial dura, collagen sponge and/or fibrin glue on defect site; anatomical layer-by-layer repair without either subfascial or CSF drain, and early ambulation.

RESULTS

Of 7 patients, wound problems developed in 2 patients. Wound aspiration and antibiotic treatment was done without wound compression in one patient, and simple irrigation followed by anatomical layer-by-layer re-closure was done in the other patient without either bed rest or lumbar drainage. Pseudomeningoceles were detected in 4 patients, including 2 patients who had wound problems. However, all pseudomeningoceles were absorbed spontaneously or stabilized on follow-up images without interventions such as bed rest, lumbar drain or wound compression.

CONCLUSIONS

Without interference of pressure equilibrium between intradural and extradural space, the defect site would heal and close. After that, the isolated pseudomeningocele would be spontaneously absorbed after certain period of time.

The True Cost of a Dural Tear: Medical and Economic Ramifications of Incidental Durotomy During Lumbar Discectomy in Elderly Medicare Beneficiaries

STUDY DESIGN

A retrospective database review.

OBJECTIVE

The aim of this study was to identify whether dural tears increase costs and the risk of wound complications and serious adverse events during the postoperative period following primary lumbar discectomy in elderly Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

Rates of incidental durotomy during lumbar spine surgery range from 1% to 17%. The full economic and medical burden of this complication remains unclear, particularly as it occurs during lumbar discectomy in elderly patients.

METHODS

The full set of prospectively gathered Medicare insurance data (2005-2012) was retrospectively reviewed. Patients who underwent primary lumbar discectomy for lumbar disc herniations from 2009 to quarter 3 of 2012 were selected. This cohort (n = 41,655) was then divided into two subgroups: those who were diagnosed with incidental durotomy on the day of surgery (n = 2052) and those who were not (control population). To select a more effective control population, patients of a similar age, gender, smoking status, diabetes mellitus status, chronic pulmonary disease status, and body mass index were chosen at random from the control population to create a control cohort. In-hospital costs, length of stay, and rates of 30-day readmission, 90-day wound complications, and 90-day serious adverse effects were compared.

RESULTS

An incidental durotomy rate of 4.9% was observed. Higher rates of wound infection [2.4% vs. 1.3%; odds ratio (OR) 1.88; 95% confidence interval (95% CI): 1.31-2.70; P < 0.001], wound dehiscence (0.9% vs. 0.4%; OR 2.39; 95% CI: 1.31-4.37; P = 0.004), and serious adverse events related to incidental durotomy (0.9% vs. 0.2%; OR 4.10; 95% CI: 2.05-8.19; P < 0.0001) were observed in incidental durotomy patients. In-hospital costs were increased by over $4000 in patients with incidental durotomy (P < 0.0001).

CONCLUSION

Incidental durotomies occur in almost one in every 20 elderly patients treated with primary lumbar discectomy. Given the increased hospital costs and complication rates, this complication must be viewed as anything but benign.

LEVEL OF EVIDENCE

4.

Surgical treatment for bacterial meningitis after spinal surgery: A case report

RATIONALE

Bacterial meningitis (BM) has been recognized as a rare complication of spinal surgery. However, there are few reports on the management of postoperative BM in patients who have undergone spinal surgery. The initial approach to the treatment of patients suspected with acute BM depends on the stage at which the syndrome is recognized, the speed of the diagnostic evaluation, and the need for antimicrobial and adjunctive therapy.

PATIENT CONCERNS

Here, we report the case of a patient with lumbar spinal stenosis and underwent a transforaminal lumbar interbody fusion at L4-L5. The dura mater was damaged intraoperatively. After the surgery, the patient displayed dizziness and vomiting. A CSF culture revealed Pseudomonas aeruginosa infection.

DIAGNOSES

The patient was diagnosed with postoperative BM.

INTERVENTIONS

Antibiotic was administered intravenously depends on the organism isolated. Nevertheless, the patient's clinical condition continued to deteriorate. The patient underwent 2 open revision surgeries for dural lacerations and cyst debridement repair.

OUTCOMES

The patient's mental status returned to normal and her headaches diminished. The patient did not have fever and the infection healed.

LESSONS

Surgical intervention is an effective method to treat BM after spinal operation in cases where conservative treatments have failed. Further, early surgical repair of dural lacerations and cyst debridement can be a treatment option for selected BM patients with complications including pseudomeningocele, wound infection, or cerebrospinal fluid leakage.

Remote Cervical Pseudomeningocele Following Anterior Cervical Corpectomy and Fusion: Report of a Case and Review of the Literature

Iatrogenic cervical pseudomeningocele is a rare event and majority are located posteriorly as a delayed complication of inadvertent dural tear after decompressive laminectomy. However, iatrogenic anterior cervical pseudomeningocele subsequent to discectomy or corpectomy is a rare pathology. The time necessary for formation of pseudomeningocele varies and depend on the width of the dural tear and the flow of cerebrospinal fluid leakage. Large tears with high CSF flow usually result in early collection of the cerebrospinal fluid in anterior compartment of the neck designated acute pseudomeningoceles. Micro-tears of dura mater, with low flow of cerebrospinal fluid may lead to late formation of a pseudomeningocele known as chronic ones. Herein a 49- year-old woman in whom cervical pseudomeningocele appeared clinically as a mass on the anterior aspect of the neck, six months after anterior cervical corpectomy for cervical spondylotic myelopathy is presented. Otherwise, she was neurologically stable. Cystoperitoneal shunt was proposed which she refused. Surprisingly, at 2-year follow-up, the cyst had remained of the same size. To the best of our knowledge, this is the first example of post-operative chronic cervical pseudomeningocele in the literature, the event that might propose the self-limited natural course of this rare pathology in chronic cases.

CT-guided epidural blood patch for treatment of CSF leak and pseudomeningocele following tethered cord release in a 3-year-old

An epidural blood patch (EBP) has become standard of care for management of postdural puncture headache, and in recent years, attempts have been made to expand its applicability. Its utility in the management of postsurgical pseudomeningocele remains poorly defined, and few reports describe its use in children. In this case, we report the successful management of lumbar pseudomeningocele via EBP in a 3-year-old after tethered cord release, thereby obviating the need for surgical repair and its potential morbidity.