Intracranial Subdural Hematoma after Lumbar Spine Surgery: A Case Report

Intracranial subdural hemorrhage following closed neural tube defect repair: illustrative case

BACKGROUND

Intracranial subdural hematomas (SDHs) due to intracranial hypotension after pediatric spine surgeries are an uncommon pathology. Such findings have typically been associated with intraoperative durotomies that are complicated by a subsequent cerebrospinal fluid (CSF) leak.

OBSERVATIONS

The patient is a 17-year-old boy with a complex past medical history who received an uncomplicated S1–2 laminectomy for repair of his closed neural tube defect (CNTD), cord untethering, and resection of a lipomatous malformation. He returned to the hospital with consistent headaches and a 2-day history of intermittent left-sided weakness. Imaging demonstrated multiple subdural collections without a surgical site pseudomeningocele.

LESSONS

The case was unique because there have been no documented cases of acute intracranial SDH after CNTD repair. There was no CSF leak, and spine imaging did not demonstrate any evidence of pseudomeningocele. The authors believed that intraoperative CSF loss may have created enough volume depletion to cause tearing of bridging veins. In younger adolescents, it is possible that an even smaller volume may cause similar effects. Additionally, the authors’ case involved resection of the lipomatous malformation and an expansile duraplasty. Hypothetically, both can increase the lumbar cisternal compartment, which can collect a larger amount of CSF with gravity, despite no pseudomeningocele being present.

Symptomatic Intracranial Hemorrhage after Dural Tear in Spinal Surgery-A Series of 10 Cases and Review of the Literature

OBJECTIVE

Intracranial hemorrhage (IH) after spinal surgery is a rare but potentially life-threatening complication. Knowledge of predisposing factors and typical clinical signs is essential for early recognition, helping to prevent an unfavorable outcome.

METHODS

A retrospective analysis was performed of patients with IH after spinal surgery treated in our institution between 2012 and 2018. The literature dealing with IH complicating spinal surgery was reviewed.

RESULTS

Our investigation found 10 patients with IH (6 female and 4 male). To the best of our knowledge, this is the largest series reported so far. The assumable incidence of IH after spinal surgery in our population was 0.0657%. Durotomy was noticed in 6 patients, all of whom were treated according to a local standard protocol. In 4 patients, the dural tear was occult. Hemorrhage occurred mostly in the cerebellar compartment. Eight of 10 patients had long-standing arterial hypertension, which seems to be a risk factor (hazard ratio, 1.58). Five patients were treated conservatively, whereas 3 required a cerebrospinal fluid (CSF) diversion procedure. In 2 patients, revision surgery with duraplasty was necessary. Seven patients were discharged with little to no neurologic symptoms, and 3 had significant deterioration. One patient died because of brainstem herniation. Review of the literature identified 54 articles with 72 patients with IH complicating spinal surgery.

CONCLUSIONS

Patients with intraoperative CSF loss should be kept under close supervision postoperatively. After opening of the dura, a watertight closure should be attempted. The use of subfascial suction drainage in cases of a dural tear as well as preexistent arterial hypertension seems to be a risk factor for the development of IH. Intracranial bleeding must be considered in every patient with unexplained neurologic deterioration after spinal surgery and should be ruled out by cranial imaging. To ensure early recognition and prevent an unfavorable outcome, a high index of suspicion is required, especially in revision spinal surgery. The treatment is specific to the extent and location of the IH, thus dictating the outcome. In most patients, conservative treatment led to a good outcome. CSF diversion measures may be necessary in patients with compression or obstruction of the fourth ventricle. Large hematomas with mass effect may require decompressive surgery.