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Table of Contents    
LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 3  |  Page : 325-327

Compressive radiculopathy due to delayed pseudomeningocele secondary to occult dural tear following tubular lumbar microdiscectomy


Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA

Date of Submission30-May-2014
Date of Decision31-May-2014
Date of Acceptance02-Jun-2014
Date of Web Publication18-Jul-2014

Correspondence Address:
Manish K Kasliwal
Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.137013

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How to cite this article:
Tan LA, Kasliwal MK, O'Toole JE. Compressive radiculopathy due to delayed pseudomeningocele secondary to occult dural tear following tubular lumbar microdiscectomy. Neurol India 2014;62:325-7

How to cite this URL:
Tan LA, Kasliwal MK, O'Toole JE. Compressive radiculopathy due to delayed pseudomeningocele secondary to occult dural tear following tubular lumbar microdiscectomy. Neurol India [serial online] 2014 [cited 2019 Dec 7];62:325-7. Available from: http://www.neurologyindia.com/text.asp?2014/62/3/325/137013


Sir,

Pseudomeningocele is an uncommon but well-recognized complication resulting from dural tears during spine surgery [1],[2] Incidental durotomy has been estimated to occur from 1.6-17.4% of spinal surgeries, [2],[3],[4] however the true incidence of iatrogenic pseudomeningocele is unknown. Most pseudomeningoceles are asymptomatic with a self-limited course. The need for surgical intervention in the absence of wound drainage or infection is uncommon. [5],[6]

A 26-year-old male under went right L5-S1 tubular microdiscectomy for right S1 radiculopathy due to L5-S1 disc herniation [Figure 1]. The surgery was uneventful and there was no recognized dural tear or cerebrospinal fluid (CSF) leak. However, he presented back with recurrent right S1 radiculopathy 8 weeks after surgery. Magnetic resonance imaging (MRI) of the lumbar spine showed presence of a small T1 iso-intense and T2 hyper-intense lesion/fluid collection at the discectomy site with mild nerve root compression [Figure 2] The incision had healed completely with no signs of infection. Following failure of conservative management, a repeat MRI at 16 weeks showed interval enlargement of the lesion noted on prior MRI [Figure 2] and a redo surgery was performed suspecting a pseudomenigocele. Intraoperatively, a CSF filled collection was noted compressing the nerve root with a durotomy in the axilla of the nerve root. The durotomy was repaired using a single stitch using special minimally invasive dural repair instruments while incorporating a small piece of muscle as a buttress patch [Figure 3]. The patient was doing well at 3 months follow-up.
Figure 1: Pre-operative T2W sagittal [left] and axial [right] MRI showing right L5-S1 disc herniation with nerve root compression

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Figure 2: Post-operative T1W axial [left], T2W axial [middle] MRI done at 8 weeks and axial T2W MRI [right] done at 16 weeks demonstrating complete removal of herniated disc fragments and a small T1 iso intense and T2 hyper intense cystic lesion/collection compressing the nerve root with interval enlargement

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Figure 3: Intraoperative photograph demonstrating the site of dural tear with CSF leak and final repair

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There are several hypotheses on the pathophysiology of symptomatic pseudomeningoceles. The common variable in all cases is the intended or unintended durotomy during surgery with or without arachnoid breach. [3],[4] Some authors believe that presence of arachnoid herniation through the durotomy defect tends to promote persistent CSF leakage. [6] Others believe that a larger durotomy defect with higher CSF flow is responsible for impaired durotomy healing; [7] although it had been argued that a small durotomy is more likely to function as an one-way "ball-valve", which may be the primary reason for pseudomeningocele formation as might have occurred in our case. [1],[8] Symptomatic pseudomeningoceles may present with headache, nausea, vomiting, tinnitus, cranial nerve palsies and fluctuant subcutaneous collection or frank wound draingae. [1],[3] Back pain and radiculopathy are also common in patients with symptomatic pseudomeningoceles, which can often be attributed to persistence of patients preoperative symptoms if not carefully recognized and imaged. Most of the cases of radicular symptoms in the literature described have been secondary to tethering of nerve root at durotomy site or nerve root herniation into the pseudomeningocele sac. [6],[9],[10],[11] Focal radiculopathy as described in the present case secondary to mass effect due to small pseudomeningocle is rather atypical. It has been postulated that there is often very minimal operative site dead space after minimally invasive spine surgery This reduces formation of large seroma/CSF collections decreasing the chances of wound dehiscence and leakage due to minimal dead space. While mostly inconsequential, th ey can become symptomatic in a delayed fashion possibly due to subtle "ball-valve" mechanism of CSF leak leading to a pseudomeningocele formation. [1] The absence of an obvious dural injury with lack of symptoms of CSF hypotension can mask the recognition of this complication. Treatment options for symptomatic pseudomeningoceles include bed rest, over-sewing the wound, needle aspiration, epidural blood patch, CSF diversion, and surgical evacuation of the pseudomeningocele with primary durotomy repair. [4],[9],[12] Our patient developed severe recurrent radiculopathy with an enlarging cystic lesion in the operative site secondary to nerve root compression and required surgery.

To conclude, small pseudomeningocele can be an unusual cause of recurrent radiculopathy following minimally invasive surgical approaches. Though they are usually asymptomatic due to minimal dead space, a clinical presentation akin to the case described here can result and should be appropriately suspected and managed. Although technically challenging during minimally invasive surgeries, every attempt to repair a dural tear should be made if recognized to avoid this unusual complication.

 
  References Top

1.Asha MJ, George KJ, Choksey M. Pseudomeningocele presenting with cauda equina syndrome: Is a ′ball-valve′ theory the answer? Br J Neurosurg 2011;25:766-8.  Back to cited text no. 1
    
2.Williams BJ, Sansur CA, Smith JS, Berven SH, Broadstone PA, Choma TJ, et al. Incidence of unintended durotomy in spine surgery based on 108,478 cases: Neurosurgery 2011;68:117-24.  Back to cited text no. 2
    
3.Couture D, Branch CL Jr. Spinal pseudomeningoceles and cerebrospinal fluid fistulas. Neurosurg Focus 2003;15:E6.  Back to cited text no. 3
    
4.Hawk MW, Kim KD. Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas. Neurosurg Focus 2000;9:e5.  Back to cited text no. 4
    
5.Hanakita J, Kinuta Y, Suzuki T. Spinal cord compression due to postoperative cervical pseudomeningocele. Neurosurgery 1985;1:317-9.  Back to cited text no. 5
    
6.Rinaldi I, Peach WF Jr. Postoperative lumbar meningocele. Report of two cases. J Neurosurg 1969;30:504-7.  Back to cited text no. 6
    
7.Tsuji H, Handa N, Handa O, Tajima G, Mori K. Postlaminectomy ossified extradural pseudocyst. Case report. J Neurosurg 1990;73:785-7.  Back to cited text no. 7
    
8.Cobb C 3 rd , Ehni G. Herniation of the spinal cord into an iatrogenic meningocele. Case report. J Neurosurg 1973;39:533-6.  Back to cited text no. 8
    
9.Fridley JS, Jea A, Glover CD, Nguyen KP. Symptomatic postsurgical cerebrospinal fluid leak treated by aspiration and epidural blood patch under ultrasound guidance in 2 adolescents: Report of 2 cases. J Neurosurgery Pediatr 2013;11:87-90.  Back to cited text no. 9
    
10.Hadani M, Findler G, Knoler N, Tadmor R, Sahar A, Shacked I. Entrapped lumbar nerve root in pseudomeningocele after laminectomy: Report of three cases. Neurosurgery 1986;19:405-7.  Back to cited text no. 10
    
11.O′Connor D, Maskery N, Griffiths WE. Pseudomeningocele nerve root entrapment after lumbar discectomy. Spine 1998;23:1501-2.  Back to cited text no. 11
    
12.Ruban D, O′Toole JE. Management of incidental durotomy in minimally invasive spine surgery. Neurosurg Focus 2011;31:E15.  Back to cited text no. 12
    


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