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| LETTER TO EDITOR |
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| Year : 2012 | Volume
: 60
| Issue : 2 | Page : 256-257 |
Cervical pseudomeningocele as a cause of neurological decline after posterior cervical spine surgery
Steven L Morgan, Vibhor Krishna, Abhay K Varma
Department of the Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| Date of Submission | 12-Feb-2012 |
| Date of Decision | 27-Feb-2012 |
| Date of Acceptance | 16-Mar-2012 |
| Date of Web Publication | 19-May-2012 |
Correspondence Address:
Abhay K Varma
Department of the Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, SC
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.96434
How to cite this article:
Morgan SL, Krishna V, Varma AK. Cervical pseudomeningocele as a cause of neurological decline after posterior cervical spine surgery. Neurol India 2012;60:256-7 |
Sir,
Durotomy is a known complication of posterior cervical spine surgery. Despite intraoperative recognition and repair, a pseudomeningocele can result. In rare cases, cervical pseudomeningocele can produce neurological deterioration secondary to cord herniation and/or cord compression. [1],[2]
A 49-year-old male presented with progressive cervical myelopathy. Magnetic resonance imaging (MRI) revealed cervical stenosis at C3-C6 levels, with cord compression and myelomalacia [Figure 1]. Patient underwent posterior decompression and instrumented fusion from C3 to C6. An unintended durotomy with cerebrospinal fluid (CSF) leak was encountered over the right C6 root during surgery. Primary repair was unsuccessful. The defect was covered with DuraMatrix® (Stryker Corporation, Kalamazoo, MI, USA), and sealed with Duraseal™ (Confluent Surgical, Waltham, MA, USA). Patient had an uneventful postoperative recovery and reported subjective improvement in the numbness and dexterity of both hands. On postoperative day 12, he presented again with worsening quadriparesis. The skin incision was well healed and there was no noticeable bulge of the incision. Emergent MRI revealed a posterior cervical pseudomeningocele extending from the inferior border of C2 body to the superior border of C6 body with severe compression of spinal cord [Figure 2]. Urgent re-exploration was undertaken. A dural rent was seen over the right C6 root with communication with the pseudomeningocele. No herniation of neural tissue through the dural defect was noted. A fresh repair was undertaken. Duragen® (Integra Lifesciences, Plainsboro, NJ, USA) patch was placed on the inside and DuraMatrix patch was then fashioned and placed on the outside of the dural tear. Repair was reinforced with Duraseal. In addition, a lumbar drain was placed intraoperatively and CSF diversion was continued for six postoperative days. Patient made steady improvements in neurologic function. A postoperative MRI at 6 months showed complete resolution of the pseudomeningocele [Figure 3].  | Figure 1: Sagittal T2-weighted preoperative image demonstrating stenosis with associated myelomalacia at the C3-C6 cervical segments
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 | Figure 2: Postoperative T2-weighted sagittal image demonstrating severe compression secondary to mass effect from posterior pseudomeningocele. T2 axial image at C3/4 demonstrates severe compression of the spinal cord secondary to pseudomeningocele
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 | Figure 3: 6 months post repair of pseudomeningocele with complete resolution of cord compression
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Posterior cervical decompression and fusion is an established method of cervical cord decompression in patients with multisegmental cervical spondylotic myelopathy. [3] The occurrence of a pseudomeningocele with cord compression following posterior cervical decompression is a rare cause of postoperative decline. Myelopathy secondary to post-surgical posterior cervical pseudomeningocele is rare, with few previous case reports. [1],[2],[4],[5],[6],[7] Neurological decline can result from cord herniation into the pseudomeningocele or direct pressure on the cord by the fluid-filled sac or both. [1],[2] Review of previous reports seems to indicate that herniation and incarceration of spinal cord through the dural defect presents in a delayed fashion (6 months to 15 years), [1],[2],[4],[5],[6],[7] whereas direct compression by an enlarging pseudomeningocele presents earlier, as in the present case. The likely explanation for delayed deterioration following spinal cord herniation and incarceration is gradual and prolonged ischemia of the cord. MRI scan is the diagnostic modality of choice. [7] Diagnosis prior to MRI typically involved a conventional myelogram. This is the first patient with post-cervical laminectomy neurological decline secondary to pseudomeningocele where the MRI has clearly demonstrated the pseudomeningocele compressing the cord. In the case reported by Hosono et al., [7] MRI demonstrated a pseudomeningocele, but no cord compression. Cord herniation into the pseudomeningocele was the cause of deterioration in that case.
Standard of care has been surgical repair of incidental durotomy with primary watertight closure using suture. Primary closure may not always be possible in far lateral durotomies, as in this patient. [8] Even a technically satisfactory primary closure can still be associated with continued CSF leakage rate of about 5-10%. [9] Recent advances such as collagen on lay (Duragen™) and fibrin glue products have been shown to decrease the incidence of CSF leakage through durotomy defects. [9],[10] Repair of the dura without primary closure and simply using collagen matrix on lay with fibrin glue has been demonstrated to result in an approximately 3% incidence of continued CSF leakage after incidental durotomy in a variety of surgical situations. [9] However, use of such dural on lay may result in a ball valve mechanism resulting in a tense pseudomeningocele as may have occurred in our case. Once a cervical pseudomeningocele develops, definitive treatment is surgical repair of the dural defect, particularly if there is associated neurological decline. In difficult-to-repair dural defects, surgical repair can be supplemented with temporary postoperative CSF diversion (lumbar drain). Awareness of rare possibility of neurological decline from posterior cervical pseudomeningocele can help in early diagnosis and quick remedial action to reverse the symptoms.
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| 9. | Narotam PK, Jose S, Nathoo N, Taylon C, Vora Y. Collagen matrix (DuraGen) in dural repair: Analysis of a new modified technique. Spine (Phila Pa 1976) 2004;29:2861-9.
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[Figure 1], [Figure 2], [Figure 3]
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