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|Year : 2020 | Volume
| Issue : 4 | Page : 903-905
Subdural Hematoma Related to Dural Tear During Lumbar Spine Surgery: A Case Report and Review of the Literature
Department of Neurosurgery, Gaziantep Medical Park Hospital, Gaziantep, Turkey
|Date of Web Publication||26-Aug-2020|
Dr. Kadir Oktay
Gaziantep Medical Park Hospital, Neurosurgery Department, Sehitkamil District, Ertugrul Street, Gaziantep
Source of Support: None, Conflict of Interest: None
Subdural hematoma is a rare complication after lumbar spine surgeries. Most of the time, the reason for this complication is intracranial hypotension related to an unintended durotomy, and the main symptom is persistent orthostatic headache. The authors present the case of a-38-year-old woman who underwent lumbar discectomy. Three weeks after the surgery, she developed subdural hematoma related to dural tear during the procedure. Emergent hematoma evacuation with craniotomy and dural tear repair was performed simultaneously because of the herniation symptoms of the patient. Clinical findings, radiological assessments, and treatment modalities have been discussed in the presence of a literature review in this case report.
Keywords: Cerebrospinal fluid leak, durotomy, intracranial hypotension, lumbar spine surgery, subdural hematoma
Key Messages: Dural injuries during lumbar spinal surgery can cause intracranial hypotension and postural headache, is the main symptom of these patients most of the time. Neurosurgeons should be alert to the possibility of IH-related subdural hematoma formations in the presence of persistent headache and neurological deterioration.
|How to cite this article:|
Oktay K. Subdural Hematoma Related to Dural Tear During Lumbar Spine Surgery: A Case Report and Review of the Literature. Neurol India 2020;68:903-5
Intracranial hypotension (IH) is a syndrome in which volume depletion of the cerebrospinal fluid (CSF) results in various neurological symptoms. Most commonly, a small tear or defect in the spinal dural sac is the underlying lesion that results in CSF leakage and IH. Causes of IH can be classified as spontaneous (primary) and secondary. Knowledge of IH is essential to spine surgeons because small proportion of patients with spontaneous IH require spine surgery. Secondary causes of IH include spine trauma, degenerative spine disorders, and various spine-related diagnostic/therapeutic procedures (iatrogenic) such as lumbar puncture, spinal anesthesia, myelography, or chiropractic manipulations., We report a rare case of a patient with mental deterioration who suffered from IH-related subacute subdural hematoma following lumbar microdiscectomy operation.
| » Case Report|| |
A 38-year-old woman who underwent L5-S1 microdiscectomy in another clinic three weeks ago, was admitted to our department with the history of persistent headache for two weeks, and progressive neurological deterioration for one day. She had no medical history before the microdiscectomy procedure. In the assessment of the medical records of the previous hospital, dural tear repair for an unintended durotomy in the microdiscectomy operation was noted. She had no complaints during the first week postoperatively. She developed a mild headache which was ameliorated by bedrest and analgesics in the second week. On the fourteenth day of the surgery, she had leakage from her lumbar wound, and skin suturing was performed in the clinic where she underwent the first operation. After one week, her headache got worse progressively, and she was admitted to our clinic subsequent to recognization of neurological deterioration by the patient's family. She had no history of recent head trauma to account for these symptoms. Her neurological examination revealed that she presented stupor and left hemiparesis. Her pupils were equal and reactive to light. There was mild CSF leakage to outside from her lumbar incision. Laboratory parameters were within the reference ranges, and she had no coagulation abnormalities. An emergent computed tomography (CT) of the brain was performed revealing 15-mm-thick subacute subdural hematoma in the right frontoparietal region with 6 mm midline shift, and ventricular effacement suggesting the mass effect [Figure 1]a. Because of CSF leakage from her incision, lumbar spinal magnetic resonance imaging (MRI) was performed and dural tear was determined [Figure 2]. Her neurological status was poor, and we planned to perform a decompressive craniectomy in case of brain swelling. Thus, we performed craniotomy instead of burr-hole drainage. Emergent hematoma evacuation with craniotomy, and lumbar dura repair was performed simultaneously under general anesthesia without any complication. Primary suturing and application of fibrin sealant were performed as dura repair. The postoperative course was uneventful and postoperative CT scan revealed complete resolution of subdural hematoma [Figure 1]b. The presence of a vascular lesion was ruled out by brain MRI and MR angiography. The patient recovered completely and discharged without any neurological deficits.
|Figure 1: (a) Preoperative brain computed tomography scan demonstrating a 15-mm-thick chronic subdural hematoma in the right frontoparietal region (white arrow) with 6 mm midline shift and ventricular effacement suggesting the mass effect (black arrow). (b) Postoperative brain computed tomography scan revealing complete resolution of subdural hematoma|
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|Figure 2: Sagital and axial T2-weighted lumbar spinal magnetic resonance imaging scans revealing dural tear in the operation area|
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| » Discussion|| |
Spine surgery is linked with a wide range of intraoperative complications including wrong-level surgery, nerve root lesion, vascular injury, and dural tearing. Dural tear is not uncommon, with reported incidence rates of 1–17%. Most common causes of dural tear are eroded or thin dura, dura adhesion, and redundant dura in patients diagnosed with a tight spinal stenosis. It is particularly prevalent in patients who have epidural fibrosis, and scar tissue adherent to the dura during revision spine surgery. In a study which was performed among the neurosurgeons of the United Kingdom, the rates of dural tears for spinal operations were 3,5% for primary discectomy, 8,5% for spinal stenosis surgery, and 13,2% for revision discectomy. In the literature, for revision spine surgery the rates are higher than primary operations as expected, ranging from 8,1% to 17,4%.
Most of the IH cases take a benign course. Orthostatic headache is the most significant symptom of IH which is activated by standing up and ameliorated by lying down. Neck pain or stiffness is also a common complaint in patients with IH. Nausea, vomiting, dizziness, cranial nerve palsies, radicular symptoms, and seizures are the other neurological symptoms which are reversible after successful treatments. There are also fatal complications following CSF leak including formations of intracranial hematomas in different locations such as subdural hematoma (SDH), epidural hematoma (EDH), intracerebral hemorrhage (ICH), and remote cerebellar hemorrhage (RCH).,,, Dural injuries resulting in CSF leakage are usually the result of direct trauma. Excessive nerve root traction, instrumentation, or residual bony spicules have been reported to lead to a durotomy. Intracranial hypotension results from CSF drainage, leading to low intracranial pressure, volüme, and resultant tension on the pain-sensitive dural sinuses which is causing the postural headache. As the intracranial pressure drops, the subdural space expands, stretching the bridging veins, and the rupture of the fragile subdural veins induces SDH formation. Dehydration and cerebral atrophy are the contributing factors for SDH formation.,,
The first step of the treatment of the patients with IH is the conservative modalities including bedrest in the Trendelenburg position, analgesics, hydration, steroids, and abdominal binder. Additionally, intravenous or oral caffeine because of the vasoconstrictive effect, and a stimulation of the CSF production may be beneficial. Postural headache and other symptoms usually resolve within 3-5 days with conservative treatments. Intracranial complications should be considered in the presence of persistent headache and neurological deterioration.
Subdural hematoma formation is one of the intracranial complications which have the potential of causing catastrophic results. Therefore, it should be treated very carefully. There are three ways of treatment when SDH has been detected following lumbar spine surgery; (1) Conservative treatments without any surgical interventions, (2) Repair of the dural tear with the exploration of the previous lumbar wound, (3) Evacuation of the hematoma with a cranial approach. The great majority of subdural hematomas in patients with dural tears can be successfully managed with conservative treatments or by directing treatment at the spinal CSF leakage without the need for hematoma evacuation. But only cranial interventions should be performed in the presence of the herniation symptoms.
The literature review demonstrated that only seven cases with SDH following lumbar spine surgery have been reported previously. Three of them were revision surgeries, and three of the surgeries included instrumentations. Three of the cases were managed with conservative modalities, and two of them were treated with the repair of dural tears. Only two of the cases required hematoma evacuation because of neurological deterioration [Table 1]. In our case, a 38-year-old woman developed subacute subdural hematoma in three weeks following a dural tear during lumbar discectomy surgery. Hematoma evacuation with craniotomy and lumbar dura repair was performed simultaneously.,,
|Table 1: The reported cases of subdural hematoma following dural tear during lumbar spine surgery|
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In conclusion, dural tear is a common complication of the spinal surgeries. Especially revision surgeries, and the interventions including instrumentations increase the rates of this complication. Dural injuries resulting in CSF leakage can cause IH, and postural headache is the main symptom of these patients most of the time. Postural headache typically resolves within 3-5 days with conservative treatments. However, neurosurgeons should be alert to the possibility of IH-related subdural hematoma formations in the presence of persistent headache and neurological deterioration.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]