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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

Lee A Tan, Manish K Kasliwal, John E O'Toole 
 Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA

Correspondence Address:
Manish K Kasliwal
Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
USA




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;62:325-327


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 2021 Feb 28 ];62:325-327
Available from: https://www.neurologyindia.com/text.asp?2014/62/3/325/137013


Full Text

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}{Figure 2}{Figure 3}

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.

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