[Surgical management of dural injuries and postoperative cerebrospinal fluid fistulas in spinal surgeries]

OBJECTIVE

To investigate the surgical management of dural injuries and postoperative cerebrospinal fluid (CSF) fistulas in spinal surgeries and to observe clinical outcomes, since intraoperative injury of dura mater and postoperative CSF fistulas are common complications of spinal surgeries.

METHODS

A retrospective research was designed and 405 patients with complete data who underwent spinal surgeries between June 2002 and March 2006 were acquired, including 298 cases of male and 107 cases of female, with the mean age of 46.2 years (ranging from 11 years to 78 years). The course of disease lasted from 3 months to 5 years. A total of 28 cases of intraoperative dural injuries and durotomies (28/405, 6.91%) were recorded, including 3 cases of cervical spinal surgery (3/152, 1.97%), 19 cases of thoracic and lumbar spinal surgery (19/239, 7.95%) and 6 cases of sacral surgery (6/14, 42.86%). CSF fistulas occurred in 6 cases of 28 patients. There were 2 cases in which no intraoperative dural injury was detected but CSF fistulas occurred after operation. The incidence of postoperative CSF fistula was 1.98% (8/405). Surgical management included closure of breach in the dura mater, oversewing every layer of the wound, bed rest and compression dressing and so on. Clinical outcomes of surgical management were recorded.

RESULTS

The average follow-up lasted for 1 year and 5 months (ranging from 3 months to 4 years). Preoperative symptoms remitted to different extents. There were 8 cases of postoperative CSF fistula which were cured ultimately. A total of 6 cases of CSF fistulas from dorsal injuries of dura mater were treated mainly by bed rest, compression dressing and reoperations, while 2 cases of fistulas from ventral and lateral injuries of dura mater were treated by additional continuous cerebrospinal fluid drainage using a lumbar subarachnoid catheter. One case of central nervous system infection occurred and was treated successfully by multi-disciplinary disposal.

CONCLUSION

Timely and correct surgical intervention and postoperative management can help to heal dural injuries in spinal surgeries and can prevent occurrence of postoperative CSF fistulas.

Intracranial hypotension following scoliosis surgery: dural penetration of a thoracic pedicle screw

The authors report on a 14 years old female with intracranial hypotension who had a history of spinal instrumentation surgery for scoliosis 3 months prior to her admission. She had been diagnosed with migraine in a neurology clinic and was under medical therapy when presented. During the investigation process, a right thoracic pedicle screw, which was penetrating and transversing the dura mater at the T3-T4 level was identified. The diagnosis and management of such a case is discussed. Knowledge of this entity is of extreme importance to spine surgeons, in order to prevent delayed diagnosis and possible complications.

Gunshot wounds to the spine: literature review and report on a migratory intrathecal bullet

Treatment of the complex injury to the spine produced by a gunshot wound remains controversial. Treatment depends on the physician's ability to understand mechanism of injury, principles of medical management, diagnostic imaging, and surgical options. Antibiotics are an important component of treatment and should be continued for a minimum of 7 days in cases of wounds that both perforate the colon and injure the spine. Corticosteroids do not affect neurologic outcome and therefore should not be used. Decompression and removal of intracanal bullets at T12 and below may improve motor function. In select cases of cervical injuries, removal of intracanal bullet fragments may be justified, particularly with incomplete lesions. Regardless of injury level, new-onset or progressive neurologic deterioration is an indication for urgent decompression. Optimal surgical timing remains a controversial issue, and more study is needed to develop treatment guidelines. Intrathecal migratory missiles represent a very rare subset of the gunshot wounds to the spine, and their treatment should be individualized. In this article, we review the literature and then describe the case of a migratory intrathecal bullet in the lumbar spine of a patient who presented with cauda equina-type symptoms.

Intrathecal migratory foreign body without neurological deficit after a gunshot wound

BACKGROUND CONTEXT

Penetrating bullets dissipate thermal and kinetic energy into surrounding tissues. Within the thecal sac, this is universally associated with neurological deficits.

PURPOSE

We report a case of intrathecal penetration of a bullet without neurological deficit.

STUDY DESIGN

Case report.

METHODS

A 14-year-old girl was shot in the back, entering adjacent to the L3 vertebra and settling within the spinal canal adjacent to the S1 vertebra. In the absence of neurological deficits, initial management was nonoperative.

RESULTS

Over the period of a week, the patient developed an episode of intense radicular pain, although her neurological examination remained normal. Location of the bullet was shown to vary from S1 to T12 on multiple imaging studies, and this was influenced by patient positioning. She subsequently underwent a bilateral hemilaminotomy and durotomy with excision of the intrathecal bullet.

CONCLUSIONS

Patients can avoid neurological injury even with an intrathecal gunshot wound. However, intrathecal bullets may then migrate and cause variable neurological complaints, necessitating surgical removal. Patient positioning can influence bullet location which can be useful in surgical planning.

Cerebrospinal fluid leak after anterior cervical disc fusion: an unusual cause of dysphagia and neck mass

OBJECTIVE

Dysphagia after anterior cervical disc fusion (ACDF) is a common complaint. We present two cases of dysphagia caused by a rare complication after ACDF: cerebrospinal fluid (CSF) leak into the neck.

STUDY DESIGN

A case series of two patients.

METHODS

Both patients underwent a chart review, comprehensive history, physical examination, flexible nasolaryngoscopy, and radiographic imaging. A literature review of the MEDLINE database (1966-2006), using key words "dysphagia" and "anterior discectomy," was performed.

RESULTS

We present two patients with persistent dysphagia after ACDF surgery caused by CSF leak into the neck. Their clinical presentation, physical and radiographic examination findings, and hospital course will be discussed.

CONCLUSIONS

CSF collection presenting as dysphagia and neck mass after ACDF must be included in the differential diagnosis because incision and drainage is contraindicated, and fine needle aspiration (FNA) must be performed under sterile conditions. Treatment including lumbar drain or re-exploration is appropriate.

Subdural hematoma following spinal cord stimulator implant

Headache following interventional procedures is a diagnostic challenge due to the multitude of possible etiologies involved. Presentation can be simple (PDPH alone) or complex (exacerbation of pre-existing chronic headache along with PDPH) or headache associated with a new onset intracranial process. Subdural hematoma is a rare complication of cranio-spinal trauma. Cranial subdural hematoma may present in an acute, sub-acute, or chronic fashion. Diagnosis of a subdural hematoma in the wake of a PDPH is difficult, requiring a high level of suspicion. Delayed diagnosis of subdural hematoma is usually related to failure to consider it in the differential diagnosis. Thorough history, assessment of the evolution of symptoms, and imaging studies may identify the possible cause and help direct treatment. Change in the character of initial presenting symptoms may be a sign of resolution of the headache or the onset of a secondary process. We report a case of acute intracranial subdural hematoma secondary to unintentional dural puncture during placement of a permanent spinal cord stimulator lead for refractory angina. There is need for careful follow-up of patients with a known post-dural tear. Failure to identify uncommon adverse events in patients with complicated spinal cord stimulator implantation may lead to permanent injury.

Acute spinal pain during an attempted lumbar epidural blood patch in congenital lumbar spinal stenosis and epidural lipomatosis

Congenital lumbar spinal stenosis is an uncommon condition that is often asymptomatic in young adults. Herein, we document the first reported occurrence of acute radicular back pain and associated congenital lumbar spinal stenosis in a healthy 24-year-old woman undergoing an epidural blood patch for treatment of a post-dural puncture headache related to an accidental dural puncture sustained during placement of a labor epidural catheter. The acute pain symptoms were elicited twice with injection of less than 1 mL of fluid into the epidural space during the fluoroscopically assisted epidural blood patch. Subsequent magnetic resonance imaging of the lumbar spine demonstrated shortened pedicle length consistent with severe congenital lumbar spinal stenosis and prominent epidural fat. We speculate that the transient increase in pressure within the epidural compartment following injection of a small amount of fluid could have compressed neural structures resulting in severe radicular pain. The prominent epidural fat could have prevented rapid disbursement of the injected fluid which could have further served to propagate the pressure increase throughout the epidural compartment. The unique radiographic features of congenital spinal stenosis could predispose some patients with this unrecognized condition to develop acute pain upon injection of a small amount of fluid into the epidural compartment. Unrecognized congenital lumbar spinal stenosis is an important addition to the differential diagnosis of acute radicular pain elicited during an epidural blood patch in previously asymptomatic patients.

Clinics in diagnostic imaging (119). Post-traumatic intracerebral pneumatocele

A 36-year-old man presented with cerebrospinal fluid rhinorrhoea after head injury in a road traffic accident three weeks prior to presentation. Magnetic resonance (MR) imaging demonstrated a hypointense cavity in the left frontal lobe communicating with the frontal horn of the left lateral ventricle, consistent with an intracerebral pneumatocele. The fistulous track communicating with the frontal sinus was demonstrated on the sagittal and coronal images. The patient underwent surgical decompression of the cavity and repair of the dural defect and fracture of the frontal bone. Postoperatively, the patient made excellent recovery. An intracerebral pneumatocele should be recognised on MR imaging, as potential complications include tension pneumocephalus and meningitis, and surgical treatment is indicated in most of the cases.

Dural damage due to a loosened hydroxyapatite intraspinous spacer after spinous process–splitting laminoplasty

✓Excellent results from laminoplasty for cervical spinal myelopathy have been reported in many studies. Nevertheless, C-5 nerve root palsy or axial pain such as neck and shoulder pain after laminoplasty are known postoperative complications. To the authors' knowledge, dural damage from dislocation of the hydroxyapatite intraspinous spacer due to absorption of the tip of the spinous process has not been reported. Two cases of dural damage from dislocation of the hydroxyapatite intraspinous spacer after laminoplasty are described.

Radiographs, computed tomography myelography, and magnetic resonance (MR) imaging revealed the dislocation of the hydroxyapatite intraspinous spacer, the absorption of the tip of the spinous process, and dural sac compression due to the hydroxyapatite intraspinous spacer. In one patient, the MR imaging studies revealed liquorrhea around the hydroxyapatite intraspinous spacers. Both patients underwent removal of the hydroxyapatite intraspinous spacer and attained good neurological recovery.

In patients with dislocation of the hydroxyapatite intraspinous spacer associated with absorption of the tip of the spinous process after spinous process–splitting laminoplasty, each case should be evaluated for aggravating symptoms of myelopathy, dural damage, and liquorrhea around the spacer.

Intracranial complications of cochlear implantation

OBJECTIVE

To describe intracranial complications after cochlear implantation in the pediatric and adult populations.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

A chart review of the intracranial complications and their management in 345 patients undergoing cochlear implantation was undertaken.

INTERVENTIONS

Variables, including age, sex, implant manufacturer, cause of deafness, intraoperative findings, and postoperative complications, were collected and analyzed.

MAIN OUTCOME MEASURE

Presence of intracranial complication of cochlear implantation.

RESULTS

There were 134 Nucleus-22 (Cochlear, Englewood, CO) devices, 50 Nucleus-24 devices, 118 Med-El (Durham, NC) devices, and 43 Advanced Bionics Corporation (Sylmar, CA) devices in 151 adults and 194 children. There was a 9.3% overall complication rate, with most (59%) being related to device failure. There were three intracranial complications (<1%), two in elderly individuals and one in a child. Two minor dural defects with cerebrospinal fluid leak at the site of the receiver/stimulator recess in Med-El devices were repaired intraoperatively with temporalis fascia. One elderly patient experienced an acute extensive subdural hematoma after Nucleus-24 implantation, which was treated successfully with immediate evacuation.

CONCLUSION

Intracranial complication rates associated with cochlear implantation are low, although potentially very serious. Surgeons should be aware of intracranial complications, especially in older individuals, and take immediate appropriate action.

The Frequency and Etiology of Intraoperative Dural Tears in 110 Predominantly Geriatric Patients Undergoing Multilevel Laminectomy With Noninstrumented Fusions

STUDY DESIGN

A retrospective analysis of the frequency and etiology of dural tears (DT), defined as an unintended incidental intraoperative durotomy, occurring in 110 predominantly geriatric patients undergoing multilevel laminectomies with noninstrumented fusions.

OBJECTIVE

To document the frequency and etiology of DT occurring in these older patients.

SUMMARY OF BACKGROUND DATA

The frequency and etiology of DT occurring in older patients are not well documented.

METHODS

The clinical (including comorbidities), neurodiagnostic, surgical procedures, and Short-Form 36 outcomes (questionnaires administered preoperatively, and 3, 6, 12 mo postoperatively) were retrospectively analyzed for these 110 patients with/without DT.

RESULTS

Intraoperative DT occurred in 10 of 110 patients. These patients were typically older (average 74 y with fistulas vs. 69 y old without fistulas), included a higher percentage of females (90% vs. 76%), and had undergone somewhat more extensive laminectomies (5.5 vs. 5.0 levels) with noninstrumented fusions (1.8 vs. 1.6 levels). Three factors seemed to contribute to DT. Marked ossification of the yellow ligament (OYL), documented in all 10 patients with DT, extended to and through the dura in 3 patients. For the 100 patients without DT, 57 exhibited moderate/hypertrophied yellow ligament and 22 showed marked OYL. Synovial cysts with marked OYL were observed in 5 of 10 patients with DT, whereas only 8 of 100 without DT had synovial cysts. Prior surgical scar, originally anticipated to be a major contributing factor to DT, was found in only 2 of 10 patients with DT (also with marked OYL) compared with 10% without DT. Short-Form 36 outcome data revealed improvement on 4 or 5 Health Scales over the first postoperative year for both populations.

CONCLUSIONS

Ten of 110 patients undergoing multilevel laminectomies and noninstrumented fusions developed unintended incidental DT attributed to OYL extending to/through the dura (3 patients), postoperative scar/marked OYL (2 patients), and synovial cysts/marked OYL (5 patients).

Complications of thoracic pedicle screws in scoliosis treatment

STUDY DESIGN

A retrospective study.

OBJECTIVE

To analyze complications with thoracic pedicle screws in scoliosis treatment at our Department over a 3-year period (1999-2001).

SUMMARY OF BACKGROUND DATA

The use of pedicle screws remains controversial for thoracic scoliosis for fear of complications.

METHODS

A total of 115 consecutive patients who underwent posterior fusion using 1035 transpedicular thoracic screws were reviewed. All patients presented a main thoracic scoliosis with a mean Cobb angle of 75.4 degrees (range, 60 degrees -105 degrees ). For thoracic screw placement, a mini-laminotomy technique was used, inserting a spatula inside the vertebral canal to palpate the borders of the pedicle. Postoperative CT scan was used in 25 patients (21.7%) to study a total of 311 screws, when the screw position was questionable.

RESULTS

An independent spine surgeon retrospectively reviewed medical records and radiographs of the patients, at a mean follow-up of 4 years. There were 18 screws misplaced (1.7%) in a total of 13 patients (11.3%). Screw malposition was symptomatic only in 1 patient (pleural effusion and fever) and asymptomatic in the other 12 cases (10.4%). Other complications included intraoperative pedicle fractures in 15 patients (13%), dural tears (without neurologic complications) in 14 cases (12.1%), and superficial wound infections in 2 (1.7%). Another operation for screw removal was performed in 5 patients (4.3%), due to pleural effusion (in 1 case), asymptomatic late lateral loosening of a malpositioned screw (in 1), and the possible future risks related the intrathoracic screw position despite the lack of any symptoms (in 3). Two cases (1.7%) were retreated due to wound infection, without removing instrumentation. There was no loss of correction at follow-up.

CONCLUSIONS

The thoracic pedicle screw placement in scoliosis patients requires utmost caution. The mini-laminotomy technique was beneficial in increasing safety of the procedure with an acceptable incidence of complications.

Pigmented villonodular synovitis originating from the lumbar facet joint: a case report

The authors successfully treated a rare case of pigmented villonodular synovitis (PVNS) that originated from the lumbar facet joint (L4-5). A 43-year-old man presented with a complaint of left severe sciatica causing difficulty in walking. Magnetic resonance imaging (MRI) demonstrated an extradural mass on the left side at L4 and the mass compressed the dural tube and was continuous with the left L4-5 facet joint. A computed tomography myelogram revealed an extradural defect of contrast medium at the L4 level and an erosion of the L4 lamina. A total synovectomy with unilateral osteoplastic laminectomy was performed. The histological findings were a diagnosis of PVNS. The patient's symptoms resolved completely and the MRI at postoperative 3 years demonstrated no recurrence of PVNS. It is important to totally remove the synovium, which is the origin of PVNS in order to prevent the recurrence. We think that our procedure is reasonable and adequate for lumbar PVNS.