Cervicothoracic intraspinal pseudomeningocele with cord compression after a traumatic brachial plexus injury

Intraspinal pseudomeningoceles: A rare complication of spinal trauma and surgery

We present two cases of acute and delayed presentations of intraspinal pseudomeningoceles, which is a rare complication of spinal trauma or surgery. Our goal is to discuss the pathophysiology, clinical presentation, imaging findings, and treatment of this rare entity. This diagnosis should be considered in patients with unexplained neurologic symptoms in the setting of prior cervical spine injury or surgery.

Repair of Delayed Meningeal Cyst after Spinal Surgery with Paraspinal Muscle Flap under Microscope

BACKGROUND

Delayed meningeal cyst (DMC) is a rare complication after spinal surgery that is often ignored by clinicians, and its in-depth research is infrequent. In particular, no consensus has been reached about its surgical treatment. We found that patients with a DMC failed after conservative treatment, epidural blood patch, subarachnoid drainage, and initial attempts to eliminate the meningeal cyst. Therefore, we introduce the application of a paraspinal muscle flap repair under a microscope for the treatment of DMC.

METHODS

In this study, 13 patients who were repaired by a paraspinal muscle flap under a microscope for DMC from January 2007 to January 2017 were retrospectively reviewed. Their ages were 18-68 years old (mean age 48.7 years). The course of the disease ranged from 3 weeks to 28 months after the operation for the primary disease, with an average of 10.6 months. Length >5 cm was called a large DMC and length >8 was called a giant DMC. By analyzing the effect of surgical treatment, we summarized the treatment experience of DMC and evaluated the risk factors for the formation of DMC.

RESULTS

All patients were treated with paraspinal muscle flap repair under a microscope, and they healed well after the operation. There was no cerebrospinal fluid leakage or other operation-related complication. The mean follow-up was 16.5 months. Reexamination of the spine MRI showed no recurrence of the DMC.

CONCLUSIONS

The application of paraspinal muscle flap under a microscope combined with glue, bedrest, and CSF drain, was an effective option for the patients with DMC.

Compressive cervicothoracic pseudomeningocele as a rare manifestation of idiopathic intrathecal hypotension after past trauma: a review

PURPOSE

Spontaneous intracranial or intrathecal hypotension (SIH) is an underdiagnosed phenomenon predominantly presenting with low cerebrospinal fluid (CSF) pressure and postural headache in the setting of CSF leak. Extrathecal CSF collections causing compression of the spinal cord or nerve roots present an even rarer subset of this disease. We aim to describe this pathology in a comprehensive manner while illustrating with a case of our own.

METHODS

We present a literature review on spinal idiopathic pseudomeningoceles and their neurological implications illustrated with a case of an anterior compressive pseudomeningocele between C2 and D7. Further investigations through a myelography and myelo-CT were able to postulate a CSF leak through a discogenic osteophytic microspur at the level C5-C6.

RESULTS

Spinal manifestations are uncommon in cases of idiopathic or spontaneous CSF leak, occurring in about 6% of patients, but myelopathy and radiculopathy involving all spinal segments do occur. In contrast to the cranial complaints, the spinal manifestations usually are not positional and are caused by mass effect from an extradural CSF collection.

CONCLUSION

The utility of multiple imaging modalities such as dynamic myelography and the use of epidural blood patches and fibrin glue polymers should be explored, and surgery is an option if the symptoms persist despite other measures.

Challenges of Managing Patients with Symptomatic Large Traumatic Cervical Pseudomeningoceles

BACKGROUND

Traumatic cervical pseudomeningoceles (TCPs) occur secondary to traction of the cervical nerve roots resulting in violation of the dura. Surgical repair is not necessary in most cases because pseudomeningoceles have a high propensity to spontaneously resolve with conservative management alone. Currently, there are a limited number of cases of large TCPs (large is defined as ≥6 cm in greatest diameter), and there is no established guideline for the management of such lesions.

CASE DESCRIPTION

We describe the cases of 2 young men in their 20s who were involved in a motor vehicle accident. Both patients suffered a brachial plexus injury and developed large TCPs. Patient 1 was treated surgically for TCP using a combined intra-/extradural approach using a fascia lata graft. Patient 2 was ultimately treated nonsurgically because a spontaneous resolution of the pseudomeningocele was achieved over the period of 7 months after the accident. Both patients underwent brachial plexus repair surgery consisting of spinal accessory nerve transfer to the suprascapular nerve and intercostal nerve transfer to the musculocutaneous nerve.

CONCLUSIONS

Disease progression of TCPs is a dynamic process, and even large lesions may spontaneously resolve without surgical intervention. When surgery is indicated, a definitive dural repair using a fascia lata graft to cover the dural tear intra- and extradurally is an effective method. Surgery must be planned carefully on a case-by-case basis, and close follow-up with thorough physical examination and serial imaging is critical to monitor disease progression.

Large Compressive Pseudomeningocele Causing Early Major Neurologic Deficit After Spinal Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

Large compressive pseudomeningocele causing a major neurologic deficit is a very rare complication that is not well described in the existing literature.

METHODS

Institutional review board consent was obtained to study 2552 consecutive extradural spinal surgical cases performed by a single senior spinal surgeon during a 10-year period. The surgeon's database for the decade was retrospectively reviewed and 3 cases involving postoperative major neurologic deficits caused by large compressive pseudomeningocele were identified.

RESULTS

The incidence of postoperative compressive pseudomeningocele causing major neurologic deficit was 0.12% (3/2552) per decade of spinal surgery with approximately 1.3% of cases incurring incidental durotomy. Average age of the patients was 57 years (range 45-78). One patient had posterior cervical spine surgery, and 2 patients had posterior lumbar surgery. All 3 patients had intraoperative incidental durotomy repaired during their index procedure. Large compressive pseudomeningocele causing major neurologic deficit occurred in the early 2-week postoperative period in all patients and was clearly identified on postoperative magnetic resonance imaging. All 3 patients were treated with emergent decompression and repair of the dural defect. All patients recovered neurologic function after revision surgery.

CONCLUSIONS

Incidental durotomy and repair causing a large compressive pseudomeningocele after spine surgery is a rare and potentially devastating event. Early postoperative magnetic resonance imaging assists in the diagnosis. Emergent decompression combined with revision dural repair surgery may result in improved outcomes. Surgeons should be cognizant of this rare cause of early postoperative major neurologic deficit in patients who had previous dural repair.

Brachial plexus injury mimicking a spinal-cord injury

Objective: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.

Clinical presentation: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.

Intervention: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.

Conclusion: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.