Spinal cord compression from traumatic anterior cervical pseudomeningoceles

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.

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.

Rare Complications of Cervical Spine Surgery: Pseudomeningocoele

STUDY DESIGN

This study was a retrospective, multicenter cohort study.

OBJECTIVES

Rare complications of cervical spine surgery are inherently difficult to investigate. Pseudomeningocoele (PMC), an abnormal collection of cerebrospinal fluid that communicates with the subarachnoid space, is one such complication. In order to evaluate and better understand the incidence, presentation, treatment, and outcome of PMC following cervical spine surgery, we conducted a multicenter study to pool our collective experience.

METHODS

This study was a retrospective, multicenter cohort study of patients who underwent cervical spine surgery at any level(s) from C2 to C7, inclusive; were over 18 years of age; and experienced a postoperative PMC.

RESULTS

Thirteen patients (0.08%) developed a postoperative PMC, 6 (46.2%) of whom were female. They had an average age of 48.2 years and stayed in hospital a mean of 11.2 days. Three patients were current smokers, 3 previous smokers, 5 had never smoked, and 2 had unknown smoking status. The majority, 10 (76.9%), were associated with posterior surgery, whereas 3 (23.1%) occurred after an anterior procedure. Myelopathy was the most common indication for operations that were complicated by PMC (46%). Seven patients (53%) required a surgical procedure to address the PMC, whereas the remaining 6 were treated conservatively. All PMCs ultimately resolved or were successfully treated with no residual effects.

CONCLUSIONS

PMC is a rare complication of cervical surgery with an incidence of less than 0.1%. They prolong hospital stay. PMCs occurred more frequently in association with posterior approaches. Approximately half of PMCs required surgery and all ultimately resolved without residual neurologic or other long-term effects.

Imaging characteristics of cervical spine extra-arachnoid fluid collections managed conservatively

OBJECTIVE

Determine the MRI characteristics of large post-traumatic cervical spine extra-arachnoid collections managed conservatively in clinically stable patients and whether evidence of clinical or imaging deterioration materialized.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective search for all patients (>16 years old) over a 17-months period who had an extra-arachnoid fluid collection reported on a post-traumatic cervical spine MRI. Patients were excluded if they had surgery for an unstable fracture (n = 21), emergent decompression (n = 1) or lacked a follow-up MRI within 15 days (n = 1). Two MSK radiologists recorded the size, morphology and MRI signal characteristics of the collections.

RESULTS

Eight patients (5 male, 3 female) met the inclusion criteria (mean age 40 years; range 19-78 years). Seven of the eight patients had fluid collections that demonstrated thin, tapered margins, extended >7 vertebral bodies and involved >180 degrees of the spinal canal. The signal characteristics of these collections varied: hyper-T1/iso-T2 (n = 1), iso-T1/T2 (n = 3), hyper-T1/hypo-T2 (n = 3) and mixed-T1/T2 (n = 1). Six of seven collections were ventral. Follow-up MRI demonstrated resolution/significant decrease in size (n = 4 between 1 and 12 days) or no change/slight decrease in size (n = 3; between 2 and 11 days). None of the seven fluid collections enlarged, no patient had abnormal cord signal, and no patient's neurologic symptoms worsened. One of eight patients had a dorsal "mass-like" collection that was slightly smaller 9 days later.

CONCLUSION

In stable patients with large, tapered post-traumatic cervical spine extra-arachnoid collections managed non-surgically, none developed (1) clinical worsening, (2) abnormal cord signal or (3) collection enlargement, regardless of the collection's signal characteristics.

Traumatic Retropharyngeal Pseudomeningocele with Atlanto-Occipital Dislocation in a Neurologically Intact Patient

Traumatic retropharyngeal pseudomeningoceles occur rarely, are associated with severe trauma, and have been reported in patients with significant neurologic deficits at presentation. We report the rare occurrence of a pseudomeningocele following a high-speed motor vehicle accident. Neurological examination showed the patient to be briskly following commands, with intact cranial nerve, motor, and sensory function. CT/MR imaging showed subarachnoid hemorrhage involving the interpeduncular cistern, a clivus fracture, a right occipital condyle fracture, an atlanto-occipital subluxation, aortic arch transection (stable and contained on CT angiogram), multiple rib fractures on the right side with associated pneumothorax, hemothorax and pulmonary contusions. His cervical spine was stabilized in a halo. He was subsequently managed in the intensive care unit and remained neurologically intact. A repeat MRI showed the interval development of a 2×1.5 cm pseudomeningocele at the craniocervical junction medial to the left occipital condyle communicating with the left anterolateral aspect of the spinal canal. Traumatic pseudomeningoceles are associated with large deceleration forces at the time of injury and are usually associated with significant neurologic deficits at presentation. However, they can arise and give rise to symptoms in a delayed fashion in trauma patients who are neurologically intact at initial presentation.

Traumatic anterior cervical pseudomeningocele causing intracranial hypotension successfully treated with blood patch: case report

Cervical pseudomeningocele is a rare complication of trauma. It develops when an extradural collection of cerebrospinal fluid (CSF) develops after a dural breach. The authors present the unusual case of a 33-year-old man with progressive headache, neck pain, mental status changes, and cardiopulmonary instability after polytrauma sustained from a motorcycle-versus-deer collision, without improvement during a 5-day hospitalization. Magnetic resonance imaging revealed a collection of CSF anterior to the cervical thecal sac compatible with an anterior cervical pseudomeningocele. A nontargeted epidural blood patch was performed with subsequent resolution of the patient's symptoms. Anterior cervical pseudomeningoceles are usually asymptomatic; however, these lesions can cause orthostatic headaches, neck pain, and cardiopulmonary compromise, as it did in the featured patient. Pseudomeningoceles should be included in the differential diagnosis for posttrauma patients with progressive neurological decline or postural headache, and blood patch may be an effective minimally invasive treatment.

Anterior spinal pseudomeningocele after C0-C2 traumatic injuries: role of the "dural transitional zone" in the etiopathogenesis

PURPOSE

Spinal pseudomeningoceles (SPM) are extradural collections of CSF (cerebrospinal fluid); a frequent association with upper cervical injuries (UCI) has been observed. We propose a possible etiopathogenetic mechanism supporting the formation of cervical SPM based on some considerations.

METHODS

We present four cases of SPM. All patients sustained a severe UCI. Three patients were symptomatic with delayed and progressive clinical signs.

RESULTS

One patient was misinterpreted as epidural hematoma and operated on due to progressive signs with postoperative clinical improvement. The rest of patients were treated conservatively; spontaneous reduction of CSF collection occurred. From a radiological standpoint: (1) a line of demarcation separated the intradural cervical compartment from the anterior epidural space, (2) CSF epidural collection was never evident at C0-C2 level and extended from C2 downwards, and (3) shape of collection was similar to epidural hematomas suggesting a ball-valve mechanism.

CONCLUSIONS

The dural layer at C0-C2 level is adherent to the thick ligamentous apparatus, as opposed to the segments below where it is solely covered by the posterior longitudinal ligament. A "transitional zone" of dura exists between the C0-C2 region and subaxial segment of the cervical spine. This watershed area constitutes a point of minor resistance. Lacerations of the meningeal layers, caused by severe UCI at the "transitional zone", drain CSF into the anterior epidural space and form SPM.