Giant pseudomeningocele after spinal surgery: A case report

Pseudomeningocele-a rare complication following thoracic spinal decompression surgery: clinical features, treatment guidelines, technical notes, and evaluation of results

PURPOSE

Pseudomeningocele (PMC) is a rare complication following thoracic spinal decompression surgery. The aim of this study is to assess the clinical features and treatment of PMC and provide the technical notes with revision surgery.

METHODS

Between January 2010 and December 2019, patients who developed PMC after posterior thoracic surgery were enrolled. An additional 25 patients who suffered cerebrospinal fluid leakage (CSFL) but did not develop PMC in the same period were randomly selected. General data, intra-operative factors, CSFL position, cost, modified Japanese Orthopaedic Association (mJOA) scores, patient satisfaction, and clinical features were recorded and compared between the two groups.

RESULTS

Eighteen patients were diagnosed with PMC after thoracic spinal surgery. The average length, width, and depth were 16.25 ± 5.73 cm, 6.96 ± 3.61 cm and 4.39 ± 2.2 cm, respectively. The most common symptom was neurological deficits following incision problems and headache. Compared with the control group, the PMC group showed a longer duration of initial surgery, greater estimated blood loss, an increased rate of CSFL on the ventral side, reduced mJOA scores, and lower patient satisfaction at the final follow-up.

CONCLUSION

PMC is a rare complication of thoracic surgery with an incidence of 1.12%. PMC typically occurs at the upper and lower thoracic spine, resulting in increased health care costs, poorer neurological recovery, and a lower rate of patient satisfaction. The management of PMC should be individualized depending on diagnosis time and symptoms.

Spontaneous Resolution of Postoperative Giant Frontal Pseudomeningocele

Cranial pseudomeningoceles are abnormal extradural collections of cerebrospinal fluid. Postoperative giant cranial pseudomeningoceles have been rarely reported in the literature and have no specific treatment guidelines. The optimal management strategy for this condition differs among authors, varying from conservative approach to surgical intervention. A spontaneous resolution of postoperative giant frontal pseudomeningocele is reported. A 41-year-old female presented a pseudomeningocele 3 weeks after a right frontal meningioma surgical resection. The pseudomeningocele progressed during the first 1.5-month postoperatively despite percutaneous aspiration and compressive bandage, it then shrank spontaneously and was completely resolved at the 15^th month since the surgery. Nonoperative treatment with a close follow-up could be a good option for asymptomatic giant pseudomeningoceles, resulting in a spontaneous resolution.

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.

Management of Giant Sacral Pseudomeningocele in Revision Spine Surgery

BACKGROUND

Giant pseudomeningoceles are an uncommon complication of spine surgery. Surgical management and extirpation can be difficult, and guidelines remain unclear.

METHODS

Here, we present a 56-year-old female patient with a history of grade III L5-S1 spondylolisthesis who was treated with 2 prior spine surgeries. The patient was treated with bone grafting for pseudarthrosis and instrumentation from L4 to ilium. After unsuccessful intraoperative and postoperative cerebrospinal fluid drainage and dural repair, the patient presented to the emergency room with debilitating positional headaches.

RESULTS

The patient underwent dural repair with bovine pericardial patch inlay sutured with 7-0 prolene, blood patch, and a dural sealant. Plastic surgery performed a layered closure, using acellular dermal matrix over the dural closure. The bilateral paraspinal flaps were advanced medially to cover the entirety of the acellular dermal matrix, and the fasciocutaneous flaps were then advanced to the midline for a watertight closure. At 3-month follow-up, the patient was headache free and had returned to her activities of daily living.

CONCLUSIONS

We conclude that early consultation with plastic surgery can be greatly beneficial to effectively extirpate dead space and resolve giant sacral pseudomeningoceles, especially if there is concern of persistent cerebrospinal fluid leakage due to relatively immobile avascular soft tissue as a result of prior revision surgery.

Compression of a giant pseudomeningocele causing transient anoxic seizures-a case report

Transient anoxic seizure upon application of pressure on a giant pseudomeningocele has never been reported in the literature; such abrupt changes in intracranial pressure due to large volume of cerebrospinal fluid (CSF) translocation, if left untreated may lead to permanent cerebral hypoxic injury and death. Here we describe a case of a 26-year-old woman who had undergone lumbar disc surgery in another unit few months ago and developed a large lump around her back. Any pressure on the lump resulted in headaches and at times episodes of seizures. Clinical examination revealed a very large fluid-filled lump consistent with a giant pseudomeningocele, confirmed by an MRI. A video EEG while applying pressure on the lump was recorded. The patient developed a typical seizure attack with a characteristic pattern of cerebral anoxia, and a paired ECG showed irregular rhythm with junctional and ventricular ectopic beats during the latter part of the attack, raising a suspicion of asystole. Upon relieving the pressure off the lump, the patient gradually regained consciousness with no permanent neurological deficit. We then discuss the pathophysiology of anoxic seizures and highlight the need to be vigilant in managing patients with such lesions in order to prevent permanent cerebral hypoxic injury and death.

Craniocervical Pseudomeningocele Following Cerebellar Meningioma Resection: Demonstration of Neck of Pseudomeningocele With Three-Dimensional Isotropic T2-Weighted SPACE Sequence at 3 Tesla (3T) Magnetic Resonance Imaging

Postoperative pseudomeningocele is an uncommon complication of craniospinal surgery. Diagnosis is reached on a postoperative computed tomography and magnetic resonance (MR) imaging. Demonstration of the location and dimension of the dural defect before surgical therapy is a very important. T1- and T2-weighted MR images revealed a significant pseudomeningocele extending from left cervicooccipital region. Magnitude and phase-contrast-MR images showed a cerebrospinal fluid (CSF) flow into pseudomeningocele, but they no revealed dural defect. Three-dimensional isotropic T2-weighted SPACE sequence revealed a signal void indicating CSF flow into pseudomeningocele and location and exact size of dural tear. Three-dimensional isotropic T2-weighted SPACE sequence is certainly the noninvasive and optimal method for demonstrating postoperative pseudomeningocele sacs. It demonstrates a pseudomeningocele regardless of an existing communication with the dural membrane.

Giant postsurgical pseudomeningocele by SPECT/CT cisternography

We describe a case of a 32-year-old man with a giant pseudomeningocele seen on MRI examination 6 months after spinal surgery. Radionuclide SPECT/CT cisternography performed after intrathecal suboccipital injection of In-DTPA identified the site of cerebral spinal fluid leak at the L4 level, and the patient underwent surgical correction of the dural defect. A repeat MRI examination 8 months later showed no signs of recurrence.