Abstract
We report the case of a 51-year-old man with no significant past medical history, who underwent elective revision spinal surgery and subsequently developed intracranial hypotension, remote cerebellar haemorrhage (RCH), and mild hydrocephalus on the fourth postoperative day. Remote cerebellar haemorrhage is a known complication of supratentorial surgery. This iatrogenic phenomenon may also occur following spinal surgery, due to dural tearing and rapid cerebral spinal fluid (CSF) leakage, resulting in intracranial hypotension and cerebellar haemorrhage. This complication may result in severe permanent neurologic sequelae; hence, it is of pertinence to diagnose and manage it rapidly in order to optimise patient outcome.
Highlights
We report the case of a 51-year-old man with no significant past medical history, who underwent elective revision spinal surgery and subsequently developed intracranial hypotension, remote cerebellar haemorrhage (RCH), and mild hydrocephalus on the fourth postoperative day
Soon after the computerized tomography (CT) myelogram, image-guided lumbar drain placement was performed, and 8cc of fibrin glue was injected at the site of the leak
Health care personnel should remain vigilant about the predisposing factors which may contribute to RCH, such as previous brain atrophy [3], patient positioning during surgery [6] possibly impairing venous drainage due to intraoperative head rotation which results in obstruction of the jugular vein at the first cervical vertebral transverse process, arterial hypertension, anticoagulation therapy [5], coagulopathy, aneurysm, arteriovenous malformation, older age, preoperative aspirin administration [16], male sex, intraoperative use of esmolol [16], preoperative seizures [16], preoperative antibiotic use [16, 19], and tumors [3, 21,22,23,24]
Summary
A 51-year-old male, with a remote previous history of L4-L5 spinal decompression and fusion, presented in our outpatient clinic with worsening lower back pain. Physical examination showed lumbar radiculopathy and neurogenic claudication, while a magnetic resonance imaging (MRI) scan of the lumbar spine revealed disc protrusions and high-grade spinal canal stenosis at the L2-L3 and L3-L4 levels. He underwent elective spinal decompression revision surgery, with an extension of instrumented fusion from L2-L5. On experiencing new onset persistent headaches on the second postoperative day, a computerized tomography (CT) myelogram was performed, and showed CSF leakage from a dural tear at the L3-L4 level (Figure 1). The patient’s subsequent hospital course was complicated by deep venous thrombosis and respiratory failure, and he was discharged to the rehabilitation unit after EVD removal, ten days after the open dural repair surgery. No residual neurological deficits were present at the time of discharge
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