Dural Laceration Research Articles

Retroperitoneal Pseudomeningocele Complicated by Meningitis Following a Lumbar Burst Fracture

This case report demonstrates an unusual complication after anterior decompression and fusion of a lumbar burst fracture. The treatment of this patient involved placement of a computed tomography-guided percutaneous drain and intravenous antibiotics to treat an infected retroperitoneal pseudomeningocele. A case of an anterior retroperitoneal pseudomeningocele complicated by meningitis is presented. This pseudomeningocele occurred in a patient after an L3 burst fracture associated with a dural laceration. The patient was admitted to the authors' trauma unit after a motor vehicle accident with an acute L3 fracture associated with incomplete paraplegia. He underwent an urgent anterior corpectomy, strut grafting, and instrumentation. At surgery, he was noted to have a large anterior dural laceration. After surgery, a large retroperitoneal pseudomeningocele developed that became infected with Staphylococcus epidermidis. After placement of a computed tomography-guided percutaneous drain and intravenous antibiotics, the pseudomeningocele resolved. His anterior fusion healed uneventfully and his neurologic deficit improved dramatically. A case of an anterior retroperitoneal pseudomeningocele complicated by meningitis is presented. This pseudomeningocele occurred in a patient after an L3 burst fracture associated with a dural laceration. The patient was treated successfully with computed tomography-guided percutaneous drain placement and intravenous antibiotics. He made an excellent functional recovery after a severe neurologic injury.

Cranial burst fracture in infants: acute recognition and management.

In the past, the diagnosis of "growing skull fracture" or "diastatic fracture" has included a subset of injuries better referred to as "cranial burst fracture." Cranial burst fracture, typically associated with severe injury in infants less than 1 year of age, is a closed, widely diastatic skull fracture accompanied by acute cerebral extrusion outside the calvarium. We treated 11 such infants at the LeBonheur Children's Medical Center and 2 at the Children's National Medical Center from January 1986 through December 1994. Infants ranged in age from 1 to 17 months, with an average age of 5.7 months. All presented with marked scalp swelling and a Glasgow Coma Scale score of 10 or less. Twelve had a history consistent with severe injury (motor vehicle accident, 7, abuse 5). The cause of injury in one patient remains unproven. Surgery (reduction of herniated cerebral tissue, repair of large dural laceration, and cranioplasty) was usually performed within 10 days of injury, a time period long enough to assure hemodynamic stability and resolution of acute cerebral swelling, yet sufficiently brief to avoid the chronic changes (scarring, parasitization of scalp vessels by damaged cortex) associated with a "growing skull fracture." Prompt repair of cranial burst fracture may prevent ongoing brain injury such as has been neuropathologically demonstrated in patients with "growing skull fracture." Magnetic resonance imaging establishes the diagnosis of cranial burst fracture in equivocal cases, rendering unnecessary a "waiting period" to see if scalp swelling resolves. Our experience, together with information in the neuropathological and neurosurgical literature, suggests that cranial burst fracture is associated with severe trauma, requires expeditious treatment, and has been underdiagnosed in the past, leading to "growing skull fracture," a condition requiring more extensive surgery.

Fractures of the floor of the anterior cranial fossa.

We treated 28 patients with anterior cranial fossa floor fractures. Computed tomography (CT) scans adjusted to bone density disclosed three fracture types: (1) penetrating fractures through the orbita or ethmoid sinus; (2) simple or multiple linear fractures; and (3) extensive comminuted anterior cranial fossa floor fractures. Thirteen patients underwent emergent surgery for treatment of open depressed fractures (most common in type 3 fractures), for foreign bodies (in type 1 fractures), and for optic canal decompression. Large dural lacerations were always present in patients with type 3 fractures, and repairs were made with dural substitutes. Only one patient developed postoperative cerebrospinal fluid leakage. Nine (32%) of the patients in our series had visual involvement, but visual acuity recovered or improved in six patients. Our study shows that initial neuroradiologic evaluation with CT scans is important in patients with frontobasal fractures, and that secure dural repair during primary operation helps prevent cerebrospinal fluid leakage.

Titanium dural clip testing

Spinal dural lacerations can be a difficult part of spinal surgery. A dural tear can result in complications that include meningitis and pseudocyst formation. Appropriate treatment for these tears is generally suturing, using 4.0, 5.0, or 6.0 suture. For successful closure of dural lacerations, the authors have collaborated in the design of a titanium clip, which resembles an aneurysm clip in appearance and is applied with standard aneurysm clip appliers. The titanium clip was tested against suture and Weck hemostatic vascular clips and found to have excellent tissue-approximating capacity and a rapid application time. It is believed that this is an appropriate device for the repair of spinal dural lacerations.

Hyponatremia and dehydration in an 11-month-old infant from cerebrospinal fluid loss from an inapparent traumatic dural laceration

The most common causes of hyponatremia in infants and young children are 1) water intoxication, 2) the syndrome of inappropriate antidiuretic hormone (SIADH), and 3) excessive sodium losses via the gastrointestinal tract, the kidneys, or the skin. In children with externalized ventriculostomy catheters, the loss of large volumes of cerebrospinal fluid (CSF) may also result in hyponatremia if there is inadequate sodium replacement.1 We describe a case of severe hyponatremia and dehydration in an 11-month-old child with an undetected traumatic dural laceration that permitted leakage of CSF.

Can lacerations of the thoraco-lumbar dura be predicted on the basis of radiological patterns of the spinal fractures?

Encroachment upon the spinal canal, separation of the pedicles, associated fractures of the laminae are assumed to be related to dural lacerations consequent to burst fractures of the thoracolumbar spine. Owing to the possible occurrence of early or delayed complications of meningeal discontinuations, the predictive value of these signs has been analyzed in a consecutive series of 50 patients, who were submitted to surgery. Dural tears were found to occur at a rate of 60%, without any statistically significant relation with any of the examined signs. The results were not consistent with the thesis that lacerations of the dura can be predicted on the basis of radiological signs.

腰椎破裂骨折に硬膜損傷を生じた１例

We report a case of dural laceration occurring with lumbar burst fractures which was suggested by preoperative MRI and confirmed by Surgery.The patient was a 37-year-old man who fell from a 6m height while working and was transported to our hospital. Plain X-ray studies showed burst and laminar fractures of the third and fourth lumbar vertebrae. However, only slight numbness was noted in the left dorsal femoral reqion. Since preoperative MRI suggested dural laceration, posterior decompression and fixation with pedicle screws were performed and the patient's postoperative course was uneventful.Surgical treatment is indicated for thoracolumbar burst fractures especially when accompanied by neurological symptoms or shows marked instability. However, dural laceration may be present even though neurological symptoms are unremarkable as in the present case. Preoperative detection of dural laceration is considered to be important for selection of appropriate treatment.

開頭手術により著明な眼球突出が改善した多量の眼か内異物症例

A 20-year-old man presented with severe exophthalmos on the left as a result of a traffic accident. X-ray films revealed that foreign bodies, suspected of being parts of the windshield, had extended into the orbital apex. An intracranial lesion, however, could not be excluded. Craniotomy (fronto-zygomatic approach) was performed to remove the orbital foreign bodies, while preserving the optic nerve, and to identify intracranial foreign bodies in a wide surgical field. No dural lacerations or intracranial foreign bodies were observed during surgery. Total removal of the orbital foreign bodies was accomplished via the left fronto-zygomatic approach. Postoperatively, there was marked improvement in the severe exophthalmos, and visual acuity was restored. This type of surgical procedure is a good approach for removing deep orbital foreign bodies and checking for the presence of possible intracranial foreign bodies.

Diagnosis and Treatment of Cauda Equina Entrapment in the Vertical Lamina Fracture of Lumbar Burst Fractures

Posterior dural lacerations associated with lumbar burst fractures are caused by impaction of the dural sac into the vertical lamina fracture. Neural elements may be extruded outside of the dura and become entrapped in the lamina fracture. This diagnosis must be made before surgery and is based on the patient's clinical presentation, the fracture pattern, and the radiographic findings. Entrapped neural elements can be successfully extracted from the lamina fracture by an opening laminoplasty of the posterior neural arch. Patients with lumbar burst fractures and radiographic evidence of posterior displacement of the neural elements in the lamina fracture should undergo posterior exploration of the spinal canal, extraction of cauda equina neural elements, and repair of the dural laceration before any spinal reduction maneuver.

Die endonasale, endoskopisch kontrollierte Versorgung von Duradefekten der Rhinobasis

18 patients presenting a circumscribed cerebrospinal fluid (CSF-) leak in the region of the ethmoidal roof, the olfactory cleft or the sphenoidal sinus, were operated on via the endonasal route. Dural laceration could be attributed to paranasal sinus surgery (iatrogenic CSF-leak, N = 11) and to other traumas (N = 6). In one case, no obvious cause was detectable (spontaneous CSF-leak). Using the 70-degree angular optical device, the dural lacerations were closed by autogenous grafts of conchal mucosa with the help of fibrin glue. The average time of postoperative observation was 17 months. No liquorrhoea, meningitis or cerebral abscess was observed postoperatively.

Dural laceration occurring with burst fractures and associated laminar fractures.

Dural laceration occurring with burst fractures and associated laminar fractures.

Diagnosis and Treatment of Cauda Equina Entrapment in the Vertical Lamina Fracture of Lumbar Burst Fractures

Posterior dural lacerations associated with lumbar burst fractures are caused by impaction of the dural sac into the vertical lamina fracture. Neural elements may be extruded outside of the dura and become entrapped in the lamina fracture. This diagnosis must be made before surgery and is based on the patient's clinical presentation, the fracture pattern, and the radiographic findings. Entrapped neural elements can be successfully extracted from the lamina fracture by an opening laminoplasty of the posterior neural arch. Patients with lumbar burst fractures and radiographic evidence of posterior displacement of the neural elements in the lamina fracture should undergo posterior exploration of the spinal canal, extraction of cauda equina neural elements, and repair of the dural laceration before any spinal reduction maneuver.

Dural Laceration in Burst Fracture of Thoracolumbar Spine

Dural Laceration in Burst Fracture of Thoracolumbar Spine

Recurrent lumbar disc herniation

Recurrent lumbar disc herniations are one cause of the failed back surgery syndrome. The differential diagnoses include retained fragments, spinal stenosis, spinal instability, scar tissue (arachnoiditis and epidural fibrosis), and medical and psychosocial factors. Recurrent herniations occur with a frequency of approximately 15%. They usually recur at the same level and on the same side as in previous discetomy. These patients usually have a pain-free interval of greater than 6 months. Physical findings are most informative when compared with previous findings. Neurotension signs may be caused by epidural fibrosis rather than disc herniation. Magnetic resonance imaging enhanced with gadolinium diethylenetriaminepentaacetic acid/dimeglutemine is the best study to distinguish between epidural scar and herniated disc material. The recurrence rate may or may not be influenced by the type of original discectomy but there is a lower incidence of recurrent herniation when the original procedure includes a fusion. Revision lumbar surgeries have a lower change of good results and a higher incidence of complications compared with primary back procedures. However, in the properly screened patient with an identified recurrent or mechanical lesion, the surgical results of revision laminectomy can yield roughly an 80% chance of good outcome. Techniques of revision laminectomy and the repair of dural lacerations are described.

Frontobasal fractures in children : Probst R.;Fiebach A.;Moser A., Laryngo-rhino-otol. (1990) 69/3 (150–154)

In 1987, four children between 5 and 13 years of age with severe frontobasal trauma and dural tears were treated operatively. A CSF rhinorrhea was manifest clinically in only two cases. In addition high-resolution computerised tomography was essential in diagnosis and planning of the operation. In each of the cases an intracranial pneumatocele indicating dural laceration was shown. The fractures were confirmed during surgery in: Case 1. The roof of the ethmoid sinus and the roof of the orbit. Case 2. Both the sphenoid sinuses. Case 3. The roof of the ethmoid sinus and the posterior wall of the frontal sinus. Case 4. The roof of the ethmoidal sinus and the posterior wall of the frontal sinus. The ontogenetically oldest part of the paranasal sinuses in the floor of the anterior cranial fossa forming the anterior part of the roof of the ethmoid bone is the site of predilection for fractures, even in children. The anterior cranial fossa was exposed in each case through a paranasal subfrontal access, in the first case combined with a frontal craniotomy by a neurosurgeon, because of the fracture of the roof of the orbit. In the second case the dural injury had to be closed at a second neurosurgical operation, because of a recurrence of the CSF leak. The third and fourth cases were treated by nasal surgery alone.

Prophylaxis of Posttraumatic Seizures

The issue of routine anticonvulsant prophylaxis for early and late posttraumatic epilepsy (PTE) has received much attention in the medical literature. Such problems as lack of standard definitions for early and late PTE, the retrospective design of most studies, the wide variability of inclusion and exclusion criteria, and the varied duration of follow-up make this body of literature extremely difficult to evaluate. Severe head trauma appears to cause injured neurons to become hyperexcitable; this in turn brings about the formation of an epileptogenic focus during the time between trauma and seizure occurrence. Both military and civilian head injury populations have been used to evaluate the incidence of PTE. Early seizures (i.e., less than 7 days) occur in approximately 3-5 percent of the head injury patients in both the military and civilian groups. Factors increasing this incidence include intracranial hematoma, focal neurologic deficits, posttraumatic amnesia (PTA) lasting greater than 24 hours, depressed skull fracture, and age less than 5 years. The incidence of late seizures is directly related to the extent of brain damage. The military population, composed primarily of cases with penetrating head injury, is associated with a late PTE incidence of approximately 30-50 percent. Closed head injuries in the military population involve a 5-15 percent seizure incidence. Late PTE incidence after head injuries in the civilian population is less than 5 percent. Risk factors associated with late PTE include loss of consciousness or PTA lasting greater than 24 hours, dural lacerations, depressed skull fractures, and various computerized tomography deficits. These factors vary slightly between the military and civilian populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of Compound-Depressed Skull Fractures in Children with Replacement of Bone Fragments

A retrospective study of 31 consecutive cases of compound-depressed skull fractures treated by bone fragment replacement between October 1983 and August 1990 was performed. Epidemiology, clinical features, therapy, and outcome were examined and compared with previous series. A protocol is presented for bone fragment treatment intraoperatively and use of intravenous antibiotics (nafcillin and Claforan) perioperatively, despite the degree of wound contamination or dural violation. Of the 31 cases, 15 had dural lacerations with 4 of these requiring patching with pericranium. The degree of wound contamination varied, with only 8 cases considered clean. The average age of patients treated was 8.6 years. At follow-up (average of 26.5 months), all patients had solid bone fusions and well-healed wounds. There were no instances of wound infection or osteomyelitis. No patient required subsequent cranioplasty. It is proposed that bone fragment removal for compound-depressed skull fractures, regardless of the degree of contamination, the presence of dural laceration, or the degree of intracerebral injury, is not necessary and that bone fragment replacement avoids a second operation for cranioplasty.

Dural laceration occurring with burst fractures and associated laminar fractures.

The cases of sixty patients in whom a burst fracture of a thoracic or lumbar vertebral body had been treated with posterior instrumentation and arthrodesis less than two weeks after the injury were retrospectively reviewed. Thirty of the patients had an associated laminar fracture. Eleven of the thirty, all of whom had a lumbar fracture and a preoperative neurological deficit, were noted at operation to have dural laceration. In four of the patients who had dural laceration, neural elements were entrapped between the fragments from the laminar fracture. None of the remaining thirty patients who did not have a laminar fracture had dural laceration (p = 0.0002). Univariate and multivariate statistical analysis revealed no significant association of the dural laceration with the patients' age or sex, or with the radiographic characteristics of the spine. There was a significant association between dural laceration and neurological deficit (p = 0.0001). In our series, the presence of a preoperative neurological deficit in a patient who had a burst fracture and an associated laminar fracture was a sensitive (100 per cent) and specific (74 per cent) predictor of dural laceration. The presence of this fracture pattern and an associated neurological deficit also predicted a risk of dural laceration with entrapped neural elements. This information may influence decisions as to whether an anterior or a posterior surgical approach should be used in such patients.

Dural Lacerations and Thoracolumbar Fractures

In the pre-CT era, Miller et al. reported the presence of dural lacerations (DL) and herniations of the cauda equina in a group of patients with thoracolumbar fractures that involved separation of the pedicles, as detailed on plain radiographs. Recently, these injuries have been well characterized on CT scan. We retrospectively reviewed our series of thoracolumbar burst fractures to assess the predictive value of CT for the presence of a DL, and the clinical significance of this finding. Twenty-five patients with 27 levels of injury were assessed. Dural lacerations were noted in eight (32%) of the cases. These were significantly associated with posterior element fractures noted on axial CT, and with motor neurologic deficits. There was no correlation between the presence of a DL and the degree of spinal canal compromise. Dural lacerations occur relatively frequently in patients with thoracolumbar fractures that require operative management. Their presence should be of particular concern in those cases with a motor deficit on presentation and a posterior element fracture on axial CT scan.

Hemiplegia Cruciata caused by a Stab Wound of the Spinal Cord

A 56-year-old female sustained a neck laceration by a piece of glass, which broke when she fell backward. She immediately became quadriplegic and was transported to a local hospital, then deteriorated and was referred to the authors' hospital. Neurological examination revealed quadriplegia that was particularly pronounced in the right arm and left leg. Pain sensation was decreased in the right upper and lower extremities below the C3 level. Cervical spine films showed glass fragments in the gap between the occipital bone and the C1 arch. Computed tomography dramatically demonstrated glass fragments that had become fixed in the spinal cord at the spinomedullary transition. A suboccipital craniectomy and C1 laminectomy allowed visualization of the dural laceration. Opening of the dura exposed a glass fragment penetrating the upper cervical spine just caudal to the left tonsil. It was successfully removed with a hemostat clamp. Postoperatively, the patient was soon able to walk without assistance. To the authors' knowledge, upper cervical spinal cord injury caused by glass has previously been reported only twice, although broken glass is a common cause of wounds. Also, this patient exhibited signs of "hemiplegia cruciata," which is thought to be due to damage to the pyramidal decussation.