Large Pseudomeningocele Research Articles

Management of a large pseudomeningocele and cerebrospinal fluid fistula after microsurgical resection of recurrent lipomyelomeningocele in children.

Symptomatic retethering in pediatric patients following complex spinal dysraphism surgery for lipomyelomeningocele (LMMC) repair occurs in approximately 20% of cases. Common complications after repeat surgery for retethering include infection, pseudomeningocele (PMC), and cerebrospinal fluid (CSF) fistula. The authors of this report aim to describe the treatment options for large PMCs or CSF fistulas in a series of patients who underwent repeat surgery for recurrent LMMC at their institution. Additionally, they review management strategies from the literature. This retrospective, descriptive case series includes patients with LMMC who required revision surgery for postoperative PMC or CSF fistula after recurrent untethering procedures at the authors' institution between 2013 and 2023. The surgical strategies for managing PMC and CSF fistula were examined. References for the narrative literature review were sourced from the PubMed and MEDLINE databases. Eight patients underwent surgery for recurrent retethering due to worsening neurological deficits, including 2 (25.0%) patients who had undergone multiple previous untethering surgeries. The mean duration between symptom onset and repeat surgery was 11.30 ± 5.50 months. Of these 8 cases, 3 (37.5%) developed large postoperative PMCs and CSF fistulas. These patients required a mean of 4.7 ± 2.9 revision surgeries (range 3-8). Management often involved multiple techniques, including local wound revision, dural repair or sealing, mechanical coverage, tissue reconstruction, and external or internal fluid diversion. In all cases, PMCs and CSF fistulas were successfully treated, and at the final follow-up, all patients had stable neurological conditions compared to their preoperative status. Managing symptomatic retethering after LMMC repair is challenging, often complicated by PMC and CSF fistulas due to missing normal anatomical tissue layers, large defects, and poor dorsal support. Successful treatment typically requires a combination of techniques to address CSF-related issues. In the authors' experience, a multifaceted approach and familiarity with these methods are essential for achieving optimal outcomes.

Abstract 291: Iatrogenic Intracranial Hypotension with Pseudomeningocele, CSF Fistula and CSF Leaks Following Dural Repair and Spinal Cord Stimulator Placement

Background Intracranial hypotension (IH) is a rare complication of cerebrospinal fluid (CSF) leakage. It can occur either spontaneously (primary) or as a result of trauma or medical intervention (secondary or iatrogenic). The incidence of IH is approximately 5 per 10,000 cases annually. Iatrogenic IH can occur following procedures that involve dural injury, such as spinal surgery, spinal cord stimulator (SCS) lead migration, or lumbar puncture. Reduced CSF flow leads to a decrease in CSF volume and subsequent intracranial hypotension, manifesting as a postural headache. Diagnosis of a CSF leak or CSF venous fistula (CVF) is typically made using CT or MR myelography. Dynamic myelography is reserved for multiple level or high‐flow CSF leaks. Dural defects are commonly treated epidural blood patch or surgical repair. In CSF venous fistula (CVF), embolization therapy may be employed. Objective: We present a case of iatrogenic IH following traumatic dural injury due to SCS lead migration complicated by the development of a large pseudomeningocele, CVF and CSF leaks. Methods A 46‐year‐old female presented with disabling postural headaches. Her surgical history included an L4‐S1 posterior fusion and laminectomy complicated by durotomy and repair in 2003, followed by 2 epidural SCS placements and bilateral SI joint fusion. In 2010, she experienced intermittent headaches described as the worst of her life, which resolved after two months. Shortly before her current presentation, the headaches returned, accompanied by tinnitus, a sensation of underwater hearing, autonomic dysfunction, confusion, and brain fog, raising concern for a CSF leak. CT myelography revealed arachnoiditis and a large pseudomeningocele at L4‐L5, though no active CSF leak was identified. Nonetheless, the patient was referred to a CSF leak specialist and treated empirically with an epidural blood patch at T12‐L1, leading to cessation of her symptoms. Five months later, the patient suffered a fall, and her symptoms recurred. CT thoracic spine revealed migration of the lower SCS epidural lead into the thecal sac. A repeat CT myelogram showed a pseudomeningocele at the left L4‐L5 region with a possible extradural leak near the L4‐L5 pedicles and a CSF leak at the T12‐L1 SCS epidural lead. Due to suspected CSF leak at multiple levels, dynamic CT myelogram was employed. Dynamic CT myelogram revealed an expansion of contrast extravasation at the left L4‐L5 pedicles and vascular uptake of contrast in the left L4‐L5 neural foramina raising suspicion of a CVF versus systemic contrast absorption in the pseudomeningocele containing the CSF leak. The patient was treated with epidural blood patches at L3‐L4, L4‐L5, and T12‐L1, microsurgical repair of the pseudomeningocele with venous ligation, and a lumbar peritoneal shunt, which resulted in significant improvement of her postural headache symptoms. L4‐S1 posterior fusion revision was performed. SCS was unable to be removed due to fusion with the bone. Conclusion Iatrogenic IH can result from persistent, recurrent, or new CSF leaks even after dural repair. In patients who develop new or ongoing postural headaches following treatment, re‐evaluation of symptoms along with repeat CT myelography may be warranted to identify any underlying issues.

Fascia lata packing and tension suturing for symptomatic pseudomeningocele after recurrent cervical intradural tumour resection

In recurrent posterior cervical intradural tumour resections, serious complications can be developed. The dural can become affected by inflammatory factors or removed during tumor resection; if cerebrospinal fluid (CSF) leakage cannot be stopped by duraplasty, artificial meninges or fascia repair, large pseudomeningocele can develop posteriorly within the soft tissue of the neck. When the pressure of the CSF cannot be maintained steadily, persistent clinical symptoms can occur, such as postural headache or central fever. Moreover, the skin can also be penetrated in a few patients even after extension of the drainage duration, lumbar cistern drainage or skin suturing, leading to the induction of life-threatening intra-cranial infections. Is there a simple and effective surgical method to address this scenario? The aim of this study was, therefore, to investigate the effectiveness of fascia lata packing and tension suturing in the treatment of symptomatic pseudomeningocele after recurrent posterior cervical intradural tumour resection. In our study, nine consecutive spinal surgery patients were recruited from January 2008 to January 2018. All pseudomeningoceles were combined with postural headache, central neurological fever or wound non-union. There were 3 cases of melanocytoma, 3 cases of nasopharyngeal carcinoma metastasis, 2 cases of breast cancer metastasis, and 1 case of spinal canal lymphadenoma. Standard patient demographics, diagnosis, post-operative symptoms, wound healing time, and the largest pre- and last follow-up pseudomeningocele area on axial MRI sections were recorded. All cases were followed-up successfully, from 12 to 24 months, with an average of 15.3 months. Our observations indicate that all wounds healed successfully. The wound union time was 20.7 days on average. After wound union, these patients became symptom free. The largest cerebrospinal fluid area on axial MRI sections improved significantly from 42.9 ± 5.01 cm2 at p re-operation to 6.6 ± 1.89 cm2 at 1 year post-operation (P < 0.05); Our data indicate that .the proposed procedure is simple, safe and effective. And more importantly, it allows rapid closure of any cerebrospinal fluid leakage pools.

Novel Technique of Percutaneous Fat Graft for Repair of Persistent Large Pseudomeningocele

Pseudomeningocele is an uncommon but problematic complication in lumbar spine surgery. Initial conservative measures frequently are successful, but persistence requires additional management. The current surgical approach can involve a range of techniques, including blood patches, hydrogel/fibrin sealants, drains, open surgical repair of the dura, or a combination of the all techniques if symptoms persist. This report demonstrates a novel technique for repair via a percutaneous approach to deliver an autologous fat graft into the pseudomeningocele. A 64-year-old woman with a history of multiple complex lumbar spinal surgeries with previous durotomy had persistent positional headaches from an unresolved pseudomeningocele from L3 to L5. The defect and symptoms remained after all available surgical options were exhausted, including blood patches, hydrogel sealants (Duraseal), and open surgical repair with muscle and Gelfoam grafts. After autologous fat harvest, the patient underwent percutaneous repair of the pseudomeningocele with simultaneous aspiration of cerebrospinal fluid and injection of fat into the defect space. At 3 months postoperatively, the patient's symptoms were resolved with no clinical or radiographic findings of nerve root or thecal sac impingement and complete obliteration of the pseudomeningocele. This less-invasive approach offers the option of open surgical repair for persistent pseudomeningocele with the use of autologous graft material.

Postlaminectomy lumbar pseudomeningocele with nerve root entrapment: a case report with review of literature.

Pseudomeningocele is a rare but well-recognized complication of lumbar surgery. Most of the patients tolerate the presence of the cyst well, however, some present with back pain and spinal claudication, presumably due to neural compression. We report a case who presented with radicular symptoms and signs after disk surgery. The cause of his pain was nerve root herniation into large pseudomeningocele. The diagnosis was made by magnetic resonance imaging. The patient underwent surgery for the pseudomeningocele with reduction in the nerve root into the dural canal and primary closure of the dural defect. Postoperative results were gratifying.

An unexpected cause of orthostatic headache

A 41-year-old woman underwent a left L5-S1 hemilaminectomy 7 months prior to the onset of an acute postural headache. MRI brain revealed intracranial hypotension. Two empiric blood patches were unsuccessful. CT myelogram showed a large pseudomeningocele at the surgical site not noted on MRI lumbar spine obtained 2 months postoperatively. Facet instability post-mesial facetectomy likely …

An unusual stab wound causing a traumatic pseudomeningocele at the craniocervical junction

A stab wound to the craniocervical junction complicated by a pseudomeningocele has been reported rarely. A 65-year-old man was stabbed with a knife, and the blade penetrated the space between the occipital bone and the atlas. On admission, he presented with quadriparesis; the left arm was predominantly affected. The sensory level was at C2 on the left side. T2-weighted MRI showed a focal area of hyperintensity at the cervicomedullary junction, localized to the left of the spinal cord. The wound was carefully cleaned and closed. Follow-up MRI revealed a large pseudomeningocele along the trajectory, which resorbed completely without intervention. The quadriparesis improved progressively, except for the left arm, which improved only slightly. The asymptomatic insignificant meningocele completely improved spontaneously without surgery.

Pseudomeningocele Following Lumbar Surgery as a Cause of Low Back Pain: Report of a Case

This paper reports a case of postoperative pseudomeningocele, which was not diagnosed initially with clinical data alone; the condition was caused by an inadvertent meningeal tear that occurred during spinal surgery. Pseudomeningocele formation is a rare postoperative complication of spinal surgery characterized by the extradural accumulation of cerebrospinal fluid following extravasation through an inadvertent dural tear. A 69-year-old woman had undergone laminectomy and posterolateral fusion at the L3-L5 level 7 years previously, for spondylolisthesis with spinal stenosis syndrome; the postoperative course was uneventful. Six years after the surgery, the patient experienced increasingly severe low back pain radiating to both gluteal regions. After prolonged but unresponsive conservative treatment, a large pseudomeningocele at the L2-L3 level was identified by myelography. The findings of MRI supported the diagnosis of pseudomeningocele. Surgery via the posterior approach exposed the pseudomeningocele after a complete laminectomy of L2-L4. The pseudomeningocele was excised 7 years after the initial operation. Complete recovery and excellent remission of symptoms was noted at 6 months after the surgery. Pseudomeningocele must always be considered as a cause of chronic back pain in patients who have undergone previous lumbar surgery, no matter how many years after the surgical procedure the symptoms may occur.

SPINAL CORD HERNIATION INTO ASSOCIATED PSEUDOMENINGOCELE AFTER BRACHIAL PLEXUS AVULSION INJURY

Abstract OBJECTIVE Posttraumatic spinal cord herniation is a rare condition. We describe a case of spinal cord herniation into an associated pseudomeningocele after a brachial plexus avulsion injury. CLINICAL PRESENTATION A 33-year-old man began to develop progressive Horner's syndrome 14 years after a brachial plexus avulsion injury. At a clinical presentation 17 years after that injury, sensory disturbance and a unilateral pyramidal sign were also evident. In addition to myelography and computed tomographic myelography findings, coronal magnetic resonance imaging scans clearly demonstrated herniation of the spinal cord into a large pseudomeningocele inside the C7–T1 intervertebral foramen. Another pseudomeningocele inside the T1–T2 intervertebral foramen was also noted. INTERVENTION The patient underwent a C6–T2 laminectomy, during which the spinal cord was found to be herniated through a dural defect into a pseudomeningocele at the C8 root level, and a second dural defect was also shown, with an arachnoid outpouching that included an avulsed T1 root. The spinal cord herniation was reduced and the dural defects were repaired. After surgery, the patient showed no significant neurological changes, and his condition stabilized. CONCLUSION Brachial plexus root avulsions may result in the formation of pseudomeningoceles and can lead to spinal cord herniation. Coronal magnetic resonance imaging is useful to demonstrate spinal cord herniation as well as pseudomeningoceles. Surgical treatment is recommended for such cases with progressive symptoms to prevent further deterioration.

Pseudomeningocele After Spine Surgery -3 cases of different symptoms-

Pseudomeningocele after spine surgery can cause various symptoms, but it can also be silent. We experienced 3 cases of pseudomeningocele with different symptoms and we analyzed the characteristics of each case. A small pseudomeningocele without connection to the subarachnoidal space can show no symptoms. A pseudomeningocele with a small dural tear and it's abutted on the duramater at a small portion can produce sciatica and limitations of straight leg raising due to adhesion of the cauda equina around the dural tear. In addition, a large pseudomeningocele with a big dural and lamina defect can produce back tenderness furthermore, a patient with such a lesion can have low back pain and leg pain that are aggravated by an increment of abdominal pressure or by impact to the body and even by walking. Pseudomeningocele should be suspected when symptoms recur after spine surgery and especially in the case of dural tear during an operation