Fistula Formation Between the Disc and Dura after Percutaneous Endoscopic Lumbar Discectomy: A Case Report

STUDY DESIGN: Case report OBJECTIVES: To document fistula formation between the disc and dura by an unrecognized dural tear after percutaneous endoscopic lumbar discectomy (PELD). SUMMARY OF LITERATURE REVIEW: The risk of durotomy is relatively low with PELD, but cases of unrecognized durotomies have been reported. An effective diagnostic tool for such situations has not yet been identified. MATERIALS AND METHODS: A patient twice underwent transforaminal PELD under the diagnosis of a herniated lumbar disc at L4-5. She still complained of intractable pain and motor weakness around the left lower extremity at 6 months postoperatively. Magnetic resonance imaging showed no specific findings suggestive of violation of the nerve root. However, L5 and S1 nerve root injury was noted on electromyography. An exploratory operation was planned to characterize damage to the neural structures. RESULTS: In the exploration, a dural tear was found at the previous operative site, along with a fistula between the disc and dura was also found at the dural tear site. The durotomy site was located on the ventrolateral side of the dura and measured approximately 5 mm. The durotomy site was repaired with Nylon 5-0 and adhesive sealants. The patient's preoperative symptoms diminished considerably. CONCLUSIONS: Fistula formation between the disc and dura can be caused by an unrecognized dural tear after PELD. Discography is a reliable diagnostic tool for fistulas formed by an unrecognized durotomy.

Three Level Thoracolumbar Spondylectomy for Recurrent Giant Cell Tumour of the Spine: A Case Report

@#Giant cell tumour (GCT) is a benign tumour but can be locally aggressive and with the potential to metastasise especially to the lungs. Successful treatments have been reported for long bone lesions; however, optimal surgical and medical treatment for spinal and sacral lesions are not well established. In treating spinal GCTs, the aim is to achieve complete tumour excision, restore spinal stability and decompress the neural tissues. The ideal surgical procedure is an en bloc spondylectomy or vertebrectomy, where all tumour cells are removed as recurrence is closely related to the extent of initial surgical excision. However, such a surgery has a high complication rate, such as dura tear and massive blood loss. We report a patient with a missed pathological fracture of T12 treated initially with a posterior subtraction osteotomy, who had recurrence three years after the index surgery and subsequently underwent a three level vertebrectomy and posterior spinal fusion.

Remote Cerebellar Hemorrhage due to Cerebrospinal Fluid Leakage or Meningitis after Spinal Surgery: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of remote cerebellar hemorrhage (RCH) as a complication of spinal surgery. SUMMARY OF LITERATURE REVIEW: Remote cerebellar hemorrhage is rare but lethal as a complication of spinal surgery. Interestingly, dural tears and cerebrospinal fluid (CSF) leakage are reported in all published cases of RCH. MATERIALS AND METHODS: A 67-year-old man had posterior lumbar decompression and posterolateral fusion for spinal stenosis at L4/5/S1. Intraoperatively, the dura was torn and there was a loss of CSF. The dural tear was sutured immediately in a water-tight manner. After surgery, the patient complained of headache and dizziness. On postoperative day 44, brain magnetic resonance imaging (MRI) showed meningeal enhancement suggesting meningitis. On postoperative day 54, brain computed tomography (CT) showed cerebellar edema and hemorrhage, and external ventricular derivation was performed. RESULTS: The patient died. CONCLUSIONS: Special attention should be paid to prevent dural damage during spinal surgery or minimize CSF leakage in the case of dural damage and tears during spinal surgery, and CT and MRI should be promptly performed for symptomatic patients.

The Use of Vessel Loop Shoelace Technique for Closure of Wound Dehiscence Caused by Dural Tears Associated with Distractive Flexion Injury of Cervical Spine

STUDY DESIGN: A case report. OBJECTIVES: To report the use of the shoelace technique for treatment of wound dehiscence caused by dural tears. SUMMARY OF LITERATURE REVIEW: It is difficult to treat wound dehiscence caused by dural tears, as it can lead to infection, loss of soft tissue, and need for a long hospital stay. MATERIALS AND METHODS: An 18-year-old male who had been injured in a traffic accident was diagnosed with bilateral facet dislocation of C7-T1, with no neurologic deficit. Clear secretion appeared during the operation, but it disappeared after posterior fusion. The wound began to open about 3 weeks after the operation. We used the vessel loop shoelace technique to suture the wound. RESULTS: The patient had the stitches taken out in the outpatient clinic three weeks after suture. His wounds are healing without complication. CONCLUSIONS: The vessel loop shoelace technique may be a useful treatment for wound dehiscence caused by dural tears.

Predictable Imaging Signs of Cauda Equina Entrapment in Thoracolumbar and Lumbar Burst Fractures with Greenstick Lamina Fractures

STUDY DESIGN: A retrospective study. PURPOSE: The aim of present study was to investigate imaging findings suggestive of cauda equina entrapment in thoracolumbar and lumbar burst fractures. OVERVIEW OF LITERATURE: Burst fractures with cauda equina entrapment can cause neurologic deterioration during surgery. However, dural tears and cauda equina entrapment are very difficult to diagnose clinically or radiographically before surgery. METHODS: Twenty-three patients who underwent spinal surgery for thoracolumbar or lumbar burst fractures were enrolled in this study. In magnetic resonance imaging T2-weighted images of the transverse plane, we defined cauda equina notch sign (CENS) as a v-shaped image that entrapped cauda equina gathers between lamina fractures. We evaluated the fractured spine by using CENS and lamina fractures and the rate of available space for the spinal canal at the narrowest portion of the burst fracture level. We classified patients into entrapment group or non-entrapment group, based on whether cauda equina entrapment existed. RESULTS: Lamina fractures were detected in 18 (78.3%) and CENS were detected in 6 (26.1%) of 23 burst-fracture patients. Cauda equina entrapment existed in all the patients with CENS. In addition, the rate of available space for the spinal canal increased according to logistic regression. The size of the retropulsed fragment in the spinal canal was the most reliable of all the factors, suggesting cauda equina entrapment. CONCLUSIONS: CENS was the most predictable sign of cauda equina entrapment associated with burst fractures.

Clinical and Radiological Findings of Nerve Root Herniation after Discectomy of Lumbar Disc Herniation

The authors report 2 cases of nerve root herniation after discectomy of a large lumbar disc herniation caused by an unrecognized dural tear. Patients complained of the abrupt onset of radiating pain after lumbar discectomy. Magnetic resonance imaging showed cerebrospinal fluid signal in the disc space and nerve root displacement into the disc space. Symptoms improved after the herniated nerve root was repositioned. Clinical symptoms and suggestive radiologic image findings are important for early diagnosis and treatment.

Relationship between Lamina Fractures and Dural Tear in Low Lumbar Burst Fractures

PURPOSE: To investigate the relationship between the greenstick laminar fractures and the dural tear in low lumbar burst fractures and their optimal treatment. MATERIALS AND METHODS: We enrolled 51 patients (52 cases) who had been diagnosed with low lumbar burst fracture from June 2003 to May 2007. The average age was 39 years (range, 22 to 58), 30 male patients (58.8%), and 21 female patients (41.2%). Average follow-up periods was 19 months (range, 11 to 45). Lumbar CT scan were taken 1 mm slices in precision for all patients. We judged it incomplete fracture if lumbar CT scans show loss of cortical continuity over 3 slices if there is an aggrement of two among one radiologist and two orthopaedic surgeons reached a consensus. Dural tear and entrapment of nerve root were confirmed intraoperatively by the senior surgeon. RESULTS: In 52 burst fractures, complete lamina fractures occurred in 21 cases and there were green stick laminar fractures in 14 cases. Neurologic defect has been found in 12 cases, 5 (63%) from complete laminar fractures and 3 (37%) from green stick laminar fractures. Dural tears has been detected in 9 cases (26%), 4 (19%) from complete laminar fractures and 5 (36%) from green stick laminar fractures. CONCLUSION: Dural tear and nerve root entrapment can be accompanied in patients with green stick fracture. There is necessary to consider the possibility of dural tear and nerve root entrapment before operation and to indentify carefully to the presence of nerve root entrapment during operation.

Predictable Factors for Dural Tears in Lumbar Burst Fractures with Vertical Laminar Fractures

OBJECTIVE: The purpose of the present study was to determine the incidence of dural tears and predictable factors suggesting dural tears in patients who had lumbar burst fractures with vertical laminar fractures. METHODS: A retrospective review was done on thirty-one patients who underwent operative treatment for lumbar burst fractures with vertical laminar fractures between January 2003 and December 2008. All patients were divided into two groups according to existence of dural tears, which were surgically confirmed; 21 patients with dural tears and 10 patients without dural tears. Clinical and radiographic findings were analyzed for their association with dural tears. RESULTS: Among a total of 31 patients, dural tears were detected in 21 (67%) patients. A preoperative neurological deficits and mean separation distances of the edges in laminar fractures were found to be the reliable factors of dural tears (p=0.001 and 0.002, respectively). Decreased ratio of the central canal diameter and interpedicular distance were also the reliable factors suggesting dural tears (p=0.006 and 0.015, respectively). However, dural tears showed no significant association with age, sex, level of injury, absence of a posterior fat pad signal, the angle of retropulsed segment, or site of laminar fracture. CONCLUSION: Our study of lumbar burst fracture combined laminar fracture revealed that dural tears should be ruled out in cases of a preoperative neurological deficits, wide separation of the laminar fracture, severe canal encroachment, and wider interpedicular distance.

Remote Cerebellar Hemorrhage after Lumbar Spinal Surgery

Remote cerebellar hemorrhage (RCH) is rare but potentially lethal as a complication of spinal surgery. We recently experienced a case of RCH in a 61-year-old man who showed mental deterioration after lumbar spinal surgery. There was dural tearing with subsequent cerebrospinal fluid (CSF) loss during the surgery. Brain computed tomography scan revealed cerebellar hemorrhage, 3rd and 4th ventricular hemorrhage and pneumocephalus. He underwent suboccipital craniectomy and hematoma removal. The most important pathomechanism leading to RCH after spinal surgery has been known to be venous bleeding due to caudal sagging of cerebellum by rapid leak of large amount of CSF which seems to be related with this case. Dural repair and minimizing CSF loss after intraoperative dural tearing would be helpful to prevent postoperative RCH.

Successfull Management of a Life Threatening Cerebellar Haemorrhage Following Spine Surgery: A Case Report

Cerebellar haemorrhages are rare life-threatening complications following spine surgery that present challenges for their diagnostic and their therapeutic management. Their patho-physiology remains unclear.

Relevancy of Posterior Column Injury and Dural Tear in Unstable Burst Fracture

PURPOSE: To analyze the pattern of posterior column injury in unstable burst fractures and to predict the possibility of dural injury. MATERIALS AND METHODS: Retrospective review was carried out on 22 patients of unstable burst fracture from Nov. 1996 to Sep. 2003. The pattern posterior column injury was analyzed by simple x-ray, CT and MRI findings. In simple x-ray, authors analyzed laminar fracture, posterior facet injury, inter-spinous widening and inter-spinous malalignment, posterior bony injury by CT, posterior inter-spinous ligament injury and dural tear by MRI. The statistical analysis was performed using Mann-Whitney test and Chi-square test. RESULTS: There were 13 men and 9 women, and mean age was 41 years-old (18~65). The level of injury showed 15 cases in T12-L2, 6 in L3, 3 L4. In simple x-ray, findings were showed 13 cases (59.1%) in laminar fracture, 7 (31.8%) in posterior facet injury, 16 (72.7%) in inter-spinous widening and 8 (36.4%) in inter-spinous malalignment. In CT, findings were showed 13 (59.1%) in laminar fracture, 10 (45.5%) in posterior facet injury, 9 (40.9%) in transverse process fracture. In MRI, findings were showed 18 (81.8%) in posterior inter-spinous ligament injury and were not showed dural tear. The combined cases of posterior bony and ligamentous injury was 6 (27%) and 5 of 6 showed dural tear and the analysis of dural tear and radiologic findings was showed positive correlation (p=0.004). CONCLUSION: Posterior ligament injury was more frequent than bony injury in unstable burst fracture. Among the posterior bony injuries, dural tear was more frequent in facet injury. Authors confirmed all dural tear with operation. In cases of posterior bony injury combined with ligamentous injuries, the possibility of dural tear was significantly higher than that of single structural injury (p=0.004).

Dural Tears Secondary to Operations of the Lumbar Spinal Disorders / 대한척추외과학회지

STUDY DESIGN: A retrospective study. PURPOSE: To review the results of the treatment of dural tears, sustained during operations on the lumbar spinal disorders. MATERIALS AND METHODS: From Jan. 1991 to Dec. 2000, 694 consecutive patients had a decompression of the lumbar spine, 35(5%) patients sustained a dural tear during the operations. Of 32 patients who were followed up for more than one year, 29 patients were detected dural tear intraoperatively. 24 patients were treated with primary repair, 4 patients with fibrin glue and one patient with dural reconstruction and fibrin glue. Postoperative management consisted of closed wound drainage for an average of 3.3 days and bed rest for an average of 9.3 days. RESULTS: The total subfascial drains averaged an output of 626(18-1698) milliliters of 32 patients. Clinical symptoms were complained of headache in 12 patients, nausea in 7 patients, dizziness and vomiting in 2 patients postoperatively, but all had resolution of these symptoms after conservative treatment. A superficial wound infection occurred in one of these patients, managed with antibiotic therapy. Whereas the deep wound infection occurred in one, managed with wound debridement and antibiotic therapy successfully. A mean follow up of 34 months was available and showed satisfactory clinical results for 29 of the patients(91%). CONCLUSION: Closed wound drainage can be used safely in the presence of a dural repair and the patient needs to keep on bed rest while the drainage into a sterile bag is performed.