Large Compressive Pseudomeningocele Causing Early Major Neurologic Deficit After Spinal Surgery

Abstract

Study design: Retrospective review.

Objectives: Large compressive pseudomeningocele causing a major neurologic deficit is a very rare complication that is not well described in the existing literature.

Methods: Institutional review board consent was obtained to study 2552 consecutive extradural spinal surgical cases performed by a single senior spinal surgeon during a 10-year period. The surgeon's database for the decade was retrospectively reviewed and 3 cases involving postoperative major neurologic deficits caused by large compressive pseudomeningocele were identified.

Results: The incidence of postoperative compressive pseudomeningocele causing major neurologic deficit was 0.12% (3/2552) per decade of spinal surgery with approximately 1.3% of cases incurring incidental durotomy. Average age of the patients was 57 years (range 45-78). One patient had posterior cervical spine surgery, and 2 patients had posterior lumbar surgery. All 3 patients had intraoperative incidental durotomy repaired during their index procedure. Large compressive pseudomeningocele causing major neurologic deficit occurred in the early 2-week postoperative period in all patients and was clearly identified on postoperative magnetic resonance imaging. All 3 patients were treated with emergent decompression and repair of the dural defect. All patients recovered neurologic function after revision surgery.

Conclusions: Incidental durotomy and repair causing a large compressive pseudomeningocele after spine surgery is a rare and potentially devastating event. Early postoperative magnetic resonance imaging assists in the diagnosis. Emergent decompression combined with revision dural repair surgery may result in improved outcomes. Surgeons should be cognizant of this rare cause of early postoperative major neurologic deficit in patients who had previous dural repair.

Keywords: incidental durotomy; major neurologic deficit; postoperative; pseudomeningocele; spine surgery.

Figure 1.

(a) Preoperative lateral radiograph, (b) postoperative sagittal and (c) axial T2 MR views in a 78 year-old patient demonstrating severe multilevel thecal sac compression from a large pseudomeningocele following lumbar decompression surgery. There is near-complete sac occlusion from L1-L5 levels and cauda equina syndrome clinically.

Figure 2.

(a) Preoperative T2 MR sagittal and axial views in a 75 year-old patient with L4-L5 stenosis. (b) Postoperative sagittal and axial T2 MR views demonstrating severe thecal sac compression at L4-L5 from a large pseudomeningocele resulting in cauda equina syndrome.

Figure 3.

(a) Preoperative sagittal CT and T2 MR view of the cervical spine in a 48-year-old patient with OPLL and myelopathy. (b) Postoperative sagittal T2 MR view in the same patient demonstrating a large pseudomeningocele with severe cord compression causing quadriplegia.