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Case report
Giant dorsolumbar pseudomeningocele: Unusual evolution of traumatic
dural tiny tear.
Abid
Hichem 1,2,*, Nefiss Mouadh 1,2, Ben Maatoug Aymen 1,2,
Bouzidi Ramzi 1,2.
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1: Department
of Orthopedic surgery Mongi Slim Hospital Tunis, Tunisia 2: College
of medicine Tunis Tunisia * Corresponding author Correspondence to: hich.abid2112@gmail.com Publication Data: Submitted:
April 28,2020 Accepted:
May30,2020 Online:
June 30,2020 This article was subject to full peer-review. This is an open access article distributed under the terms of the
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Abstract |
|
The
pseudomeningocele is a rare entity usually described in the literature as
complication of lumbar surgery. We hereby report a case of a giant
dorsolumbar pseudomeningocele arising after fracture-dislocation of the
dorsolumbar spine. Keywords: Pseudomeningocele,
spine, trauma, surgery. |
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Introduction Pseudomeningocele
is an extradural cystic collection of cerebrospinal fluid (CSF). The cysts
are located in the paraspinal space and rarely reach the subcutaneous area.
Huge cysts are always symptomatic and require surgical repair. Spinal
pseudomeningoceles are a common complication of large tears in the
dural-arachnoid layer. The postoperative etiology is the most frequent. The
defect can be also traumatic or congenital [1]. Observation We
report a case of a 31-year-old patient, a victim of a road traffic accident
which caused severe polytrauma including a C2 Magerl type fracture of T11,
with a partial neurological deficit (Frankel B). The patient underwent an
emergency T11-T12 laminectomy, posterior fixation of T10-T11-T12-L1 and a
posterolateral bone graft (Figure 1). We discovered two millimetric dural
breaches opposite T11 which were respected. These dural dehiscence lesions
were not related to the laminectomy. The postoperative course was uneventful.
Figure 1:Post-operative X ray following laminectomy, posterior
fixation, and posterolateral graft. |
At two years follow
up, the patient was complaining of persistent back pain at the operative site.
This has been attributed to the fixation materials. The removal of the material
was performed with intraoperative discovery of a small right posterolateral
pseudo-meningocele at T11 level which was respected. One year later, the
patient presented with a right paravertebral painful mass measuring 20 cm.
There were no associated neurological
symptoms. The MR scan revealed a
dorsolumbar paraspinal giant pseudomeningocele (Figure 2). There was diffuse
extradural CSF collection extending from T10 to L1 with no compression of the
spinal cord. The patient underwent excision of the pseudomeningocele and
repair of the dural sac defect (Figures 3). The right foraminal breach
was closed with biological fibrin glue. Seen two years later , the patient had
no complaints and the MR scan was
normal.
Figure 2: Axial MRI showing
dorsolumbar paraspinal pseudo meningocele : extradural CSF intensity cystic
collection in the lumbar paraspinous area.
Figure 3 Per-operative
findings of giant pseudo
meningocele and a size-increased dural
defect.
Discussion
Pseudomeningoceles with a size of more than eight
centimeters in diameter has been
reported previously in only 22 cases [1,2]. Pseudomeningoceles are usually
asymptomatic being embedded in the posterior paraspinal soft tissue. Otherwise
they cause variable symptoms depending on the size and the location. Persistent
pain and palpable mass were the characteristic symptoms in our case. MRI is the
gold standard for diagnosis and follow-up after treatment [3]. A pseudomeningocele
appears as a hypointense lesion on T1 weighted sequences, and hyperintense
lesion on T2 weighted sequences. Rarely, pseudomeningoceles can be complicated
by nerve herniation, progressive myelopathy or meningitis [4].
Once
diagnosed, surgical repair is recommended for large pseudomeningoceles to
prevent fistulization and infection [5,6]. Several procedures have been
described in literature in the management of pseudomeningoceles. The treatment
options include simple observation for spontaneous resolution of small lesions,
epidural blood patch, external lumbar subarachnoid drainage, synthetic dural
patch, and closure of the dural sac [7]. This observation may encourage spinal
surgeons to repair small dural tears to avoid potential CSF leak and its complications.
Conflict
of Interest: None
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