Lumbar Myofascial Flap for Pseudomeningocele Repair
Object: Initial management for lumbar pseudomeningoceles entails the closed external drainage of cerebrospinal fluid (CSF) with or without blood patch application. The presence of longstanding pseudomeningoceles and those associated with nonmicroscopic dural tears can be more problematic. Additionally the failure of nonoperative measures may necessitate surgery. Ideally the procedure should involve repairing the dural defect, removing the encapsulated cavity of the pseudomeningocele, and obliterating the extraspinal dead space to minimize the recurrence of the problem.
Methods: The authors describe a technique performed in 12 patients with large ( 5-cm-diameter) pseudomeningoceles referred for management following the failure of less aggressive measures. Diagnosis was based on symptoms of lumbar wound swelling, postural headaches, back and leg pain, and was confirmed by imaging studies. In all patients subarachnoid CSF drainage and initial operative attempts to obliterate the pseudomeningocele had failed. They were treated between July 1990 and July 1998. The cause of the pseudomeningoceles was lumbar discectomy (four patients), lumbar decompression (one patient), lumbar decompression and placement of instrumentation (five patients), and intradural procedures (two patients). Their mean age was 47.9 years (range 20 67 years), and they presented at a mean of 5.5 months postoperatively (range 3 weeks 37 months). In all cases there was a satisfactory repair of the pseudomeningocele, dead space obliteration, and long-term symptomatic resolution.
Conclusions: Lumbar myofascial advancement for this problem is a useful technique in cases of symptomatic pseudomeningoceles. This technique requires the medial advancement of the musculofascial units of the paravertebral muscles for a layered closure over the exposed spinal canal with obliteration of the pseudomeningocele.
The incidence of intraoperative durotomy ranges from 3.1 to 14%. It is greater for reoperations (17.4%) than the initial surgery (1.8%). In the majority of cases these are recognized and repaired primarily. They can be reinforced with fibrin glue and the patient should then undergo a period of bed rest. Some authors have argued that it is the primary repair and not bed rest that is critical to the success of this treatment. Despite meticulous repair, a postoperative lumbar pseudomeningocele may occur. Pseudomeningoceles warrant immediate attention because their associated morbidity ranges from headache and lumbar discomfort to severe back pain and radiculopathy secondary to nerve rootlet entrapment. Should the pseudomeningocele result in a cutaneous CSF leak, the patient is exposed to the risk of central nervous system infection. The incidence of lumbar pseudomeningoceles is reported to be between 0.3 and 5%. Surgical repair is indicated if the CSF drainage, which may be supple-mented by epidural blood patch application, does not result in a resolution of the problem. The failure of nonoperative treatment and simple surgery by using dural repair with subsequent reaccumulation of an encapsulated pseudomeningocele requires more aggressive treatment. When posterior spinal instrumentation and paravertebral muscle atrophy are present, the situation is exacerbated because there is much less of a tamponade effect acting upon a dural CSF leak.
Object: Initial management for lumbar pseudomeningoceles entails the closed external drainage of cerebrospinal fluid (CSF) with or without blood patch application. The presence of longstanding pseudomeningoceles and those associated with nonmicroscopic dural tears can be more problematic. Additionally the failure of nonoperative measures may necessitate surgery. Ideally the procedure should involve repairing the dural defect, removing the encapsulated cavity of the pseudomeningocele, and obliterating the extraspinal dead space to minimize the recurrence of the problem.
Methods: The authors describe a technique performed in 12 patients with large ( 5-cm-diameter) pseudomeningoceles referred for management following the failure of less aggressive measures. Diagnosis was based on symptoms of lumbar wound swelling, postural headaches, back and leg pain, and was confirmed by imaging studies. In all patients subarachnoid CSF drainage and initial operative attempts to obliterate the pseudomeningocele had failed. They were treated between July 1990 and July 1998. The cause of the pseudomeningoceles was lumbar discectomy (four patients), lumbar decompression (one patient), lumbar decompression and placement of instrumentation (five patients), and intradural procedures (two patients). Their mean age was 47.9 years (range 20 67 years), and they presented at a mean of 5.5 months postoperatively (range 3 weeks 37 months). In all cases there was a satisfactory repair of the pseudomeningocele, dead space obliteration, and long-term symptomatic resolution.
Conclusions: Lumbar myofascial advancement for this problem is a useful technique in cases of symptomatic pseudomeningoceles. This technique requires the medial advancement of the musculofascial units of the paravertebral muscles for a layered closure over the exposed spinal canal with obliteration of the pseudomeningocele.
The incidence of intraoperative durotomy ranges from 3.1 to 14%. It is greater for reoperations (17.4%) than the initial surgery (1.8%). In the majority of cases these are recognized and repaired primarily. They can be reinforced with fibrin glue and the patient should then undergo a period of bed rest. Some authors have argued that it is the primary repair and not bed rest that is critical to the success of this treatment. Despite meticulous repair, a postoperative lumbar pseudomeningocele may occur. Pseudomeningoceles warrant immediate attention because their associated morbidity ranges from headache and lumbar discomfort to severe back pain and radiculopathy secondary to nerve rootlet entrapment. Should the pseudomeningocele result in a cutaneous CSF leak, the patient is exposed to the risk of central nervous system infection. The incidence of lumbar pseudomeningoceles is reported to be between 0.3 and 5%. Surgical repair is indicated if the CSF drainage, which may be supple-mented by epidural blood patch application, does not result in a resolution of the problem. The failure of nonoperative treatment and simple surgery by using dural repair with subsequent reaccumulation of an encapsulated pseudomeningocele requires more aggressive treatment. When posterior spinal instrumentation and paravertebral muscle atrophy are present, the situation is exacerbated because there is much less of a tamponade effect acting upon a dural CSF leak.
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