Postoperative meningocele after anterior cervical discectomy and arthroplasty on a case report.

Anterior dural tears complicated by cerebrospinal fluid (CSF) leakage with anterior meningocele are rare. Indeed, in the literature, cases are described during anterior arthrodesis, but no cases of post-cervical arthroplasty are described. The management of this type of complication is poorly described and not consensual. We present a case of a patient who underwent cervical arthroplasty complicated by an anterior meningocele at 1 month after the first surgery. Imaging revealed a compressive anterior meningocele in relation to the clinically progressive worsening. Revision surgery consisted of a combination of closure of the gap with a fatty patch covered with a TachoSil patch, followed by reinsertion of a new cervical prosthesis. At the last follow-up at 1 year, the patient showed no residual effects of the complication, and the mobility of the disc prosthesis was not impaired by it. Clinical results of the arthroplasty are also very satisfactory. Although these types of complications are rare, it is important to have a consensus on the management of anterior meningocele. In our experience, TachoSil appears to be a satisfactory option for the management of these complications.

Intraspinal pseudomeningoceles: A rare complication of spinal trauma and surgery.

We present two cases of acute and delayed presentations of intraspinal pseudomeningoceles, which is a rare complication of spinal trauma or surgery. Our goal is to discuss the pathophysiology, clinical presentation, imaging findings, and treatment of this rare entity. This diagnosis should be considered in patients with unexplained neurologic symptoms in the setting of prior cervical spine injury or surgery.

Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery.

Suboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.

Ethmoidal meningoencephalocele in a C57BL/6J mouse.

An otherwise healthy two-month-old female C57BL/6J mouse presented with a left-sided head tilt. Differential diagnoses included idiopathic necrotizing arteritis, bacterial otitis media/interna (Pasteurella pneumotropica, Pseudomonas aeruginosa, Streptococcus sp., Mycoplasma pulmonis and Burkholderia gladioli), encephalitis, an abscess, neoplasia, a congenital malformation and an accidental or iatrogenic head trauma. Magnetic resonance imaging (MRI) revealed a large space-occupying right olfactory lobe intra-axial lesion with severe secondary left-sided subfalcine herniation. Following imaging, the animal was euthanized due to poor prognosis. Histopathologic examination revealed a unilateral, full-thickness bone defect at the base of the cribriform plate and nasal conchae dysplasia, resulting in the herniation of the olfactory bulb into the nasal cavity. There was also a left midline-shift of the frontal cortex and moderate catarrhal sinusitis in the left mandibular sinus. The MRI and histopathologic changes are consistent with a congenital malformation of the nasal cavity and frontal aspect of the skull known as an ethmoidal meningoencephalocele. Encephaloceles are rare abnormalities caused by herniation of contents of the brain through a defect in the skull which occur due to disruption of the neural tube closure at the level anterior neuropore or secondary to trauma, surgical complications, cleft palate or increased intracranial pressure. The etiology is incompletely understood but hypotheses include genetics, vitamin deficiency, teratogens, infectious agents and environmental factors. Ethmoidal encephaloceles have been reported in multiple species including humans but have not been reported previously in mice. There are multiple models for spontaneous and induced craniofacial malformation in mice, but none described for ethmoidal encephaloceles.

Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review.

BACKGROUND: Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series. METHODS: The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient. RESULTS: This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up. CONCLUSIONS: This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.

Surgical treatment of rostrotentorial meningioma complicated by foraminal herniation in the cat.

OBJECTIVES: This study was performed to evaluate retrospectively the clinical signs, complications and postoperative outcomes of feline intracranial meningioma (IM) with concurrent cingulate, transtentorial and foramen magnum herniations. METHODS: The medical records and MRI scans of cats with IM and cerebral herniation were reviewed. Cases involving concurrent cingulate, transtentorial and foramen magnum herniations were included. Owners were contacted to obtain long-term follow-up information. RESULTS: Seven cats (four castrated males and three spayed females) met the inclusion criteria. Median age was 13.0 years (range 9.9-16.1 years) and median duration of clinical signs was 35 days (range 21-163 days). The clinical signs of cats with cerebral herniation included visual impairment (n = 5 [71.4%]), ataxia (n = 4 [57.1%]), impaired consciousness (n = 2 [28.6%]), head pressing (n = 2 [28.6%]), paresis (n = 1 [14.3%]), torticollis (n = 1 [14.3%]) and personality changes (n = 1 [14.3%]). Median tumour volume, cranial cavity volume and tumour volume:intracranial volume ratio before surgery were 3.37 cm3 (range 3.23-11.5 cm3), 32.6 cm3 (range 29.8-78.3 cm3) and 10.4% (range 5.3-35.3%), respectively. Median overall tumour excision rate was 90.6%. Preoperative intracranial pressure (ICP) ranged from 15 to 32 mmHg (median 29 mmHg). In all cases, the ICP dropped to 0 mmHg immediately after tumour removal. No adjuvant therapy was required after surgery. The median survival period was 612 days (range 55-1453 days). CONCLUSIONS AND RELEVANCE: The results of this study indicate that surgical treatment of rostrotentorial IM is effective and allows prolonged survival, even in cats with concurrent cingulate, transtentorial and foramen magnum herniations.

Repair of giant lumbosacral pseudomeningocele with fast-resorbing polymer mesh in a pediatric patient operated for posterior dysraphism.

Lumbar pseudomeningocele is a common complication of spinal surgery. It is caused by dural defect, and it consists of extradural collection of cerebrospinal fluid communicating with subarachnoid space. Usually it is small, asymptomatic, and self-limiting. In case of persistence, common treatments include bedrest, puncture and compressive dressing, subcutaneous or subarachnoid lumbar drainage, surgical re-exploration for durotomy closure, and blood patch. Fast-resorbing polymer mesh has been recently used for closure osseous gap in adult patients who developed giant pseudomeningocele following laminectomy. We report the case of a 16-year-old girl, affected by spinal dysraphism, who developed a persistent giant lumbar pseudomeningocele after repeated surgery for detethering of the spinal cord and removing of spinal lipomyelomeningocele. She was finally treated with fast-resorbing polymer mesh, to fill the gap of the posterior osseous defect and to provide support for the thecal sac. For our best knowledge, this is the first pediatric case reported in literature on this kind of reconstruction. In complex cases of pseudomeningocele, implant of fast-resorbing polymer mesh may represent an option also in pediatric patients.

Giant Symptomatic Meningocele as a Delayed, Adult Complication of Lipomyelomeningocele.

BACKGROUND: An expanding cohort of patients with spina bifida live well into adulthood and pose complex management challenges due to unique combinations of adult health issues overlying congenital problems. CASE DESCRIPTION: We present a case of a 45-year-old woman with an expanding, disfiguring, painful lumbar meningocele more than 40 years after her only surgery as a 3-year-old child. A team of pediatric and adult neurosurgeons as well as plastic/reconstructive surgeons successfully performed surgery to obliterate the meningocele, with preservation of her baseline functional status, and no evidence of recurrence after more than 1 year of follow-up. CONCLUSIONS: Symptomatic meningocele may present in a long-delayed fashion in adult patients with a history of spina bifida. Surgical treatment may provide symptomatic benefit.

Comparing the results of duraplasty using amniotic membrane versus pericranium as dural graft; concerning CSF leakage and pseudomeningocele.

Purpose: In many brain surgeries, dura cannot be primarily repaired and it is necessary to use a graft. Appropriate repair of dura plays a major role in preventing CSF leakage and meningitis. In the cases where sufficient Pericranium is not available for recovery, we need to use graft from other resources. The present study compares the results of amniotic membrane dural graft and pericranium dural graft in terms of CSF leakage and Pseudomeningocele. Materials and methods: This is a semi-empirical research. Thirty cases underwent dural graft with amnion membrane because of inadequate local pericranium for repair. There were 30 other historical cases that had undergone auto-graft dural graft with Pericranium in the same center.Results: The average age of the participants in Pericranium graft group (P, n = 30) and those in amniotic graft group (A, n = 30) was 39.1 ± 15 and 43.9 ± 19 years old, respectively. As for the P and A groups, there were 14 and 17 males, respectively. Two cases of CSF leakage (7%) were observed in P group, while none was reported in A group. There were 3 cases (10%) of meningitis in Pericranium group and 2 cases (7%) were reported in amnion group. Out of 2 cases of meningitis in group P, 2 cases were associated with CSF leak. 5 cases of Hydrocephalus (17%) were observed in group P and 9 cases (30%) were reported in group A. No significant difference was observed between the two groups in any complication. The frequency of hydrocephalus was significantly higher in posterior fossa craniotomy.Conclusion: Amniotic membrane may provide a good source for cases with a large dural defect and can be utilized for all ages. Of course, its application in cases of posterior fossa craniotomy needs to be carefully studied so that the best results may be obtained.

Resistant Pseudomeningocele following Craniotomy for Non-Traumatic Acute Intracranial Haematoma in Very Young Children: Report of Four Cases.

BACKGROUND: The incidence of non-traumatic intracranial haemorrhage among neonates is less than among adults. However, the outcomes are generally poor, with high rates of morbidity and mortality. Non-traumatic intracranial haemorrhage can cause a sudden increase in intracranial pressure, requiring emergency craniotomy for evacuation. METHODS: We report 4 cases following craniotomy for non-traumatic acute intracranial haematoma in very young children. The surgical technique and postoperative course are discussed, with emphasis on dural repair to avoid resistant pseudomeningocele. RESULTS: Despite successful management of the acutely raised intracranial pressure, all patients afterwards developed tense pseudomeningoceles and required formal dural repair. This led to a change in institutional practice and modifications to the surgical technique. CONCLUSION: The authors highlight the postoperative occurrence of resistant pseudomeningoceles in young children after clot evacuations and leaving the dura open. They describe the surgical procedures to avoid these pseudomeningoceles.

Descriptive and risk factor analysis of nonsyndromic sacral agenesis: National Birth Defects Prevention Study, 1997-2011.

Sacral agenesis is a rare birth defect characterized by partial or complete absence of the sacrum. We sought to (a) describe case characteristics, (b) estimate birth prevalence, and (c) identify risk factors for nonsyndromic sacral agenesis using data from the National Birth Defects Prevention Study (NBDPS). The NBDPS was a population-based, case-control study involving pregnancies with estimated dates of delivery from October 1997 through December 2011. We estimated birth prevalence using all NBDPS eligible cases. Using self-reported maternal exposure information, we conducted multivariable logistic regression analysis to identify potential risk factors overall and among women without diabetes. The birth prevalence of sacral agenesis was 2.6/100,000 live births. In the multivariable analysis, multifetal pregnancy, pre-existing Type 1 diabetes, and pre-existing Type 2 diabetes were positively and significantly associated with sacral agenesis, albeit estimates were imprecise. Preexisting Type 1 diabetes was the strongest risk factor (adjusted odds ratio = 96.6, 95% confidence interval = 43.5-214.7). Among women without diabetes, periconceptional smoking was positively and significantly associated with sacral agenesis. Our findings underscore the importance of smoking cessation programs among women planning pregnancy and the importance of better understanding the role of glycemic control before and during pregnancy when designing interventions for primary prevention of sacral agenesis.

Postoperative Cerebellar Cyst with Pseudomeningocele After Tumor Removal at the Craniovertebral Junction.

BACKGROUND: Cerebellar cyst formation after surgery is uncommon, and few cases of this condition have been previously reported. These cases had an intraparenchymal cyst in the cerebellar hemisphere that required surgical fenestration of the cyst. We herein present a rare case of a postoperative cerebellar cyst with pseudomeningocele and magnetic resonance images indicating a fistula between the cyst and pseudomeningocele. CASE DESCRIPTION: A patient presented with an intraparenchymal cyst and surrounding edema in the cerebellar hemisphere that developed after a C1 laminectomy and a small suboccipital craniectomy for the removal of an accessory nerve neurinoma at the craniovertebral junction. Fast imaging employing steady-state acquisition images identified the fistula connecting the cyst and extradural cerebrospinal fluid retention. Conservative management with administration of dexamethasone induced spontaneous regression of the cyst, and no recurrence had occurred by the 1-year follow-up. CONCLUSIONS: Watertight dural closure is important for the prevention of this rare complication after posterior fossa surgery. However, an arachnoid tear on the cerebellar fissure and adjacent dural defect are necessary antecedents for this rare condition. High-resolution fast imaging employing steady-state acquisition images could provide additional information for the etiology of postoperative cerebellar cyst.

Temporal bone meningoencephaloceles and cerebrospinal fluid leaks: experience in a tertiary care hospital.

OBJECTIVE: To recount experience with cerebrospinal fluid otorrhoea and temporal bone meningoencephalocele repair in a tertiary care hospital. METHOD: A retrospective review was conducted of 16 cerebrospinal fluid otorrhoea and meningoencephalic herniation patients managed surgically from 1991 to 2016. RESULTS: Aetiology was: congenital (n = 3), post-traumatic (n = 2), spontaneous (n = 1) or post-mastoidectomy (n = 10). Surgical repair was undertaken by combined middle cranial fossa and transmastoid approach in 3 patients, transmastoid approach in 2, oval window plugging in 1, and subtotal petrosectomy with middle-ear obliteration in 10. All patients had successful long-term outcomes, except one, who experienced recurrence after primary stage oval window plugging, but has been recurrence-free after second-stage subtotal petrosectomy with middle-ear obliteration. CONCLUSION: Dural injury or exposure in mastoidectomy may lead to cerebrospinal fluid otorrhoea or meningoencephalic herniation years later. Congenital, spontaneous and traumatic temporal bone defects may present similarly. Middle cranial fossa dural repair, transmastoid multilayer closure and subtotal petrosectomy with middle-ear obliteration were successful procedures. Subtotal petrosectomy with middle-ear obliteration offers advantages over middle cranial fossa dural repair alone; soft tissue closure is more robust and is preferred in situations where hearing preservation is not a priority.

Iatrogenic meningoencephalocele after traumatic perforation of the cribriform plate during nasal intubation of a preterm infant.

Traumatic iatrogenic meningoencephaloceles infants are rare and there is no consensus on management in the literature. This article presents a case of a meningoencephalocele diagnosed 15 months after a traumatic perforation of the cribriform plate due to a difficult intubation of a preterm infant that was treated by an endoscopic endonasal surgery. A close collaboration between pediatricians and ENT surgeons appears essential for early diagnosis and management. Endoscopic endonasal approach for meningoencephalocele management has several advantages and is a safe procedure when performed by an experienced surgeon.

Is Pseudomeningocele an Absolute Sign of Root Avulsion Brachial Plexus Injury?

BACKGROUND: The finding of pseudomeningocele from cervical myelogram is widely accepted as a pathognomonic sign for diagnosing root avulsion in brachial plexus injury. In general, motor power in this setting should be absent. However, in clinical practice, we observed that motor power in some patients was still preserved. The objective of this study is to evaluate the accuracy of pseudomeningocele from cervical myelogram for predicting root avulsion in brachial plexus injury. METHODS: We retrospectively reviewed 201 patients with brachial plexus injury from 2007-2011. Four patients were excluded due to open wound injury. Motor power of the key muscle of each nerve root was evaluated by skilled hand surgeons. All cervical myelogram was interpreted by radiologists. Sensitivities, specificities, positive predictive values and negative predictive values were calculated with 95% confidence interval. RESULTS: Thirty and 29% of pseudomeningocele occurred at C7 and C8 level, respectively. The sensitivity of pseudomeningocele of each root from C5 to T1 was low (range, 10-62%). The specificity was high only at C5 (91%) and T1 (96.2%). Over 20% of patients with pseudomeningocele at C6-8 levels had some motor function. The initial muscle power of these patients was M1 or M2 and 70% of them recovered to at least M3 at the final follow-up. CONCLUSIONS: Pseudomeningocele is not an absolute sign for diagnosing of root avulsion in brachial plexus injury due to its high false positive rate when compared with preoperative motor function of each root. Careful examination of the key muscle of each root is extremely crucial to prevent unnecessary operation on that cervical nerve root.

Cerebrospinal Fluid Leak and Symptomatic Pseudomeningocele After Intradural Spine Surgery.

OBJECTIVE: To describe the incidence of and characterize risk factors for cerebrospinal fluid leak and symptomatic pseudomeningocele (CSFL/SP) after intradural spine surgery. METHODS: A retrospective analysis of a prospectively collected and consecutive series of patients undergoing intradural spine surgery by the senior author (A.D.L.) was conducted over a period of 20 years. RESULTS: Data on 460 surgeries performed on 430 consecutive patients were gathered. The incidence of CSFL/SP formation was 2.8% (n = 13). Of the 13 cases complicated by CSFL/SP, 4 were successfully managed nonoperatively (4/13, 31%); 9 postoperative CSFL/SP required surgical repair (9/13, 69%), making for an overall postoperative surgical repair rate of 1.9% (9/460). Factors significantly related to development of postoperative CSFL/SP on the Fisher exact test were surgery located at the craniocervical junction (risk ratio [RR] 2.7, P = 0.03) and use of any external cerebrospinal fluid drain (any drain: RR 2.5, P = 0.02; lumbar drain specifically: RR 2.6, P = 0.02), the latter finding most likely being attributable to selection bias. No significant difference was observed between primary dural closure and closure incorporating the use of one or more dural repair adjuncts. In addition, the total number of dural repair adjuncts used did not significantly influence the development of postoperative CSFL/SP. CONCLUSIONS: We present the largest series of intradural spine surgeries focusing specifically on the risk factors for and management of CSFL/SP. Although craniocervical junction surgery and use of external cerebrospinal fluid drain were associated with CSFL/SP, type of closure and type/number of dural substitutes were not.