Abstract
Incidental durotomy during spine surgery carries a risk of cerebrospinal fluid (CSF) leakage, pseudomeningocele formation, and reoperation, and incomplete dural closure remains a frequent and troublesome problem. We report the management of a giant lumbar pseudomeningocele with a CSF fistula occurring after previous disc surgery, treated with a combined multilayer repair.
A 40-year-old woman, previously operated on twice for an L4-L5 disc herniation, presented with persistent lumbar pain, tinnitus, and a large subcutaneous CSF collection that enlarged on the Valsalva maneuver. MRI demonstrated a giant pseudomeningocele with a laterally located CSF fistula. Because the fistula was too lateral for safe direct suturing, it was repaired in a sandwich fashion using an autologous blood patch, TachoSil, an autograft fascia lata sutured circumferentially, and a vascularized muscular flap sutured tightly over the fascia lata, under loupe magnification. Neither fibrin sealant nor a subarachnoid drain was used, in order to avoid their associated risks.
The aspirated CSF was hyperproteic and bacteria-free. The postoperative course was uneventful and the patient was discharged in good health, with no recurrence at one-month follow-up. This combined technique — blood patch, TachoSil, autologous fascia lata, and a vascularized muscular flap — proved effective for treating the giant pseudomeningocele and preventing further complications such as CSF fistula and meningitis.
