Conservative Management of Pseudomeningocele Secondary to Lumbar Laminectomy: A Case Report.

doi:10.21203/rs.3.rs-4298648/v1

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Conservative Management of Pseudomeningocele Secondary to Lumbar Laminectomy: A Case Report.

https://doi.org/10.21203/rs.3.rs-4298648/v1

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Introduction:

Pseudomeningocele is a rare complication following laminectomy, which can present with various symptoms. This case report aims to highlight the successful conservative management of a patient who developed a pseudomeningocele after lumbar disc herniation surgery.

Case presentation:

A 41-year-old woman presented with persistent low back pain radiating to both lower limbs after a previous laminectomy surgery. Despite the severity of her pain, there were no signs of neurological deficits. An MRI revealed a pseudomeningocele, indicating a dural leak as a result of the previous surgery. The patient was managed conservatively with pain control, rest, exercises, and physical therapy. Over a six-week period, her symptoms gradually improved, and at the 12-month follow-up, she reported minimal residual discomfort with no signs of recurrence or neurological deficits. Follow-up MRI performed one year postoperatively showed a remarkable reduction in the size of the meningocele compared to the postoperative image.

Conclusion

This case report illustrates the successful outcome of conservative management in a patient presenting with a pseudomeningocele following lumbar disc herniation surgery. Early recognition and appropriate management of this complication are vital to prevent potential neurological sequelae. Further studies and continued awareness of conservative management approaches for pseudomeningocele are warranted to establish evidence-based guidelines for patient care.

Pseudomeningocele

lumbar disc herniation

laminectomy

low back pain

conservative management

Postlaminectomy Lumbar Pseudomeningocele (PLP) is a relatively rare but well-reported complication following spinal surgeries, particularly lumbar laminectomies. PLP occurs as a result of dural tears or a persistent communication between the thecal sac and the extradural space. As a consequence, cerebrospinal fluid (CSF) accumulates within the pseudomeningocele, leading to the formation of a cystic mass [1, 2]. These pseudomeningoceles may cause delayed clinical manifestations and pose a considerable diagnostic challenge for physicians.

In this study, we present the clinical details and management of a 41-year-old woman who developed low back pain with radiation to both lower limbs three months after undergoing surgery for lumbar disc herniation. The subsequent MRI study revealed the presence of pseudomeningocele secondary to laminectomy. We discuss the presentation, diagnosis, and subsequent treatment of this rare complication.

A 41-year-old woman presented with persistent low back pain radiating to both lower limbs. She had previously undergone L5 laminectomy due to disc herniation (Fig. 1) three months ago, elsewhere. Although her pain was severe, she did not report any motor or sensory deficits or bladder disturbance. Upon examination, motor and sensory functions were found to be within normal limits. The straight leg raise, deep tendon reflexes, and gait evaluation were also unremarkable. There were no signs of infection or wound dehiscence in the surgical site.

Based on the clinical presentation, an MRI study was ordered to investigate the cause of the persistent symptoms. The MRI revealed the presence of a pseudomeningocele, characterized by the accumulation of CSF outside the dural sac, extending from L3-L5 level. The pseudomeningocele appeared as a cystic collection anterior to the dura, consistent with cerebrospinal fluid accumulation (Fig. 2). This finding suggested a possible dural leak resulting from the previous laminectomy procedure. Based on the clinical presentation and radiological findings, a diagnosis of pseudomeningocele secondary to laminectomy was established.

Due to absence of neurological symptoms, the patient was managed conservatively, with a focus on symptom control and promoting proper CSF reabsorption. The patient was advised to modify her daily activities and avoid engaging in strenuous physical exertion, lifting heavy objects, or adopting poor posture. Rest periods were recommended to avoid exacerbating the symptoms. The patient underwent supervised physical therapy sessions. This included exercises aimed at strengthening the lumbar paraspinals and core muscles, improving flexibility, and correcting postural abnormalities. Besides these exercises, dry needling and taping were conducted on the lumbar paraspinal muscles to alleviate discomfort and support the affected area. Lumbar brace with bars was prescribed to control and limit the movement of the lumbar spine during the recovery phase. As a part of the conservative treatment plan, the patient was prescribed non-steroidal anti-inflammatory drugs and muscle relaxants to manage pain.

Follow-up visits were scheduled to monitor the patient's progress. Over a six-week period, the patient reported a gradual reduction in low back pain and radiation to the lower limbs. The patient's neurological examinations remained normal throughout the treatment period. At the 12-month follow-up, the patient reported minimal residual discomfort, with no signs of recurrent pseudomeningocele or further neurological deficits observed. A follow-up MRI performed one year postoperatively showed a remarkable reduction in the size of the meningocele compared to the postoperative image (Fig. 3). The reduction in size of the meningocele indicated successful management and resolution of the condition.

Pseudomeningocele is a rare complication of lumbar disc herniation surgery, albeit with potential significant morbidity. Early recognition and appropriate management, as demonstrated in this case, can lead to favorable outcomes.

The primary cause of PLP lies in the occurrence of unintended dural tears during spinal surgeries. These dural tears may result from various factors, including surgical technique, anatomical variations, excessive exposure of the dura, or preexisting connective tissue disorders [3]. Other potential causes include the use of high-speed drills, inadequate suture repair, unrecognized durotomy, or inadvertent removal of the ligamentum flavum leading to persistent communication between the extradural and intradural spaces [1, 4, 5].

Following a dural tear, CSF leakage may persist due to the disrupted integrity of the dural sac, leading to the accumulation of CSF within the pseudomeningocele. As CSF continues to accumulate, the surrounding soft tissues may become progressively distended, resulting in the formation of a cystic mass known as PLP. In some cases, the CSF may also herniate through the bony defect, causing remitting and relapsing symptoms [2].

Patients with PLP commonly report symptoms that may include persistent or recurrent low back pain, radiculopathy, sensory changes, or motor weakness. Neurological deficits, such as cauda equina syndrome, may also be observed in severe cases [6–8]. Other symptoms may include fluid-filled swelling or a palpable lump in the surgical site, drainage of clear fluid through the wound, and even orthostatic headaches [3, 9]. The onset of symptoms can occur anywhere from a few days to years following the initial surgery, which can complicate the diagnosis and management of PLP [10]. Clinicians should maintain a high level of suspicion for this complication when patients present with characteristic symptoms following lumbar disc herniation surgery.

Among several radiological modalities, Magnetic Resonance Imaging (MRI) is the recommended modality for detecting PLP. MRI can visualize the cystic lesion, assess the extent of dural tear, and identify any neural compression. Additional tests, such as computed tomography myelography, may be performed to enhance visualization of the dural defect and CSF leakage.

The management of PLP should be tailored to the individual's specific circumstances and symptoms. Conservative management is usually the initial approach for pseudomeningocele, especially in patients without neurologic deficits [11, 12]. This involves providing symptomatic relief and promoting CSF reabsorption by avoiding activities that raise intra-abdominal pressure, limiting physical strain, and utilizing lumbar bracing if necessary. Pharmacological treatments and physical therapy can be used to reduce the symptoms and improve the patient’s function. Close monitoring of symptoms and regular follow-up evaluations are crucial to assess the patient's response to conservative treatment, as was the case with our patient [13].

If the patient experiences severe intensity pain, worsening neurological symptoms (e.g., progressive weakness, numbness, or loss of bowel/bladder control), or signs of cauda equina syndrome, surgery is typically indicated [12, 14, 15]. Timely interventions may prevent irreversible nerve damage and promote better outcomes. The surgical techniques may involve primary dural repair, reinforcement with grafts, or closure with synthetic patches [5, 13, 16]. Minimally invasive techniques, such as percutaneous aspiration or fibrin glue injections, have also been reported in some cases [17, 18].

In conclusion, lumbar pseudomeningocele is a complication that can occur after lumbar spine surgery, causing CSF leakage into surrounding tissues. The symptoms can range from persistent back pain to neurological deficits. Accurate diagnosis through imaging studies is crucial for formulating an appropriate treatment plan. This case report illustrated the successful outcome of conservative management in a patient presenting with a pseudomeningocele following lumbar disc herniation surgery. Although conservative management may be effective for some cases, more invasive interventions such as surgical repair may be required for severe or persistent pseudomeningoceles. Early recognition and appropriate management of this complication are vital to prevent potential neurological sequelae.

Acknowledgments

None

Funding

None

Conflicts of interest/Competing interests

The authors have no conflicts of interest to declare.

Ethics approval

Not applicable

Consent to participate

The patient gave her consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Written Consent for publication

The patient gave her consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Availability of data and material

The data that support the findings of this study are available on request from the journal.

Code availability

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Authors' contributions

HA and PR both contributed to the conception and design of the case report. HA performed the literature review and gathered the relevant data and images. PR wrote the initial draft of the manuscript and conducted a thorough analysis of the case. Both authors participated in revising the manuscript critically for important intellectual content and gave final approval of the version to be published. PR is the corresponding author for this manuscript and can be contacted for any inquiries or further information.

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Editor assigned by journal
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You are reading this latest preprint version

Conservative Management of Pseudomeningocele Secondary to Lumbar Laminectomy: A Case Report.

Status:

Version 1

Abstract

Introduction:

Case presentation:

Conclusion

Figures

Introduction

Case presentation

Discussion

Conclusion

Declarations

References

Status:

Version 1