Traumatic Fracture of Thin Pedicles Secondary to Extradural Meningeal Cyst
Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey, Jersey Medical School, Newark, New Jersey.Journal of Surgical Technique and Case Report 04/2011; 3(1):40-3. DOI: 10.4103/2006-8808.78472
Spinal dural meningoceles and diverticula are meningeal cysts that have a myriad of clinical presentations and sequelae, secondary to local mass effect. Our objective is to report a technical case report, illustrating a traumatic spinal injury with multiple pedicle fractures, secondary to atrophic lumbar pedicles as well as the diagnostic workup and surgical management of this problem. Posterior lumbar decompression, resection of the meningeal cyst, ligation of the cyst ostium, instrumentation, and fusion were performed with the assistance of intraoperative isocentric fluoroscopy. The cyst's point of communication was successfully located with intraoperative fluoroscopy and the lesion was successfully excised. We suggest that patients with traumatic spinal injuries, having evidence of pre-existing anomalous bony architecture, undergo advanced imaging studies, to rule out intraspinal pathology. The positive clinical and radiographic results support the removal and closure of the pre-existing meningeal cyst at the time of treatment of traumatic spinal injury. Intraoperative isocentric fluoroscopy is a helpful tool in the operative management of these lesions.
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ABSTRACT: Background: Symptomatic extensive spinal extradural meningeal cyst (SEMC) developing after traumatic brachial plexus injury (TBPI) is rare. We discuss the mechanism of extensive SEMC development, surgical strategies, and preventive measures against SEMC after TBPI. Case description: A 58-year-old man with TBPI 16 years previously developed spastic paraparesis of the lower limbs, sensory disturbance below the periumbilical level, and dysfunction of bladder and bowel over 2 years. The patient couldn't walk and was wheelchair bound. Magnetic resonance imaging (MRI) revealed an extensive multilocular extradural cyst posterior to the spinal cord ranging from the C4 to Th6 level, associated with severe spinal cord compression. On constructive interference in steady-state MRI, the cyst was divided, with many septa, and extended to the root sleeves. During the operation, transdural communication sites of cerebrospinal fluid (CSF) into the cyst were revealed at C5/6, C6/7, and C7/Th1 levels around the nerve root sleeves. Treatment involved unroofing of the cyst wall and closure of the transdural CSF communication without cyst removal. Autologous muscle pieces were placed over the defect to close the transdural communication. Two weeks postoperatively, MRI showed decreased cyst size and reduced spinal cord compression, and the patient could walk without support. It was thought that the patient's daily lifting of heavy weights at work and an excessive exercise regimen increased CSF pressure and cyst size after TBPI. Conclusion: For patients with TBPI, it is necessary to prevent greater CSF pressure and to perform long-term follow-up MRI after injury.
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