Pseudomeningocele/CSF fistula in a patient with lumbar spinal implants treated with epidural blood patch and a brief course of closed subarachnoid drainage. A case report.
METHODS
This case report illustrates the development of a cerebrospinal fluid fistula and pseudomeningocele in a patient after lumbar discectomy and fusion with instrumentation.


OBJECTIVE
The patient is treated successfully with a combined treatment protocol of epidural blood patch and brief course of spinal drainage.


BACKGROUND
Many surgeons advocate a trial of cerebrospinal fluid diversion for postoperative cerebrospinal fluid fistula. This treatment may be problematic in patients with spinal implants because a trial of cerebrospinal fluid diversion may not obliterate the extradural anatomic dead space that is created by instrumentation procedures and increases the rist of infection. A few case reports indicate that epidural blood patch also may be an effective management technique. A combined treatment protocol that may offer some advantages to either treatment alone is described


METHODS
The patient was brought to the radiology department, and a lumbar spinal drain was placed at the L2-L3 interspace under fluoroscopic guidance with the patient in the prone position. A Tuohy needle was inserted into the pseudomeningocele, and the collection was drained. Thirty milliters of blood drawn from an antecubital vein was injected into the epidural space over the laminectomy site. Spinal drainage was continued for 4 days.


RESULTS
The treatment protocol resulted in resolution of cerebrospinal fluid leakage in the patient. This result was confirmed by myelogram.


CONCLUSIONS
Postoperative pseudomeningocele and cerebrospinal fluid fistula in patients with spinal instrumentation can be treated successfully with epidural blood patch and a brief course (4 days) of spinal drainage. This combined treatment protocol may have some advantages to treatment with 7 days of cerebrospinal fluid diversion or to percutaneous epidural blood patch alone.
Department of Neurosurgery, University of California, San Francisco, USA.
B M
BM
McCormack
S L
SL
Taylor
S
S
Heath
J
J
Scanlon
D000328:Adult; D017217:Blood Patch, Epidural; D002555:Cerebrospinal Fluid; D017586:Diskectomy / Q000009:adverse effects*; D004322:Drainage; D004824:Epidural Space; D005402:Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D006801:Humans; D016268:Internal Fixators; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D008588:Meningocele / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D009192:Myelography; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D013123:Spinal Fusion; D014057:Tomography, X-Ray Computed