Minimally invasive repair of a pseudomeningocele caused by a sheared intrathecal catheter following implantation of a drug delivery system
- Department of Neurosurgery, Ochsner Medical Center, New Orleans, USA
- Department of Neurosurgery, University of Montreal, Montreal, Quebec, Canada
- Department of Pain Management, Ochsner Baptist, New Orleans, USA
P. O. Champagne
Department of Neurosurgery, Ochsner Medical Center, New Orleans, USA
DOI:10.4103/sni.sni_279_17Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: S. Raju, P. O. Champagne, L. Walsh, Daniel J. Denis. Minimally invasive repair of a pseudomeningocele caused by a sheared intrathecal catheter following implantation of a drug delivery system. 06-Dec-2017;8:297
How to cite this URL: S. Raju, P. O. Champagne, L. Walsh, Daniel J. Denis. Minimally invasive repair of a pseudomeningocele caused by a sheared intrathecal catheter following implantation of a drug delivery system. 06-Dec-2017;8:297. Available from: http://surgicalneurologyint.com/surgicalint-articles/minimally-invasive-repair-of-a-pseudomeningocele-caused-by-a-sheared-intrathecal-catheter-following-implantation-of-a-drug-delivery-system/
Background:Shearing of an intrathecal catheter during implantation of a drug delivery system is an underreported complication that can be challenging to manage.
Case Description:A 53-year-old man with refractory cancer pain had an intrathecal pump system implanted. The procedure was complicated with catheter shear and retention in the intrathecal space. A second catheter was successfully placed but formation of a painful pseudomeningocele and ineffective pain relief complicated the outcome. A minimally invasive approach through a tubular retractor was employed to access the spinal canal via a laminotomy, the sheared catheter was removed and the dural defect repaired. Complete resolution of the pseudomeningocele and efficient pain control were observed at follow-up.
Conclusion:Minimally invasive approach to the spine is demonstrated as a safe and effective alternative in this case of retained catheter induced cerebrospinal fluid (CSF) leak.
Keywords: Cerebrospinal fluid leak, minimally invasive surgery, pseudomeningocele, retained intrathecal catheter
Percutaneous placement of an intrathecal catheter is commonly performed for drug delivery or cerebrospinal fluid (CSF) diversion. Catheter breakage is an underreported complication that can occur during or after the procedure and may result in CSF leak, pseudomeningocele and failure or drug delivery to the intrathecal space.[
A 53-year-old man was referred to the pain management clinic for a 7 months history of intractable thoracic back pain and abdominal pain following surgical resection of a duodenal adenocarcinoma (stage IV). His pain was refractory to all treatments previously tried, with a reported maximal pain intensity of 10/10. His pain did not respond to methadone, hydromorphone, cyclobenzaprine, gabapentin, pregabalin nor lidocaine patches. Previous interventional therapies provided only temporary, if any, relief. These included neurolysis of the celiac plexus, neurolysis of the superior epigastric nerve, 12th intercostal nerve, and paraspinal trigger point injections. Given, his lack of response, the decision was made to move forward with a trial of intrathecal medication in preparation for a possible intrathecal drug delivery. At this time, he was receiving oral long acting morphine 100 mg three times daily, oral morphine 30 mg every 6 h as needed, tizanidine 4 mg three times daily as needed, and amitriptyline 25 mg every evening. The intrathecal drug trial was successful leading to the implantation of an intrathecal delivery system. During the implantation, the intrathecal catheter was successfully placed through a Tuohy needle at L3-4. In the course of the Tuohy removal, the epidural portion of the catheter was sheared. The fractured portion could not be removed. The decision was made to leave the sheared catheter in place. A second catheter was successfully placed at the same level and connected to the pump.
In the immediate postoperative period, the patient reported about 50% pain relief but 10 days after the procedure, he began to experience orthostatic headaches, nausea, vomiting, and the development of a painful lump in his right paraspinal lumbar area. The physical exam was unremarkable for any neurological deficits, but a tender mass was palpable in the left paraspinal area at L3-4. A pseudomeningocele in the subcutaneous lumbar tissue was demonstrated on computed tomographic (CT) imaging. Two intrathecal catheters were noted on CT imaging entering the spinal canal at the L3-4 level and a few millimeters of the proximal tip of the sheared catheter were visualized into the epidural space [
The patient was initially treated conservatively with bed rest for 48 h, but his symptoms did not improve over time. In addition, to the symptomatic pseudomeningocele and intracranial hypotension, the patient presented significant anxiety due to his concerns about the retained drain fragment. Surgical resection of the retained catheter with CSF leak repair was then recommended.
The patient underwent a minimally invasive repair of symptomatic CSF leak and removal of the sheared intrathecal catheter. Under general anesthesia with the patient prone on a Wilson frame, an 18 mm right-sided longitudinal incision 15 mm of the midline at L3-L4 was planned using fluoroscopy. Serial dilators were inserted and final 18 mm diameter retractor was docked at the junction of the inferior L3 lamina and facet complex.
A L3 laminotomy and medial facetectomy were performed and upon removal of the ligamentum flavum, CSF became visible in the surgical field. The functional intact catheter was visible at the midline in the epidural space and some CSF was leaking around its insertion site in the dura. The second sheared catheter was identified following completion of a L4 laminotomy and CSF was freely leaking from its open end [
Intra-operative images showing (a) the functional catheter (right side) and the tip of the non-functional catheter (left side), (b) forceps being used to pull the severed catheter and (c) purse string suture being made around the remaining functional catheter to ensure a watertight closure and (d) before closure with a suture at the site of the sheared catheter and the purse string suture around the functional catheter
The non-functional catheter tip was removed with micro bayonet curved tip forceps [
Postoperatively, the patient complained of nausea and abdominal pain that improved in the weeks following procedure. He further reported complete resolution of his postural headaches and was able to tolerate continued use of his functioning morphine pump. Complete resolution of his presenting symptoms with no evidence of CSF leak was confirmed at 8 weeks postoperatively. The patient continued to benefit from palliative care until his death 5 months after the procedure.
Intrathecal catheters are commonly used for CSF diversion or drug delivery. Complications involving the catheter itself such as leakage, fracture, dislodgement/migration, kink/occlusion, disconnection at the pump, granuloma formation, or infection may warrant catheter revision or explanation. Catheter-related complications can occur in 3% to 76% of patients implanted with an intradural drug delivery system (IDDS) with catheter breakage, migration, and obstruction being more frequently reported.[
Indications for surgical extraction of a sheared intrathecal catheter
Management of a retained intrathecal catheter and surgical removal must be decided on an individual basis. Low surgical risk, progressive neurological symptoms, infectious risk, presence of pseudomeningocele, scheduled spine surgery at the same level, migrating catheter, and patient psychological distress are factors that can support surgical removal of a retained catheter fragment.[
The place of MIS for extraction of intradural foreign objects and repair of cerebrospinal fluid leak
MIS of the spine through tubular retractors has gained popularity due to its decreased surgical morbidity and the potential to achieve better postoperative clinical outcome.[
Intradural surgery can be safely performed through tubular retractors using MIS techniques.[
We present the first case of successful removal of a retained intra/extradural catheter and treatment of resulting CSF leak through a minimally invasive approach. We present this approach as an optimal alternative for this population of terminally-ill patients in which more extensive procedures are preferably avoided.
MIS technique utilizing commonly available instruments can be successfully and safely used to remove retained sheared intrathecal catheters and to repair persistent spinal CSF leak after implantation of a IDDS. Although more technically demanding when compared to open approaches, MIS offers the advantage of minimizing the surgical morbidity, without creating a significant empty space in which CSF can accumulate, and thus can possibly decrease the incidence of postoperative pseudomeningocele.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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