Dural leakage due to ipsilateral needle placement for spinal level localization in unilateral decompression surgery: A case report
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, Aarau,
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern,
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrassse, Switzerland.
Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrassse, Switzerland.
DOI:10.25259/SNI_245_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 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: Lukas Andereggen1,2, Markus M. Luedi3. Dural leakage due to ipsilateral needle placement for spinal level localization in unilateral decompression surgery: A case report. 03-May-2021;12:205
How to cite this URL: Lukas Andereggen1,2, Markus M. Luedi3. Dural leakage due to ipsilateral needle placement for spinal level localization in unilateral decompression surgery: A case report. 03-May-2021;12:205. Available from: https://surgicalneurologyint.com/surgicalint-articles/10779/
Background: A spinal dural defect caused by needle placement for spinal level localization is an uncommon complication of cerebrospinal fluid leak with the potential for the development of intracranial hypertension.
Case Description: Our 48-year-old patient underwent unilateral fenestration and sequestrectomy for intractable L5 radiculopathy due to disc herniation at the level L4–5 on the right side. The spinal level was identified with fluoroscopy after placement of a 24-gauge Sprotte spinal needle on the right side. Intraoperatively, a sub-millimeter spinal dural defect was visualized on the ipsilateral side.
Conclusion: Caution is needed when needle placement is used to localize the spinal level for unilateral surgery.
Keywords: Dural puncture, Intracranial hypotension, Lumbar spinal surgery, Postdural puncture headache, Sealing
State-of-the-art lumbar microdiscectomy is superior with respect to pain intensity when compared to conservative treatment in patients with refractory long-lasting sciatica.[
The patient provided written informed consent for this case report.
A 48-year-old otherwise healthy trucker (BMI 26.3 kg/m2) presented with intractable L5 radiculopathy on the right side refractory to conservative therapies. Lumbar magnetic resonance imaging revealed a right-sided cranially migrated lumbar intervertebral disc herniation at the level L4–L5, compressing the L5 nerve root [
The site of dural puncture by a spinal needle placed in the wrong location during level identification. (a) T2-weighted magnetic resonance imaging showing cranially migrated disc herniation at the level L4–L5. (b) Location of the spinal needle at the level L4–L5, with a relatively deep position between the spinal process. (c) Intraoperative images reveal the single interrupted stitch at the dura (arrow), with depiction of the L5 nerve and underlying disc herniation.
Following right-sided microsurgical fenestration and flavectomy, a dural puncture was identified adjacent to the outgoing L5 nerve root on the right side. The sub-millimeter defect was sealed with a simple interrupted 5–0 monofilament suture. Subsequently, a sequestrectomy was performed [
Sub-millimeter spinal dural defects can be sufficient to induce IH, with potentially life-threatening sequelae.[
Primary closure by dural suturing can be technically difficult in minimally invasive spinal surgeries.[
Avoidance of IH is critical. If inserted too deeply, a contralateral needle placed in a unilateral spinal decompression is advised, as it might compensate for IH development through the tamponade effect afforded by the posterior spinal canal. In the case of CSF leakage, proper intraoperative surgical and anesthesiological measures are crucial, even if leakage is in the sub-millimeter range.
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