Herniation of the cauda equina into the facet joint through a pseudomeningocele: A case report and literature review
- Department of Orthopedic Surgery, Noshiro Kosei Medical Center, Noshiro, Japan.
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan.
Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Akita, Japan.
DOI:10.25259/SNI_893_2020Copyright: © 2020 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: Jumpei Iida1, Naohisa Miyakoshi2, Michio Hongo2, Hiroshi Sasaki1, Hiroki Ito1, Hitoshi Kubota1, Takeshi Sato1, Yoichi Shimada2. Herniation of the cauda equina into the facet joint through a pseudomeningocele: A case report and literature review. 20-Jan-2021;12:30
How to cite this URL: Jumpei Iida1, Naohisa Miyakoshi2, Michio Hongo2, Hiroshi Sasaki1, Hiroki Ito1, Hitoshi Kubota1, Takeshi Sato1, Yoichi Shimada2. Herniation of the cauda equina into the facet joint through a pseudomeningocele: A case report and literature review. 20-Jan-2021;12:30. Available from: https://surgicalneurologyint.com/surgicalint-articles/10529/
Background: Incidental durotomy is a well-known complication of spinal surgery. It can lead to persistent cerebrospinal fluid leakage resulting in significant secondary complications. Here, we present a case in which the cauda equina herniated into a pseudomeningocele that penetrated a facet joint, leading to lower extremity radiculopathy warranting surgical correction.
Case Description: One year ago, a 67-year-old male underwent a partial left L4-L5 laminectomy. At surgery, a durotomy was repaired with a nylon suture and reinforced with a fat patch. He subsequently presented with severe left lower extremity radiculopathy and a partial cauda equina syndrome. On MR, the cauda equina had herniated into a pseudomeningocele that penetrated the left facet joint. Once the defect was repaired at surgery, the patient’s symptoms improved.
Conclusion: It is critical to correctly repair an intraoperative durotomy to avoid further neurological deficits that may include cauda equina herniation into pseudomeningoceles penetrating facet joints.
Keywords: Cauda equina, Incidental durotomy, Posterior spinal fixation, Pseudomeningocele
Incidental durotomy occurs in 0.5–18% of spinal operations.[
A year ago, a 67-year-old male presented with the acute onset of left-sided low back, hip, and left lower extremity pain for which he underwent a left-sided L4-L5 laminectomy. During surgery, there was a 2 mm left-sided durotomy that was repaired with a nylon suture and a fat patch graft. The subsequent MR examinations documented a persistent CSF leak that spontaneously resolved 3 months later. However, the patient again presented a year later with recurrent left-sided radiculopathy characterized by SLR 10 degrees, 3–4 motor function involving the iliopsoas, tibialis anterior, and extensor hallucis longus muscle distributions, and decreased left patellar and Achilles responses.
The lumbar X-ray showed the prior operative defect at the L4–L5 level, while the MR documented a left-sided pseudomeningocele extending into the left L4–L5 facet joint [
The patient underwent a secondary procedure 7 days later consisting of a L4–L5 facetectomy with posterior L4–L5 lumbar interbody fusion [
Patients who experience traumatic intraoperative dural tears during lumbar surgery may develop postoperative recurrent/persistent radiculopathy and/or cauda equina syndromes attributed to herniation of neural tissues into pseudomeningoceles.
In this case, the cauda equina herniated into a pseudomeningocele that extended into the left L4–L5 facet joint. Other authors have reported herniation of nerve roots/ cauda equina through dural defects attribute to similar lumbar surgery (e.g., transdural cauda equina incarceration after microlumbar discectomy),[
However, only rarely has the nerve root herniated into a pseudomeningocele that then extended into a facet joint (e.g., in Nishi et al. the nerve root herniated into a large pseudomeningocele [
Here, a pseudomeningocele developed due to an inadequately repaired dural tear during a lumbar discectomy and resulted in cauda equina herniation into the resultant pseudomeningocele that then extended into the facet joint. In the future, such dural repairs should avoid nylon sutures; rather, it is best to 7-0 Gore-Tex sutures or its equivalent where the needle is smaller than the suture itself, and the suture/knot will not “unfurl.” Further, it muscle patch grafts not fat grafts should supplement dural closures, as a fat graft shrink/resorb, thus failing to maintain occlusion the leakage site.
During a left L4–L5 laminectomy, a durotomy resulted in the cauda equina herniation into a left-sided L4–L5 pseudomeningocele with extension into the left L4–L5 facet joint. Once the pseudomeningocele was repaired, the patient’s recurrent radiculopathy/cauda equina syndrome was repaired.
This study was approved by the Medical Ethics Board of Noshiro Kosei Medical Center (approval number YD-057).
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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