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09-MARCH-2020 HUSNI LUTFI ABDEL-HAQ 45 YEARS
POST-TRAUMATIC CSF LEAK FORM THE PREVIOUSLY OPERATED DISCECTOMY L4-5.
Anamnesis
The patient was operated by me for huge extruded
disc L4-5 with left downward migration
15-November-2018. The patient then came
09-December-2019 still complaining of left
sciatica with improvement of the power of the
left foot. MRI performed 07-December-2019
showing small piece of disc fragment at L4-5
left side. Dorsiflexion of the left foot at that
time was +4/5. The patient then came
27-February-2020 telling that he got severe
headache with fainting for 15 days several days
after falling down 10-February-2020. The patient
then noticed a pocket of CSF collection under
the skin at the operative site and above 2 days
later. Routine MRI done 18-February-2020 showing
CSF pocket at the level of the operative site.
On examination: The patient is walking normally
without scoliotic stance SLRS was 60 degrees
with pain left side. SMLLs was normal.
The patient was sent for MRI of the lumbar spine
with 3D myelography to confirm the presence of
the CSF leak and its origin. It was performed
08-March-2020 and showed that the defect was in
the upper left corner of the previously exposed
dura.
The patient was put with the head
down and the operative field at most upper position.
The old incision refreshed. Exposure of the wound
and exploration of the CSF pocket. There is
longitudinal tear of the scar at the operative site.
Using 4 zero nylon, the tear was water-tightly
closed. The patient was put with head up,
hyperventilation and Valsalva maneuver. No CSF leak.
The muscle with pedicle from the left side was
reflected to repaired site to add more security. Routine closure of the
wound.
Smooth postoperative recovery.
Comments
CSF leak usually take place the first
week after surgery. In the case the patient suffered trauma
after 2 years of his surgery. The dura usually is hard to be
torn directly at the surgical field. It must be torn around
the scar tissue. for what 3D myelography was performed.
According to its data it must be from the left upper corner
of the dural scar.
During surgery, the findings were
different. The scar was longitudinally torn at the midline
and inferior.
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Fig:-1 The CSF pocket.
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .
