Postoperative pseudomeningocele Presenters name Arial 24 pt Meeting

Postoperative pseudomeningocele Presenter’s name Arial 24 pt Meeting Arial 24 pt Presenter’s title Arial 20 pt City, Month, Year Arial 20 pt

• Lumbar decompression for canal stenosis • Discharged home and returns a week later • Headache • Swelling under lumbar wound

Differential diagnosis?

• Infection • Pseudomeningocele • Mode of investigation?

Clinical Management?

Pseudomeningocele • “Pseudo” because collection not encompassed by dura • Large collections need revision surgery and repair • Low pressure headaches • Fluctuant swelling • May leak through wound (beta 2 transferrin positive) • Can cause new/recurrent lower limb symptoms • Nerve root herniation from dural defect • Compressive element from pseudomeningocele

Inadvertent durotomy • Revision surgery has a higher rate of dural breach • Tight stenosis and dural outpouching during decompression • When there is excessive bleeding obscuring a dural injury • Kerrison punch • Sharp bone edges • How do you minimise risks in revision surgery?

Prevention in revision surgerys • Check for adhesions during decompression • Work from normal anatomy • Light and magnification • Neuropathies • Balance leaving alone or dissecting adherent areas free • Check no sharp bone edges at end

Dural tear • Do nothing • Direct repair • Patching • Gravity-only drain • CSF diversion

Direct repair • Exposure/magnification/ illumination • Neuropathies • Low suction • May need to extend tear • Reduce herniated neural elements • Watertight closure (Valsalva) • Reinforce with local muscle/fascia and fibrin glue • Close off dead space in all layers

Postoperative management of dural tear • Lie flat • Can mobilize soon if direct repair • Rehydrate • Monitor wound for any leakage • Observe for ongoing headaches • Further leak may require revision surgery/remote CSF drain • Persisting headaches can indicate intracranial subdural haematoma – consider a CT scan

Take-home messages • Inadvertent dural breach is more common in revision surgery • Direct repair is best • Alternative strategies if direct repair not possible • Late presentation with pseudomeningocele can occur • Beta 2 transferrin is very sensitive for CSF • Ongoing leak of CSF through wound risks meningitis

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