PMC5306974_01
Preoperative MRI sagittal and axial T2-weighted postgadolinium images showed a pseudomeningocele at L3-L4 levels with paravertebral extension and psoas muscle remodeling (black arrow).
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This is the case of 34-year-old female with neurofibromatosis type 1 and scoliosis who underwent surgery for low back pain and MRI diagnosis of pseudomeningocele at L3 level with paravertebral extension (Figures 1(a) and 1(b)).
Postoperative CT and X-rays (a and b) showing L3 hemilaminectomy and L2-L5 stabilization with Hartshill rectangle and titanium wire. One-year follow-up after the first operation, sagittal and axial T2-weighted MRI images (c and d) disclosed a relapse of the operated pseudomeningocele at L3-L4 level with vertebral body remodelling (black arrow) and spinal roots displacement and convolution (asterisk).
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The patient was operated by L3 hemilaminectomy, reconstruction of the dural sac with water tight stitch, and L2-L5 stabilization with Hartshill rectangle and titanium wire (Figures 2(a) and 2(b)) as reported in the treatment of thoracolumbar instability and deformities. After one-year follow-up, the patient referred progressive pain and numbness in L5 left distribution and MRI disclosed a relapse of the operated pseudomeningocele at L3-L4 level (Figures 2(c) and 2(d)).
One year after the second operation an axial T2 and T1-weighted postgadolinium MRI images disclosed a pseudomeningocele with roots compression and displacement of the psoas muscle (white arrow).
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After one year an MRI disclosed a pseudomeningocele relapse (Figures 3(a) and 3(b)) and the patient underwent a third surgical procedure by L2-L4 hemilaminectomy and reconstruction by synthetic dura mater and autologous fat grafts with postoperative subarachnoid drainage for one week.
Sagittal and axial T2 weighted (a and b) and axial T1 weighted postgadolinium MRI images at six months after the third operation showed a new giant pseudomeningocele with intra-abdominal extension. The sagittal and axial T2 weighted MRI images (a and b) demonstrated dural sac and cauda roots compression (white arrows) and the inhomogeneous non-CSF like content of the pseudomeningocele (black arrow) probably due to the presence of surgical patch materials and blood products. Axial T1 weighted after gadolinium MRI picture (c) excluded pathological enhancement (white arrow).
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After six months MRI showed a giant pseudomeningocele with intra-abdominal extension (Figures 4(a), 4(b), and 4(c)).
After six months, the patient was fine without neurological deficit or abdominal symptoms and the spinal sagittal and axial T2-weighted MRI images showed no relapse of the pseudomeningocele (a and b). The sagittal T2-weighted MRI demonstrated the decompression of cauda roots (white arrows), even if appeared clumped together due to postsurgical scar. In the axial T2-weighted MRI the residual meningocele (white arrow) and the ADM (asterisk) with fat patch were demonstrated. The surgical incision completely healed was shown in image (c).
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ADM sutured directly on the dural defect with reabsorptive stiches. After six months, the patient was fine without neurological deficit or abdominal symptoms and the spinal MRI showed no relapse of the pseudomeningocele (Figures 5(a), 5(b), and 5(c)).