PMC9479648_01
Stab wound in the lower right quadrant of the lumbar region, 6 cm above tuffier's line (TL) and 3 cm from midline (ML), showing active CSF outflow through the skin wound (Panel A).
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F1
Physical examination revealed a 3-cm skin wound at the right paravertebral lower-back region, 3 cm from the middle line, and 6 cm cephalic from the Tuffier's line leaking clear fluid [Figure 1 Panel A].
(a and b) Midsagittal view of a T2-weighted (a). MRI of the lumbar spine showing dural tear (white arrowhead) and L4 right lamina relation to the CSFL trajectory (b) (black arrows). (c and d) Axial view of a T2-weighted (c) and contrast-enhanced T1-weighted (d) MRI of the lumbar spine exhibiting paravertebral rupture of the longus and iliocostalis muscles related to dural tear and lamina fracture up to epidermis (black arrow).
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F2
T2-weighted and T1-contrast-enhanced Magnetic Resonance Imaging (MRI) were performed and confirmed a traumatic CSFL extending from the inferior border of the L4 right lamina, including the paravertebral longissimus, iliocostalis muscles, up to the skin [Figure 2].
Sutured wound with CSFL contained (Black dotted circle) in described location.
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F3
Three days after removing the subarachnoid catheter, the recurrence of the CSFL was noted [Figure 3].
(a and b) Midline (ML) approach, right paraspinal dissection with exposure of vertebral L4-L5 space. Vertebral L4 Spinal process (SP-L4), right lamina (RL-L4), right facet joint (RFJ-L4), and their relations with the CSFL (white dotted circle) were exposed. Right L4 laminectomy was performed, exposure of the interspinal ligament (ISL) and ligament Flavors (LF) shows the compromised in the traumatic CSFL route until the dural defect in the medial segment (White dotted circle). (c) Paraspinal pedicle flap was obtained from the erector spinae and thoracolumbar fascia fixed to the SP-L4, ISL, and the LF assisted with hemostatic material in the peripheral areas.
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F4
An ipsilateral paravertebral Longissimus thoracis muscle plus fascia free-flap was required to achieve complete dural closure [Figure 4].
Postoperative wound with outstanding healing process without cutaneous or contained CSFL.
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F5
Postoperatively, resolution of the subcutaneous collection and headache was noted [Figure 5].