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Leakage of cerebro-spinal fluid after removal of a pedicular screw

  • Jean LegayeEmail author
Case Report
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Abstract

A case of cerebro-spinal fluid leakage occurring after the removal of a pedicular screw is reported. It allowed emphasizing the frequency of the dural tears in spinal surgery, particularly when pedicular screws are used. Moreover, the removal of screws having involved neurological complications can induce other lesions, such in the reported case. This removal procedure is not benign and requires precautions and a monitoring identical to the other spinal procedures.

Keywords

Cerebro-spinal leak Burst fracture Pedicular screw Removal 

Fuite de LCR après ablation d’une vis pédiculaire

Résumé

Un cas de fistule de liquide céphalo-rachidien survenue après ablation d’une vis pédiculaire vertébrale est rapporté. Les brèches de la dure-mère sont fréquentes en chirurgie rachidienne, particulièrement lorsque des vis pédiculaires sont utilisées. De plus, l’ablation de vis responsables de complication neurologique peut elle aussi induire des lésions supplémentaires, comme dans le cas rapporté. L’ablation de vis pédiculaires n’est donc pas un geste bénin, mais nécessite les mêmes précautions et surveillance que les autres interventions rachidiennes.

Mots-clés

Liquide céphalo-rachidien Fracture vertébrale Vis pédiculaire Ablation 

Introduction

The removal of spinal implants was considered as benign. The reported case revealing an unsuspected misplacement of a pedicular screw emphasizes the risk and the potential complications of such procedures.

Clinical case

A patient F.B., 19 years old, was admitted for a burst fracture of L1 after a fall in the stairs. An acute cauda equina syndrome was diagnosed. An intra-canalar bone fragment from the posterior edge of the vertebral body involved a compression of the spinal cord. A large laminectomy from L2 to T12 was immediately performed, pushing away the bone fragment, and a posterior stabilization with pedicular screws from L3 to T11. The patient recovered quickly the force of the lower limbs and his walk, but persisted a bilateral hypoesthesia in the S1 area, as well as an anesthesia S3–S4. A revalidation allowed a partial recovery of the tonicity of the anal sphincter. A urinary incontinence required self-catheterizations for a hypotonic and a reflective bladder.

The removal of the osteosynthesis pedicular screws was performed without difficulty 18 months after the traumatism. The initial approach was used, avoiding carefully the laminectomy. The disassembling and removal of the device was easy. Any immediate complication was observed. The patient recovered quickly from the pre-operative condition. The wound was perfect and dry. The urinary probe was removed according to the urologist treating the patient. But after a usual effort of miction with abdominal compression at the third post-operative day, there abruptly appeared a clear flow through the scar. A measurement of Beta-2-transferine concluded to a leakage of cerebro-spinal fluid (CSF).

An exploration by myelography with CT scan was performed. It concludes to a CSF leakage through the right pedicle screw tract in L3. (Fig. 1.) This screw was indeed initially misplaced but without neither neurologic complication nor immediate leakage, the screw obstructing the pedicle. The flow was quickly dried up after 48 h of bed rest. The wound was then perfect and dry; the patient was authorized to rise after 5 days. The flow did not reappear and the functional condition remained unchanged.
Fig. 1

CT-scan with myleography of L3: pseudo-meningocele connected to dural tears through a misplaced pedicular screw tract

Discussion

Complications following lumbar spine surgery are reported to occur in 15–30% of cases [15]. Leakage of CSF and pseudo-meningocele are common etiologies. Wang et al. [18] reported a rate of 14% of incidental durotomy during 641 consecutive laminectomy procedures for lumbar degenerative stenosis. They are either immediate by iatrogenic direct lesion, or late by progressive erosion of the dura on osseous tips. Moreover, any increase in the pressure of the CSF by Valsalva’s effect (cough, vomiting or post-anesthesia nausea, etc.) will tend to fissure an already weakened dura.

A midline dural tear in the spine is readily repaired; however, far-lateral or ventral dural tears are problematic. It should be repaired at the time of the original operation either directly by application of sutures or utilizing a fascia or fat graft, or a tissue-plug technique with fibrin glue [2, 6]. Some authors recommend a bed rest for nearly 7 days [18]; others permit to ambulate immediately after surgery [11]. Cammisa et al. [3] concluded after a review of 74 dural tears that incidental durotomy, if recognized and treated appropriately, does not lead to long-term sequelae. On the other hand, Goodkin and Laska [9] reported that considering the frequency with which a dural tear is listed as one of the complaints in medical malpractice cases involving surgery of the lumbar spine, it cannot be considered an entirely “benign event”.

Direct dural tears can also occur for vertebral traumatisms, mainly for “burst” fracture by axial trauma [5, 12]. The dura will be then wounded either by an osseous fragment expelled in the medullar canal, or at the time of the reduction repositioning this one. Keenen [12] reported a 7.7% incidence of dural tears in surgically treated patients with lumbar burst fractures. Eighty-six percent of them had a neurological deficit. So he recommended exposing the dura for an initial inspection before any reduction maneuver when surgically treating lumbar burst fractures with a neural deficit.

The use of pedicular screw is currently admitted as useful in spinal surgery, mainly for the correction and the fixation of vertebral fractures [10, 19]. Combined distraction with extension during fixation using pedicular screws was found to decompress the canal and inter-vertebral foramens in a burst fracture [14]. Transpedicular instrumentation provides rigid fixation and produces pain free fusion results. Several authors consider that pedicle screw fixation has an acceptable rate of complication and neurological injury [4, 16, 19]. Nevertheless, the use of pedicle screws even by experienced surgeons carries some risk for misplacement and neurological damage. Correct placement of transpedicular screws seems to be more difficult than it looks [8, 17]. A computer-assisted technique is much more accurate and safe than manual insertion. It can decrease the incidence of incorrectly positioned pedicle screws [1, 13]. However, neurological symptoms are not constant in the event of misplacement, as in the reported case. Only at the time of removal of the screw there appeared leakage of CSF, revealing the initial misplacement.

The diagnosis of dural tears is essential because of the infectious risk (meningitis, etc.) if a flow through the scar occurs. The clinical symptoms are the headaches in station reduced in lying position, the pain and stiffness of the neck, nausea and vomiting, photophobia and visual troubles.

A flow through the scar must be conducted to measure the beta 2 transferrine, which is a specific test for the CSF. It is a protein produced by the neuraminidase of the cerebral tissues. It is present exclusively in the CSF and the lymph.

The imagery also helps to the diagnosis. The magnetic resonance imaging allows the visualization of pseudo-meningoceles. The CT-scan will be less powerful, except if it is associated to the myelography. Afterwards, it allows the localization of the tear in order to direct the repairing surgical procedure [7].

The case reported here highlights also the inherent risk of the removal of pedicular screws. Lesions of the neurological structures can indeed occur at this time in the event of ignored misplacement. This gesture is thus not benign and may be complicated by potential after-effect. Moreover, if a screw appears misplaced inducing neurologic symptoms, the removal must be performed under direct vision of the dura and the nerve roots.

Conclusion

Incidental durotomy is not rare in spinal surgery. Penetration of the dura and injury to the neural elements can occur when pedicle screw instrumentation is used. Removal of the screw under these circumstances may cause additional complications or neurologic injury.

References

  1. 1.
    Amiot LP, Lang K, Putzier M et al (2000) Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine. Spine 25(5):606–614CrossRefPubMedGoogle Scholar
  2. 2.
    Black P (2002) Cerebrospinal fluid leaks following spinal surgery: use of fat grafts for prevention and repair. Technical note. J Neurosurg 96(2 Suppl):250–252PubMedGoogle Scholar
  3. 3.
    Cammisa FP Jr, Girardi FP, Sangani PK et al (2000) Incidental durotomy in spine surgery. Spine 25(20):2663–2667CrossRefPubMedGoogle Scholar
  4. 4.
    Castro WH, Halm H, Jerosch J et al (1996) Accuracy of pedicle screw placement in lumbar vertebrae. Spine 21(11):1320–1324CrossRefPubMedGoogle Scholar
  5. 5.
    Colachis SC, Rea GL (1992) Dural tear following traumatic spinal cord injury. A delayed complication. Am J Phys Med Rehabil 71(6):352–355PubMedCrossRefGoogle Scholar
  6. 6.
    Eismont FJ, Wiesel SW, Rothman RH (1981) Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 63(7):1132–1136PubMedGoogle Scholar
  7. 7.
    Eljamel MS, Pidgeon CN (1995) Localization of inactive cerebrospinal fluid fistulas. J Neurosurg 83(5):795–798PubMedCrossRefGoogle Scholar
  8. 8.
    Faraj AA, Webb JK (1997) Early complications of spinal pedicle screw. Eur Spine J 6(5):324–326CrossRefPubMedGoogle Scholar
  9. 9.
    Goodkin R, Laska LL (1995) Unintended “incidental” durotomy during surgery of the lumbar spine: medicolegal implications. Surg Neurol 43(1):4–12CrossRefPubMedGoogle Scholar
  10. 10.
    Halm H, Niemeyer T, Link T et al (2000) Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis. Eur Spine J 9(3):191–197CrossRefPubMedGoogle Scholar
  11. 11.
    Hodges SD, Humphreys SC, Eck JC et al (1999) Management of incidental durotomy without mandatory bed rest. A retrospective review of 20 cases. Spine 24(19):2062–2064CrossRefPubMedGoogle Scholar
  12. 12.
    Keenen TL, Antony J, Benson DR (1990) Dural tears associated with lumbar burst fractures. J Orthop Trauma 4(3):243–245PubMedCrossRefGoogle Scholar
  13. 13.
    Merloz P, Tonetti J, Pittet L et al (1998) Pedicle screw placement using image guided techniques. Clin Orthop 354:39–48CrossRefPubMedGoogle Scholar
  14. 14.
    Panjabi MM, Oda T, Wang JL (2000) The effects of pedicle screw adjustments on neural space in burst fracture surgery. Spine 25(13):1637–1643CrossRefPubMedGoogle Scholar
  15. 15.
    Sarrazin JL (2003) Imaging of post-operative lumbar spine. J Radiol 84:241–250PubMedGoogle Scholar
  16. 16.
    Schulze CJ, Munzinger E, Weber U (1998) Clinical relevance of accuracy of pedicle screw placement. A computed tomographic-supported analysis. Spine 23(20):2215–2220; discussion 2220–2221Google Scholar
  17. 17.
    Sjostrom L, Jacobsson O, Karlstrom G et al (1993) CT analysis of pedicles and screw tracts after implant removal in thoracolumbar fractures. J Spinal Disord 6(3):225–231PubMedCrossRefGoogle Scholar
  18. 18.
    Wang JC, Bohlman HH, Riew KD (1998) Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am 80(12):1728–1732CrossRefPubMedGoogle Scholar
  19. 19.
    Yue JJ, Sossan A, Selgrath C et al (2002) The treatment of unstable thoracic spine fractures with transpedicular screw instrumentation: a 3-year consecutive series. Spine 27(24):2782–2787CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  1. 1.Orthopaedic Surgery DepartmentUniversity Hospital Mont-GodinneYvoirBelgium

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