Abstract
Purpose: To discuss the diagnostic and therapeutic challenges presented by an adolescent girl with delayed postural headaches and photophobia that occurred three months after an apparently uncomplicated microscopic lumbar discectomy.
Clinical features: A previously healthy girl was admitted to our hospital with a one-week history of an unremitting, frontal-retroorbital postural headache and photophobia. Three months before admission, the patient had undergone a L5-S1 left hemi-laminotomy and foraminotomy with microdiscectomy for excision of a herniated intervertebral disc. Conservative treatment failed to provide symptomatic relief. Cranial magnetic resonance imaging showed enhancement of the pachymeninges, consistent with intracranial hypotension. A chronic cerebrospinal leak was identified by high-resolution computed tomography (CT) my-elography. Epidural blood patches were performed, with and without CT guidance, that provided temporary relief of the patient’s symptoms; however, direct suture plication of the dural tear was eventually required for definitive treatment.
Conclusion: This case emphasizes that delayed presentation of dural injury may occur after lumbar surgery and describes the potential therapeutic implications for this unusual complication.
Résumé
Objectif: Discuter le diagnostic et les défis thérapeutiques posés par une adolescente présentant des céphalées posturales différées et de la photophobie trois mois après une discectomie lombaire microscopique apparemment sans complications.
Éléments cliniques: Après une semaine de céphalées posturales frontales rétro-orbitaires accompagnée de photophobie, une jeune fille précédemment saine a été admise à notre hôpital. Trois mois avant son admission, la patiente avait subi une hémilaminectomie gauche L5-S1 et une foraminotomie par microdiscectomie pour l’excision d’un disque intervertébral hernié. Le traitement traditionnel n’a pas procuré de soulagement des symptômes. Une imagerie par résonance magnétique crânienne a montré une croissance de la dure-mère, compatible avec de l’hypotension intracrânienne. Une fuite chronique du liquide céphalorachidien a été détectée grâce à une myélographie par tomodensitométrie à haute résolution. Des blood patches périduraux ont été réalisés avec et sans guidage to-modensitométrique, ce qui a permis de soulager les symptômes de la patiente ; toutefois, une plicature directe de la déchirure durale par suture a finalement été nécessaire pour obtenir un traitement définitif.
Conclusion: Ce cas souligne le fait qu’une lésion durale peut survenir de façon différée après une chirurgie lombaire et décrit les implications thérapeutiques possibles de cette complication inhabituelle.
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This work was supported entirely by departmental funds.
Conflicts of interest: None declared.
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Kundu, A., Sano, Y. & Pagel, P.S. Case report: Delayed presentation of postural headache in an adolescent girl after microscopic lumbar discectomy. Can J Anaesth 55, 696–701 (2008). https://doi.org/10.1007/BF03017746
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DOI: https://doi.org/10.1007/BF03017746