Pain After Repair of Dural Tear and Pseudomeningocele

///Pain After Repair of Dural Tear and Pseudomeningocele
Pain After Repair of Dural Tear and Pseudomeningocele
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  • koobi336
    Participant
    Post count: 8

    Hello, I had a micro discectomy L4-L5 on 12/3/2018. I developed a large swelling at the surgical site and it was determined via MRI in early Feb 2019 that it was due to a dural tear and CSF leak. This resulted in a second surgery on 2/7/2019 to repair the dural tear. Since that 2/7/2019 surgery I have had continued back pain and numbness in the left foot. My Dr. ordered an MRI on 3/6/2019 to make sure the CSF leak was repaired. I still have the back pain primarily when sitting and numbness in left foot nearly 5 weeks after the corrective surgery. I had a follow up visit with my Dr. yesterday. He says the pseudomeningocele is significantly smaller. He does not believe it is still leaking spinal fluid, but says it is difficult to tell 100% from the MRI alone. He said even if it was still spinal fluid, since it is much smaller and contained now he wouldn’t do anything at this point anyway. He said many patients with back surgeries develop fluid filled pockets and they never go away so he is not concerned. I am concerned that I still have this back pain. Is this indeed common at 5 weeks after a surgery to repair a large pseudomeningocele and is this likely to resolve over time? How much time should I give it before being concerned about permanent back pain? I have included the results of my latest MRI below in case it is helpful. Thanks for any advice.

    CLINICAL DATA: Postprocedural pseudomeningocele. Postop laminectomy
    12/03/2018. Surgical repair of pseudomeningocele 02/07/2019

    EXAM:
    MRI LUMBAR SPINE WITHOUT AND WITH CONTRAST

    TECHNIQUE:
    Multiplanar and multiecho pulse sequences of the lumbar spine were
    obtained without and with intravenous contrast.

    CONTRAST: 16mL MULTIHANCE GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN

    COMPARISON: MRI lumbar spine 09/06/2018, 01/24/2019

    FINDINGS:
    Segmentation: Normal
    Alignment: Slight retrolisthesis L3-4 L4-5 unchanged
    Vertebrae: Normal bone marrow. Negative for fracture or mass.
    Negative for discitis or osteomyelitis.
    Conus medullaris and cauda equina: Conus extends to the L2 level.
    Conus and cauda equina appear normal.
    Paraspinal and other soft tissues: Fluid collection posterior to the
    laminectomy defect on the left at L4-5 has improved. This now
    measures 18 x 24 mm on axial images, 42 mm cranial caudal dimension.

    This is now localized in the muscles and does not extend to the skin
    surface as noted previously. There is a small subcutaneous fluid
    collection in the midline. Findings most compatible with CSF leak
    with interval improvement in pseudomeningocele. No mass-effect or
    compression of the thecal sac. Minimal enhancement of the wall of
    the fluid collection.

    Negative for retroperitoneal fluid collection or mass

    Disc levels:
    T12-L1: Schmorl’s node without stenosis
    L1-2: Schmorl’s nodes without stenosis
    L2-3: Negative
    L3-4: Mild disc and facet degeneration. Negative for stenosis
    L4-5: Small central disc protrusion unchanged from the prior study.
    Left laminectomy. Spinal canal and neural foramina widely patent
    L5-S1: Negative

    IMPRESSION:
    Postop laminectomy left L4-5. Significant improvement in fluid
    collection posterior to the laminectomy defect compatible with
    healing CSF leak. No evidence of infection or osteomyelitis. Small
    central disc protrusion L4-5 unchanged. Negative for stenosis or
    neural impingement.

    Electronically Signed
    On: 03/06/2019 12:43

    Donald Corenman, MD, DC
    Moderator
    Post count: 6657

    It is uncommon but not unheard of that a dural leak can occur after a microdiscectomy. It sounds like your surgeon did the right thing and tried to seal the leak. The leak can have nerves tangled in it and when they get “pushed out of the way”, they can complain which might explain your numb foot. Back pain is a different animal.

    Back pain could be from the further removal of bone to get to the leak or from muscle manipulation due to surgery but that should go away fairly rapidly. It might take some time for the disc to settle after a microdisectomy so be prepared to have some pain for 2-3 months. One unusual but potential possibility is a post-operative infection by a skin organism called P. Acnes which causes back pain without fevers or chills. Some labs tests can help to rule this out.

    Unfortunately, it is a matter of time and patience to allow this leak to seal and become non-symptomatic.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
    koobi336
    Participant
    Post count: 8

    Dr. Corenman, Thank you so much for your reply. My original discectomy was 3.5 months ago and I am feeling that particular pain almost gone. This new back pain is more since the second surgery 5 weeks ago to repair dural tear and pseudomeningcele. He didn’t mention further bone removal, but did say one tear was right under a bone and difficult to access.

    You mention a matter of time for the leak to seal. Is it possible the leak did not seal completely and might still seal more on its own? My Dr. released me to do pretty much any activity I want. Would it be wise to still take it very easy for awhile? If so, how long?

    I also am concerned about epidural fibrosis. Would that have been evident on the recent MRI? The pain is worse when sitting. I can not sit for more than 30 mins. Some of the exercises I have read to prevent EF also are hard on dural tears, so I am not sure whether to do them or not. What do you think? Thanks so much for your help!

    Donald Corenman, MD, DC
    Moderator
    Post count: 6657

    Dural tears can be hard to fully seal as even the suture needle, as small as it is, can create a small leak from the stitch going through the dural substance. We all generally put patches on these leaks, similar to patching an inner tube but these patches need to “heal in” unlike an inner tube patch which sticks immediately. This is you are required to lie flat for 24 hours after surgery and why activity is reduced after the repair for 2-4 weeks after the fix.

    Epidural fibrosis is scarring on the outside of the dura which always occurs to some extent with any spine surgery. It is necessary after a dural repair as this scar seals the dura.You are correct in that you can’t “floss the nerve”-stretch the nerve in physical therapy speak too much as you don’t want to disturb the repair.

    Back pain is generally not caused by dural tears. Headaches and a stiff neck are more dural leak symptoms. You are only 5 weeks from your repair surgery. Give it 3 months after surgery to determine if your back pain goes away.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
    koobi336
    Participant
    Post count: 8

    Hello Dr. Corenman,
    It has now been several more weeks with the same symptoms over 4 months since discectomy and 9 weeks since dural tear repair surgery, not really improving. Back pain when sitting/standing. My doctor has not seen me since. Does it seem at this point that it must be caused by epidural fibrosis or do these back pains often still resolve with more time? If epidural fibrosis is the cause, what do you think about the treatment studies combining Pentoxifylline and vitamin e. Would it be worth trying this? Do epidural steroid injections help resolve, or are oral steroids more effective? Anything other suggestions? Thanks for your help.

    Donald Corenman, MD, DC
    Moderator
    Post count: 6657

    Back pain is generally not caused by epidural fibrosis. Mainly back pain is caused by the disc and occasionally by the facet. Pentoxifylline and vitamin E should not hurt you but I would be very doubtful that you could gain relief from these supplements.

    Epidural steroids can be helpful and sometimes curative for lower back pain caused by the swollen annulus.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
     
    Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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