Pain After Repair of Dural Tear and Pseudomeningocele

Tagged: CSF leak after a microdiscectomy

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koobi336
Participant

March 12, 2019 at 12:51 pm

Post count: 10

#30223

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

March 14, 2019 at 8:20 am

Post count: 8660

#30230

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

March 14, 2019 at 9:13 am

Post count: 10

#30235

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

March 16, 2019 at 8:52 am

Post count: 8660

#30245

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

April 10, 2019 at 4:29 am

Post count: 10

#30337

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

April 10, 2019 at 7:20 am

Post count: 8660

#30338

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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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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