A Case of Ventral Spinal Cord Herniation from a Chronic Dural-pleural Fistula Resulting in Thoracic Myelopathy

Abstract

Formation of a dural-pleural fistula is uncommon after anterior thoracic spine surgery, tumor, or trauma. The goal of surgical management is to terminate the connection between the pleura and subarachnoid space. We describe a case of chronic dural-pleural fistula in a 70-year-old woman and present a unique surgical treatment option. The patient presented 25 years after an anterior thoracic surgery she had undergone for a thoracic disc herniation, with a dural-pleural fistula and ventral herniation of the spinal cord into the defect. She was treated with a bovine pericardium sling patch to cover the defect. This case highlights the identification of a chronic thoracic dural-pleural fistula and surgical treatment with double intradural and extradural layering of bovine pericardium sling patch, which has not been described previously for chronic thoracic dural-pleural fistula.

Pneumocephalus resulting from chest infection complicated by pleural-subarachnoid fistula

“…Both surgical repair and conservative management have been reported in the literature, including for example; bed rest, chest tube insertion, external lumbar drainage, positive pressure ventilation, epidural blood patch, or subcutaneous biological glue injection [ 1 , 2 , 7 ]. Interestingly, in our case, spontaneous closure of the fistula took place which is the least expected pathway as reported in the literature [4] , and follow-up CT scans of the brain showed a subsequent gradual decrease in the degree of pneumocephalus.…”

“…Milloy et al in 1959 are the first ones who report a pleural-subarachnoid fistula [1] . It occurs when attract formed between pleural and meningeal tears [4] . In the literature, there are less than 60 cases of Pleural-subarachnoid fistula.…”

“…Pleural-subarachnoid fistula cause hydrostatic pressure differences between the pleural cavity and the CSF spaces, Thus, during inspiration the low intrathoracic pressure acts as a cavum and allows for the CSF to accumulates in the pleura, results in pleural effusion, and vice versa during the expiration where the air will be pushed to the CSF space resulting in pneumocephalous [ 4 , 7 , 8 ]. Nevertheless, the clinical manifestation is most commonly pleural effusion and pneumothorax respectively.…”

“…Diagnosis of Pleural-subarachnoid fistula can be challenging, a combination of clinical, radiological, and laboratory data would help in reaching the diagnosis and preventing meningitis and progressive myelopathy [4] . Chest radiograph and chest CT will recognize the pleural effusion, but they are nonspecific, while pleural effusion analysis using β2 transferrin is a highly sensitive and specific test for detecting the presence of CSF [ 2 , 1 , 9 ].…”

“…These two modalities are the most commonly used and are the best confirmatory tests [3] . Other less invasive although less sensitive modalities include MRI imaging [ 4 , 7 ].…”