Anterior sacral pseudomeningocele following minimal trauma

Abstract

<jats:p>Sacral fractures are rare and seldom result in formation of a sacral pseudomeningocele. Treatment of these pseudomeningoceles usually consists of conservative management with flat bedrest or open operative management. The authors describe the case of a 55-year-old woman with an anterior sacral pseudomeningocele that was successfully treated using a lumbar drain for temporary continuous CSF drainage. The patient first presented to an outside institution several days after sacral trauma from an ice skating fall. Initial symptoms included throbbing headaches relieved by lying flat. Head and cervical spine CT demonstrated no abnormality. As symptoms worsened, she presented to another institution where MRI of the lumbar spine indicated sacral fracture with pseudomeningocele. The patient subsequently transferred to the authors' facility, where symptoms included headaches and occasional mild sacral pain. Given her headaches and the authors' concern for CSF leak, another head CT scan was performed. This revealed no subdural hematoma or other abnormality. A subsequent CT myelogram revealed an anterior sacral pseudomeningocele at S3–4 with an anterior irregular linear filling defect, likely representing torn dura. Treatment included placement of a lumbar drain (10 ml/hr) and flat bedrest. Resolution of the CSF leak occurred on postprocedure Day 9. At the 4-week follow-up visit, the patient had no clinical symptoms of CSF leak and no neurological complaints. To our knowledge, this is the first description of temporary continuous CSF drainage used to treat a posttraumatic sacral pseudomeningocele. This technique may reduce the need for potentially complicated surgical repair of sacral fractures associated with CSF leak in select patients.</jats:p>

Unsuspected cerebrospinal fluid leak following a minor sacral fracture: A case report

“…In rare instances where a CSF leak occurs subsequent to a minor sacral fracture resulting from low-energy trauma, it is probable that there exists a pre-existing anatomical condition predisposing to this complication. Such conditions may include spina bifida occulta, meningeal cysts, or other pathological findings that can predispose the individual to sacral bone thinning and remodeling [6] . Due to the possible relationship between a pre-existing spine defect and the formation of CSF leaks in the sacral segment, radiologists should prompt always search for dural defects or possible CSF leaks in patients with sacral trauma who also have cystic sacral lesions or clearly thinned and remodeled sacrum.…”

“… No No Conservative Cools et al. [6] Fracture of S3 vertebral body and a collection contiguous with the dural sac extending from the sacral canal to the presacral region No No Lumbar drainage Akahane et al. [7] Intrasacral meningocele connecting with fluid collection posterior to the sacrum and gluteal area bilaterally.…”

“…On the other hand, Cools et al. [6] described a minor sacral fracture complicated with a CSF leak following a fall on the back in a patient who did not have any identifiable sacral anatomical defects. Cawley et al.…”

Successful management of a giant anterior sacral meningocele with an endoscopic cutting stapler: case report

“…18,22 ASM formation has also been described in the context of minor trauma to the anterior sacrum, through the same proposed mechanism of CSF pulsation and subsequent erosion. 9 Otherwise, some clinical conditions such as Currarino's triad and Marfan's have been associated with ASMs. In the present report, our patient did not have any of these associated conditions.…”

Vertebral body erosion by pseudomeningocele

“…Multiple cases of posterior bony erosion because of postsurgical pseudomeningoceles have been described previously. However, this is the first reported case of vertebral body erosion because of an anterior iatrogenic pseudomeningocele [1][2][3].…”