Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note

Felbaum, Daniel R.; Mueller, Kyle; Anaizi, Amjad; Mason, Roger A.; Jean, Walter C.; Voyadzis, Jean Marc

doi:10.7759/cureus.946

Cited by 11 publications

(7 citation statements)

References 19 publications

(17 reference statements)

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“…Various adjuncts have been investigated, from the type of dural graft or sealant used to whether the bone flap was replaced or the type of wound closure used (e.g., myofascial cuff technique), but in our opinion, there is no substitute for careful closure of the dura, done in conjunction with the various soft-tissue layers (muscle, fascia, ga- lea, and skin). 3 The same degree of attention given to the reason for the operation itself should be paid to wound closure; it should not be automatically relegated to a trainee without proper instructions or supervision.…”

Section: Study Resultsmentioning

confidence: 99%

A hospital-based analysis of pseudomeningoceles after elective craniotomy in children: what predicts need for intervention?

Norrdahl¹,

Jones²,

Dave

et al. 2020

Journal of Neurosurgery: Pediatrics

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OBJECTIVEIn pediatric patients, the development of a postoperative pseudomeningocele after an elective craniotomy is not unusual. Most will resolve with time, but some may require intervention. In this study, the authors analyzed patients who required intervention for a postoperative pseudomeningocele following an elective craniotomy or craniectomy and identified factors associated with the need for intervention.METHODSAn institutional operative database of elective craniotomies and craniectomies was queried to identify all surgeries associated with development of a postoperative pseudomeningocele from January 1, 2010, to December 31, 2017. Demographic and surgical data were collected, as were details regarding postoperative events and interventions during either the initial admission or upon readmission. A bivariate analysis was performed to compare patients who underwent observation with those who required intervention.RESULTSFollowing 1648 elective craniotomies or craniectomies, 84 (5.1%) clinically significant pseudomeningoceles were identified in 82 unique patients. Of these, 58 (69%) of the pseudomeningoceles were diagnosed during the index admission (8 of which persisted and resulted in readmission), and 26 (31%) were diagnosed upon readmission. Forty-nine patients (59.8% of those with a pseudomeningocele) required one or more interventions, such as lumbar puncture(s), lumbar drain placement, wound exploration, or shunt placement or revision. Only race (p < 0.01) and duraplasty (p = 0.03, OR 3.0) were associated with the need for pseudomeningocele treatment.CONCLUSIONSClinically relevant pseudomeningoceles developed in 5% of patients undergoing an elective craniotomy, with 60% of these pseudomeningoceles needing some form of intervention. The need for intervention was associated with race and whether a duraplasty was performed.

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Section: Study Resultsmentioning

confidence: 99%

A hospital-based analysis of pseudomeningoceles after elective craniotomy in children: what predicts need for intervention?

Norrdahl¹,

Jones²,

Dave

et al. 2020

Journal of Neurosurgery: Pediatrics

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“…Conceptually, a watertight dural closure is a technically simple proposition. However, postoperative CSF leakage has been the most frequent serious complication, especially in posterior fossa surgery, because of its gravity-dependent location [1][2][3][4][5][6][7]13,23,[26][27][28]30,32]. Many reports have discussed factors leading to postoperative CSF leaks after resection of vestibular schwannomas, which is notorious for postoperative CSF leaks [3,22,28,31,32].…”

Section: Discussionmentioning

confidence: 99%

Dural And Skull Base Reconstruction To Eliminate Postoperative Complications Related To Cerebrospinal Fluid Leakage: Technical Nuances And Surgical Outcomes

Nonaka

Fukushima

Hayashi

et al. 2021

Preprint

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BACKGROUND: Cerebrospinal fluid (CSF) leakage is a common complication associated with neurosurgical procedures, and eliminating postoperative CSF leaks remains challenging. OBJECTIVE: Unique applications of free or vascularized flaps for watertight dural and skull base reconstruction are presented. METHODS: A total of 512 cases of cranial surgeries were examined focused on the postoperative complications that required revision surgery. These cases were divided into skull base (SB) lesions and non-SB lesions according to the site of dural opening. The postoperative complications were analyzed according to their relationship to the CSF. A free flap, including fascial, myofascial, or pericranial flap, is routinely prepared for later use in dural closure in all cranial surgeries. A pedicled vascularized pericranial flap (VPF) is also used for SB dural reconstruction in extended surgical procedures.RESULTS: There were 434 cases of SB lesions and 78 cases of non-SB lesions. Of the 512 surgical cases, 27 (5.3%) required revision surgery due to patients’ postoperative conditions or complications. There were 9 cases (1.8%) of CSF-related and 18 cases (3.5%) of non-CSF-related complications. Eight of nine cases of CSF-related complications (88.9%) were seen in posterior fossa surgery. Postoperative CSF leaks that required revision surgery were seen in 4 cases (0.8%). SB reconstruction using a VPF was performed in 40 cases of SB surgeries. No postoperative infection was seen in these 40 cases, and only 1 case (2.5%) of pseudomeningocele, which required revision surgery, occurred. CONCLUSION: Dural reconstruction using a fascial flap or VPF plays an important role in achieving successful surgery.

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“…Further, PMC development in posterior fossa surgery is theorized to be multifactorial and may be driven not only by surgical technique; but also patient factors, increasing age, hydrocephalus, large adjacent CSF cisterns, the effects of gravity causing dural strain in the recumbent position and increased subcutaneous dead space after striping attachments from the occipital bone. [1][2][3][4][5]9 Despite the frequency of PMC complication there is no consensus for treatment and little advancement in terms of optimal management and the timing for intervention for PMCs. 2,6 Traditionally, conservative management is trialed and management proceeds to operative intervention in the form of CSF diversion procedures or revision surgery in patients with non-resolution of the PMC.…”

Section: Discussionmentioning

confidence: 99%

“…1,9 Regardless of modification to technique, the panacea to watertight dural closure remains elusive. Further, PMC development in posterior fossa surgery is theorized to be multifactorial and may be driven not only by surgical technique; but also patient factors, increasing age, hydrocephalus, large adjacent CSF cisterns, the effects of gravity causing dural strain in the recumbent position and increased subcutaneous dead space after striping attachments from the occipital bone.…”

Section: Discussionmentioning

confidence: 99%

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Epidural blood patch for treatment of a large suboccipital pseudomeningocele

Richardson

Tommasi

2017

Int Surg J

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Pseudomeningocele complication is a challenging and common neurosurgical problem. Posterior cranial fossa surgery is reported to have higher pseudomeningocele postoperative complication rates compared to supratentorial surgery. Treatment of posterior fossa pseudomeningoceles can be cumbersome and various techniques have been described ranging from conservative measures to re-operation. We describe a case of a 27 year old woman who developed a large symptomatic suboccipital pseudomeningocele following posterior fossa decompression surgery; this was successfully treated by an epidural blood patch. The current body of literature regarding the treatment of posterior fossa pseudomeningocele is limited. Whilst the use of an epidural blood patch for pseudomeningocele treatment is not novel, this is the first case of standard epidural blood patch, performed in the lumbar region, for treatment of a posterior fossa pseudomeningocele. Epidural blood patch is a minimally invasive technique that is underutilized. This paper demonstrates the use of epidural blood patch as an alternative method for treatment of a large suboccipital pseudomeningocele and summarizes the current literature. It is hoped this paper will highlight the epidural blood patch as a potentially effective treatment option that should be considered when managing posterior fossa pseudomeningocele complications prior to escalation to surgical revision.

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Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note

Cited by 11 publications

References 19 publications

A hospital-based analysis of pseudomeningoceles after elective craniotomy in children: what predicts need for intervention?

A hospital-based analysis of pseudomeningoceles after elective craniotomy in children: what predicts need for intervention?

Dural And Skull Base Reconstruction To Eliminate Postoperative Complications Related To Cerebrospinal Fluid Leakage: Technical Nuances And Surgical Outcomes

Epidural blood patch for treatment of a large suboccipital pseudomeningocele

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