Approximately one million spinal surgeries are performed in the United States each year. The risk of an incidental durotomy (ID) and resultant persistent cerebrospinal fluid (CSF) leakage is a significant concern for surgeons, as this complication has been associated with increased length of hospitalization, worse neurological outcome, and the development of CSF fistulae. Augmentation of standard dural suture repair with the application of fibrin glue has been suggested to reduce the frequency of these complications. This study examined unintended durotomies during lumbar spine surgery in a large surgical patient cohort and the impact of fibrin glue usage as part of the ID repair on the incidence of persistent CSF leakage. A retrospective analysis of 4,835 surgical procedures of the lumbar spine from a single institution over a 10-year period was performed to determine the rate of ID. The 90-day clinical course of these patients was evaluated. Clinical examination, B-2 transferrin assay, and radiographic imaging were utilized to determine the number of persistent CSF leaks after repair with or without fibrin glue. Five hundred forty-seven patients (11.3%) experienced a durotomy during surgery. Of this cohort, fibrin glue was used in the dural repair in 278 patients (50.8%). Logistic models evaluating age, sex, redo surgery, and the use of fibrin glue revealed that prior lumbar spinal surgery was the only univariate predictor of persistent CSF leak, conferring a 2.8-fold increase in risk. A persistent CSF leak, defined as continued drainage of CSF from the operative incision within 90 days of the surgery that required an intervention greater than simple bed rest or over-sewing of the wound, was noted in a total of 64 patients (11.7%). This persistent CSF leak rate was significantly higher (P < 0.001) in patients with prior lumbar surgery (21%) versus those undergoing their first spine surgery (9%). There was no statistical difference in persistent CSF leak between those cases in which fibrin glue was used at the time of surgery and those in which fibrin glue was not used. There were no complications associated with the use of fibrin glue. A history of prior surgery significantly increases the incidence of durotomy during elective lumbar spine surgery. In patients who experienced a durotomy during lumbar spine surgery, the use of fibrin glue for dural repair did not significantly decrease the incidence of a persistent CSF leak.
CSF leak; Lumbar spine surgery; Tisseel; Fibrin glue; Incidental durotomy
Incidental or intentional durotomy causing cerebrospinal fluid (CSF) leakage, leading to the formation of a pseudomeningocele is a known complication in spinal surgery. Herniation of nerve roots into such a pseudomeningocele is very rare, but can occur up to years after initial durotomy and has been described to cause permanent neurologic deficit. However, cauda equina fiber herniation and entrapment into a pseudomeningocele has not been reported before. Here, we present a case of symptomatic transdural cauda equina herniation and incarceration into a pseudomeningocele, 3 months after extirpation of a lumbar Schwannoma. A 59-year-old man, who previously underwent intradural Schwannoma extirpation presented 3 months after surgery with back pain, sciatica and loss of bladder filling sensation caused by cauda equina fiber entrapment into a defect in the wall of a pseudomeningocele, diagnosed with magnetic resonance imaging. On re-operation, the pseudomeningocele was resected and the herniated and entrapped cauda fibers were released and replaced intradurally. The dura defect was closed and the patient recovered completely. In conclusion, CSF leakage can cause neurological deficit up to years after durotomy by transdural nerve root herniation and subsequent entrapment. Clinicians should be aware of the possibility of this potentially devastating complication. The present case also underlines the importance of meticulous dura closure in spinal surgery.
Pseudomeningocele; Dura defect; Nerve root entrapment
Pseudomeningoceles are a rare complication after spinal surgery, and studies on these complex formations are few.
Between October 2000 and March 2008, 11 patients who developed symptomatic pseudomeningoceles after spinal surgery were recruited. In this retrospective study, we reported our experiences in the management of these complex, symptomatic pseudomeningoceles after spinal surgery. A giant pseudomeningocele was defined as a pseudomeningocele >8 cm in length. We also evaluated the risk factors for the formation of giant pseudomeningoceles.
All patients were treated successfully with a combined treatment protocol of open revision surgery for extirpation of the pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage. Surgery-related complications were not observed. Recurrence of pseudomeningocele was not observed for any patient at a mean follow-up of 16.5 months. This result was confirmed by magnetic resonance imaging.
We conclude that a combined treatment protocol involving open revision surgery for extirpation of pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage is safe and effective to treat giant pseudomeningoceles.
There is increasing awareness of the need to inform patients of common complications that occur during surgical procedures. During lumbar spine surgery, incidental tear of the dural sac and subsequent cerebrospinal fluid leak is possibly the most frequently occurring complication. There is no consensus in the literature about the rate of dural tears in spine surgery. We have undertaken this study to evaluate the incidence of dural tears among spine surgeons in the United Kingdom for commonly performed spinal procedures. Prospective data was gathered for 1,549 cases across 14 institutions in the United Kingdom. The results give us a baseline rate for the incidence of dural tears. The rate was 3.5% for primary discectomy, 8.5% for spinal stenosis surgery and 13.2% for revision discectomy. There was a wide variation in the actual and estimated rates of dural tears among the spine surgeons. The results confirm that prospective data collection by spine surgeons is the most efficient and accurate way to assess complication rates for spinal surgery.
Complication rates; Incidental durotomy; Lumbar spine surgery
Authors report a rare case of acute intracranial subdural and intraventricular hemorrhage that were caused by intracranial hypotension resulted from cerebrospinal fluid leakage through an unidentified dural tear site during spinal surgery. The initial brain computed tomography image showed acute hemorrhages combined with preexisting asymptomatic chronic subdural hemorrhage. One burr hole was made over the right parietal skull to drain intracranial hemorrhages and subsequent drainage of cerebrospinal fluid induced by closure of the durotomy site. Among various methods to treat cerebrospinal fluid leakage through unidentified dural injury site, primary repair and spinal subarachnoid drainage are well known treatment options. The brain imaging study to diagnose intracranial hemorrhage should be taken before selecting the treatment method, especially for spinal subarachnoid drainage. Similar mechanism to its spinal counterpart, cranial cerebrospinal fluid drainage has not been mentioned in previous article and could be another treatment option to seal off an unidentified dural tear in particular case of drainage of intracranial hemorrhage is needed.
Cerebrospinal fluid; Intracranial hemorrhage; Intracranial hypotension; Spine surgery
Four patients underwent lumbar surgery. In all four patients, the dura was minimally torn during the operation. However, none exhibited signs of postoperative cerebrospinal fluid leakage. In each case, a few days after the operation, the patient suddenly experienced severe recurring pain in the leg. Repeat magnetic resonance imaging showed transdural nerve rootlets entrapped in the intervertebral disc space. On exploration, ventral dural tears and transdural nerve rootlet entrapment were confirmed. Midline durotomy, herniated rootlet repositioning, and ventral dural tear repair were performed, and patients' symptoms improved after rootlet repositioning. Even with minimal dural tearing, nerve rootlets may become entrapped, resulting in severe recurring symptoms. Therefore, the dural tear must be identified and repaired during the first operation.
Nerve rootlet entrapment; Lumbar disc herniation; Laminectomy; Discectomy; Dura tear; Dura repair
The common etiologies of pneumocephalus, presence of air in the intracranial cavity, are trauma and cranial surgery. Pneumocephalus after spinal surgery is an unusual postoperative complication. We report the case of a male 59-year-old man who developed a pneumacephalus after posterior lumbar surgery for spinal stenosis. Intraoperatively, a cerebrospinal fluid leak following a dural tear was noted and immediately repaired. The next day, the patient complained of headache and dizziness. Head and lumbar computed tomography scans revealed significant air in the frontal region, several cisterns, intraventricle, and extra-dural area in the spine canal. Symptoms were spontaneously resolved within 2 weeks with conservative management.
Pneumocephalus; Spinal surgery; Dura tearing
The incidence of cerebrospinal fluid (CSF) fistula after transtemporal skull base surgery can range from 4% to 19%. The risk of CSF leak may be related to tumor size and location, the extent of the dural defect, and the technical aspects of the wound reconstruction. Prevention of meningitis depends on the early detection and management of CSF leakage. Five hundred eighty-nine patients underwent a variety of transtemporal surgical approaches for the extirpation of skull base tumors at our institution from July 1988 to October 1999. The medical records were reviewed retrospectively to identify the tumor histology, size, and location, as well as the surgical approach, defect reconstruction technique, and the incidence of postoperative CSF leak. The risk of CSF fistulae was greatest in using the retrosigmoid approach (8%) and lowest in those who underwent a translabyrinthine approach (4%). Tumor size had no bearing on the incidence of the CSF leak and the overall incidence of meningitis was 1.0%. This article outlines our institutional objective for the prevention and management of CSF fistula after transtemporal skull base surgery. Illustrative cases will be presented.
Cerebrospinal fluid fistula; transtemporal approach; meningitis
Objective: Retrospectively assess the efficacy of lumbar cerebrospinal fluid (CSF) drainage placed preoperatively in skull base operations in decreasing the incidence of postoperative CSF fistula. Methods: A retrospective review of 150 patients undergoing a posterior fossa craniotomy from 1989 to 2000 was conducted. Patients were divided into those receiving preoperative lumbar drains and those that did not. The rates of postoperative CSF leakage were compared between the two groups. Patient data were analyzed to determine if there were other comorbidities affecting the postoperative incidence of CSF leakage such as smoking, diabetes, or hypertension. Results: Between 1989 and 1994, 25/72 (35%) patients with no preoperative lumbar drain had a postoperative CSF leak. From 1995 to 2000, 9/78 (12%) patients with a preoperative lumbar drain had a CSF leak. This was a 23% decreased incidence of postoperative CSF leakage and a significant decrease in the probability (p < 0.001) of CSF leakage in patients treated with a preoperative lumbar drain. The comorbidities of diabetes, smoking, or hypertension did not increase the probability of a CSF leak (p = 0.43). Conclusions: A preoperatively placed lumbar drain can significantly lower the rate of postoperative CSF leakage after skull base surgery. The drain is a well-tolerated adjunct to dural closure and helps increase surgical exposure of the posterior fossa. The comorbidities of diabetes, smoking, or hypertension do not contribute to an increased rate of CSF leakage.
Cerebrospinal fluid fistula; lumbar drain; retrosigmoid; translabyrinthine
We report on a patient who underwent lumbar disc surgery with application of ADCON-L gel. Postoperatively he suffered from acute headache, nausea, and vomiting. A lumbar pseudomeningocele was demonstrated on magnetic resonance imaging (MRI). Furthermore, cranial MRI revealed bilateral, chronic subdural haematomata which indicated intracranial hypotension syndrome or continuous leakage of cerebrospinal fluid at the lumbar site.
With conservative treatment the problems were gradually reduced and eventually the subdural haematomata were no longer detected. The pseudomeningocele persisted over a 4 month period of observation.
Because of the complications we found, the local application of ADCON-L during lumbar disc surgery should be critically evaluated.
The spinal dura is anchored within the vertebral canal by connective tissue in the epidural space as well as the spinal roots. Inadvertent disruption of these dural attachments may lead to durotomy and cerebrospinal fluid (CSF) leaks. We observed well-developed connective tissue ligaments connecting the lumbar dura to the spinal column and examined these tissues microscopically.
Intraoperative images were obtained during lumbar laminectomy procedures. They demonstrated connective tissue attachments, linking the lumbar dura to the spinal column in the dorsal midline and dorsolaterally. Tissue samples were obtained and examined microscopically. We then conducted a search of the literature to find references to dural attachments to the spinal column.
Histological examination of the samples showed minimal cellular fibrous tissue. To date no references to these attachments have been made in neurosurgical literature. Previous studies, including live, cadaveric, and radiographic examinations, have demonstrated a dorsomedian fold of dura attached to the junction of the ligamentum flavum, and dorsolateral ligaments that divide the dorsal epidural space into an anterior and posterior compartment.
Epidural fibrous connections or ligaments between the dura and the lumbar spinal column may be of clinical importance to the neurosurgeon. Care should be taken during lumbar procedures not to disrupt or tear these ligaments as this may cause dural tears and CSF leaks. Identifying these ligaments and cutting them sharply may prevent inadvertent durotomies.
Anatomic study; epidural space; spinal column
The authors describe a case of 28-year-old man who presented with cervical myelopathy and lumbar radiculopathy due to the giant cervical pseudomeningocele extending to the lumbar spine at 10 years after previous brachial plexus injury. To evaluate the communicating tract between pseudomeningocele and subarachnoidal space, the multidetector-row helical CT with simultaneous myelography was performed preoperatively. The surgical treatment in the cervical spine included the resection of pseudomeningocele and the repair of dural defects communicating into the cyst following multi-level laminoplasty and foraminotomies. At 6 years after surgery, the significant neurologic recovery and complete obliteration of cysts in the whole spine area were maintained. This serves as the first report describing the significant neurologic recovery after the surgical treatment of giant cervical pseudomeningocele extending to the lumbar spine after previous brachial plexus injury.
Giant pseudomeningocele; Cervical spine; Lumbar spine; Communicating tract; Surgical treatment
Dural substitutes are used to achieve a watertight closure in situations where adequate closure is not possible .This study was conducted to evaluate the efficacy and safety of use a new collagen matrix dural substitute ( Duradry, Tecnodry, Belo Horizonte MG) in repair or expansion of cranial and spinal dura-mater.
30 patients operated on between March and September 2008, were studied. Surgical logs were reviewed for sex, age, diagnosis, location of the graft, technique and presence of fistula or infection. The patients were followed-up for at least 3 months, and the presence of complications as cerebrospinal leakage, infection, aseptic meningitis, hydrocephalus, pseudomeningocele were analysed.
Only one patient presented with CSF fistula. No patients presented with wound infections, hydrocephalus, pseudomeningocele, meningitis, brain abscesses or signs of toxicity related to the material.
The new dural substitute used in this study is effective and safe, and the initial results are similar to those of other dural substitutes reported in the literature.
Cerebrospinal fluid leak; Duraplasty; Collagen matrix
Retropharyngeal pseudomeningocele after atlanto-occipital dislocation is a rare complication, with only five cases described in the literature. It develops when a traumatic dural tear occurs allowing cerebrospinal fluid outflow, and it often appears associated with hydrocephalus. We present a case of a 29-year-old female who suffered a motor vehicle accident causing severe brain trauma and spinal cord injury. At hospital arrival the patient scored three points in the Glasgow Coma Scale. Admission computed tomography of the head and neck demonstrated subarachnoid hemorrhage and atlanto-occipital dislocation. Three weeks later, when impossibility to disconnect her from mechanical ventilation was noticed, a magnetic resonance imaging of the neck showed a large retropharyngeal pseudomeningocele. No radiological evidence of hydrocephalus was documented. Given the poor neurological status of the patient, with spastic quadriplegia and disability to breathe spontaneously due to bulbar-medullar injury, no invasive measure was performed to treat the pseudomeningocele. Retropharyngeal pseudomeningocele after atlanto-occipital dislocation should be managed by means of radiological brain study in order to assess for the presence of hydrocephalus, since these two pathologies often appear associated. If allowed by neurological condition of the patient, shunting procedures such as ventriculo-peritoneal or lumbo-peritoneal shunt placement may be helpful for the treatment of the pseudomeningocele, regardless of craniocervical junction management.
Atlanto-occipital dislocation; Pseudomeningocele; Retropharyngeal; Spinal cord injury
Pseudomeningocele is most commonly the result of a rent in the meninges during spine surgery. Noniatrogenic causes exist but are rare. Pseudomeningoceles may heal spontaneously, but they may also slowly enlarge. They rarely present as a mass within the abdomen. The objective of this study was to present the first case report of hydronephrosis secondary to lumbar pseudomeningocele.
Single case report and literature review.
Single case report.
This man had undergone extensive lumbar spine surgery for pain and spondylolisthesis. He subsequently developed a pseudomeningocele that caused hydronephrosis of the left kidney. He was treated with surgical intervention and had resolution of his hydronephrosis and his flank and groin pain. He also had improvement of his back pain.
This report shows an unusual cause of hydronephrosis—a pseudomeningocele presenting as an abdominal mass that compressed the ureter.
Hydronephrosis; Pseudomeningocele; Cauda equina syndrome; Lumbar surgery; Paraplegia; Spine surgery
A patient with spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak required localization of the leakage site prior to surgical management. Conventional, computed tomography and prone digital subtraction myelography failed to localize the dural tear, which was postulated to be dorsally located. We present here a digital subtraction myelographic approach to accurately localize a dorsal site of CSF leakage by injecting iodinated contrast via a lumbar drain with the patient in the supine position.
Spontaneous intracranial hypotension; digital subtraction myelography; CSF leak
Remote cerebellar hemorrhage (RCH) is rare but potentially lethal as a complication of spinal surgery. We recently experienced a case of RCH in a 61-year-old man who showed mental deterioration after lumbar spinal surgery. There was dural tearing with subsequent cerebrospinal fluid (CSF) loss during the surgery. Brain computed tomography scan revealed cerebellar hemorrhage, 3rd and 4th ventricular hemorrhage and pneumocephalus. He underwent suboccipital craniectomy and hematoma removal. The most important pathomechanism leading to RCH after spinal surgery has been known to be venous bleeding due to caudal sagging of cerebellum by rapid leak of large amount of CSF which seems to be related with this case. Dural repair and minimizing CSF loss after intraoperative dural tearing would be helpful to prevent postoperative RCH.
Remote cerebellar hemorrhage; Spinal surgery; Dural tear; Cerebrospinal fluid leakage
Incidental dural tears or durotomy (ID) during lumbar decompressive surgery is a relatively rare complication causing severe consequences. Their incidence varies widely among different authors (1-17%) and in general depends on the type and complexity of the spinal procedures performed.
With the present investigation the authors aim to evaluate the incidence of incidental durotomies during the different types of decompressive and reconstructive surgical procedures in the lumbar region, also indicating the most common reasons for incidental durotomies, treatment options and the early and remote outcome.
MATERIAL AND METHODS:
The records of 553 consecutive patients with different types of posterior and posterolateral decompressive and reconstructive procedures in the lumbar region are investigated retrospectively for the period January 2005 – march 2009.
The overall incidence of the incidental durotomies in the investigated group is 12.66%. In the subgroups it varies depending on the specificity of the surgical procedures performed. The biggest is the number of IDs in the reoperative spinal surgery subgroup, followed by the subgroup of the patients who sustained spinal trauma, followed by those with degenerative spinal stenosis, tumors and lumbar disc herniations.
IDs should be considered as a serious complication with a multitude of unwanted consequences for the patients. Prevention is the best way to treat the complications and disability that attend the unwanted dural tears. Knowing about the mechanisms and predisposing factors for that objectionable complication is a matter of utmost importance when planning and performing spinal surgical procedures.
incidental durotomy (ID); unintentional dural tear; CSF leak; spinal surgery; complication
Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.
Remote intracranial hemorrhage; Cerebrospinal fluid leakage; Spinal surgery
The authors retrospectively reviewed a series of 18 hard thoracic herniated discs (HTHD) operated by thoracoscopy. Isolated cases of HTHD have been reported in the literature, but no series describing these lesions has been published. Seventy-two percent of the herniated discs were situated between T8 and T12. Fifty-six percent of the patients had radiographic sequelae of Scheuermann’s disease. Postoperatively, 83% had neurological improvement. In seven cases (39%), a plane separating the herniated disc and the dura mater was found surgically. In 11 patients, no separating plane was found during surgery. The lesion was intradural in three patients (17%) and adherent to the dura mater in eight (44%). Among these 11 patients, surgery was complicated by a dural tear in the first seven that led to a high risk of cerebrospinal fluid fistula: four of these seven patients had required surgical revision. In the last four, the zone of adhesion of the HTHD to the dura mater was preserved, successfully preventing dural tear
Calcified thoracic disc herniation; MRI; Scheuermann; Thoracic spine; Thoracoscopy
A patient with remote cerebellar hemorrhage (RCH) who was presented at the authors' hospital with seizure and delayed emergence from anesthesia after loss of cerebrospinal fluid (CSF) through a dural tear during lumbar spine surgery is described. RCH is a rare and unpredictable complication after spinal surgery. Its most common clinical features are diminished consciousness, headache, and seizure. Its mechanism is still disputed, but is probably venous bleeding secondary to significant intra- or post-operative loss of CSF. Therefore, RCH must be considered in patients with unexplained mental deterioration or disturbance upon emergence and seizure from general anesthesia after spine surgery.
Brian hemorrhage; Delayed emergence; General anesthesia; Lumbosacral region; Seizure; Surgery
The complications of 648 consecutively inserted Universal AO pedicle screws (140 in the thoracic spine and 508 in the lumbar spine) performed by one surgical team to treat 91 patients with spinal problems, were reviewed. The spinal pathology consisted of: scoliosis (34 patients), degenerative lower lumbar spinal disease (25 patients), neoplastic spinal disease (11 patients), thoracic kyphosis (8 patients), spinal fractures (7 patients), lumbo-sacral spondylolisthesis (3 patients), and osteomyelitis (3 patients). Intraoperative complications were: screw misplacement (n = 3), nerve root impingement (n = 1), cerebrospinal fluid leak (n = 2) and pedicle fracture (n = 2). Postoperative complications were; deep wound infection (n = 4), screw loosening (n = 2) and rod-screw disconnection (n = 1). The conclusion was that pedicle screw fixation has an acceptable complication rate and neurological injury during this procedure is unlikely.
Spinal instrumentation; Pedicle screw
We report a rare case of intracranial hypotension that was complicated by a subdural hematoma following spine surgery. Intraoperatively, we did not notice any breach of the dura. However, the patient continued to have fluid leakage from the inferior edge of the lumbar incision. During revision surgery, a small dural tear was identified and repaired. It is likely that a small dural tear was overlooked or the dura was weakened during the initial operation and caused a subdural hematoma associated with intracranial hypotension.
Subdural hematoma; Intracranial hypotension; Spine surgery; Cerebrospinal fluid
The Chiari 1 malformation (CM1) involves decent of the tonsils of the cerebellum through the foramen magnum. Symptomatic disease requires a posterior fossa decompression with or without an expansile duraplasty. To date, the optimal surgical treatment for CM1 has not been delineated. The extent of bony removal, size of the dural opening, necessity for expansion of the dural space, choice of materials for the duraplasty, and possible need for augmentation with dural sealant are all factors that continue to be debated amongst neurological surgeons worldwide. We herein evaluate the use of fibrin sealant augmentation in combination with locally harvested autologous pericranium for duraplasty in adult CM1 decompression.
Retrospective data collected from January 2006 to December 2011. Data were reviewed for surgical site infection or meningitis, cerebrospinal fluid leak, symptomatic pseudomeningocele, radiographic improvement of hindbrain compression, and postoperative recurrence of symptoms at a minimum of 1 year of follow-up. Outcomes were studied clinically, radiographically, as well as by using a patient-specific questionnaire.
Twenty-two consecutive patients were included. One patient required a revision for a delayed graft dehiscence in the setting of a rare form of aseptic meningitis with cerebrospinal fluid (CSF) pleocytosis due to a nonsteroidal anti-inflammatory drug (NSAID) allergy. All remaining patients had successful decompressions with full resolution of their symptoms except for one patient who had persistent headaches.
Autologous pericranium with dural sealant augmentation is an effective technique for expansile duraplasty in CM1 decompressions.
Autologous pericranium; chiari malformation; duraplasty; dural sealant
The authors review their experience in detecting occult traumatic dural lesions. In a retrospective study covering the period from January 1, 1984 to December 31, 1996, 23 patients were evaluated for occult traumatic dural lesions. Clinical presentation, diagnostic work-up, and management of the dural lesions were analyzed.
The clinical presentations of the previously undetected dural lesions of the anterior skull base were meningitis in eight cases, cerebrospinal fluid (CSF) rhinorrhea in eight cases, both meningitis and CSF rhinorrhea in five cases, and a pulsating swelling in the region of the right upper eyelid in one case. In another case a fracture of the posterior frontal wall was detected incidentally on the preoperative CT scan performed prior to surgery for chronic sinusitis. One patient had a CSF fistula of the lateral skull base in addition to the frontobasal fistula. The interval between trauma and diagnosis varied from 1 to 48 years. Dural lesions were localized by high-resolution CT, fluorescein nasal endoscopy, CT cisternography, and MRI. Intraoperative exposure of the dural lesions and duraplasty were possible in all cases. During the first attempt successful repair of the dural lesions was accomplished in 22 (95.7%) of the 23 patiants. Two interventions were necessary to close a CSF leak of the cribriform plate.
Modern clinical and radiologic diagnostic methods should be employed to search for an occult dural lesion in patients with recurrent meningitis, meningitis caused by upper airway pathogens, or CSF rhinorrhea. The patient will remain at risk of potentially fatal meningitis until the lesion is appropriately repaired by duraplasty.