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Bilateral subdural haematomata and lumbar pseudomeningocele due to a chronic leakage of liquor cerebrospinalis after a lumbar discectomy with the application of ADCON-L gel
  1. J Kuhn1,
  2. B Hofmann1,
  3. H O Knitelius2,
  4. H H Coenen3,
  5. H Bewermeyer1
  1. 1Department of Neurology, Kliniken der Stadt Köln, Krankenhaus Merheim, Ostmerheimerstrasse 200, D-51109 Cologne, Germany
  2. 2Department of Radiology, Kliniken der Stadt Köln, Krankenhaus Merheim, Ostmerheimerstrasse 200, D-51109 Cologne, Germany
  3. 3Märkische Rehakliniken, Department of Orthopedy, Paulmannshoeherstrasse 14, D-58515 Lüdenscheid, Germany
  1. Correspondence to:
 Dr Jens Kuhn
 Department of Neurology, Kliniken der Stadt Köln, Krankenhaus Merheim, Ostmerheimerstrasse 200, D-51109 Cologne, Germany; Kuhnjkliniken-koeln.de

Abstract

The anti-adhesion gel ADCON-L has been available since the end of the 1990s. During disc surgery it can be applied to the spinal nerve roots and the dura mater spinalis in order to inhibit fibroblast migration and thus avoid postoperative adhesions or excessive keloids, respectively. Due to the way ADCON-L works, inadvertent, intraoperational dural lesions may stay open much longer than usual because ADCON-L inhibits the natural healing process. Possible consequences are a chronic leakage of cerebrospinal fluid in combination with intracranial hypotension syndrome.

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.

  • MRI, magnetic resonance imaging
  • ADCON-L gel
  • bilateral subdural haematoma
  • intracranial hypotension syndrome
  • lumbar discectomy
  • pseudomeningocele

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Postoperative scarring and fibrous adhesions frequently develop after lumbar discectomies. These fibrous adhesions may stretch or compress nerve roots thus causing postoperative kinematic pains or even new radicular lesions.

Since the end of the 1990s the anti-adhesion gel ADCON-L has been available for application to the operational site to avoiding postoperative scarring. ADCON-L inhibits fibroblast migration and thus protects the nerve roots, the dura, and the spinal canal from postoperative adhesions and is completely absorbed within 4–6 weeks.1 Its effectiveness was tested in animal experiments and also on humans.2–4 Several studies discuss the clinical usefulness of ADCON-L gel after lumbar discectomies.2,5–7 In addition to the desirable reduction of excessive postoperative scarring, side effects and complications following ADCON-L application have been reported.8,9

We report a patient who underwent lumbar discectomy with the application of ADCON-L gel and who had severe postoperative complications.

CASE REPORT

In 2000, a 46 year old medical doctor underwent a lumbar discectomy at L5/S1. In 2003, the patient again suffered from acute back pain. After flavectomy and foremanotomy the right S1 radicle was exposed and several subligamentous disc sequestra at L5/S1 were excised. ADCON-L gel was then applied.

Two weeks after the operation the patient experienced acute, diffuse headaches, especially when sitting or standing. He also complained of nausea, vomiting, and vertigo. Neurological examination revealed a slight stiffness of the neck. When walking or standing up, the patient swayed and complained about increasing headaches and blurred vision.

Cranial magnetic resonance imaging (MRI), especially FLAIR sequences, showed hyperintense, subdural haematomata in each of the cerebral hemispheres and subdural haemorrhage on the tentorium and in the interhemispheric space (figs 1 and 2).

Figure 1

 Cranial MRI (axial FLAIR sequence) showing bilateral, small subdural haematomata (arrows) and subdural haemorrhage on the tentorium.

Figure 2

 Cranial MRI (axial FLAIR sequence) also showing bilateral, small subdural haematomata (arrows).

The brain parenchyma and the large cerebral vessels showed no pathological changes.

MRI of the lumbar spine confirmed the resection of the right vertebral arch of L5. At the same location a collection of intraspinal and epidural cerebrospinal fluid was found, which extended through the defective vertebra to the deep paraspinous muscles (figs 3 and 4). The meninges at L5 showed poorly defined outlines. There was no extruded or sequestered intervertebral tissue.

Figure 3

 MRI of the lumbar spine (sagittal T2 sequence) showing pseudomeningocele at L5/S1 with extension from the dorsal dura to the paraspinous muscles.

Figure 4

 MRI of the lumbar spine (transverse T2 sequence) showing pseudomeningocele at L5/S1 with extension from the right dorsolateral dura through the postoperative defective vertebra to the paraspinous muscles.

Laboratory parameters including blood count, electrolytes, coagulation parameter, pancreas and liver enzymes, retention values, thyroid parameter, C-reactive protein, and protein electrophoresis were within the reference ranges.

Review of clinical history, clinical picture, and MRI led to a diagnosis of postoperative fistula of cerebrospinal fluid with the formation of a lumbar pseudomeningocele and bilateral subdural haematomata due to intracranial hypotension syndrome caused by a chronic, lumbar leakage of cerebrospinal fluid.

The patient did not want another surgical intervention in order to close the dural leak. With conservative treatment of the symptoms the patient’s problems disappeared within 4 weeks; however, he continued to experience headaches under stress, a lack of concentration, and a general decrease in vitality.

Three months after the discectomy, MRI showed complete absorption of the subdural haematomata (figs 5 and 6), but it also revealed that the lumbar pseudomeningocele had not changed in size.

Figure 5

 Cranial MRI (axial FLAIR sequence) 3 months after the discectomy showing complete absorption of the subdural haematomata.

Figure 6

 Cranial MRI (axial FLAIR sequence) 3 months after the discectomy which was normal.

DISCUSSION

During lumbar disc surgery very small dural tears can happen unintentionally.8,10 If these lesions are not noticed during the operation, the dural tear closes spontaneously in most cases with the help of fibroblasts or fibrocytes. The local application of ADCON-L gel inhibits the immigration of fibroblasts and thus the natural healing of small tears. A possible consequence is a constant leakage of cerebrospinal fluid and hence intracranial hypotension syndrome, which is characterised by acute headaches, nausea, and vomiting.

In about a dozen cases complications due to chronic dural leaks have been reported after lumbar discectomies with the application of ADCON-L gel.2,8,9 Hieb et al performed lumbar discectomies on 27 patients and applied ADCON-L gel locally; five patients developed a dural leak. A further 79 patients, who did not receive treatment with ADCON-L gel, did not develop dural leaks.8 In most cases a leakage of cerebrospinal fluid in the operational site was documented by myelography.8,9 A considerable extradural collection of cerebrospinal fluid documented by MRI was also described as a sign of a cerebrospinal fluid fistula.8 Because of persisting headaches and other physical symptoms, surgical closure of the dural leak became necessary in most cases.8,9 The problem was solved for a few patients with closed subarachnoid drainage.8,11

In the case of our patient, MRI demonstrated extradural collection of cerebrospinal fluid in the lumbar site of operation which suggested a dural leak, that is, a pseudomeningocele. In addition, the subsequent continuous leakage of cerebrospinal fluid at the lumbar site evidently caused pronounced intracranial hypotension syndrome so that bilateral chronic subdural haematomata developed. The patient suffered from acute, diffuse headaches, especially when standing up, and also from nausea, vomiting, and a considerable decrease in vitality. Subdural haematomata are rare but severe complications which may develop as a result of intracranial hypotension syndrome.12,13

In almost all described cases, as in the case of our patient, symptoms of intracranial hypotension syndrome appear only 2–3 weeks after the operation.8,9

As far as we know, the combination of subdural haematomata and lumbar pseudomeningocele after a discectomy with the application of ADCON-L gel has not previously been described.

Considering the documented cases and the complications suffered by our patient, patients should be forewarned of the potential risk of cerebrospinal fluid leakage and intracranial hypotension syndrome following the application of ADCON-L gel.

REFERENCES

View Abstract

Footnotes

  • Competing interests: none declared

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