If only symptomatic pseudomeningoceles require investigative surgery what defines symptomatic?
Neurologic signs of different character and grade will make a pseudomeningocele symptomatic. Otherwise, why should you prescribe imaging diagnostics ?
OK - Following removal of an intradural extrademullary schwannoma the patient recovers well with only mild neurological deficits resulting from damage to both the spinal cord and the nerve root from which the tumour was scrapped. The nerve root was preserved but the tumour was scrapped from the margins of the nerve.
Recovery following surgery was excellent and the patient returned to working full time 8 weeks later. Though six weeks after excision the patient reported several episodes of left thigh spasm while undergoing PT sessions and occasional uncontrolled spasms in all four limbs when sitting down.
The first of six monthly monitoring MRI scans revealed a pseudomeningocele over the back of the patients spinal canal, into the epidural space impinging upon the posterior column of spinal fluid over the length of the laminectomy. The patient who had not been informed about the pseudomeningocele reported feeling unwell with increasing neurological problems three weeks after the monitoring MRI showed the pseudomeningocele.
A second monitoring MRI scan done six months after the pseudomeningocel was found showed that it had expanded slightly while the post surgical changes in posterior soft tissues became less prominent. The patient continued to complain and indicate concern.
So how would you decide if the pseudomeningocele was causing the additional symptoms reported by the patient or not?
As far as I understood 6 months postoperatively there was an expansion of the pseudomemimgocele on MRI. I believe the signs of progressiveness should be also taken into consideration. Does the patient have also any symptoms of disturbed liquor flow regulation ? If so the pseudomeningocele should be treated surgically.
Most of the pseudomeningocells are asymptomathic. It is frequently seen after Chiari malformation repair. Most of them are spontaneously getting smaller and smaller and dissapaire. If there is differnce in volum in first and second MR sections in favor of growing. This means that there is ball valve mechanism which CSF enter the meningocell cavity and traps there. Operation indicate these rare cases.
Thank you for your response Professor Tanchev and Professor Ozer.
I have just posted another question: How would you fill the cavity over the back of the spinal canal following a laminectomy? I would be grateful for any replies you may wish to provide. I have provided further details with the question.
Usually, I suture the paravertebral muscles in an inverted way. But I have to pin-point that in the current practice a laminectomy should be followed by implant stabilization and bone grafting to eliminate the drawbacks (segment destabilization !) of the laminectomy per se.
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