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Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(22)00084-X
10.1016/j.inpm.2022.100093
100093
Letters to the Editor
Symptomatic lumbar pseudomeningocele from post-operative dural leak treated with autologous platelet-rich plasma epidural patch: A case study
Chang Albert H. ahchang@uw.edu
∗
University of Washington Department of Rehabilitation Medicine, 325 Ninth Avenue, Box 359612, Seattle, WA, 98104, USA
Seroussi Richard res@seattlespine.com

University of Washington Department of Rehabilitation Medicine, 325 Ninth Avenue, Box 359612, Seattle, WA, 98104, USA
Seattle Spine and Sports Medicine Clinic, 3213 Eastlake Ave East, Suite A, Seattle, WA, 98102, USA
Singh Virtaj vsingh@seattlespine.com

University of Washington Department of Rehabilitation Medicine, 325 Ninth Avenue, Box 359612, Seattle, WA, 98104, USA
Seattle Spine and Sports Medicine Clinic, 3213 Eastlake Ave East, Suite A, Seattle, WA, 98102, USA
∗ Corresponding author. ahchang@uw.edu
02 5 2022
6 2022
02 5 2022
1 2 1000939 2 2022
15 4 2022
18 4 2022
© 2022 The Authors
2022
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcDear Editor,

In this case report, we describe successful dural leak repair using an epidural platelet-rich plasma (PRP) patch on a patient whose lumbar surgery was complicated by dural leak with pseudomeningocele formation. This patient had not responded to less invasive treatments for his pseudomeningocele, and had been scheduled for dural repair surgery, which fortunately was avoided following the epidural PRP injection.

Incidental durotomy (ID) following lumbar decompressive surgery is a relatively uncommon but well-established post-operative complication, with previous reports estimating an overall incidence of 12.6%. While the majority of ID are detected intraoperatively and repaired, they may also go undetected. Often ID heal spontaneously without sequelae, but there are many potential complications including development of a cerebrospinal fluid (CSF) fistula and pseudomeningocele [1].

Pseudomeningoceles are defined as abnormal collections of CSF without a surrounding membrane that communicate through the extradural space. Depending on their size and location, pseudomeningoceles can be asymptomatic and tend to spontaneously resolve. For symptomatic patients, more aggressive intervention is warranted. Treatment modalities include epidural blood patches, percutaneous drainage, and surgical dural repair [2].

The theorized mechanism of action for PRP involves the degranulation of platelets releasing various growth factors (GF) including vascular endothelial GF, fibroblast GF, platelet-derived GF, epidermal GF, hepatocyte GF, insulin-like GF 1, 2, matrix metalloproteinases 2, 9, and interleukin 8 [3]. These growth factors are thought to ultimately assist in the healing process of wounds, and in this case the dura mater.

A 63-year-old man presented with severe postural headaches twelve days following a midline sparing L4-L5 laminotomy, performed for L4-L5 central stenosis. The pain was relieved with supine posture and only partially relieved with tramadol, caffeine, and acetaminophen when the patient was upright. Post-operative lumbar magnetic resonance imaging (MRI) without contrast 18 days post-op revealed CSF leakage with developing pseudomeningocele at the surgical site (see Fig. 1).Fig. 1 T2-weighted lumbar MRI without contrast taken 18 days post-op, showing CSF fistula tracking posteriorly from the epidural space. Axial view at L4-L5 is shown in the right panel. CSF has high signal intensity and tracks posteriorly from the epidural space. CSF leakage into the L4-L5 facet joint also occurred as partial facetectomy was part of the laminotomy procedure. White arrow highlights a small pseudomeningocele just under the skin.

Fig. 1

He returned to the spine surgeon at an outpatient visit and had approximately 50 mL of clear fluid drained from the pseudomeningocele. After the procedure, he noted improvement in his postural headaches in an upright position. However, three days after this procedure, his postural headaches recurred along with worsening left sided sciatica. Portable ultrasound was obtained and showed an enlarging pseudomeningocele.

The patient trialed various noninvasive treatments including bed rest, oral analgesics, caffeinated beverages, and tightly wrapping the lumbar spine at the level of the pseudomeningocele. Despite these measures, the patient continued to worsen with postural headache and left sided sciatica. Repeat lumbar MRI scan was taken 36 days post-op revealed marked worsening of the pseudomeningocele (Fig. 2).Fig. 2 T2-weighted lumbar MRI scan without contrast taken 36 days post-op. The pseudomeningocele had markedly grown in size from prior imaging at 18 days post-op. There was thought to be hydrostatic compression from CSF in the epidural space causing left-worse-than-right sided sciatica, which was notably worsened with upright posture.

Fig. 2

Given the severity of the patient’s symptoms and the growth of the pseudomeningocele, the patient’s neurosurgeon did not believe that a standard blood patch would reliably resolve the dural leak. Surgical dural repair was planned for six days after the repeat lumbar MRI scan 42 days post-op. During the week leading up to the surgery, an attempt at sealing the dural leak was performed with an epidural PRP injection at the surgical site under fluoroscopic guidance. The decision to try an epidural PRP injection first as opposed to blood patch was done primarily due to the preference of the patient. With his background as an interventional pain physician, he theorized that the hyper-concentration of growth factors in PRP may be more effective than an epidural blood patch in healing his more extensive dural leak.

Prior to the procedure, the patient had been advised to avoid NSAIDs and aspirin for 2 weeks. After obtaining written consent, the patient underwent a blood draw of 120 ​ccs [done in 4 separate 30 ​ccs syringes which were pre-filled with 4.2 ​ccs of anticoagulant citrate dextrose solution A (ACD-A)]. The blood was then put into a Arthrex Angel PRP Processing Kit and spun on the leukocyte poor, 2% HCT setting. While the PRP was processed over approximately 20 minutes, an attempt was made to draw off more fluid from the pseudomeningocele. Using sterile technique with the patient lying prone and under fluoroscopic guidance, a 22-gauge, 3.5-inch spinal was advanced into the fluid pocket. A spinal needle was used as opposed to a Touhy due to a combination of clinician familiarity and the accessibility of the supplies in the clinic. In hindsight, a spinal needle may increase risk of dural puncture due to its sharper tip, and a Touhy would be preferable. 20 mL of further drainage from the pseudomeningocele was obtainable via this approach with this gauge of needle. The needle was then further advanced into the L4/5 epidural space via an interlaminar approach confirmed by contrast (Fig. 3). Interlaminar approach was chosen over transforaminal because it allowed for a more targeted injection of PRP closer to the site of the dural leak. The total of 4 ​ccs of PRP that was obtained via centrifuge was then injected into the epidural space. The procedure was tolerated well and the patient was laid in a supine position for the next hour.Fig. 3 Sagittal fluoroscopic image showing the spinal needle and contrast dye in the L4/L5 epidural space, accessed via interlaminar approach.

Fig. 3

Immediately following the procedure, the patient noted improvements in his postural headaches, but had fairly significant ongoing left-sided sciatica when upright, possibly due to hydrostatic compression from the PRP injectate itself or from the potentially inflammatory properties of PRP. Within two days though, his left sciatica significantly improved, and his surgical dural repair was canceled.

Six days after the PRP procedure, the patient returned to lighter duty work. Eleven days after the procedure, symptoms continued to improve and the fluid mass in his lower lumbar spine was decreasing in size.

The patient obtained his 3rd postoperative MRI scan over five months after his lumbar surgery (Fig. 4), having returned to full activities including whitewater rafting within two months after his PRP procedure. This third MRI scan was obtained for this case report and not for clinical purposes.Fig. 4 T2-weighted lumbar MRI scan without contrast taken 167 days post-op. The pseudomeningocele is fully resolved. There is still some fluid in the facet joints at L4-L5, of unclear clinical significance.

Fig. 4

We believe that this is an early case report detailing the resolution of post-operative dural leak complicated by symptomatic pseudomeningocele formation utilizing an autologous platelet-rich plasma epidural injection.

Small dural leaks are often asymptomatic and self-limited, but the risk for symptomatic dural leaks and complications such as pseudomeningocele increase with more invasive interventions such as lumbar decompression surgery. It is estimated that 10–15% patients will require a repeat surgery as a result of post-operative complications [4]. Besides surgical dural repair, more conservative treatment options include percutaneous drainage of extradural CSF and epidural blood patches. Similar to epidural blood patches, PRP epidural injections include a low risk of immunogenicity because the injectate is autologously sourced.

Treatment for dural leaks complicated by pseudomeningocele formation continues to be varied and reliant on clinical discretion. The patient described in the case experienced a post-operative dural leak with rapid growth of a pseudomeningocele refractory to drainage and multiple trials of conservative treatment. When compared to standard epidural blood patches, preparing a PRP injection is a more involved and expensive process. There is insufficient evidence provided in this case to suggest that an epidural PRP injection is more efficacious when compared to an epidural blood patch. However, this case report demonstrates another potential modality of treatment for dural leaks, albeit very similar in principle to standard epidural blood patches. Additional supportive evidence should be acquired before this approach can be more readily recommended.

Disclosures

The authors have no competing interests; no funding, grants, or equipment were provided for this case series. The authors have no financial disclosures.

Written informed consent was obtained from the patient included in the case report.
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