Cerebrospinal fluid fistulas after iliosacral screw removal in post-traumatic pseudomeningocele
© The Author(s) 2011
Received: 4 October 2010
Accepted: 10 October 2011
Published: 3 November 2011
Sacral fractures are rare but severe injuries. They are often associated with neurological impairment and pelvic instability. We present a case of a 28-year-old woman who sustained an H-type fracture of the sacrum with complete cauda equina syndrome treated with cauda equina decompression and pelvic percutaneous stabilization with an iliosacral screw. Two years after she underwent screw removal, but complained of back and nape pain after the operation. A lumbosacral MRI showed the presence of a lytic lesion involving the S1 and S2 bodies that was judged to be a pseudomeningocele leaning against the sacral screw hole and cerebrospinal fluid fistulas through this. To our knowledge, this is the first case of such a complication after sacral screw removal to be reported.
The incidence of pelvic fractures is about 30 per 100,000/year. Involvement of the sacrum occurs in approximately 45% of the cases , and is more frequent in cases of high-energy trauma.
Numerous techniques have been advocated for the fixation of posterior pelvic ring and sacral fractures [2, 3]; among these, the use of iliosacral or transiliosacral screws is widely accepted to be the gold standard due to its mechanical stability . Various complications of this technique have been described in the literature: nerve injury, misplaced screws, fixation failures, infection, and lack of posterior pelvic reduction [4, 5].
In this report, we describe a case of symptomatic cerebrospinal fluid fistulas after sacral screw removal in a young woman. To our knowledge, this complication has never been described before.
Eight days after the trauma, open reduction and internal fixation of the T-shaped acetabular fracture was performed by a modified Kocher–Langenbeck approach with surgical dislocation of the hip according to Ganz .
The patient was discharged from the hospital 15 days after without any further complications. Three months after surgery she was walking without pain and she had a good range of movement of the right hip. The lesion of the cauda equina did not show any recovery.
She was admitted to our hospital in June 2009 to remove implants under general anesthesia because of the local pain caused by the heads of the trochanteric screws and the trans-sacral screw. She was discharged the day after the procedure with partial weight-bearing indicated for two weeks. Two days after, she went to the emergency department complaining of intense back and nape pain associated with difficulty walking and standing. The pain was reduced in the supine position.
The neurological diagnosis was liquor hypotension due to the interruption of the pseudomenincocele wall by the screw thread during its removal. The patient was evaluated by a neurosurgeon, who decided not to operate; just follow her clinically and radiologically. The therapy was bed rest and hydration. Nine days after she showed complete remission of the symptoms. At six months follow-up, the patient was healthy, even though there was no improvement in the neurological symptoms.
The patient gave her informed consent prior to being included in the study.
Seventy-eight sacral fractures were treated at our center from 2002 to September 2010 with 116 trans-sacral or iliosacral screws. The complications of this cohort were a lack of reduction (eight cases), one trans-sacral screw rupture, and one sacral nonunion.
Anterior pseudomeningocele after trauma is a rare entity . Pseudomeningocele is an extradural collection of cerebrospinal fluid (CSF) that results from a dural breach . The causes may be classified into three categories: iatrogenic (the most common), traumatic, and congenital. The incidence of iatrogenic pseudomeningocele ranges from 0.3 to 13%. Trauma-related pseudomeningoceles are rare and the true incidence is unknown . Traumatic pseudomeningoceles are usually associated with a nerve root stretch injury with possible avulsion of the nerve root itself [9, 10]. The dural tear is walled off by proliferation of dura and arachnoid mater, and the cyst enlarges because of a pressure differential .
They are even more rare at the sacral level than those higher on the spine because of the stability of the bony pelvis [9, 10]. For the case described here, a possible explanation of the anterior development of the pseudomeningocele with sacral erosion could be a complete and extensile lesion of the dura at the fracture level and the posterior closure of the lesion with a synthetic patch; as the pseudomeningocele was lying against the smooth shaft of the screw, its wall was damaged by the screw thread during its removal, thus causing liquorrhea.
MRI was not performed after her first hospital admission. After a sacral fracture associated with cauda equina syndrome, a follow-up MRI may be useful for diagnosing a post-traumatic pseudomeningocele, thus avoiding this kind of complication.
Conflict of interest
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- Beaule’ PE, Antoniades J, Matta JM (2006) Trans-sacral fixation for failed posterior fixation of the pelvic ring. Arch Orthop Trauma Surg 126(1):49–52View ArticleGoogle Scholar
- Matta JM, Saucedo T (1989) Internal fixation of pelvic ring fractures. Clin Orthop Relat Res 242:83–97PubMedGoogle Scholar
- Siebenrock KA, Gautier E, Woo AKH et al (2002) Surgical dislocation of the femoral head for joint debridement and accurate reduction of fractures of the acetabulum. J Orthop Trauma 16(8):543–552PubMedView ArticleGoogle Scholar
- Routt ML Jr, Simonian PT, Mills WJ (1997) Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma 11(8):584–589PubMedView ArticleGoogle Scholar
- Sagi HC, Lindvall EM (2005) Inadvertent intraforaminal iliosacral screw placement despite apparent appropriate positioning on intraoperative fluoroscopy. J Orthop Trauma 19(2):130–133PubMedView ArticleGoogle Scholar
- Schimpf M, Brennan T (2005) Anterior pseudomeningocele evacuate as a pelvic mass. Am J Obstet Gynecol 192(6):2071–2072Google Scholar
- Couture D, Branch CL Jr (2003) Spinal pseudomeningoceles and cerebrospinal fluid fistulas. Neurosurg Focus 15(6):E6PubMedView ArticleGoogle Scholar
- Hawk MW, Kim KD (2000) Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas. Neurosurg Focus 9(1):E5PubMedView ArticleGoogle Scholar
- Deans W, Leibrock LG, Bloch S et al (1979) Cerebrospinal fluid hypotension secondary to traumatic rupture of lumbosacral meninges. Surg Neurol 12(3):223–226PubMedGoogle Scholar
- Hadley MN, Carter LP (1985) Sacral fracture with pseudo meningocele and cerebrospinal fluid fistula: case report and review of the literature. Neurosurgery 16(6):843–846PubMedView ArticleGoogle Scholar