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Marsupialization and distal obliteration of a lumbosacral dural ectasia in a nonsyndromic, adult patient.

Nguyen HS, Lozen A, Doan N, Gelsomin M, Shabani S, Maiman D - J Craniovertebr Junction Spine (2015 Oct-Dec)

Bottom Line: Her symptoms initially improved, but shortly thereafter recurred.This approach significantly improved her symptoms at 5 months follow-up.This method may offer an effective therapy option as it serves to limit the expansile dura, reducing the cerebrospinal fluid sump and the potential for intracranial hypotension.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA.

ABSTRACT
Dural ectasia is frequently associated with connective tissue disorders or inflammatory conditions. Presentation in a patient without known risk factors is rare. Moreover, the literature regarding the treatment options for symptomatic dural ectasia is controversial, variable, and limited. A 62-year-old female presents with intractable, postural headaches for years. A lumbar puncture revealed opening pressure 3 cm of water. A computed tomography myelogram of the spine demonstrated erosion of her sacrum due to a large lumbosacral dural ectasia. An initial surgery was attempted to reduce the size of the expansile dura, and reconstruct the dorsal sacrum with a titanium plate (Depuy Synthes, Westchester, PA, USA) to prevent recurrence of thecal sac dilatation. Her symptoms initially improved, but shortly thereafter recurred. A second surgery was then undertaken to obliterate the thecal sac distal to the S2 nerve roots. This could not be accomplished through simple ligation of the thecal sac circumferentially as the ventral dura was noted to be incompetent and attempts to develop an extradural tissue plane were unsuccessful. Consequently, an abundance of fibrin glue was injected into the thecal sac distal to S2, and the dural ectasia was marsupialized rostrally, effectively obliterating the distal thecal sac while further reducing the size of the expansile dura. This approach significantly improved her symptoms at 5 months follow-up. Treatment of dural ectasia is not well-defined and has been variable based on the underlying manifestations. We report a rare patient without risk factors who presented with significant lumbosacral dural ectasia. Moreover, we present a novel method to treat postural headaches secondary to dural ectasia, where the thecal sac is obliterated distal to the S2 nerve roots using an abundance of fibrin glue followed by marsupialization of the thecal sac rostally. This method may offer an effective therapy option as it serves to limit the expansile dura, reducing the cerebrospinal fluid sump and the potential for intracranial hypotension.

No MeSH data available.


Related in: MedlinePlus

(a) Computed tomography myelogram (sagittal plane) demonstrates large lumbosacral dural ectasia. (b) Computed tomography myelogram (axial plane) demonstrates large lumbosacral dural ectasia
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Figure 1: (a) Computed tomography myelogram (sagittal plane) demonstrates large lumbosacral dural ectasia. (b) Computed tomography myelogram (axial plane) demonstrates large lumbosacral dural ectasia

Mentions: The patient is a 62-year-old female who complains of headaches for her entire life but recently became progressively severe over the last couple of years. Headaches become progressively severe after 20-30 min of being upright. After lying down, the headaches slowly subside. Magnetic resonance imaging brain and magnetic resonance angiogram neck without significant findings. A lumbar puncture revealed opening pressure 3 cm of water, concerning for low spinal pressure. A computed tomography (CT) myelogram of the spine demonstrated the erosion of her sacrum due to a large dural ectasia [Figure 1], which was felt to be the source of her postural headaches.


Marsupialization and distal obliteration of a lumbosacral dural ectasia in a nonsyndromic, adult patient.

Nguyen HS, Lozen A, Doan N, Gelsomin M, Shabani S, Maiman D - J Craniovertebr Junction Spine (2015 Oct-Dec)

(a) Computed tomography myelogram (sagittal plane) demonstrates large lumbosacral dural ectasia. (b) Computed tomography myelogram (axial plane) demonstrates large lumbosacral dural ectasia
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4660503&req=5

Figure 1: (a) Computed tomography myelogram (sagittal plane) demonstrates large lumbosacral dural ectasia. (b) Computed tomography myelogram (axial plane) demonstrates large lumbosacral dural ectasia
Mentions: The patient is a 62-year-old female who complains of headaches for her entire life but recently became progressively severe over the last couple of years. Headaches become progressively severe after 20-30 min of being upright. After lying down, the headaches slowly subside. Magnetic resonance imaging brain and magnetic resonance angiogram neck without significant findings. A lumbar puncture revealed opening pressure 3 cm of water, concerning for low spinal pressure. A computed tomography (CT) myelogram of the spine demonstrated the erosion of her sacrum due to a large dural ectasia [Figure 1], which was felt to be the source of her postural headaches.

Bottom Line: Her symptoms initially improved, but shortly thereafter recurred.This approach significantly improved her symptoms at 5 months follow-up.This method may offer an effective therapy option as it serves to limit the expansile dura, reducing the cerebrospinal fluid sump and the potential for intracranial hypotension.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA.

ABSTRACT
Dural ectasia is frequently associated with connective tissue disorders or inflammatory conditions. Presentation in a patient without known risk factors is rare. Moreover, the literature regarding the treatment options for symptomatic dural ectasia is controversial, variable, and limited. A 62-year-old female presents with intractable, postural headaches for years. A lumbar puncture revealed opening pressure 3 cm of water. A computed tomography myelogram of the spine demonstrated erosion of her sacrum due to a large lumbosacral dural ectasia. An initial surgery was attempted to reduce the size of the expansile dura, and reconstruct the dorsal sacrum with a titanium plate (Depuy Synthes, Westchester, PA, USA) to prevent recurrence of thecal sac dilatation. Her symptoms initially improved, but shortly thereafter recurred. A second surgery was then undertaken to obliterate the thecal sac distal to the S2 nerve roots. This could not be accomplished through simple ligation of the thecal sac circumferentially as the ventral dura was noted to be incompetent and attempts to develop an extradural tissue plane were unsuccessful. Consequently, an abundance of fibrin glue was injected into the thecal sac distal to S2, and the dural ectasia was marsupialized rostrally, effectively obliterating the distal thecal sac while further reducing the size of the expansile dura. This approach significantly improved her symptoms at 5 months follow-up. Treatment of dural ectasia is not well-defined and has been variable based on the underlying manifestations. We report a rare patient without risk factors who presented with significant lumbosacral dural ectasia. Moreover, we present a novel method to treat postural headaches secondary to dural ectasia, where the thecal sac is obliterated distal to the S2 nerve roots using an abundance of fibrin glue followed by marsupialization of the thecal sac rostally. This method may offer an effective therapy option as it serves to limit the expansile dura, reducing the cerebrospinal fluid sump and the potential for intracranial hypotension.

No MeSH data available.


Related in: MedlinePlus