Formation of subdural hygroma after surgery for degenerative spinal disease: observation from practice

AIM. To describe the clinical observation of a rare complication in the form of the formation of a decompensated form of subdural hygroma in a patient after decompressive stabilizing intervention at the L4-L5 level.
CLINICAL CASE. Patient N., 63 years old, complained of pain in the posterolateral surface of the right lower limb. History of endoscopic decompression of the spinal canal at the place of residence for spinal canal stenosis at the L4-L5 level in 2021 and 2022. According to the Lumbosacral Spine MRI: multifactorial stenosis of the spinal canal at the L4-L5 level with compression of the L5 root by the discosteophyte complex.
Intraoperatively, a defect of the dura mater was obtained without damage to the arachnoid membrane and there was no leakage of cerebrospinal fluid.
On the 3rd day after surgery, the patient began to complain of an intense headache, on the 5th day during verticalization, an episode of loss of consciousness was noted. A CT scan of the brain was performed, according to the results of which pneumocephaly is determined subdurally and along the sickle of the brain. On the 14th day, the patient showed decreased alertness to moderate stupor, and hypertensive dislocation symptoms. According to CT of the brain, a subdural hygroma of the left frontal region with a volume of 150 cm3 and a transverse dislocation to the right by 13 mm was detected. The following surgical intervention was performed: microsurgical removal of the subdural hygroma in the left frontal region with a volume of 1, Stuckey ventriculocisternostomy 1. After 1 day, negative dynamics were noted: according to CT of the brain, an increase in the subdural hygroma to 120 cm3 with a transverse dislocation of up to 16 mm. A repeated surgical intervention was performed in the volume of subdural-peritoneal shunting. The postoperative period was satisfactory. On the control CT of the brain the volume of subdural contents decreased to 10 cm3, transverse dislocation to the right to 3 mm. The patient was discharged in satisfactory condition on the 21st day.
CONCLUSION. The present clinical observation is of great interest due to rare formation of this complication during decompressive-stabilizing interventions on the spinal column. When clinical symptoms of intracranial hypotension appear, it is necessary to stay alert and conduct clinical and instrumental diagnostics to exclude the formation of this complication.

1. Prodan A. I., Perepechay O. A., Kolesnichenko V. A., Balan S. I., Chernyshev A. G. Complications of surgical treatment for lumbar spinal stenosis. Russian Journal of Spine Surgery. 2009;(1):031–037. (In Russ.). Doi: https://doi.org/10.14531/ss2009.1.31-37.

2. Eismont F. J., Wiesel S. W., Rothman R. H. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am. 1981;(63):1132–1136.

3. Finnegan W. J., Fenlin J. M., Marvel J. R., Nardini R. J., Rothman R. H. Results of surgical intervention in the symptomatic multiply-operated back patient. Analysis of sixty-seven cases followed for three to seven years. J Bone Joint Surg Am. 1979;(61):1077–1082.

4. Friedman J. A., Ecker R. D., Piepgras D. G., Duke D. A. Cerebellar hemorrhage after spinal surgery: report of two cases and literature review. Neurosurgery. 2002;50(6):1361–1353. Doi: 10.1097/00006123-200206000-00030.

5. Friedman J. A., Piepgras D. G., Duke D. A., McClelland R. L., Bechtle P. S., Maher C. O., Monta A., Perkins W. J., Parisi J. E., Brown R. O. Remote cerebellar hemorrhage after supratentorial surgery. Neurosurgery. 2001;(49):1327–1340.

6. Kitchel S. H., Eismont F. J., Green B. A. Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation on the spine. J Bone Joint Surg Am. 1989;71(7):984–987.

7. Pham M. H., Tuchman A., Platt A., Hsieh P. C. Intracranial complications associated with spinal surgery. Eur Spine J. 2016;25(3):888–894. Doi: 10.1007/s00586-015-4241-2.

8. Lv Y., Xiang H. Seizures and Consciousness Disorder Secondary to Intracranial Hypotension After Spinal Surgery: A Case Report and Literature Review. Front Neurol. 2022;(13):923529. Вoi: 10.3389/fneur.2022.923529.

9. Khalatbari M. R., Khalatbari I., Moharamzad Y. Intracranial hemorrhage following lumbar spine surgery. Eur Spine J. 2012;21(10):2091–2096.

10. Floman Y., Millgram M. A., Ashkenazi E., Rand N. Remote Cerebellar Hemorrhage Complicating Unintended Durotomy in Lumbar Spine Surgery. Int J Spine Surg. 2015;(9):29. Вoi: 10.14444/2029.

11. Williams B. J., Sansur C. A., Smith J. S., Berven S. H., Broadstone P. A., Choma T. J., Goytan M. J., Noordeen H. H., Knapp DR. Jr., Hart R. A., Zeller R. D., Donaldson W. F. 3rd, Polly D. W. Jr., Perra J. H., BoachieAdjei O., Shaffrey C. I. Incidence of unintended durotomy in spine surgery based on 108,478 cases. Neurosurgery. 2011;68(1):117–123. Doi: 10.1227/NEU.0b013e3181fcf14e. PMID: 21150757.

12. van den Berg J. S., Sijbrandy S. E., Meijer A. H., Oostdijk A. H. Subdural hygroma: a rare complication of spinal anesthesia. Anesth Analg. 2002;94(6):1625–1627. Doi: 10.1097/00000539-200206000-00049. PMID: 12032041.

13. Wong A. P., Shih P., Smith T. R., Slimack N. P., Dahdaleh N. S., Aoun S. G., El Ahmadieh T. Y., Smith Z. A., Scheer J. K., Koski T. R., Liu J. C., Fessler R. G. Comparison of symptomatic cerebral spinal fluid leak between patients undergoing minimally invasive versus open lumbar foraminotomy, discectomy, or laminectomy. World Neurosurg. 2014;81(3-4):634–640. Doi: 10.1016/j.wneu.2013.11.012. PMID: 24239738.

14. Rahman M., Summers L. E., Richter B., Mimran R. I., Jacob R. P. Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the “classic” open approach. Minim Invasive Neurosurg. 2008;51(2):100–105. Doi: 10.1055/s-2007-1022542. PMID: 18401823.

15. Reina M. A., Alvarez-Linera J., Lopez A., Benito-Leon J., De Andres J. A., Sola R. G. Magnetic resonance in dural post-puncture headache in patient with cerebrospinal fluid hypotension. Rev Esp Anestesiol Reanim. 2002;(49):89–100.

16. Garcia-Morales I., Porta-Etessam J., Galan L., Lagares A., Molina J. A. Recurrent subdural haematomas in a patient with spontaneous intracranial hypotension. Cephalalgia. 2001;(21):703–705.

17. Schievink W. I. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;(295):2286–2296. Doi: 10.1001/jama.295.19.2286.

18. Upadhyaya P., Ailani J. A review of spontaneous intracranial hypotension. Curr Neurol Neurosci Rep. 2019;(19):22. Doi: 10.1007/s11910-019-0938-7.

19. Chan S. M., Chodakiewitz Y. G., Maya M. M., Schievink W. I., Moser F. G. Intracranial hypotension and cerebrospinal fluid leak. Neuroimaging Clin N Am. 2019;(29):213–226. Doi: 10.1016/j.nic.2019.01.002.

20. Farb R. I., Nicholson P. J., Peng P. W., Massicotte E. M., Lay C., Krings T. et al. Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management based on MRI and digital subtraction myelography. Am J Neuroradiol. 2019;(40):745–573. Doi: 10.3174/ajnr.A6016.

21. Garcia-Morales I., Porta-Etessam J., Galan L., Lagares A., Molina J. A. Recurrent subdural haematomas in a patient with spontaneous intracranial hypotension. Cephalalgia. 2001;(21):703–705.

22. Franksson C., Gordh T. Headache after spinal anesthesia and a technique for lessening its frequency. Acta Chir Scand. 1946;94(5):443–454. Upadhyaya P., Ailani J. A review of spontaneous intracranial hypotension. Curr Neurol Neurosci Rep. 2019;(19):22. Doi: 10.1007/s11910-019-0938-7.

23. Beier A. D., Soo T. M., Claybrooks R. Subdural hematoma after microdiscectomy: a case report and review of the literature. Spine J. 2009;(9):e9–e12. Doi:10.1016/j.spinee.2009.06.012.

24. Wells J. B., Sampson I. H. Subarachnoid hemorrhage presenting as post-dural puncture headache: a case report. Mt Sinai J Med. 2002;(69):109–110.

25. Chan S. M., Chodakiewitz Y. G., Maya M. M., Schievink W. I., Moser F. G. Intracranial hypotension and cerebrospinal fluid leak. Neuroimaging Clin N Am. 2019;(29):213–226. Doi: 10.1016/j.nic.2019.01.002.

26. Farb R. I., Nicholson P. J., Peng P. W., Massicotte E. M., Lay C., Krings T. et al. Spontaneous intracranial hypotension: a systematic imaging approach for CSF leak localization and management based on MRI and digital subtraction myelography. Am J Neuroradiol. 2019;(40):745–573. Doi: 10.3174/ajnr.A6016.

27. Bosacco S. J., Gardner M. J., Guille J. T. Evaluation and treatment of dural tears in lumbar spine surgery: a review. Clin Orthop Relat Res. 2001;(389):238–247. Doi: 10.1097/00003086-200108000-00033. PMID: 11501817.

28. Eismont F. J., Wiesel S. W., Rothman R. H. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am. 1981;63(7):1132–1136. PMID: 7024283.

29. Guerin P., El Fegoun A. B., Obeid I., Gille O., Lelong L., Luc S. et al. Incidental durotomy during spine surgery: Incidence, management and complications: a retrospective review. Injury, 2011.

30. Cammisa F. P. Jr., Girardi F. P., Sangani P. K., Parvataneni H. K., Cadag S., Sandhu HS: Incidental durotomy in spine surgery. Spine (Phila Pa 1976). 2000;(25):2663–2667.

31. Narotam P. K., Jose S., Nathoo N., Taylon C., Vora Y. Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique. Spine (Phila Pa 1976). 2004;(29):2861–2869.

32. Jankowitz B. T., Atteberry D. S., Gerszten P. C., Karausky P., Cheng B. C. Faught R. et al. Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery. Eur Spine J. 2009;(18):1169–1174.

33. Karaeminogullari O., Atalay B., Sahin O., Ozalay M., Demirors H., Tuncay C. et al. Remote cerebellar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review. Neurosurgery. 2005;(57(1 Suppl)):E215.

34. Saxler G., Kramer J., Barden B., Kurt A., Pfortner J., Bernsmann K. The long-term clinical sequelae of incidental durotomy in lumbar disc surgery. Spine (Phila Pa 1976). 2005;(30):2298–2302.

35. Kolesov S. V. Khirurgiya deformatsii pozvonochnika; eds by S. P. Mironov. Moscow: Avtorskaya Akademiya; 2014. 272 p. (In Russ.).

36. Dolotin D. N., Mikhailovsky M. V. Early infection in surgery of idiopathic scoliosis. Russian Journal of Spine Surgery. 2016;13(2):24–27. (In Russ.).