Spinal Hernia Repair and Cauda Equina Repositioning After Lumbar Decompression under Three-Dimensional Microscopy: A Case Report and Literature Review

Summary

Dural hernia following spinal endoscopic surgery is a rare complication. Here, we report a case of nerve root hernia associated with the absence of dural repair, prolonged operation time, and increased abdominal pressure due to postoperative constipation. Early dural tear repair and monitoring postoperative constipation can help prevent cauda equina herniation.

Abstract

Cauda equina herniation (CEH) is a relatively rare and severe perioperative complication that may occur after lumbar spine surgery. Here, we present a case report of a 36-year-old female patient who experienced CEH after an endoscopic L5-S1 laminectomy and discectomy. The patient presented with right L5-S1 radiculopathy that correlated with findings in medical imaging and physical examination. Subsequently, she underwent endoscopic L5-S1 laminotomy and discectomy. A day after the operation, the patient developed urine leakage, hematochezia, aggravated constipation, and found no relief from pain in the right lower limb. MRI revealed cerebrospinal fluid leakage at the surgical site. After consultation with the urology and anorectal department, the patient was fitted with a urinary catheter, prescribed hemorrhoid medication, and underwent anal sphincter training as recommended by the doctor. After 1 week of treatment, the patient's urinary function returned to normal, but constipation persisted while the pain in the right lower limb eased. After 5 months, the patient was hospitalized due to radiating pain in both lower limbs and constipation. An MRI revealed herniation of the L5/S1 nerve root sac. Subsequently, L5/S1 total laminectomy decompression and dural sac repair were performed under a three-dimensional (3D) microscopy. Postoperatively, lower limb pain and constipation were alleviated. CEH following spinal endoscopy, though rare, demands significant clinical attention. The successful outcome in this case illustrates the value of surgical revision under 3D microscopic guidance, offering a viable strategy for patients presenting with this complication.

Introduction

Iatrogenic nerve root herniation is a rare complication of lumbar endoscopic surgery and may occur due to intraoperative dural tear and cerebrospinal fluid leakage^1,2,3. There are few reports on the symptoms of iatrogenic nerve root herniation, which are mainly attributed to spinal cord or nerve root compression^4,5. Percutaneous endoscopic is a safe and effective minimally invasive spinal surgery⁶. However, due to the requirement for continuous irrigation with a water medium, identifying cerebr....

Protocol

Informed consent was acquired from the patient before initiating the treatment, and the study underwent ethical review by the ethics committee.

1. Preoperative work-up for the first surgery

1. CT, MRI, DR, and physical examination were performed to identify the L5/S1 affected segment and determine the surgical method (Figure 1).
2. Lower limb vascular issues were ruled out, and the patient underwent an anesthetic assessment before .......

Discussion

There are few reports documenting nerve root compression resulting from dural sac herniation¹. Herniation of the spine can be categorized as spontaneous, iatrogenic, or traumatic⁸. In this case, the patient's condition was primarily attributed to dural injury and compromised arachnoid integrity. Long-term constipation experienced by the patient resulted from increased abdominal pressure, cerebrospinal fluid flow, arachnoid herniation, and compression of nerve roots, ult.......

Materials

Name	Company	Catalog Number	Comments
Kestrel View II	Mitaka Kohki Co., Ltd.	000 46	3D Microscope
Mersilk	Ethicon	SA87G	Suture