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    • The recurrence rate of CFT is not

    2018-10-22

    The recurrence rate of CFT is not high and has been reported to be around 17–30%, mainly in cases of inadequate excision. However, there has been no reported recurrence of CFT in the mesentery during the follow-up period. Generally, complete excision is an adequate treatment to avoid recurrence of CFT. However, it may be difficult to clean up minor tumors of <2mm in size at multiple sites and consequently these tumors will be left untreated, especially when the patient is without any discomfort. Sleigh et al. suggested using repeated CT to monitor the tumor in the pleural or the mediastinal location. In our case, we used gastroscopy to monitor CFT in the GI tract, because endoscopy is more efficient and provides clearer demonstration than CT for this purpose.
    Introduction Dural tears, which are defined as unintended incidental durotomy, are an unfortunate but significant complication of lumbar spine surgery. Dural tears are infrequent during microsurgical discectomy. These tears are usually small, heal without complications, and are primarily closed with sutures. However, occasionally a small tear may not be recognized during the procedure, which may lead to severe postoperative complications, such as pseudomeningocele, nerve root entrapment, cerebrospinal fluid (CSF) fistula, and even Mifepristone infection. The prevalence of these problems is unknown. Cauda equina entrapment in the pseudomeningocele is a rare complication in spinal surgery. It is known that a burst fracture is the most common cause of cauda equina entrapment.
    Case report Recurrent disc herniation was suspected. MRI revealed a free disc fragment at the L2-3 level with caudal migration. T2-weighted images suggested CSF accumulation within the epidural space and paraspinal muscle (Fig. 1). The diagnosis was recurrent disc herniation and dural tear, resulting in a CSF leak at the L2-3 level. We then undertook on L2-3 laminectomy and dural repair. A free disc fragment was removed. We found a 0.5-cm longitudinal dural tear on the ventral surface at the L2-3 level, and swollen and congested nerve roots of the cauda equina were seen to herniate through the small longitudinal opening into the cavity of the removed nucleus pulposus (Fig. 2). The nerve roots were firmly trapped and not movable. We opened the dural sac extensively to reposition the roots. The tear was covered by a piece of dural substitute using polyglycolic acid (PGA) mesh and fibrin glue (Fig. 3).
    Discussion The incidence of inadvertent dural tears with CSF leakage during microsurgical lumbar discectomy has been reported to be approximately 4% of cases. However, dural tears resulting in a small dural defect that involves herniation and incarceration of cauda equina nerve roots are extremely rare after nontraumatic spinal surgery. Only seven cases of iatrogenic nerve root herniation after discectomy have been previously described. All of the patients underwent reoperation, and transdural nerve root incarceration resulted in complete recovery in five cases. Of the three patients who had a dural defect at the ventral side, two were left with a permanent neurologic deficit (Table 1). In this patient, the dural tear and CSF leakage were not recognized during the initial operation. It was presumed that a small dural tear did not rupture the arachnoid membrane. Because of the thin, delicate nature of the arachnoid, incidental increases in cerebrospinal pressure inevitably lead to a postoperative rupture of the arachnoid as well as CSF leakage. Kothbauer and colleagues and Nishi and colleagues reported that increased abdominal pressure plays a role in the development of cauda equina herniation. This occurs in the same manner as abdominal wall hernias. The classical symptoms of radiculopathy caused by a herniated lumbar disc include pain, numbness, and muscle weakness in the area supplied by the affected nerve roots. Radiculopathy is seldom characterized by persistent muscle cramps and fasciculations. Cramps and fasciculations may occur in lower motor neuron disease and may further implicate anterior horn cell dysfunction. The irritation to the cauda equina and hyperactivity of the stimulated motor neuron may cause muscle fasciculations. In our patient, the entrapment of the nerve roots may have played a role in his persistent muscle cramps and fasciculations, which were possibly due to continuous nerve root pinching and twitching.