gms | German Medical Science

Objective: The rates of intraoperative dural tear range from 3.5% for primary lumbar discectomy to over 10% for lumbar revision discectomy. Most of the reported cases of intracranial haemorrhage after spinal surgery involved intraoperative dural tearing or cerebrospinal fluid (CSF) leakage. We report a rare case of an non-aneurysmal cerebellar subarachnoid haemorrhage caused by a CSF leak following lumbar revision discectomy and review the literature.

Case report:A 70-year-old man with a history of hypertension, smoking, and adipositas presented clinical signs and symptoms and MR imaging studies consistent with a reherniated nucleus pulposus at the L4–L5 disc space. He underwent a lumbar revision discectomy. Intraoperatively, an incidental small durotomy occurred and was repaired uneventfully. One closed suction drain was placed subfascially. Shortly after extubation the patient had a reduced level of consciousness. Two hours postoperatively, the drain had drawn 250 ml clear fluid tinged with blood, consistent with CSF. The man developed severe headache, and lost consciousness. The emergency computed tomographic scan showed an atypical cerebellar subarachnoid haemorrhage in the sulci as well as haematoma of cortex of both cerebellar hemispheres. Haemorrhage and edema led to compression of the fourth ventricle and subsequent non-communicating hydrocephalus. The subfascial wound drain was removed. The patient was immediately transferred to the operation room for external ventricular drain and suboccipital decompression. Angiography did not reveal the focus of bleeding. Tracheotomy was performed. Concomitantly, the patient developed pneumonia, Clostridium difficile associated diarrhea, meningitis and epileptic seizures as well as a coagulation disorder. Over the next weeks the patients state of consciousness improved. Five weeks postoperatively, the man was transferred to a rehabilitation department. Two months later he developed pneumonia and died there.

Conclusions: This report adds to the literature one complication in lumbar disc surgery. Non-aneurysmal cerebellar subarachnoid haemorrhage is a rare but potentially lethal complication of lumbar disc surgery. The postoperative CSF loss is a possible mechanism for this cerebellar subarachnoid haemorrhage. Preventing dural injury during spinal surgery, dural repair and minimizing CSF loss after intraoperative dural tearing, especially during suction drain, would be helpful to prevent cerebellar subarachnoid haemorrhage.