Pseudomeningocele after biportal endoscopic spine surgery: A case report

Journal Pre-proof Pseudomeningocele after Biportal Endoscopic Spine Surgery: A case report Sang-Su Kang, Ju-Eun Kim, Dae-Jung Choi, Eugene J. Park PII:

S0972-978X(19)30540-9

DOI:

https://doi.org/10.1016/j.jor.2019.10.004

Reference:

JOR 839

To appear in:

Journal of Orthopaedics

Received Date: 10 October 2019 Accepted Date: 19 October 2019

Please cite this article as: Kang SS, Kim JE, Choi DJ, Park EJ, Pseudomeningocele after Biportal Endoscopic Spine Surgery: A case report, Journal of Orthopaedics, https://doi.org/10.1016/ j.jor.2019.10.004. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.

Pseudomeningocele after Biportal Endoscopic Spine Surgery: A case report Sang-Su Kang1, Ju-Eun Kim, M.D.2※, Dae-Jung Choi, M.D.2, Eugene J Park, M.D.3

Department of Orthopaedic Surgery, Leaders Hospital, Seoul, South Korea

1 2

Department of Orthopaedic Surgery, Himnaera Hospital, Pusan, South Korea Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, 3

Republic of Korea

※

Correspondence to: Ju-Eun Kim, MD, Ph D

Department of Orthopedic Surgery, Himnaera Hospital, Busan, South Korea Fax: 82-53-422-6605 Tel: 82-53-420-5638 E-mail: [email protected] No conflict of interest

1

Abstract

2

Background: Biportal endoscopic spinal surgery (BESS) was recently introduced and became prevalent fast.

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Incidental dural tear (IDT) could happen as one of the common complications even in endoscopic spine surgery.

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Case description: A 45-year old male underwent discectomy by BESS. IDT sized about 15mm at the dorsal

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surface of dura occurred during the laminotomy procedure with an osteotome. Revision surgery was planned for

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assuming that the IDT is small enough to be sealed with a patch.

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Conclusion: Revision surgery using BESS for a small-sized IDT could be reasonable alternative treatment to

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preserve the soft tissue, the primary purpose of MISS.

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

24

Introduction

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Incidental dural tears (IDT) incidentally happen intraoperatively during surgical procedures using instruments. A

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small tear could be treated with or even without direct repair. However, postoperative pseudomeningocele is a

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rare complication of IDT, occurred by extradural accumulation of the cerebrospinal fluid (CSF) leakage through

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the dural tear.1 Since the majority of the postoperative pseudomeningoceles are asymptomatic, its accurate

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incidence could not be reported and is ambiguous.2

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Biportal endoscopic spine surgery (BESS) is one of minimally invasive spine surgery (MISS) through a

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percutaneous approach with using endoscopic facilities and instruments. Technical details are similar to

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microscopic spinal surgery, but the technical merits of preserving back muscles through small skin incisions

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resemble percutaneous full endoscopic spine surgery. Through two independent portals for viewing and working

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separately, an unconstrained working space is created with a panoramic view of the surgical site. It permits the

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same procedures such as microscopic spine surgery for indications, including spinal stenosis, foraminal stenosis,

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disc herniation, and pyogenic spondylitis, which are comparable to open spine surgery. Due to the removal of

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bone and soft tissue debris from the surgical site by the outflow of saline, and the isolation of the surgical site

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from the environment using a percutaneous approach, postoperative surgical site infection is reported low.3-7

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Overall complications after BESS occurred in 6.0%, and IDT was the most common one with 3.0%,7, which is

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comparable to that of conventional spinal surgery (0.5~18%).8 Half of IDTs occur during the early stage of the

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learning curve due to poor understanding of endoscopic surgical view, unskilled handling of surgical

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instruments, and need of delicate triangulation of the endoscope and instruments.

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When IDT is encountered during minimally invasive spine surgery or endoscopic spine surgery, surgeons

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agonize whether to convert to open incision and repair with more extensive dissection, which minimizes the

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merits of MISS. Once symptomatic pseudomeningocele happens, open debridement and thorough repair are

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considered mandatory. Therefore, we report a case of MISS revision using BESS for the treatment of

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postoperative pseudomeningocele due to IDT during BESS.

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Case report

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A 45-year-old male was admitted to the hospital complaining of left lower extremity radiating pain and lower

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back pain. Three months of conservative treatment, including nerve blocks, temporarily, but not permanently,

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improved his symptoms. MRI of the lumbar spine showed L5-S1 level herniated disc on the left paracentral

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zone. (Fig 1.) On March 2017, discectomy through interlaminar space using BESS was performed. Before

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draping, the level was confirmed under fluoroscopic guidance, by placing a spinal needle placed on the index

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disc level. Two portals, viewing and working, were made 1 centimeter proximal and distal to the spinal needle

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and as close as possible to the spinous process. The size of the incision was about 1 centimeter through which

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endoscope and surgical instruments could pass. An additional fascia incision was made perpendicular to the skin

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to make the saline outflow fluent. The saline bag was hung about 1.7 meters from the ground using gravity for

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water infusion rather than arthroscopic pump system. Through the viewing portal, the trocar of the endoscope

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was inserted, and through the working portal, a periosteal elevator was inserted, and both instruments were

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docked on the distal end of the target lamina. After triangulation of the endoscope and surgical instrument, the

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soft tissue around the interlaminar space was swept away using a Cobb elevator. Afterward, under endoscopic

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guidance, ipsilateral laminotomy was performed using burr and Kerrison rongeur. After laminotomy,

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ligamentum flavum was removed, followed by discectomy. In this case, a dural tear occurred during the

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laminotomy procedure using an osteotome. (Fig 1.) The size of the tear was less than 1 centimeter and was

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located in the central area. Due to the small size, we did not repair the tear and put a drain above the dura, and

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completed the procedure. The preoperative left lower extremity radiating pain improved after surgery. However,

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he suffered from sweating and complained of a headache during sitting or walking. CSF leakage through the

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skin incision and headache persisted until 8 days after surgery. The follow-up MRI taken 2 weeks after surgery

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showed mass-like lesion on L5-S1 level between the dura and skin. (Fig 2.) Although, three weeks after surgery,

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headache improved and the patient was discharged without other discomforts.

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surgery, the patient complained of mass on the lower back. Follow up MRI taken 9 weeks after surgery showed

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a cystic lesion sized 1.5x3 centimeters on L5-S1 level. Aspiration of the cyst using a spinal needle was

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performed, and close observation was planned afterward. However, the patient complained of a larger mass on

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the lower back a week later. The follow-up MRI on 10 weeks after surgery showed a 6x6 centimeters sized

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lesion, and revision surgery was scheduled. (Fig 3.)

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On the outpatient 2 months after

During revision surgery, rather than open approach, the interlaminar approach by BESS was used with usage of

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two portals previously made from the primary surgery. By placing the endoscopic sheath more proximally than

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the previous corridor, the endoscope was safely positioned in the lamina proximal to the laminotomy site. A

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small freer was inserted through the working portal, and the working space was created. Coagulation, ablation,

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and removal of the pseudomeningocele membrane were carefully performed using a radiofrequency device and

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endoscopic shaver.

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multi-layer. The fascia of the portals was sutured in a water-tight fashion. (Fig 4.)(Video 1) Two years after the

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operation, the patient is living without any symptoms.

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Discussion

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BESS is one of emerging MISS that has several merits. Recent studies reported that BESS could decrease spinal

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fusion procedure after decompression surgery. It is due to limited damage to the posterior ligamentous complex

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and soft tissue by minimizing paraspinal muscle dissection during surgery. Besides, the facets and bony

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structures of the contralateral side could be preserved compared to conventional open laminectomy. Furthermore,

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continuous saline irrigation allows clear surgical view with the prevention of infection.3,5-7 Some technical

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complications during BESS are reported, including postoperative hematoma, nerve root injury, and incomplete

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decompression. Among them, IDT showed the highest incidence of 3%.7 Postoperative pseudomeningocele is a

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complication coming out a few weeks later after IDT during lumbar surgery.

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pseudomeningocele after laminectomy is reported to be between 0.068 to 2%.10,11 Postoperative

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pseudomeningocele most commonly occur after unrecognized opening of the dura, arachnoid, and pia mater.12

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Symptomatic pseudomeningocele usually occurs in the lumbar region since majority of the spine surgery

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includes lumbar region and the hydrostatic pressure of CSF is higher compared to other cervical or thoracic

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spine.2 The typical symptom of postoperative pseudomeningocele is postural headache, localized back pain, and

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radiculopathy. If the nerve root is herniated through the dura and strangulated, the patient may suffer additional

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radicular pain and motor deficits.13 Treatment of pseudomeningocele is controversial, especially in

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asymptomatic cases. It is affected by several factors, such as sac size, location, symptoms, etc. Usually,

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asymptomatic pseudomeningocele does not require treatment. Also, since even large pseudomeningocele could

102

be spontaneously absorbed, conservative treatment can be a treatment option in asymptomatic cases. However,

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symptomatic cases lasting for over months are surgical candidates.14 Especially, in large-sized

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pseudomeningocele, since further complication such as infection could occur through the fistula, immediate

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open surgical repair is recommended.15 Percutaneous subarachnoid drainage has been used as the treatment of

Under endoscopic guidance, fibrin sealant patches were used to cover the dural tear site in

9

The incidence rate of

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the dural cutaneous fistulas and early pseudomeningoceles.16 This procedure can help to create a seal at the

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leakage site and promote healing by CSF diversion. For large dural defect that is difficult for primary closure,

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closure with patch technique using autologous tissue or dural allograft is recommended.17 Pseudomeningocele

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with adhesion to the dura should be removed.

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Dura has naturally excellent and fast healing power . Psedomeningocele is first detected as a soft mass under

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the subcutaneous layer a few weeks after surgery. So the large dura tear site more than 1 centimeter could be

112

healed and shrinkage into smaller one. If the tear site is less than 1centimeter, it can be a good indication of

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patch compression to prevent rootlets incarceration and promote dural closure. One of the surgeons’ concerns

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about revision operation for pseudomeningocele is how to find the dural tear under the scar tissue.

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Pseudomeningocele under the skin is made by CSF leakage so that it has a tract connecting directly into the

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opening of dural tear site. Direct invasion into the pocket to chase the tract into the torn site was feasible using

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BESS. Debridement of pseudomembrane in the muscle and subcutaneous layer was performed by shaving and

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curetting to make small fresh bleeds to promote healing and closing the vacant tract. After finding the unsealed

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defect, about 1cm sized patch with additional same sized gel foam compression is enough to close the defect. A

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drain should not be inserted. Hematoma should be collected at the site to compress over the patch and close the

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area without third space is a feasible theory of patch compression method for treatment of small-sized dural tear

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less than 1cm. Two-day (48 hours) bed rest is enough before ambulation after patch compression method.

123 124

Conclusion

125

Revision surgery for pseudomeningocele after IDT using BESS could be an effective alternative treatment

126

before attempting conversion to open surgery. The size of dural tear decreased spontaneously after time, which

127

patch compression was sufficient during revision surgery. Performing such method instead of open surgery

128

could preserve the merits of MISS.

129 130

No potential conflict of interest relevant to this article was reported.

131 132 133

1.

Wilkinson HA. Nerve-root entrapment in "traumatic" extradural arachnoid cyst. J Bone

Joint Surg Am. 1971;53(1):163-166. 2.

Hawk MW, Kim KD. Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas.

134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170

Neurosurg Focus. 2000;9(1):e5. 3.

Kim JE, Choi DJ. Clinical and Radiological Outcomes of Unilateral Biportal Endoscopic Decompression by 30 degrees Arthroscopy in Lumbar Spinal Stenosis: Minimum 2-Year Follow-up. Clin Orthop Surg. 2018;10(3):328-336.

4.

Kim JE, Choi DJ. Biportal Endoscopic Transforaminal Lumbar Interbody Fusion with Arthroscopy. Clin Orthop Surg. 2018;10(2):248-252.

5.

Kim JE, Choi DJ. Unilateral biportal endoscopic decompression by 30 degrees endoscopy in lumbar spinal stenosis: Technical note and preliminary report. J Orthop. 2018;15(2):366371.

6.

Kim JE, Choi DJ, Park EJ. Clinical and Radiological Outcomes of Foraminal Decompression Using Unilateral Biportal Endoscopic Spine Surgery for Lumbar Foraminal Stenosis. Clin

Orthop Surg. 2018;10(4):439-447. 7.

Kim JE, Choi DJ, Park EJJ, et al. Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis. Asian Spine J. 2019;13(2):334-342.

8.

Takahashi Y, Sato T, Hyodo H, et al. Incidental durotomy during lumbar spine surgery: risk factors and anatomic locations: clinical article. J Neurosurg Spine. 2013;18(2):165-169.

9.

Solomon P, Sekharappa V, Krishnan V, David KS. Spontaneous resolution of postoperative lumbar pseudomeningoceles: A report of four cases. Indian J Orthop. 2013;47(4):417-421.

10.

Swanson HS, Fincher EF. Extradural arachnoidal cysts of traumatic origin. J Neurosurg. 1947;4(6):530-538.

11.

Teplick JG, Peyster RG, Teplick SK, Goodman LR, Haskin ME. CT Identification of postlaminectomy pseudomeningocele. AJR Am J Roentgenol. 1983;140(6):1203-1206.

12.

Rinaldi I, Hodges TO. Iatrogenic lumbar meningocoele: report of three cases. J Neurol

Neurosurg Psychiatry. 1970;33(4):484-492. 13.

Hadani M, Findler G, Knoler N, Tadmor R, Sahar A, Shacked I. Entrapped lumbar nerve root in pseudomeningocele after laminectomy: report of three cases. Neurosurgery. 1986;19(3):405-407.

14.

Lee KS, Hardy IM, 2nd. Postlaminectomy lumbar pseudomeningocele: report of four cases.

Neurosurgery. 1992;30(1):111-114. 15.

Couture D, Branch CL, Jr. Spinal pseudomeningoceles and cerebrospinal fluid fistulas.

Neurosurg Focus. 2003;15(6):E6. 16.

Pau A. Postoperative "meningocele spurius". Report of two cases. J Neurosurg Sci. 1974;18(2):150-152.

17.

Shaffrey CI, Spotnitz WD, Shaffrey ME, Jane JA. Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients. Neurosurgery. 1990;26(2):207-210.

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Figure legend

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Fig 1. (A) Sagittal T2-weighted image of MRI showing L5-S1 paramedian disc herniation. (B) Axial T2-

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weighted images showing L5-S1 paramedian disc herniation. (C-E) Intraoperative endoscopic images. (C)

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Removing the S1 superior articular process using an osteotome. (D), (E) L-shaped dural tear. (F) Removing the

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disc fragment using a Kerrison rongeur. (G) Covering the dural tear with artificial dermis under endoscopic

180

guidance.

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Fig 2. Postoperative MRI showing decompression of thecal sac accompanied with fluid collection on the

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posterior epidural space.

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Fig 3. MRI on postoperative week 9. (A) Sagittal T2 weighted image shows fluid collection in the epidural

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space and just beneath the skin. (B) Sagittal T1 weighted image shows low signal intensity of the fluid. (C) T2

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weighted axial image shows fluid compressing the dura along with the subcutaneous fluid collection. (D) T2

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weighted coronal image shows a 6x6 cm sized fluid collection on the subcutaneous area.

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Fig 4. Intraoperative endoscopic images during revision. (A) A pseudomeningocele tissue was found around the

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dural tear site. (B) The pseudomeningocele tissue was removed using a Kerrison rongeur. (C) After removal of

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pseudomeningocele tissue, the border between which and the dura was confirmed. (D) A fibrin sealant patch

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was used to cover the dural tear. (E,F) MRI after revision surgery shows improvement of dural indentation due

191

to fluid collection and decrement of fluid.

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