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Lumbar spine CT myelogram obtained on postoperative day 20 due to clinical concern for suspected rectothecal fistula. (A) Sagittal reconstruction soft tissue window shows communication between the spinal column and rectum (dotted arrow) with contrast extending into the sigmoid colon (solid arrow). (B) Sagittal reconstruction bone window shows intrathecal contrast in the pseudomeningocele and extending anteriorly into the rectum (solid arrow). (C) Axial image shows residual contrast within sigmoid (thick arrow) and pseudomeningocele. Findings confirm rectothecal fistula.
Source publication
We present a case of an iatrogenic rectothecal fistula in a 34-year-old man who underwent repair of a congenital anterior sacral meningocele, intraoperatively complicated by rectal perforation. Postoperatively, the patient developed symptoms of meningitis prompting concern for the cerebrospinal fluid leak. Subsequent workup with computed tomography...
Context in source publication
Context 1
... sion ensued as to the most appropriate modality to evaluate for clinically suspected rectothecal fistula, with consideration of a barium enema, however, CT myelography was ultimately decided upon. On postoperative day 20, a lumbar spine CT myelogram unequivocally demonstrated a pseudomeningo- cele fistulization to the rectum ( Fig. 4 ). The next day, a mul- tidisciplinary team of surgeons intraoperatively identified the fistula at the site of the prior rectal tear and turbid fluid ante- rior to the pseudomeningocele. ...
Citations
Anterior sacral meningocele is a rare congenital anomaly encountered in neurosurgical practice. In all, approximately 200 cases of this rare congenital malformation have been reported till date. Surgical management has been accepted beyond doubt as the treatment of choice and posterior surgical approach has been adopted in majority of the cases, however there are no concrete guidelines for choosing anterior or posterior approach. The authors report here an unusual presentation of a giant anterior sacral meningocele in an adult. A 30year old male, presented with persistent constipation and urinary retention. On evaluation, a giant anterior sacral meningocele of size 13x10x13cm was seen on imaging causing significant compression of the rectum and bladder. A single stage surgery was planned via trans-abdominal approach. Successful excision of the meningocele sac was done along with dural repair, thus relieving the patient of his symptoms. The authors reflect on the cases reported in literature and the approaches used by other surgeons. The authors also discuss in this paper, the reasons for choosing the anterior approach in such rare cases and their observations during the intra and post-operative course. The authors conclude by enumerating the advantages of the anterior approach while also suggesting key operative steps to prevent complications.
Study design:
Retrospective case series.
Objective:
Anterior sacral meningocele (ASM) is a rare disorder. We reviewed 11 cases of congenital ASM and classified them into three types based on the anatomy and relationship between the cyst and sacral nerve roots.
Summary of background data:
The cohort with ASM is relatively large; the classification is novel and has not been previously reported.
Methods:
Eleven consecutive patients with ASM who underwent surgery between February 2014 and January 2019 were retrospectively analyzed. They included four males and seven females. The dorsal transsacral approach was adopted in all cases. The follow-up time was at least 3 months.
Results:
We attempted to classify ASM into three types. Of the 11 cases, six were caudal type, two were paraneural type, and three were nerve-root type. The meningocele was ligated after exploring no nerve involvement, in Type I and II. For Type III, the herniating sac and involved nerve roots were ligated when the nerve roots were indicated as nonfunctional on neurophysiological monitoring; otherwise, the sacral nerve roots were protected and imbricated on the residual sac like a hand-in-glove, and sutured to reconstruct the nerves sleeve. Eight cases were accompanied by tethered cord syndrome (TCS); spinal cord detethering was done with one-stage operation. Ten patients' presenting symptoms improved at 3 to 6 months' follow-up; notably, constipation significantly improved. Only one case accompanied by an epidermoid cyst had a second laparoscopic surgery by a general surgeon.
Conclusion:
Aim of surgical treatment is to obliterate the communication between the subarachnoid space and herniated sac, detether the spinal cord, and resect the congenital tumor. The new classification helps to recognize the relationship between the meningocele and sacral nerve roots, and subsequently adopt different surgical strategies. We consider the dorsal transsacral approach relatively feasible, safe, and with lower complication.
Level of evidence:
4.
