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

This was a rare case of a 36-year-old female who developed the post-spinal surgery dural hernia linked to untreated dural care. Long surgery and constipation induced the pressure. Treatment involved the quick dural repair, and constipation monitoring to prevent the cauda equina syndrome.

This case emphasized there's a significance of early recombination dural repair. And constipation which to fend off serious nerve problem areas. Post-operative constipation ramped up abating pressure in the patient, causing a rarer but tricky dural hernia.

3D microscopic access during surgery was chosen for its precision, clear fetal well, and ability to repair the dural effectively, ensuring optimal recovery of the patient. The patient showed a significant improvement post-operatively, with reduced lamp pen. And normalized the bodily functions.

Fixing dural cares earlier and monitoring post-op constipation can prevent nesting nerve hernias. We would like to see more studies on dural tear management during endoscopic procedures and on managing postoperative constipation. After making the incision at the surgical site, a dissector was used to bluntly separate the paraspinal muscles laterally, ensuring comprehensive exposure of the transverse processes and articular processes.

Full visualization of the L5 and S1 levels was achieved, followed by meticulous hemostasis to provide optimal visibility for the surgical field. Under the guidance of a three dimensional microscope, a rongeur and an osteotome were used to meticulously resect the bilateral laminate, and a portion of the medial articular processes at L5-S1. During the surgery, the protruding nerve roots were observed.

Precise instruments were used to resect the small joints that were compressing the nerve roots and the spinal canal. Then, utilizing a nerve root dissector, the nerve roots and dura mater were guided inward, facilitating the repositioning of the herniated nerve fibers back into the spinal cord. Subsequently, the dura mater and nerve roots were carefully relaxed and sutured with a five millimeter vascular suture.

The effused cerebral spinal fluid was cleared, and the nerve roots and dura mater were repositioned. Finally, a drainage tube was placed at the surgical site. And using a size one non-absorbable suture, the incision was closed.

The preoperative radiographic and MRI images confirmed lumbar spine stability, and disc herniation on the right side at L5-S1, while the CT scan corroborated the MRI findings. Postoperative MRI conducted on the third day after the first surgery showed cerebro spinal fluid leakage and injury to the lower end plate of L5.Five months after the initial operation, the MRI indicated a cauda equina hernia at L5-S1, along with cerebrospinal fluid leakage and injury to the upper end plate of L5.The CT scan supported these observations. The second surgery effectively repaired the dural tear and cauda equina herniation, as evidenced by the postoperative MRI, which showed a restored fecal sac.