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Proper procedure when encountering scarring on Dura Mater?

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    Proper procedure when encountering scarring on Dura Mater?

    First, apologies is this isn't the correct place to post. If it needs to be moved to another forum please feel free to do so. I've only just found the site and started reading articles.

    On to the main topic:

    Is there a consensus as to what should be done in the case where a surgeon encounters a large amount of established scar tissue external to the dura mater while performing a new fusion surgery on a patient who had adjacent areas fused prior to the current procedure?

    And would the answer be affected by what would have been known to the neurosurgical profession in early 2013 compared to now?

    If accepted procedure would be to remove the scar tissue no matter the fact it covered my Dura Mater and that the Dura was noted to be weakened in the area already, then I can understand that sometimes you just never know what will happen. However if this procedure should have been contra-indicated by common neuro or orthopedic surgical or knowledge then it matters a lot to me.

    To explain my case:
    In 2013 I was having my L3/L4 level fused due to severe stenosis and degenerated disc. While in there I requested that the hardware from L4-S1 be removed (those levels were fused in 2004). When he went to do the hardware removal the hardware was covered in scar tissue that extended to cover the dura mater. He removed the scar tissue from the dura mater while getting to the hardware. He noted some definite spinal leaking and attempted to cover both the leak and the area of the scar tissue removal with dural glue.

    He did not realize how frail the dura mater had become under the scar tissue and, post-op, I suffered a large tear (1" diameter) in the dura at that spot which resulted in needing revision surgery 2 weeks later.

    During the revision surgery 2 weeks later, when I was opened up, about 1.5 liters of CSF (cerebral spinal fluid) was flushed out of the area and no significant CSF appeared to be in the Cauda Equina, and the nerves in the CE had been exposed to blood and tissue normally held exterior to the CE by the dura mater. Photographs show severe inflammation of the nerves through the Cauda Equina along with an internal Pseudomeningocele.

    No treatment (anti-inflammatories, stem cell treament or otherwise) were given to me to reduce the sub-arachnoid inflammation. Anti-inflammatory treatment was considered by my surgeon to be of too great a risk to the bone growth in my L3/L4 fusion (understandable, though I grow bone stupidly well and even if I didn't I, in hindsight, would prefer to be dealing with a revision fusion than with what I ended up with).

    All of the nerves in my CE at the lower L4 through L5 region are scarred against the wall of the CE and fully tethered. Additionally MRIs have shown a very large Psuedomeningocele filled with CSF surrounding the L3-S1 region of the spinal cord (120 degree circle, like a pac-man eating a pill if you see it on cross-section) that appeared to have active fluid exchange between itself and the Cauda Equina. This may have self-sealed in the following year, I have not had follow-up imaging done on it, but if not I worry that if I ever suffer infection in the Psuedomeningocele could lead to it reaching my CSF in the spinal cord.

    At this point I would really like to know what the accepted procedure would have been? Had I woken up and been told "I couldn't remove your hardware because the scar tissue was affecting the spinal cord" I would have been ok. The hardware removal was supposed to just be a "since you're in there, it would be nice to be rid of the hardware as my muscles in my lower back still spasm some from them". But it was not anything close to a high priority for me.

    Disclosures: I only have 2 months left to decide whether I am pursuing a case regarding what happened. I have not decided one way or the other. Finding out if this should have been known to leave the scar tissue in place is much of what I will be using to decide whether I am pursuing legal action or not. Once the 2 months are up the statute of limitations will have passed and if I haven't filed then this chapter of is done and I move on to just living with the problems of nerve tethering. Some may not want to respond because of this, and I understand that. Others may be more willing to respond because this is a time-sensitive question.

    Either way, thank you for reading this.

    PS. I have full records including photographs, images and notes from the above mentioned procedures.

    Quick additional notes:

    * MRI images from late 2012, prior to my L3/L4 fusion, showed healthy nerves (no inflammation, not tethered) in the same region that is now tethered. Imaging does show evidence of the internal psuedomeningocele at that level (indirectly based on about 40% of the region being void of nerves) but there was still space for the other nerves to slide as needed.

    * My surgeon did diagnosis the Arachnoiditis in the inflammatory stage during the revision procedure 2 weeks after the fusion and so was aware of it being present and visually documented the inflammation in photographs that I have.

    * MRIs in late 2013 clearly show void space in the region with nerves obviously tethered to the wall of the CE at that point.