Management of Traumatic Lumbar Meningo-radicular Injury Caused by Foreign Body Penetration using Sling Technique

BackgroundNon-missile penetrating spinal injuries (NMPSI) can cause delayed neural injury, including cerebrospinal fluid (CSF) leakage and spinal cord herniation, related to dural defects. To repair ventral dural defect (VDD) is particularly challenging in trauma patients and, in a meanwhile, there has been a well-established method: sling technique, used for patients with idiopathic spinal cord herniation (ISCH) in whom VDD being the primary pathology to deal with.Case presentationThis 51-year-old man fell down from an altitude of six meters and landed on a plier. The neurological examination revealed decreased muscle strength (grade 3/3) in bilateral lower extremities. Computed tomography showed a pair of pliers penetrating L4 lamina, spinal canal through vertebral body, psoas muscle into retroperitoneal cavity with inferior vena cava (IVC) indentation. Emergent laparotomy revealed intact IVC with no major organ damage, and the plier was removed from back under direct visualization of IVC. Immediate posterior approach showed a through-and-through VDD. Sling technique with COOK® dura substitute was applied to cover the VDD and fixed with 7-0 prolene after neurolysis. There was no CSF leakage or nerve tissue herniation afterward. He regained working ability with full muscle strength except for a minor sequal of paresthesia of right toe.ConclusionsIn patients with NMPSI with VDD, indirect duraplasty using sling technique originally developed for treating patients with ISCH is suitable and effective in preventing CSF leakage and delayed neural injury. We further propose an algorithm emphasizing key decision makings for repairing dural defect while preventing delayed neural injury.