Abstract
This is the case of a 66-year-old male with cervical myelopathy secondary to severe
cervical stenosis manifesting as worsening dexterity and numbness in his right hand.
The patient underwent C3–C6 laminoplasty with bilateral foraminotomies. During the
procedure an incidental durotomy occurred which was patched intraoperatively with
Duragen and Tisseel. At 1 month follow-up, the patient reported that he was doing
well and skin sutures were removed. Two days later, the patient presented to the emergency
department with postoperative wound dehiscence, cerebrospinal fluid (CSF) drainage,
altered mental status and lethargy. At that time, a computed tomography (CT) scan
confirmed a tension pneumocephalus which was treated with a cranial burr hole and
revision durotomy repair. The patient improved and was discharged to a rehabilitation
facility with intact motor and cognitive function. At the 1-year follow-up appointment,
he continued to do well without sequelae.
Keywords
tension pneumocephalus - dural tear - durotomy
