In Reply: Omentomyelopexy for the Treatment of a Persistent Lumbar Pseudomeningocele: A Case Report With Technical Note

To the Editor: We appreciate Kammoun et al1 for their thoughtful and collegial comments regarding our report and for highlighting the epidural blood patch (EBP) as a minimally invasive option for the management of postoperative cerebrospinal fluid (CSF) leak and symptomatic pseudomeningocele. We can agree that EBP is a well-established therapy in the setting of postdural puncture headache,2 spontaneous CSF hypotension,3 selected focal (“pinpoint”) postoperative leaks,4,5 and, in some cases, early-stage pseudomeningocele.6 In our case,7 a large, irreparable dural defect was present, and the pseudomeningocele persisted despite multiple revision surgeries, diversion procedures, application of free fat grafts, fibrin sealant, and dural reconstruction using fascia lata. We believe that EBP, in the setting of a long-standing, complex dural defect after repeated surgical interventions, was unlikely to be beneficial. This was not a unique experience in our practice. In another patient with thoracic chondrosarcoma and visible dural invasion, en bloc corpectomy and resection of approximately three-quarters of the dural sac circumference at T10-T12 was needed, followed by dural repair with fascia and fibrin glue application. After CSF leak occurred, with large dural defect and preexisting paraplegia in mind, we did not hesitate to proceed with omentomyelopexy, wrapping a vascularized omental flap around the defect, which resulted in definitive CSF leak resolution. For these reasons, in light of the patient's prolonged and complex clinical course marked by multiple unsuccessful reconstructive surgeries, and meaningfully recovered neurological function, we elected to pursue omentomyelopexy as a salvage, last-resort strategy, which ultimately resulted in durable resolution of the pseudomenigocelle. Nevertheless, we would like to emphasize that omentomyelopexy should be considered only in highly selected patients with persistent CSF leak or pseudomeningocelle, when conventional dural repair techniques and less invasive measures have failed.