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# anterior-sacral-meningocele  Case Report Giant anterior sacral meningocele repaired through a posterior approach.    ## Abstract  **Purpose:** Anterior sacral meningoceles are rare forms of spinal dysraphism produced by herniation of the thecal sac through a bone defect in the anterior sacral wall. The patients may remain asymptomatic or present with nonspecific symptoms such as long-term constipation, urinary dysfunction, lower back pain, or perineal hypoalgesia.   **Methods:** We present the case of a 82-year-old female patient with a giant anterior sacral meningocele that was initially confused with various entities such as inguinal hernia and an ovarian cyst.   **Results:** Once the anterior sacral meningocele was confirmed through a MRI-scan she was successfully treated using a posterior transsacral approach. We present a brief review of the current literature and discuss the surgical treatment options.   **Conclusion:** These lesions are difficult to diagnose without a strong suspicion due to the multiple range of nonspecific symptoms such as low lumbar pain, obstetric problems, and bowel and bladder difficulties. Special care should be taken in order to avoid erroneous diagnoses that may expose the patient to unnecessary surgical procedures. Because these lesions usually do not regress spontaneously, surgical treatment is mandatory for symptomatic or growing masses. The dural defect can be repaired with a variety of anterior transabdominal or posterior transsacral approaches, being the posterior approach a more definitive one.   ***Keywords:*** *Anterior sacral meningocele, posterior approach, abdominal pain*  diff --git a/figures/ASM postIQ 2 sacro.jpg b/figures/ASM postIQ 2 sacro.jpg  new file mode 100644  index 0000000..028bc69  Binary files /dev/null and b/figures/ASM postIQ 2 sacro.jpg differ diff --git a/figures/ASM preIQ.jpg b/figures/ASM preIQ.jpg  new file mode 100644  index 0000000..3ae21d3  Binary files /dev/null and b/figures/ASM preIQ.jpg differ diff --git a/manuscript.md b/manuscript.md  new file mode 100644  index 0000000..e648682  --- /dev/null  +++ b/manuscript.md 
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# Giant anterior sacral meningocele repaired through a posterior approach.  ---  ## Abstract  **Objetive:** Anterior sacral meningoceles are rare forms of spinal dysraphism produced by herniation of the thecal sac through a bone defect in the anterior sacral wall. The patients may remain asymptomatic or present with nonspecific symptoms such as long-term constipation, urinary dysfunction, lower back pain, or perineal hypoalgesia.  **Methods:** We present the case of a 82-year-old female patient with a giant anterior sacral meningocele that was initially confused with various entities such as inguinal hernia and an ovarian cyst.  **Results:** Once the anterior sacral meningocele was confirmed through a MRI-scan she was successfully treated using a posterior transsacral approach. We present a brief review of the current literature and discuss the surgical treatment options.  **Conclusion:** These lesions are difficult to diagnose without a strong suspicion due to the multiple range of nonspecific symptoms such as low lumbar pain, obstetric problems, and bowel and bladder difficulties. Special care should be taken in order to avoid erroneous diagnoses that may expose the patient to unnecessary surgical procedures. Because these lesions usually do not regress spontaneously, surgical treatment is mandatory for symptomatic or growing masses. The dural defect can be repaired with a variety of anterior transabdominal or posterior transsacral approaches, being the posterior approach a more definitive one.  ***Keywords:*** *Anterior sacral meningocele, posterior approach, abdominal pain*  ---  ## Introduction.  Anterior sacral meningocele (ASM) is a relative rare anomaly of the pre-sacral region, it is defined as a meningeal cyst produced by agenesis of a portion of the anterior sacrum which develops into a herniation of meninges through the defect[@Quigley1984]. It is been reported that erosion of the anterior wall of the sacrum and even sacral fractures could develop into this kind of lesions [@Cools2013]. In approximately 50% of cases, associated malformations are found, which includes spina bifida, spinal dysraphism, imperforated anus, etc [@Dahan2001]. Sometimes is associated with syndromes such as Currarino and Marfan syndromes [@Kole2014]. The presentation of anterior sacral meningoceles can be subtle with very unspecific symptoms, it is for that reason that despite a thorough medical history and physical examination the diagnoses could be challenging. The clinical and radiological features of this condition may vary depending on the patient, although neurological complications are considered uncommon, meningitis, sepsis, obstetric problems, and bowel and bladder difficulties can develop [Muthukumar2002; @Hanna2001]. Surgical treatment is the standard for symptomatic or growing masses with compression of adjacent structures. The dural defect can be repaired with a variety of anterior or posterior neurosurgical approaches depending on characteristics of each patient and the features of the cyst [@Ashley2006]. We present a case of a 82-year-old female patient with an anterior sacral meningocele that was successfully treated via an open posterior approach. We discuss the treatment options and a review of the literature  ## Case Report.  A 82-year-old woman with a history of lumbar and low abdominal pain for several years. She was treated by the general practitioner without improvement of symptomatology. After several months she was referred to the general surgeon with a diagnosis of inguinal hernia on the left side. The patient underwent surgery and the inguinal hernia was repaired, however there was no improvement over a period of six months.  Following her insistent complains, the physician requested an abdominal ultrasound scan, which showed a large cystic collection on the pelvic area consistent with a giant ovarian cyst and an AP &L lumbar X-rays which confirmed a severe scoliotic deformity between L2 and S1, with a right sided curvature and over 45 degrees angle. The patient was then referred to the gynecologist who performed an endoscopic approach with puncture of the cyst. During the procedure the content was found to be similar to CSF, raising the suspicion of an anterior sacral meningocele, hence the procedure was stopped immediately. The patient was kept admitted into the hospital for 7 more days where consecutive imaging examinations ruled out and abdominal collection of CSF.    The patient was then referred to our department. A complete physical and neurological examination was made. The patient mainly complained of lower abdominal pain with overflow incontinence, sciatic pain in both legs with a predominance on the left side, and mechanical lower lumbar pain. The neurological examination showed no motor deficits at lower extremities with preservation of tone and reflexes. Sensitivity was patchy in both legs around L5 and S1 dermatomes, but resulted quite inconsistent. An MRI (Figure 1) showed an anterior pre-sacral cyst eroding the anterior wall of S2 and S3, herniating through an anterior sacral defect. The collection measured 10x9cm, exerting compression on the rectum and the bladder in a significant way.  Due to these pelvic symptoms and the presence of a growing mass, a new surgical procedure consisting in a posterior sacral laminectomy and ligation of the meningocele cyst was proposed. We believe this approach is appropriate to get a correct exposure of the cyst neck.    The procedure was performed in a prone position, a sacral laminectomy was executed, after exposure of the dural sac, we note that the dura was so thin that it kept tearing continuously. We proceeded with the dissection intraduraly in order to achieve the greatest possible exposure of the anterior sacral defect. After complete intradural exposure the anterior sacral defect lean out, subsequently we introduce the suction into the defect, once we were certain that there was no nerve root on it, the suction pressure allowed us to pull up the anterior wall of the pseudomeningocele and then we pursued with the ligation of the neck. The intradural procedure ended by placing an anterior and posterior dural patch in order to prevent CSF fitula. A lumbar drain was placed for similar reasons.  The patient remained in bed rest for about 5 days, the lumbar drain remain open for 2 days. She was mobilized on day 3 and noted to be full strength on motor examination, with no bowel or bladder problems. With further improvement of the symptomatology, she remained hospitalized for 7 days and was discharged without any complications. A 3 months post surgery MRI (Figure 2) was made, revealing complete closure of the anterior sacral meningocele with no compression of the pelvic structures. Although the abdomino-pelvic symptoms disappear, the lumbar pain remained with lower intensity probably caused by the severe scoliosis that the patient had.  ## Discussion.  ASM develops as a result of a defect characterized by focal erosion or hypogenesis of segments of the sacrum with herniation of the meningeal sac through the defect into the pelvis. They accounts for 5% of retrorectal masses, and are usually diagnosed in the second or third decades. They are more prevalent in women [@Villarejo1983]. Presentation in elderly patients is less common, however it can occur as in the case described.  The presentation of ASM can be subtle. Therefore, the patient’s medical history and physical examination findings are critical diagnostic tools. The patients may remain asymptomatic or present with nonspecific symptoms such as long-term constipation, urinary dysfunction, lower back pain, or perineal hypoalgesia [@Mohta2011; @Quigley1984]. These symptoms may be due to direct compression of the herniated meningeal sac, spinal cord tethering, or sacral nerve root compression [@Muthukumar2002]. Furtermore, fluid shifts between the sac and the spinal subarachnoid space can cause intermittent low-pressure headache, nausea and vomiting related to changes in body position [@Villarejo1983]. As a result of the nonspecific symptoms, the diagnosis can be difficult and ASM occasionally can be confused with other entities.  The diagnostic tests include plain radiograph which could show the curved appearance of the residual sacrum scalloped beneath the defect. This finding is considered pathognomonic, and presents in 50% of cases [@Martin1988]. CT-scans are useful to display bony anomalies and lumbar erosions. Intrathecal contrast enhanced CT scanning is the diagnostic procedure of choice. Nevertheless, this method usually is discarded as it is invasive and has the disadvantage of ionizing radiation. MRI is the gold standard as it is safe, rapid, and noninvasive [@Lee1988]. Abdominal ultrasound could reveal the presence of an intra-abdominal cystic lesion. Careful examination should be made to avoid misdiagnosis with cysts in other locations. Confusion with ovarian cysts is not rare, as in the case we present, and has also been described in other reports [@Erdogmus2006; @Polat2013]  In our patient, as a consecuence of the misdiagnosis, a presumed ovaryan cyst puncture was performed with the consequent CSF leak into the abdominal cavity. However, spontaneous fistula can occur sometimes [@Koksal2011; @Sánchez2008; @Bergeron2010].  Surgical options consist primarily of either an anterior transabdominal or a posterior transsacral approach. The main goal of surgery should be to safely disconnect the cyst from subarachnoid space to prevent further enlargement, thereby reducing the compression of nearby structures.  The anterior transabdominal approach may be performed via laparoscopic or open trans-abdominal/laparotomy, usually it is not considered as the first surgical option unless decompression and rapid removal of the cyst wall is required. Extreme caution must be taken when extensive resection of the cyst wall is performed since adherence to surrounding visceral structures can lead to complications such as fecal or vesical fistulas [@Ashley2006].  Several reports have stressed the advantages of the posterior transsacral technique [@Massimi2003; @Villarejo1983]. This anatomical approach was first described by Adson et al. in 1938 and even today it is considered as a relatively easy and safe technique. This approach allows ligation of the stalk of the ASM without the need to decompress or remove the cyst, decreasing the risk of further infections. Other advantages of this approach are control of the nerve roots, filum terminale and dura matter.  ## Conclusions.  We present a case of a giant anterior sacral meningocele with some interesting nuances. Although the diagnosis sometimes can be very challenging, this phatology should always be kept in mind in order to avoid erroneous diagnoses that may expose the patient to unnecessary invasive procedures. Imaging is critical, but a careful obtained medical history can reveal important clues. Surgery is generally advised, especially if there is compression on pelvic structures. Multiple surgical approaches are available. Nonetheless, the posterior approach remains the treatment of choice for most lesions. 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# Giant anterior sacral meningocele repaired through a posterior approach.  ## Authors:  - Jesús Lafuente  - Juan Diego Patino [[email protected]](mailto:[email protected])  - Demian Manzano  - David Rodríguez  1:Departamento de Neurocirugía.   Hospital del Mar, Barcelona.   Passeig Marítim, 25-29. Barcelona. 932 48 30 00.