Management of Post-Traumatic Pseudomeningocele as Consequence of Root Nerve Avulsion: Case Report and Review of the Literature

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Thank you for the opportunity to read the manuscript titled: “Management of Post-traumatic Pseudomeningocele as consequence of Root Nerve Avulsion: Review of the Literature” by Bradaschia and co-authors. In what follows please find my comments to the authors. The paper addresses a clinically relevant issue of pseudomeningocele management, an area with limited established guidelines, making this a potentially valuable contribution to neurosurgical and trauma-related literature.

These are my comments to the authors:

 

1. Some sentences could be more concise for better readability. For instance, “In contrast with meningoceles…” could be simplified to, “Unlike meningoceles, pseudomeningoceles are CSF-filled cysts confined by paraspinous tissue and communicating with spinal subarachnoid spaces.” Revisions throughout would improve clarity and aid reader comprehension.

2. The authors could briefly comment on the limitations of the review, especially given the low number of articles meeting inclusion criteria, to provide context for the findings.

 

Author Response

Comment: "Some sentences could be more concise for better readability. For instance, “In contrast with meningoceles…” could be simplified to, “Unlike meningoceles, pseudomeningoceles are CSF-filled cysts confined by paraspinous tissue and communicating with spinal subarachnoid spaces.” Revisions throughout would improve clarity and aid reader comprehension."

Answer: We revised the article once again, changing some sentences, including the one you reported, to enhances the overall readability.

 

Comment: "The authors could briefly comment on the limitations of the review, especially given the low number of articles meeting inclusion criteria, to provide context for the findings"

Answer: We decided to add a "Limitations" section to underline that our case report should be taken as an attempt to manage a rare pathology of which almost no data could be found in literature, except for the 5 reported studies.

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

The authors did shorten the discussion enough to make the paper more readable I still have doubts regarding the use of an external lumbar drain to reduce the pressure inside the pseudomeningocele, something that might or might not happen, due to the potential presence of a baloon valve mechanism. However, it is clear now that this was an attempt to a solution and that it can be taken as that. This said, why was the drain used for the first 24 post-operative hours? To avoid the replenishment of the meningocele? This should not have been a problem anymore. Please clarify this point in the final version of the manuscript to enhance clarity. However, the current version of the paper is satisfactory and I believe it deserves publication

Author Response

Comment: "This said, why was the drain used for the first 24 post-operative hours? To avoid the replenishment of the meningocele?"

Answer: The external lumbar drainage (EDL) was kept in place for 48h after surgery (or 72h considering the surgery day), closed the morning of the third day after surgery, removed at the beginning of the fourth day and the patient was discharged the fifth day. The decision on the timing was totally arbitrary, as reported in the newly added "Limitations" section, and we cannot state for sure the true efficacy of the EDL itself. Therefore this case report should be taken as an attempt to manage a rare pathology of which almost no data could be found in literature, except for the 5 reported studies. We are proud anyway for the interest shown by the reviewer in reading the paper. 

Round 2

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Although authors' effort to modify the paper is appreciated, I still remain doubtful regarding their decision to use an external CSF drain to reduce pressure inside the pseudomeningocele( because there is no proof that this could work in other contexts neither that it was useful in the present one) and in relation to the short follow-up, that does not prove the problem was solved. 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to read the manuscript titled: “Management of Post-Traumatic Pseudomeningocele as Consequence of Root Nerve Avulsion: Systematic Review of the Literature and a Case Report” by Bradaschia and co-authors. In what follows please find my comments to the authors.

 

1. My understanding is that several key considerations must be addressed before conducting a systematic review. Firstly, there should be a defined research question that is specific, clear, and answerable. Secondly, there must be sufficient studies available to warrant a systematic review. Finally, it is essential to ensure that the topic is relevant to current issues in the field and contributes meaningfully to the body of knowledge. In my opinion, the submitted manuscript only partially addresses the third precondition and does not meet the first two. For this reason, I suggest that the authors use the term "review" or "scoping review" in the title and throughout the manuscript and provide a more detailed description of their methodology in the methods section, as suggested in the comments below.

2. The introduction could benefit from a more detailed background regarding the pathophysiology of pseudomeningoceles and a brief mention of the incidence of these complications, with citations.

3. Materials and Methods: The search terms, although relevant, appear somewhat limited. It would be beneficial to clarify if additional search techniques (e.g., MeSH terms or Boolean operators) were used to refine the search further. 

4. The exclusion of articles regarding post-traumatic retropharyngeal pseudomeningocele secondary to Atlanto-Occipital Dislocation (AOD) is mentioned briefly, but the rationale behind this exclusion could be expanded upon for clarity.

5. The case report could benefit from a discussion of alternative management strategies considered for this patient, especially if any non-surgical options were evaluated.

6. A more thorough discussion of the patient’s postoperative course, particularly the management of the hemidiaphragm paralysis, would provide a more comprehensive understanding of the outcome.

7. Discussion: There are multiple instances of "Invalid source specified" in the discussion, which significantly detracts from the readability and credibility of the manuscript. 

8. The discussion could be expanded to better contextualize the case in the broader scope of the literature. 

9. A deeper exploration of potential complications or risks associated with external lumbar drainage, such as infection or persistent CSF leakage, would add more depth to the proposed management strategy. 

10. The conclusion could be stronger if it included more definitive recommendations for future research or clinical practice.

Author Response

First above all, I shall thank the reviewer for its time and work.

 

Comment: "For this reason, I suggest that the authors use the term "review" or "scoping review" in the title and throughout the manuscript and provide a more detailed description of their methodology in the methods section, as suggested in the comments below".

Answer: we have corrected in the text as requested.

 

Comment: "The introduction could benefit from a more detailed background regarding the pathophysiology of pseudomeningoceles and a brief mention of the incidence of these complications, with citations"

Answer: we implemented the introduction part. Regarding the incidence, unfortunately no data is provided in literature about the true incidence, due to the rarity of the pathology itself.

 

Comment: "Materials and Methods: The search terms, although relevant, appear somewhat limited. It would be beneficial to clarify if additional search techniques (e.g., MeSH terms or Boolean operators) were used to refine the search further. "

Answer: we specified better the boolean operators used in the research phase. 

 

Comment: "The exclusion of articles regarding post-traumatic retropharyngeal pseudomeningocele secondary to Atlanto-Occipital Dislocation (AOD) is mentioned briefly, but the rationale behind this exclusion could be expanded upon for clarity"

Answer: we explained why the AOD were excluded, since the pathophysiology of the formation of the pseudomeningocele is different compared to the nerve root avulsion. 

 

Comment: "The case report could benefit from a discussion of alternative management strategies considered for this patient, especially if any non-surgical options were evaluated".

Answer: we added in the case report the multidisciplinary meeting we had with the interventional neuroradiologist and the Skull Base Unit neurosurgeons, with the possible strategies proposed. At the end, we were forced to used the External Lumbar Drainage solution as a prophylactic method to prevent the CSF leakage in case of rupture of the pseudomeningocele. The ideal case would have been not to touch the CSF collection at all. 

 

Comment: "A more thorough discussion of the patient’s postoperative course, particularly the management of the hemidiaphragm paralysis, would provide a more comprehensive understanding of the outcome"

Answer: we implemented the follow-up part with the data available to date. Talking about the hemidiaphragm paralysis, the patient started immediately a respiratory physiotherapy to reinforce the intercostal muscles in order to improve the respiratory function.

 

Comment: "Discussion: There are multiple instances of "Invalid source specified" in the discussion, which significantly detracts from the readability and credibility of the manuscript".

Answer: we correct the references, hoping to correct the "invalid source specificed" problem.

 

Comment: "The discussion could be expanded to better contextualize the case in the broader scope of the literature".

Answer: we expanded the whole discussion, adding new details and references.

 

Comment: "A deeper exploration of potential complications or risks associated with external lumbar drainage, such as infection or persistent CSF leakage, would add more depth to the proposed management strategy".

Answer: we added also the potential risk of an ELD, as infection and hemorrage, considered anyway negligible compared to the risk of a CSF leakage from the wound. 

 

Comment: "The conclusion could be stronger if it included more definitive recommendations for future research or clinical practice".

Answer: we encourage a discussion on the topic, since we think it is a rare but quite interesting clinical condition that need to be addressed.

Reviewer 2 Report

Comments and Suggestions for Authors

The present paper describes a condition that is quite rare, post-traumatic pseudomeningocele secondary to lower cervical roots avulsion. Just a few other similar papers have been reported, that leads to a dificulty in understanding what the bnest treatment could be, including non treatment. In my opinion, the report needs to be significantly shortened. The introduction regarding in detail what happened to this patient at the moment of avulsion is not useful, just a simple recolelction of the moment of trauma and its consequence would have been enough. Also, I have some concerns regarding the use of an external lumbar drain. It is true that this solution is largely used in exyternal CSF leaks or when abnormal CSF colelctions are seen in areas where surgery occurred (a typical example being the huge fluid volumes that can be oserved after posterior cranial fossa surgery). However, in these cases the communication between the ventricular system and the collection is almost direct and a high flow leak is suspected. It has to be considerered that it isimpossible to establish the moment the collection appeared and if it was growing (there is no mention of it in the text)- Taking into account that  the drainage volume was set at 5 mls/h, that means 120 mls a day, that the usual volume to grant a high flow leak is around 240 mls/day and that the cyst contained a relatively small amount of CSF (50 mls) it is difficult to state what the real impact of the drainage was. Also, when looking at the post-operative MRI, the cyst did not disappear, it remained there although significantly smaller. And if we consider the short follow up (6 months), how can we be sre the cyst did not grow back again? 

In conclusion, although the case is "relatively" interesting, I see some methodological mistakes, including the lack of information about the results of the nerve transfer. Would it have worked there was a reason to support cyst opening. If it did not, why touch something that was not really having a clinical impact?

Comments on the Quality of English Language

Language needs minor editing

Author Response

First above all, I want to thank the reviewer for its time and worrk.

Comment: "The introduction regarding in detail what happened to this patient at the moment of avulsion is not useful, just a simple recolelction of the moment of trauma and its consequence would have been enough".

Answer: We shortened the introduction of the case report as requested.

 

Comment: "It has to be considerered that it isimpossible to establish the moment the collection appeared and if it was growing (there is no mention of it in the text)".

Answer: We could not know if the pseudomeningocele were growing, since we had only one pre-op MRI done, but based on what the patient remembered, the CSF collection was stable since the first injury.

 

 Comment: "... it is difficult to state what the real impact of the drainage was".

Answer: it is indeed, as it is in posterior cranial fossa surgeries unfortunately. To date there is no confirm even for the surgery fo the posterior cranial fossa of the real efficacy of the external lumbar drainage.

 

Comment: "...how can we be sre the cyst did not grow back again?".

Answer: we will update our case report (if published earlier) with the 12-months outpatient clinic visit in order to confirm or not the relapse of the pseudomeningocele itself.

 

Comment: "Would it have worked there was a reason to support cyst opening. If it did not, why touch something that was not really having a clinical impact?".

Answer: we did not want to touch the pseudomeningocele, but working around it in order to reach the brachial plexus, but during the mobilization phase the pseudomeningocele was teared. External lumbar drainage was indeed used as a prophilactic tool in case of a rupture of the CSF collection.