Taming the persistent seroma: multidisciplinary management following complex spinal revision surgery - a case report

Chronic seroma and pseudomeningocele formation following spinal instrumentation, particularly in the setting of prior infection and multiple revision surgeries, remains rare but pose a significant therapeutic challenge due to high recurrence rate. In this context, we present a complex case of pseudomeningocele that evolved into a persistent seroma with cutaneous fistula after multi-level lumbar fusion with a comprehensive review of sclerotherapy protocols.

A 75-year-old patient with prior L3-S1 fusion surgery presented with rod fracture and underwent surgical revision. Postoperatively, a collection with purulent discharge and altered consciousness raised suspicion of a dural breach, later confirmed by Beta-Trace protein testing. Despite multiple revisions and placement of a pedicled SGAP flap, persistent pseudomeningocele developed, evolving in a chronic seroma after CSF leak resolution. The course was further complicated with chronic Staphylococcus Epidermidis infection. Revision surgery with flap mobilization and capsulectomy failed to resolve the seroma. Due to limited surgical options, a multi-instillation doxycycline sclerotherapy protocol via radiologically guided drain was initiated.

The sclerotherapy protocol resulted in progressive decrease in drain output, ultimately allowing for drain removal after 34 days. Follow-up ultrasound 7 days and 3 months after drain removal showed no significant fluid collection. No recurrence of fistula or seroma was observed during follow-up.

This case highlights the challenges of managing postoperative wound complications in spinal surgery, particularly in the context of prior infection, hardware exposure, and suspected cerebrospinal fluid leak. A pedicled SGAP flap provided durable coverage, and doxycycline sclerotherapy proved an effective salvage treatment for persistent seroma after unsuccessful surgical revision.