Background:  Complex midline back wounds are usually not optimally treated with primary closure. There is a paucity of   current literature on the management of pseudomeningocoeles.  Although a number of techniques have been described, no current single technique is ideal.   Primary layered closure of soft tissue over imbricated the  pseudomeningocoele is the pre-eminently recommended method.   When the patients condition is complicated by a cerebral spinal fluid (CSF) leak, the problem is more  urgent, the patient is at risk for meningitis.   In theory, it should be possible to provide a watertight closure of a dural leak and resolve the problem.  However, due to technical difficulties, efforts to provide a truly cerebrospinal fluid tight closure falls short of being achieved.

Methods:   The technique we describe includes meticulous   dissection of pseudomeningocoele to its neck, opening the pseudomeningocoele, repair of dural defect with acellular dermal patch, resection of pseudomeningocoele leaving adequate residual tissue to make a two layer pants over vest closure, and   wide mobilization of paraspinous muscle with importation of muscle into wound in overlapping fashion, thereby obliterating dead space and tamponading the dural repair. The vascularity is based on lateral row perforators after ligation of the medial row.  Leaving the lateral row perforators intact provide excellent vascularity with adequate mobility.  A dural patch and utilization of the myeolcoele remnant is incorporated into the layer, held in place with acellular dermis, and fibrin glue.

Results:   We have demonstrated a one hundred percent success rate within this small series.   These techniques were incorporated into the care of 9 patients between (3 male, 6 female) between January 2004 and July 2006.   One patient’s defect was low cervical, one mid thoracic, and seven low lumbar.  All wounds were closed in a single stage after careful flap section based on the wound's needs and anatomic location.

Conclusions:  The technique presented d raws from the contributions of previous authors on the management of hostile back wounds permiting reliable back reconstruction for this difficult problem with minimal morbidity. Although our series is small, the technique appears to be safe and efficacious.    While initially devised to treat pseudomeningocoeles it may be applied prophylactically for patients at risk of developing back wounds with CSF leaks.