Case of fatal cerebellar hemorrhage following lumbar spinal surgery with dural leak

Background: Remote cerebellar hemorrhages are more commonly reported after supratentorial surgeries, but rarely occur after spinal procedures, particularly those involving a cerebrospinal fluid leak/dural tear (DT). Case Description: For L3-L5 lumbar stenosis and L4/5 grade I spondylolisthesis, a 64-year-old female underwent a L3/4 XLIF (extreme lateral lumbar interbody fusion) and L4/5 posterior lumbar interbody fusion (PLIF with pedicle screw fixation). Notably, during the PLIF, there was likely a traumatic DT (i.e., likely unrecognized at the time or not repaired); mistakenly, the surgeons applied a drain using maximal negative pressure. Within 8 postoperative h, the patient developed a severe headache and rapid neurological deterioration. The brain computed tomography revealed bilateral cerebellar hemorrhages with tonsillar herniation. Despite an emergent suboccipital craniotomy for hematoma evacuation, the patient expired on postoperative day 13. Conclusion: Here, a 64-year-old female underwent a L3/4 XLIF combined with L4/5 PLIF for L3-5 stenosis with grade I L4/5 spondylolisthesis. An unrecognized and/or untreated DT likely occurred during the L4/5 PLIF, leading to the mistaken placement of a “maximal negative pressure drain.” Within 8 postoperative h, she developed a severe headache and acute neurological deterioration. Although she underwent emergent surgery for bilateral cerebellar hemorrhages, which were responsible for her sudden neurological worsening, she died 13 days later.