[Technical specification of epidural blood patch for treatment of spinal cerebrospinal fluid leakage].

Spinal cerebrospinal fluid leakage is a common cause of spontaneous intracranial hypotension. Traditional treatment methods include conservative treatment and surgical treatment, but conservative treatment is ineffective for some patients, while surgical treatment is rarely used in clinical practice due to severe trauma. Minimally invasive surgery at appropriate time is an important method to handlecerebrospinal fluid leakage. Therefore, the Group of Headache and Facial Pain, Pain Branch of Chinese Medical Association formulated this technical specification of epidural blood patch for treatment of normal dural sac tension spinal cerebrospinal fluid leakage. This paper mainly discusses the concept and mechanism, indications and contraindications, operation methods, complications and treatment methods of epidural blood patch in order to improve clinical efficacy, reduce neuralsystem complications and reduce the incidence of adverse events.

Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: a systematic review and meta-analysis.

BACKGROUND: Perioperative cerebrospinal fluid (CSF) leakage is a major complication of pituitary adenomas transsphenoidal surgery. Lumbar drainage (LD) is a common method of treating CSF leakage. But whether intraoperative LD can prevent CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery remains controversial. Clarity on the appropriate use of LD is needed. METHODS: A systematic literature review was conducted in the PubMed, EMBASE, and Web of science databases. Articles were included when they compared intraoperative LD with intraoperative no-LD CSF leakage rates during pituitary adenomas transsphenoidal surgery. RESULTS: Overall, 5 studies containing 678 cases met the inclusion criteria. When data were provided on intraoperative CSF leakage rates, the meta-analysis showed a significant difference in favor of intraoperative LD. When data were provided on postoperative CSF leakage rates, the meta-analysis also demonstrated a significant difference in favor of intraoperative LD. CONCLUSIONS: Although the results of this meta-analysis suggest intraoperative LD can reduce the risk of CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery, the available evidence is indefinite. To some extent the results suggest intraoperative LD's potential positive role. Further studies that include well-designed prospective, randomized controlled clinical trials are necessary for further verification.

Lumbar drains: Practical understanding and application for the otolaryngologist.

INTRODUCTION: Lumbar drains are frequently used in patients with otolaryngologic concerns. These can be used therapeutically or prophylactically with the primary purpose being to modulate CSF pressure. Within otolaryngology, lumbar drains are most frequently used for cerebrospinal fluid leaks - either due to cerebrospinal fluid fistulas or in skull base surgery as these allow for potential healing of the defect. While not typically placed by otolaryngologists, a basic understanding of lumbar drains is beneficial in the context of patient management. MANAGEMENT: A lumbar drain is inserted into the intrathecal space in a patient's lumbar spine. Though considered to be a benign procedure, complications are relatively frequent, and adjustment or replacement of the drain may be required. Complications include infection, epidural bleeding, retained hardware, sequelae of relative immobility, or may relate to over-drainage, ranging from mild headache to cranial neuropathies, altered mental status, pneumocephalus, intracranial hemorrhage, and death. While in place, neurologic exams should be performed routinely and should include motor and sensory exams of the lower extremities. A patient should be monitored for fevers, nuchal rigidity, and other signs of infection or meningitis. The CSF fluid should be grossly examined to identify changes, but routine laboratory tests are not typically run on the fluid itself. Drainage rates will vary usually between 5 and 20 mL per hour and must be frequently reassessed and adjusted based upon signs of intracranial hypotension. Drains should be removed when appropriate and should not be left in more than 5 days due to the increased infectious risk. CONCLUSION: Lumbar drains are important tools used in patients with otolaryngologic pathologies. Otolaryngologists and otolaryngology residents should be familiar with these catheters to determine if they are working correctly and to identify adverse effects as early as possible.

An Unusual Cause of Chronic Headache in an Adolescent Boy: A Case Report.

Spontaneous intracranial hypotension (SIH) is an under-diagnosed cause of headache in children and adolescents. SIH results from cerebrospinal fluid (CSF) leak due to breach in the dura mater and the etiology for dural breach is often diverse. We report an adolescent boy who presented with chronic episodic headache that later progressed to daily headache. There was a typical history of worsening of headache on upright position and relief of headache on lying down. He was treated with migraine prophylaxis in another hospital but there was no response. Marfanoid features and brisk deep tendon reflexes were observed on clinical examination. Brain magnetic resonance imaging (MRI) revealed sagging of the brain stem, pachymeningeal enhancement, and tonsillar herniation. MRI of spine myelogram confirmed multiple levels of CSF leak. He was initially managed with supportive measures and fluoroscopic-guided fibrin glue injection. Although child remained symptom-free for the next 6 months, he again developed headache. MRI and computed tomography spine myelogram revealed a meningeal diverticulum in the lumbar spine. He was managed with an autologous epidural blood patch and he has been well since then. In this report, we highlight the clinical and radiological pointers to the presence of SIH in children with recurrent headache.

Treatment of cerebrospinal fluid leak after spine surgery.

Owing to the complexity of spinal surgery, there is a great prevalence of dural tear causing cerebrospinal fluid (CSF) leakage. Many studies focused on suture repair for dural tear to stop CSF leak. Now some new treatment strategies have shown a promising effect that is listed as follows: 1) creating watertight dural closure to stop CSF leak with the help of dural substitute material; and 2) retarding CSF leak by changing pressure difference, including reducing the subarachnoid fluid pressure, increasing the epidural space pressure and both. In fact several methods mentioned above are usually combined to treat CSF leak. However, no update review summarized the relevant studies implemented in recent years. In this review, the authors would compare the effects of different dural closure techniques, and introduce the latest treatment methods and mechanisms.

Cerebrospinal Fluids Leaks of the Cranial Vault Management with Compression Cap: Case Series.

Cerebrospinal fluid leaks of the cranial vault, constitute one of the most common complications after neurosurgical procedures. In this paper we introduce to you an observational study, in which a series of patients with this complication where managed by using elastic compression hat during 18 hours per day, for two weeks to four months. Every one of them presented complete resolution of the leak, without any recurrence until actual controls. After that we perform a review of the literature, demonstrating this is a new therapeutic management, being us the first group on reporting it. According to the observed results, it was concluded that despite more studies are required, the use of elastic compression hats for this kind of patients could be effective and safe.

Management and Outcomes of Cerebrospinal Fluid Leak Associated With Anterior Decompression for Cervical Ossification of the Posterior Longitudinal Ligament With or Without Dural Ossification.

STUDY DESIGN: A retrospective clinical study. OBJECTIVE: To analyze and evaluate the clinical outcomes of cerebrospinal fluid (CSF) leak after anterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) with or without dural ossification (DO). SUMMARY OF BACKGROUND DATA: Anterior decompression can be highly efficacious in the treatment of OPLL. However, in some cases of OPLL, there often exists DO and fusion with the posterior longitudinal ligament, which may increase the chance for CSF leak during an anterior decompression surgery. MATERIALS AND METHODS: A retrospective analysis was performed on 126 OPLL patients (89 men and 37 women) treated with anterior decompression surgery between January 2008 and January 2012. The mean age at operation was 61 years (ranging from 46 to 72 y) and the average duration of diagnosis was 4.2 years (ranging from 3 d to 7 y). DO was present in 11 patients, of whom 7 developed dural tear or defect. Among the 115 patients without DO, only 4 developed dural tear. Intraoperative dural repair was performed with gelatin foam onlay and fibrin glue seal. Postoperative care for CSF leak involved bed rest, CSF drainage, nutritional support, and antibiotics. RESULTS: A total of 11 cases associated with dural tear or defect developed postoperative CSF leak (an overall incidence of 8.7%). There was a statistically significant difference (P<0.001) in the incidence of CSF leak between the DO group (63.6%) and the non-DO group (3.5%). While leakage in 3 patients resolved spontaneously within 5 days of surgery, intermittent CSF cysts developed in 8 patients. These were treated with circular pressure bandages, repeated aspiration, and lumbar drainage. All 8 cases resolved 14-30 days after surgery. These 11 patients were followed up for an average of 12.8 months (range of 1 to 36 mo) with an average Japanese Orthopedic Association score of 51.2% and no significant neurological deficit or persistent headaches were recorded. CONCLUSIONS: Patients with DO are at increased risk for dural injury while undergoing anterior decompression for the treatment of OPLL. This is associated with a high incidence of CSF leak. However, the majority of patients with CSF leak could be managed conservatively.

Special MRI Techniques to Suss out Spontaneous Cerebrospinal Fluid Leaks.

ABSTRACT: Anterior skull base cerebrospinal fluid (CSF) fistulas result from skull base osteodural defects, allowing subarachnoid space CSF to escape into pneumatized cavities such as the paranasal sinuses and nasal fossa. Precise localization, characterization, and effective treatment of CSF leaks is essential to prevent meningitis, treatment failure, or recurrence. Advances in magnetic resonance imaging have improved radiologists' ability to localize and characterize anterior skull base CSF fistulas. This article reviews new imaging techniques enabling diagnostic location of CSF fistulas, with an emphasis on magnetic resonance imaging-based techniques.

Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review.

BACKGROUND: Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy. METHODS: PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection. RESULTS: The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques. CONCLUSIONS: Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.

Developing a Spinal CSF Leak Program in a Multihospital Network.

OBJECTIVE: Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare and challenging to diagnose and treat. Patients may present to a variety of physicians, and many patients are often referred to a specialized center with a dedicated spinal CSF leak program and expertise in this condition. To our knowledge, there are no reported publications on how to create such a program. CONCLUSION: In this article, we describe the specific steps we took to develop a spinal CSF leak program, which we have implemented over a multihospital network.

Cerebral Venous Thrombosis: An Unexpected Complication with Cerebrospinal Fluid Leaks after a Fall in a Patient with Spinocerebellar Ataxia Type 6.

A 65-year-old woman with spinocerebellar ataxia presented with generalized seizures due to subcortical hemorrhaging. Magnetic resonance imaging (MRI) revealed obstruction of the superior sagittal sinus. Despite treatment, she became comatose. MRI newly revealed subdural fluid collection and descent of the brainstem. Her history indicated a recent fall, prompting additional studies, which revealed lumbar fracture and cerebrospinal fluid (CSF) leaks. We performed an epidural blood patch, and her consciousness was fully restored in one month. This is the first report of cerebral venous thrombosis with CSF leaks in the lumbar region due to a fall injury.

Dural sealants for the management of cerebrospinal fluid leakage after intradural surgery: current status and future perspectives.

Introduction: Cerebrospinal fluid leakage is a complication after intradural surgery and is associated with severe secondary complications like compromised wound healing and meningitis. Dural sealants are meant to augment the primary dural closure in order to achieve a watertight closure. Areas covered: This review summarizes the efficacy of currently available dural sealants. Potential future improvements and biomaterials are discussed. Expert opinion: The use of a dural sealant seems to be the logical method to prevent CSF leakage. However, based on the efficacy of currently available dural sealants according to systematic reviews and in vitro studies, a significant effective dural sealant seems is still lacking. A new dural sealant has to be thoroughly assessed before clinical application in in vitro, in vivo and clinical trials. A new research area within sealant development might be the introduction of dural sealants with both antimicrobial and analgesic properties.

Intrathecal Saline Infusion as an Effective Temporizing Measure in the Management of Spontaneous Intracranial Hypotension.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a rare condition for which no optimal treatment guidelines have been determined. The most common presentation is orthostatic headaches, but patients can present with a variety of symptoms. CASE DESCRIPTION: We present a case of a 34-year-old man who developed progressive orthostatic headaches and bilateral subdural collections. His symptoms along with imaging of his brain and spine were consistent with SIH. Unfortunately, his symptoms continued to progress, and his level of consciousness became affected. The patient did not respond to either conservative management or epidural blood patching. As the result of his worsening condition, a lumbar drain was inserted for the intrathecal infusion of normal saline to prevent tonsillar herniation. Once the infusion was started, his level of consciousness improved. It was discovered that his cerebrospinal fluid leak was due to an osteophyte within his thoracic spine, which was eroding the dura. He underwent a costo-transversectomy with the removal of the osteophyte and repair of the dural defect. The patient had some improvement after this procedure, but he remained more somnolent than expected. On subsequent imaging, it was found that his subdural collections had increased slightly in size and it was decided to drain them. Both collections were released under high pressure, and he went on to make an excellent recovery. CONCLUSIONS: This case demonstrates that an intrathecal saline infusion can be used as an effective temporizing measure in patients with critical symptoms of SIH and it also alerts clinicians that low-pressure subdural collections can progress to subdural collections under high pressure.

Disturbed Consciousness and Coma: Diagnosis and Management of Intracranial Hypotension Caused by a Spinal Cerebrospinal Fluid Leak.

OBJECTIVE: The diagnosis and treatment of intracranial hypotension associated with a spinal cerebrospinal fluid (CSF) leak, especially in comatose patients, have yet to be established. METHODS: Clinical manifestations, neuroimaging findings, and treatment outcomes in 11 patients (Glasgow Coma Scale score 10 ± 4) were described and compared with 36 patients with normal consciousness. RESULTS: Patients with disturbed consciousness were diagnosed at a significantly older age (55 ± 11 years; P < 0.001) than those without (42 ± 8.8 years). Neuroimaging findings in patients with disturbed consciousness were characterized by a smaller midbrain-pons angle (7.8 ± 10°; P < 0.001), brainstem swelling (122%; P = 0.002), and thicker subdural hematomas (16 ± 7.0 mm°; P < 0.001). Epidural blood patch (EBP) alone did not achieve sustained improvements in patients with disturbed consciousness but did in most patients without (94%; P = 0.001). Over the treatment course, 5 patients progressed to coma, which correlated with a high signal intensity on T2-weighted magnetic resonance imaging in the brainstem. Hematoma drainage before EBP caused neurologic deterioration in 2 patients. Simultaneous EBP after hematoma drainage achieved sustained improvements in 5 of 6 patients. Simultaneous microsurgical dural repair after hematoma drainage achieved more rapid improvements in 3 of 3 patients. CONCLUSIONS: Among patients with intracranial hypotension caused by a spinal CSF leak, disturbed consciousness may occur in elderly patients because of severe diencephalic-mesencephalic deformities. Simultaneous EBP after safe hematoma drainage is indicated for these patients. Alternatively, dural repair is indicated for patients for whom the spinal level of dural disease has been identified. Hematoma drainage before EBP is not recommended because it caused deterioration.

Cervical Foraminal Epidural Blood Patch for the Targeted Treatment of Refractory Cerebrospinal Fluid Leakage From a Dural Sleeve.

Epidural blood patches (EBPs) are routinely used to treat symptoms (eg, headaches) associated with spontaneous intracranial hypotension. Although cerebrospinal fluid leakage commonly involves the periforaminal areas of the cervical or thoracic spine, EBPs have been historically performed at the lumbar level. Recent evidence suggests that targeting the causative spinal segment may provide greater clinical benefits. While previous reports have targeted foraminal leaks with segmental thoracic or cervical injections, we present a case report detailing the novel use of a navigable epidural catheter to perform a selective EBP at the C7/T1 foramen.

[Idiopathic Intracranial Hypotension].

Idiopathic intracranial hypotension (hypovolemia) is almost exclusively provoked by cerebrospinal fluid (CSF) leakage through spontaneously rent dural sac. An initial clinical feature of a severe headache with or without nausea/vomiting should be differentiated from a life-threatening stroke. An early diagnosis and proper therapy may guarantee a good outcome, while delays may promote complicated manifestations and irreversible poor outcome in a few patients. In this article, neuro-imaging studies of some demonstrable cases are presented and the outlets of the spinal CSF and spinal CSF pathways are shown with immunohistological staining.

Imaging of Cerebrospinal Fluid Leak.

A cerebrospinal fluid leak from the cranial cavity requires presence of a fistulous communication between the subarachnoid and extracranial space through the skull base. Imaging plays a crucial role in identifying and characterizing the skull base defect and evaluating coexisting pathologies that may alter surgical approach. The authors discuss the epidemiology, imaging, and management of cerebrospinal fluid leak, with particular reference to the imaging modalities and findings.

Targeted epidural patch with n-butyl cyanoacrylate (n-BCA) through a single catheter access site for treatment of a cerebral spinal fluid leak causing spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) usually occurs in the setting of a spontaneous cerebral spinal fluid (CSF) leak. We report the first description of a case of SIH caused by a CSF leak which improved after a targeted epidural patch with n-butyl cyanoacrylate (n-BCA) at the right T1-T2 level. An 81-year-old woman presented with an orthostatic headache for 6 days. MRI of the brain with contrast demonstrated low lying cerebellar tonsils, an engorged transverse sinus flow void, bifrontal small subdural fluid collections, and diffuse dural enhancement. CT myelography showed extravasation of intrathecal contrast at the right T1-T2 level. A targeted epidural patch was performed by injection of n-BCA through a catheter at the right T1-T2 level. After treatment, the patient's symptoms immediately improved and she was without a headache at 1-year follow-up.

Avoiding and Managing Intraoperative Complications During Cervical Spine Surgery.

The incidence of intraoperative complications in cervical spine surgery is low. However, when they do occur, such complications have the potential for causing considerable morbidity and mortality. Spine surgeons should be familiar with methods of minimizing such complications. Furthermore, if they do occur, surgeons must be prepared to immediately treat each potential complication to reduce any associated morbidity.