Managing Cerebrospinal Fluid (CSF) Leak after Lumbar Spinal Fusion: When Conservative Treatment is not the Answer?

INTRODUCTION: CSF leaks are a known complication of lumbar fusion surgery. There is a scarcity of literature describing the management of this complication. The aim of this study was to identify patients who are at risk of requiring further intervention for managing CSF leaks. METHODS: The Nationwide Inpatient Sample (NIS) database was used to identify patients who had lumbar fusion in the United States from 2002 to 2014. Inpatient outcomes including the incidence and risk factors for requiring an intervention were calculated. Secondary outcomes including average length of stay (LOS), mean cost, and mortality rates were calculated. All statistical analyses were conducted based on multivariate regression models using the SPSS software. RESULTS: A total of 11,636 patients with post-operative CSF leak after elective lumbar fusion were identified in the NIS database from 2002 to 2014. Of these patients, 79.9% (9,294/11,636) required an advanced intervention including epidural blood patch, simple repair, or operative management. There was an increase of 13% per year in the use of an intervention in managing CSF leaks. After controlling for several confounding factors, independent risk factors for requiring an intervention included: older age (OR: 1.01; 95% CI: 1.005-1.013; p<0.0001), lateral approach (OR: 1.52; 95% CI: 1.26-1.81; p<0.0001) and posterior approach (OR: 1.60; 95% CI: 1.34-1.91; p<0.0001) compared to anterior approach. Nonsurgical treatment was associated with increased length of stay (5.93±4.61 vs. 5.25±3.63;p<0.0001) with similar hospitalization costs (119,537.2±89,045.6 vs. 120,277.9±87,894.1; p=0.72) and mortality (0.3% vs. 0.3%; p>0.05). CONCLUSION: Spine surgeons should be aware of certain patient and procedure-specific characteristics that increase the risk of requiring an intervention for CSF leak management after lumbar fusion to improve patient outcomes.

Assessing The Feasibility of Selective Piezoelectric Osteotomy in Transorbital Approach to The Middle Cranial Fossa: Anatomical and Quantitative Study and Surgical Implications.

OBJECTIVES: To verify the feasibility and to discuss advantages and disadvantages of a piezoelectric orbitotomy (PO) during Superior Eyelid Endoscopic Transorbital Approach (SETOA). METHODS: Five adult specimens underwent exoscopic/endoscopic SETOA to middle cranial fossa. The surgical corridor was created via piezoelectric orbitotomy by performing three selective and safe micrometric bone cuts providing a one-piece trapezoid bone flap which was repositioned and secured at the end of procedure. A 3D scan of the bone flap allowed us to reconstruct a 3D model and calculate its volume. An illustrative case demonstrating the application of this novel technique was also presented. RESULTS: Anatomical-morphometric quantitative analysis showed a mean bony-volume gain of 1,574.26 mm3 by using PO. PO yielded concrete surgical advantages and theoretical benefits in terms of functional and esthetic outcomes. All osteotomies were micrometric clear-cut and precise, resulting in a very thin bony gap; a complete sparing of soft tissues and neurovascular structures in- and around the orbit was observed. Lateral orbital wall reconstruction by replacing the bone flap aims to mitigate the risk of enophthalmos, proptosis, CSF leakage, pseudomeningocele and pulsatile headache, which represent significant challenges in the relevant literature. CONCLUSION: PO may offer a viable, selective, effective, safe alternative to high-speed drilling during SETOA, especially for patients affected by intra-axial pathologies in which a watertight closure is mandatory. This procedure could prevent/decrease the risk of some of the main postoperative complications associated to the standard SETOA, resulting potentially in better functional and esthetic outcome.

Incidental durotomy during tubular microdiscectomy does not preclude same-day discharge.

PURPOSE: One of the major advantages of a minimally invasive microdiscectomy is that when CSF leak occurs, there is minimal anatomic dead space for ongoing leakage following removal of the tubular retractor. However, there are no published reports that address the safety and long-term outcomes of same-day discharge for CSF leak after tubular microdiscectomy. METHODS: This is a retrospective compartive study of 30 patients with incidental durotomy during minimally invasive tubular microdiscectomy occurring between January 1, 2009 to August 31, 2023 at our institution. RESULTS: There were 16 patients (53%) admitted to hospital and 14 (47%) patients discharged home the same day following CSF leak. There were no differences in patient demographics between the two groups at baseline. Twenty-nine out of 30 (97%) of the patients had onlay duraplasty, and one (3%) patient was repaired using sutures through the tubular retractor. None were converted to an open approach. The hospitalized group was kept on bed rest overnight or for 24 h. The discharge group was kept on best rest for 2 h or mobilized immediately after surgery. No patients in either group required readmission or revision surgery for CSF leak. The average length of admission for the hospitalized group was 2.4 ± 4.0 days. CONCLUSION: Patients with CSF leak during minimally invasive tubular microdiscectomy can be safely discharged home the same day.

Traumatic CSF rhinorrhea associated with COVID-19 testing: a case series and systematic review.

BACKGROUND: This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review. METHODS: Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review. RESULTS: Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8%) had no reported predisposing factor in their clinical history. Common defect sites included the cribriform plate (52.9%), sphenoid sinus (29.4%), and ethmoid roof (17.6%). Four patients (11.8%) presented with meningitis. The median time between the traumatic COVID swab and the detection of CSF leak was 4 weeks (IQR 1-9). Patients with meningitis had a median leak duration of 12 weeks (IQR 8-18). The average leak duration was significantly longer in patients with meningitis compared to without meningitis (p = 0.029), with a moderate effect size (r = - 0.68). Most cases (92.9%) managed with endoscopic endonasal surgical repair were successful. CONCLUSIONS: This report clarifies the presentation, risk factors, and management of CSF leaks attributable to diagnostic nasopharynx swabbing procedures in the COVID-19 era. Timely surgical repair is the recommended management option for such leaks.

Bridging the spinal dysraphism spectrum between terminal myelocystocele and spinal cord lipoma: a report of two cases of true terminal lipomyelocystocele with holo-cord syrinx.

Terminal myelocystocele (TMC) is a rare form of spinal dysraphism which arises due to aberration in the secondary neurulation process involving the caudal cell mass. Terminal myelocystocele has been defined by Pang et al. based on essential and non-essential features. One of the non-essential features includes non dysraphic lipomas which do not tether to the neural placode. We are presenting two cases which meets all the essential criteria outlined by Pang et al. for TMC but also show the presence of a lipomatous component tethering to the neural placode, similar to a dysraphic lipoma. Through this article, we want to showcase a subset which represents "true" terminal lipomyelocystocele (TLMC), bridging the spectrum of spinal dysraphism between TMC and lipomyelomeningocele (LMM).

Reuse of Nasoseptal Flaps for Endoscopic Endonasal Skull Base Reconstruction.

Introduction Pedicled nasoseptal flap (NSF) placement is a critical component of skull base reconstruction after endoscopic endonasal approaches (EEAs). The effectiveness of NSF reuse has not been thoroughly studied. Prior reports using flaps harvested at one center and reused at another may have technical variability bias. Methods We identified patients who underwent both their initial and NSF-reused surgeries at Weill Cornell Medical College from 2004 to 2022 using a prospective database of all EEAs. Surgical pathology, intraoperative leak grade, use of cerebrospinal fluid (CSF) diversion and skull base coverage were examined. The primary outcome measure was occurrence of CSF leak. Results Fourteen patients (six women, eight men) underwent 14 first time and 14 revision operations with median age of 36.6 years (interquartile range [IQR]: 23.9-61.3) at the time of the NSF reuse. The median interval between the first NSF use and reuse was 70.6 months (IQR: 16.6-87). Eight patients were operated on for pituitary adenoma. Nonadenomas included three craniopharyngiomas and one case each of epidermoid, ependymoma, and chordoma. There were 16 high-flow, 8 low-flow intraoperative leaks, and 4 with no leak. CSF diversion was used in 24 operations. There were three postoperative leaks, one after a first operation and two after NSF reuse. All postoperative CSF leaks, whether first or second operations, occurred in cases with both high-flow intraoperative CSF leak and incomplete NSF coverage ( p = 0.006). Conclusion NSF reuse is effective at preventing postoperative CSF leak. The primary predictors of leak are high-flow intraoperative leak and inadequate defect coverage with NSF, regardless of the operation number.

Anatomical-Radiological Aspects and Their Influence on the Results of Pituitary Adenomas Endoscopic Endonasal Surgery.

Introduction Endoscopic endonasal surgery has globally improved postoperative results in pituitary adenomas. Material and Methods We retrospectively analyzed 101 patients who underwent endonasal endoscopic surgery for pituitary adenomas in the period from 2016 to 2021. Data on epidemiological variables, preoperative radiological factors including tumor volume, tumor appearance, cavernous sinus invasion (modified Knosp scale), degree of extension according to the SIPAP (stands for the five directions in which a pituitary adenoma can extend: suprasellar, infrasellar, parasellar, anterior, and posterior) classification, and preoperative visualization of the healthy gland on magnetic resonance imaging (MRI) were collected as well as intra- and postoperative cerebrospinal fluid (CSF) leak. As variables of interest, data on the degree of tumoral resection and preservation of hormonal function were collected. Results Among the preoperative factors related to greater tumoral resection, we found a lesser tumoral extension according to the SIPAP scale, and the absence of a postoperative CSF leak had a statistically significant relation with greater hormonal preservation. Conclusion The SIPAP classification is a simple-to-measure preoperative radiological variable that could predict the extent of resection, and, conversely, the occurrence of a postoperative CSF leak has been associated with an inferior endocrinological outcome in this type of surgery.

Assessing the effects of spontaneous intracranial hypotension on quality of life, work ability and disability.

BACKGROUND: Spontaneous intracranial hypotension (SIH), characterized by headaches due to cerebrospinal fluid leaks or low pressure, is a challenging condition to diagnose and treat and affects the quality of life. METHODS: An 8­week online survey was conducted to assess the impact of SIH on symptoms, sociodemographics and quality of life. The cohort was comprised of patients who had a self-reported diagnosis of SIH and were divided into two groups: those with radiological evidence of SIH and those with clinical suspicion but no radiological evidence. Mental health and disability were evaluated using the Depression, Anxiety and Stress Scale-21 (DASS-21) and the Henry Ford Hospital Headache Disability Inventory (HDI). RESULTS: A total of 86 participants were included in the study, 59 with radiological evidence and 27 without. Most participants were female (84.9%) with a mean age of 44.8 years. Orthostatic headache was more common in participants without radiological evidence (74.1% vs. 42.4%). The severity in those with radiological evidence was 27.1% mild, 27.1% moderate, 30.5% severe and 15.3% extremely severe, while those without had 7.4% mild, 18.5% moderate, 63.0% severe and 11.1% extremely severe headaches. Mental health assessment using the DASS-21 scale showed that 77.9% of all participants reported signs of depression, 96.5% reported anxiety and 89.5% reported stress. The HDI showed 2.3% total disability, 40.7% severe, 19.8% moderate and 37.2% mild. The impact on employment was significant: 15.1% were able to work full-time, 48.8% part-time, 30.2% were unable to work and 5.8% retired early due to SIH. CONCLUSION: The study demonstrates the broad impact of SIH affecting physical health, mental well-being, and socioeconomic status, and calls for multifaceted and robust management approaches to address its complex effects on patients.

Use of Subfascial Passive Bile Bag Drainage for the Management of Durotomies in Spine Surgery.

INTRODUCTION: Historically, the use of subfascial drains for the management of durotomies was avoided due to concerns about the creation of cerebrospinal fluid (CSF) fistulas. Currently, there are limited series utilizing subfascial drainage for CSF leak management, many of which utilize suction drainage. We report our experience with the use of subfascial passive drainage in the management of such leaks. OBJECTIVE: To demonstrate the efficacy of a passive subfascial bile bag for diversion of CSF post-operatively in concert with a post-operative head of bed (HOB) protocol for the management of durotomies in spine surgery. METHODS: We performed a retrospective chart review of patients who underwent spinal surgery at a single institution performed by one surgeon. Cases utilizing a passive subfascial bile bag for durotomies were identified. A total of 1,882 consecutive surgeries were reviewed, and 108 met the inclusion criteria. The primary outcome was return to the operating room (OR) and/or the need for lumbar drain placement. Patient sociodemographic information and pre-, intra-, and post-operative clinical characteristics were reviewed. RESULTS: A total of 108 patients underwent subfascial bile bag CSF diversion after intra-operative durotomy. Four patients (3.7%) experienced post-operative CSF leakage requiring lumbar drain placement, while only two (1.9%) patients required a return to the OR. One patient returned to the OR for symptomatic pseudomeningocele and the other for ongoing CSF drainage from their wound. CONCLUSION:  Durotomies are known to increase complication rates, including reoperation. The use of subfascial passive bile bag drainage in concert with a post-operative HOB protocol is a safe and effective manner to manage durotomies while minimizing the need for reoperation.

Transvenous embolization of cerebrospinal fluid-venous fistulas: A comprehensive technical video guide.

Cerebrospinal fluid (CSF)-venous fistulas necessitate a comprehensive understanding of spinal venous anatomy for successful embolization.1 This video details the essential technical and anatomical nuances of CSF-venous fistula embolization at various spinal levels, including the cervical, thoracic, and lumbar spine. Precise microcatheter navigation, guided by a detailed understanding of spinal venous anatomy, is crucial for reaching the fistula site and successful treatment. Embolization typically focuses on the foraminal vein, paraspinal vein, and lateral epidural plexus, aiming to create a comprehensive liquid embolic plug.2 As experience with this procedure grows, continued refinement of techniques and exploration of optimal access routes will further enhance success rates.

Long term results with medpor® reconstruction of the anterior skull base at a single institute.

OBJECTIVES: To evaluate a technique of multi-layered CSF repair following endonasal anterior skull base surgery using medpor graft. DESIGN: Retrospective review of consecutive case series from a single centre. SUBJECTS: 68 cases of repair of CSF leaks utilising medpor identified from a larger prospectively maintained database of endonasal endoscopic procedures at our centre. METHODS: Retrospective review of a database of consecutive anterior skull base cases from 2016-2022, and further data collection from electronic hospital records. RESULTS: During follow up there were 7 cases of post-op CSF leak (10.3%). There were no radiological complications, and no cases of medpor removal or extrusion. Rates of infection were low, there were 3 (4.4%) cases of confirmed bacterial meningitis within our cohort. The mean length of stay was 4.7 days (median 3 days), with 16 cases discharged on the first post-operative day. CONCLUSIONS: Our experience of using medpor in anterior skull base reconstruction demonstrates that medpor is a readily available, easily handled, and reliable graft option with relatively low rates of infection and post-op CSF leak. Its use reduces the use of autologous graft materials and the associated donor site morbidity. Our long term follow up data further demonstrates the safety and efficacy of this technique.

Deep learning to predict risk of lateral skull base cerebrospinal fluid leak or encephalocele.

PURPOSE: Skull base features, including increased foramen ovale (FO) cross-sectional area, are associated with lateral skull base spontaneous cerebrospinal fluid (sCSF) leak and encephalocele. Manual measurement requires skill in interpreting imaging studies and is time consuming. The goal of this study was to develop a fully automated deep learning method for FO segmentation and to determine the predictive value in identifying patients with sCSF leak or encephalocele. METHODS: A retrospective cohort study at a tertiary care academic hospital of 34 adults with lateral skull base sCSF leak or encephalocele were compared with 815 control patients from 2013-2021. A convolutional neural network (CNN) was constructed for image segmentation of axial computed tomography (CT) studies. Predicted FO segmentations were compared to manual segmentations, and receiver operating characteristic (ROC) curves were constructed. RESULTS: 295 CTs were used for training and validation of the CNN. A separate dataset of 554 control CTs was matched 5:1 on age and sex with the sCSF leak/encephalocele group. The mean Dice score was 0.81. The sCSF leak/encephalocele group had greater mean (SD) FO cross-sectional area compared to the control group, 29.0 (7.7) mm2 versus 24.3 (7.6) mm2 (P = .002, 95% confidence interval 0.02-0.08). The area under the ROC curve was 0.69. CONCLUSION: CNNs can be used to segment the cross-sectional area of the FO accurately and efficiently. Used together with other predictors, this method could be used as part of a clinical tool to predict the risk of sCSF leak or encephalocele.

Management of Recurrent Cerebrospinal Fluid Rhinorrhea Caused by Sequential, Anatomically Separated Skull Base Defects-A Case-Based Systematic Review.

OBJECTIVE: Recurrent cerebrospinal fluid (CSF) rhinorrhea caused by sequential, anatomically separated skull base defects is rarely reported in the literature. Neither management nor etiology has been sufficiently investigated. We present an illustrative case and a systematic review of the literature regarding etiology, diagnostics, and management of this rare phenomenon. METHODS: A systematic literature search looking for articles reporting sequential CSF leaks with multiple skull base defects was performed. Data from included articles were descriptively reported, and the quality of the included studies was assessed with Grading of Recommendations Assessment, Development and Evaluation. RESULTS: A 71-year-old woman with posttraumatic CSF rhinorrhea and left-sided CSF otorrhea due to a left-sided horizontal fracture of the petrous bone presented at our institution. After initial surgical repair and a 10-week symptom-free interval, CSF rhinorrhea recurred. Imaging revealed a preexisting contralateral meningoencephalocele of the lateral sphenoid recess causing recurrent CSF rhinorrhea most likely after initial traumatic laceration. The defect was successfully treated. A literature search identified 366 reports, 6 of which were included in the systematic review with a total of 10 cases. Quality was deemed good in 8 of 10 cases. The most common location for primary and sequential CSF leaks was along the sphenoid bone (4/10 and 5/10 patients, respectively). All publications except one reported the presence of a meningo (encephalo)cele as cause of the sequential CSF leak. CONCLUSIONS: Occurrence of recurrent CSF rhinorrhea due to an anatomically separated sequential skull base lesion remains a rare phenomenon. Reassessment of imaging studies and a structured diagnostic workup to detect sequential CSF leaks independent of the primary lesion should is recommended.

Graftless Primary Dural Closure Following Retrosigmoid Approach: Doing More With less.

INTRODUCTION: Achieving watertight dural closure without grafts via the retrosigmoid approach can be challenging, contributing to a significant rate of postoperative cerebrospinal fluid (CSF) leaks. This study describes a dural incision technique for achieving primary dural closure without grafts following the retrosigmoid approach and presents clinical data from the authors' experience. METHODS: Clinical and surgical data of 227 patients who underwent the dural incision technique following the retrosigmoid approach for various pathologies were retrospectively reviewed. To achieve no-graft watertight dural closure, the dural incision involves 2 critical steps: a 1 cm transverse incision of the dura parallel to the foramen magnum to drain CSF from the cisterna magna, and a vertical linear opening of the retrosigmoid dura. Dural incisions were closed watertight with vicryl 4/0 running sutures, without the use of grafts, fibrin glue, hemostatic overlays, or dural substitutes. Pre- or postoperative lumbar drainage was not employed. RESULTS: Primary watertight dural closure was successfully achieved in all patients without the use of grafts or duraplasty. The average duration of dura closure was 17.7 minutes. During an average follow-up period of 49.3 months, there were no instances of CSF leaks or meningitis. CONCLUSIONS: In the authors' preliminary experience, the linear dural incision described herein was effective for achieving a no-graft, watertight primary dural closure in the retrosigmoid approach, with no CSF leaks or meningitis in our series. Validation of these preliminary data in a larger patient cohort is necessary.

Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases.

BACKGROUND: Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS: From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. RESULTS: Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). CONCLUSIONS: Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.

An algorithm for the surgical approach to spontaneous temporal bone CSF leak.

OBJECTIVE: To suggest a comprehensive algorithm for the surgical approach for correcting of sources of temporal bone CSF leaks. METHODS: A case series for patients operated in a single academic tertiary referral center between 2011 and 4.2022. Included in the study were 46 patients, 5 of whom had a bilateral problem, resulting in 51 pathologic temporal bones. The presentation was an active CSF leak (38 patients) or bacterial otogenic meningitis (8 patients). Follow up ranged from 8 months to 5 years. RESULTS: Of the 42 ears operated via the default middle fossa approach, 37 were successful (88 %) in controlling CSF leak. None had intracranial complications or sensorineural hearing loss. Location, number and size of the defects, hearing status, associated superior semicircular canal dehiscence, additional intra-temporal or intra-cranial pathologies may indicate a transmastoid approach. Of the six ears that had a canal wall up mastoidectomy as a primary procedure, one required revision due to ongoing CSF leak. Five revision cases and three primary cases were effectively sealed with a subtotal petrosectomy and obliteration. One was lost to follow-up. Hearing was reconstructed with bone-anchored hearing implants in 6 out of these 8 ears. CONCLUSIONS: The middle fossa approach could be used as a default approach for sealing TD. There are a number of indications for transmastoid approaches in both primary and revision cases. Obliteration of the ear was used in all revision cases. The suggested algorithm can help in planning surgery for temporal bone CSF leaks or a history of otogenic meningitis.

Management of Cerebrospinal Fluid Leak After Intrathecal Baclofen Pump Procedures in Adolescents With Cerebral Palsy: A Retrospective Study.

STUDY OBJECTIVE:  Epidural blood patches (EBPs) are frequently performed in children with cerebral palsy (CP) to manage post-dural puncture headache (PDPH) due to cerebrospinal fluid (CSF) leak after intrathecal baclofen pump (ITBP) placement or replacement procedures. The purpose of our study was to review the incidence and management of CSF leak following ITBP placement or replacement procedures in children with CP. The study was a retrospective review of 245 patients representing 310 surgical cases of baclofen pump insertion (n=141) or reinsertion (n=169) conducted at a 125-bed children's hospital with prominent specialty orthopedics surgical cases. MEASUREMENTS:  Demographic and clinical information was obtained from the anesthesia pain service database on all new ITBP placement and subsequent replacements over an eight-year period. MAIN RESULTS:  The overall incidence of CSF leak in our population was 16% (50 of 310) and 18% (25 of 141) with a new ITBP placement. Children with diplegia were associated with a threefold risk of developing CSF leak. Of patients who developed CSF leak (n=50), 68% (n=34) were successfully treated conservatively, while 32% (n=16) required EBPs. EBPs were successful in 87.5% (14 of 16) of patients at relieving PDPH on the first attempt.  Conclusions: CSF leak is a known problem after ITBP placement and replacement. Most patients were successfully treated with conservative management and EBPs were successful in patients failing conservative therapy. Diagnosing PDPH in non-verbal patients can be challenging.

Innovations in the Treatment of Spinal Cerebrospinal Fluid Leaks.

Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.

Suturing and Closure of Diaphragma Sella to Augment Sellar Floor Repair after Endonasal Endoscopic Resection of Large Pituitary Adenoma.

Background Large pituitary adenoma often pushes the diaphragma sella and extends to the suprasellar compartment. The thinned out diaphragma may get opened during endonasal endoscopic surgery and pose high risk for cerebrospinal fluid (CSF) leak. Such larger defects are difficult to plug with fat graft that tends to slip in to the subarachnoid space. Here, we describe a unique technique of closure of diaphragma sella that augment repair of the skull base in such cases. Materials and Method The free edge of diaphragma sella was sutured with the anterior tuberculum sella dura in five cases of large pituitary adenoma that needed extra arachnoidal resection. Suturing was done with 6-0 prolene using endoscopic needle holder that converted a large diaphragm defect in to a smaller arachnoid rent and was easily plugged with fat graft. Result None of these patients had postoperative CSF leak. Conclusion Though technically difficult, direct repair of the diaphragma sella is possible. This augments the skull base reconstruct and effectively reduces the chances of postoperative CSF leak.

The Impact of Preoperative Spinal Injection Timing on the Postoperative Complications of Lumbar Fusion.

OBJECTIVE: To determine the impact of epidural spinal injections (ESIs) on postoperative surgical complications. METHODS: This retrospective all-payer database analysis identified 202,181 adult patients undergoing one- to three-level transforaminal lumbar interbody fusion (TLIF) from 2010 to 2020. A 1:1 exact matching on comorbidities and demographics was performed, creating 2 cohorts: 1) patients who received an ESI within 90 days of surgery and 2) patients who did not receive an ESI. The primary outcome was surgical complication rates between groups at 30 days postoperatively. For the secondary outcome, patients were stratified based on injection time before surgery: 1-30, 31-45, 46-60, 61-75, and 76-90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. The P value was set to 0.05 for the primary analysis, and the Bonferroni correction was utilized for the secondary outcome. RESULTS: Exact matching produced 12,491 pairs for analysis. Groups were well-matched on demographics, comorbidities, and fusion levels. The 30-day postoperative rates of surgical complications, hematomas, wound disruptions, or surgical site infections did not differ between groups (P > 0.05). The rate of cerebrospinal fluid (CSF) leak was increased in the ESI group (0.19% vs. 0.09%, P = 0.042). When temporally stratified, patients receiving an ESI within 30 days had significantly higher odds of CSF leak (odds ratio: 4.24, 95% confidence interval: 1.97-9.14). CONCLUSIONS: Patients who receive an ESI within 30 days of transforaminal lumbar interbody fusion are at an increased risk for CSF leak. While the incidence of CSF leak remains small, it may be advisable to avoid ESIs at least 30 days before surgery for certain patients.