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Cerebrospinal Fluid Leak: Repair and Outcomes


Summary of Key Points

  • Cerebrospinal fluid (CSF) fistulas and pseudomeningoceles are rare complications of spinal surgery.

  • CSF fistulas usually develop shortly after surgery, resulting in increased postoperative morbidity, duration of hospitalization, and cost of care.

  • Pseudomeningoceles develop more slowly and may remain asymptomatic.

  • In the absence of CSF wound drainage, magnetic resonance imaging is the imaging study of choice for diagnosis.

  • Beta-2 transferrin level is more accurate than glucose level at identifying CSF.

  • Conservative care includes wound oversewing, epidural blood patch, and closed lumbar subarachnoid drainage.

  • Surgery is indicated with failed conservative treatment or with signs and symptoms of significant radiculopathy or myelopathy.

  • Suture repair of a durotomy may be supplemented with patch grafts, dural substitutes, or dural sealants.

Cerebrospinal fluid (CSF) fistulas and pseudomeningoceles are both relatively rare complications of spinal surgery. These two complications may also occur as a result of needle penetration of the dura following myelography, epidural injections, or insertion of an epidural catheter. When associated with spinal surgery they typically result from either a planned or an inadvertent durotomy during surgery. Although most durotomies heal uneventfully following a primary suture closure, those that do not heal may allow for further CSF leakage that can form either a subcutaneous collection or a fistulous tract with drainage through the healing wound.

The development of a CSF fistula can result in a range of postoperative morbidities. Potential consequences of persistent CSF leakage include meningitis, spinal epidural abscess, intracranial or intraspinal hemorrhage, and headache. Each of these complications may lead to prolonged hospitalization, with a significant increase in the overall cost of care, particularly if additional surgery is required to manage the CSF leak.

The development of a pseudomeningocele is typically a much slower process than the development of a CSF fistula and may initially be asymptomatic. However, if expansion of the pseudomeningocele continues it may cause significant pressure in the epidural space, resulting in a palpable mass associated with persistent back pain, headaches, or leg pain because of nerve root entrapment within the dural defect. A fistula connecting the CSF within the pseudomeningocele to another cavity such as the pleura may also develop over time.

Although most postoperative CSF fistulas and pseudomeningoceles can be managed conservatively, some may require surgical repair. The appropriate management of these two problems depends on the persistence of any CSF leakage, as well as the presence of any associated symptoms.

Incidence

The incidence of CSF fistula is relatively low. A majority of dural tears heal spontaneously following primary repair, and only a small percentage of patients develop persistent CSF leakage and associated symptoms. In a multicenter study of 108,463 spinal surgeries, the incidence of dural tears during the course of bone removal or during dural sac or root retraction was noted to be 1.6%. The incidence was higher for surgery in the lumbar and thoracic regions (2.1 and 2.2%, respectively) than it was in the cervical region (1.0%). Revision surgery and age greater than 80 years were factors contributing to a higher incidence of durotomies. The study also noted a significant association between unintended durotomy and the development of a new neurological deficit ( P < .001).

McMahon et al. reported on a series of 3000 elective spinal surgeries at an academic center and noted the rate of incidental durotomies to be 3.5% in these patients. The incidence was higher (6.5%) for revision cases. Thoracolumbar cases had a higher rate (5.1%) compared with cervical cases (1.3%). When physician training was examined, residents were responsible for 49% of all durotomies. Spine fellows accounted for 26%, and attending surgeons accounted for 25% of the durotomies.

An elevated incidence of durotomies has also been reported following radiation therapy to the surgical site and in patients undergoing surgery for synovial cysts, higher grade spondylolisthesis, ossification of the longitudinal ligament (OPLL) in the cervical spine, and lumbar disc herniation through a minimally invasive tubular retractor approach.

The incidence of pseudomeningoceles is more difficult to determine because most cases are asymptomatic. Although the majority of pseudomeningoceles are found in the lumbar region they can also occur in the thoracic and cervical spine, particularly following anterior cervical surgery for OPLL. Swanson et al. reported a 0.07% incidence of pseudomeningocele in a review of 1700 exploratory laminectomies. Schumacher et al. reported the incidence of pseudomeningoceles to be less than 0.1% in 3000 patients who had undergone a lumbar discectomy. Teplick et al. reported a 2% incidence of pseudomeningocele in a series of 400 symptomatic postlaminectomy patients examined with computed tomography (CT). None of these patients required reoperation.

The incidence of pseudomeningocele is higher in patients who have previously received radiation therapy or for those patients with intradural lesions requiring an intentional durotomy. Zide et al. reported a higher incidence of pseudomeningocele in patients who underwent surgery for intramedullary spinal cord neoplasms following radiation therapy and in patients who had surgery for tethered spinal cord. ,

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