Spinal CSF leak

management
intra and post
operative
Mohamed Elassy
Neurosurgery resident
Faculty of medicine
Port-said university
Unintended durotomy

• Unintentional opening of the dura during spinal surgery has an

incidence of 0–14%.
• Terminology: The terms “unintended durotomy,” “incidental
durotomy,” or even just “dural opening,” have been recommended in
preference to “dural tear” which may imply carelessness when none
was present.
• Dural openings have been associated with one or more alleged
complications or sequelae in medical malpractice suits involving
surgery on the lumbar spine.
The injury:
• dural opening is often a standard part of the operation for intradural
disc herniation, tumors, etc. Although not frequent (for incidence, see
above)
• it may result from an event or events that produce more serious
injuries.
• There were no long-term differences in nerve root injuries, mortality,
additional operations, or outcome measures. Short-term differences
included longer inpatient stay, increased blood loss, and duration of
surgery.
Etiologies:
• unanticipated anatomic variations
• adhesion of the dura to removed bone
• slippage of an instrument
• an obscured fold of dura caught in a rongeur or curette
• thinning of the dura in cases of longstanding stenosis
• and the possibility of a delayed CSF leak caused by perforation of the
dura when it expands onto a surgically created spicule of bone.
• The risk may be increased with anterior decompression for OPLL, with
revision surgery, and with the use of high-speed drills.
Possible sequelae of dural opening
Well documented
• 1. CSF leak , may produce “spinal headache”
a) contained: pseudomeningocele
b) external: CSF fistula
• 2. herniation of nerve roots through opening
• 3. associated nerve root contusion, laceration, or injury to the cauda equina
• 4. CSF leak collapses the thecal sac and may increase blood loss from epidural bleeding
Less well documented
• 1. arachnoiditis
• 2. chronic pain
• 3. bladder, bowel, and/or sexual dysfunction
• 4.meningitis.
• 5.Pain or sensory/motor deficits may be associated with injuries to nerve roots or delayed
• 6.herniation of nerve roots through the dural opening.
Investigations to detect defect and
leak :
• Standard MRI, even with a heavily T2-weighted image,
is often not sensitive enough to detect an episodic leak.
• CT myelography is more commonly needed to identify
a site of contrast extravasation, and it may require a
timed or dynamic study.
• Volume infusion to increase pressure may increase the
diagnostic yield.
• Digital subtraction myelography is increasingly used,
particularly in cases of CSF-venous fistula.
Intraoperative dyes
• This section covers visible dyes that may be useful in the O.R. For radio-
opaque dyes.
• the intrathecal (IT) use of the following agents:
• Indigo carmine: a blue dye which has been used intrathecally
• Methylene blue: is probably cytotoxic and appears to become fixed to
neural tissue. It should therefore not be used as a stain in neurosurgical
operations or diagnostic tests. CNS damage (some permanent) occurred
in 14 patients given an IT injection of a 1% solution. Symptoms included:
paraparesis, quadriplegia, multiple cranial nerve involvement (including
anosmia and optic atrophy), dementia, and hydrocephalus.
• Fluorescein: although intrathecal injection (e.g., to look for CSF leak)
has been used by ENT surgeons with apparently acceptable results,
there is a risk of seizures. 2.5% fluorescein is diluted 1:10 with CSF or
saline and ≈ 6 ml is injected into the spinal subarachnoid space (or 0.5
ml of 5% fluorescein mixed with 5–10 ml of CSF3).
• Fluorescein has also been used IV (adult dose: 1 amp IV) to help mark
areas of the brain where there is breakdown of the blood-brain
barrier (BBB), e.g., in tumors
• Indigocyanine green (ICG): used for intraoperative angiography .
Treatment:
• If the opening is recognized at the time of surgery, watertight primary closure
(with or without patch graft) should be attempted with nonabsorbable suture if
at all possible to prevent pseudomeningocele and/or CSF fistula. watertight
closure , A tight, multilayer closure is critical to prevent local CSF collections from
leaking outward to the skin.
• A cottonoid placed over the opening prevents aspiration of nerve roots.
• Care must be taken to avoid incorporating a nerve root into the closure.
• When the opening is in the far (anterior) side of the dura, consideration may be
given to intradural repair accessed through a posterior durotomy which is
subsequently closed (this may risk additional injury to the nerve roots).
• Biocompatible fixatives (e.g., fibrin glue) may be used to supplement primary
closure.
Primary repair may be impossible in some situations (e.g., when the opening
cannot be found or accessed, as is sometimes the case when it occurs on the nerve
root sleeve) and alternatives here include
• placement of a fat or muscle graft, fascia, fat over the suspected leak site
• use of the patient’s own blood for a “blood patch” (one technique is to have the
anesthesiologist draw ≈ 5–10 ml of the patient’s blood from an arm vein, keeping
it in the syringe for several minutes until it starts to coagulate, and then to have
the anesthesiologist inject the blood onto the dura)
• use of gelfoam, fibrin glue
• Alloderm and duragen
• Some recommend that the wound not be drained post-op, Others use a
subcutaneous drain or epidural catheter.
• CSF diversionary procedures (e.g., through a drain inserted 1 or more levels
away) may also be used.
• Although bed rest × 4–7 days is often advocated to reduce symptoms
and facilitate healing , normal post-op mobilization is not associated
with a high failure rate (bed rest is recommended if symptoms
develop).
• In one report of 8 patients with leaks that appeared post-op,
reoperation was avoided when treated by resuturing the skin under
local anesthesia, followed by bed rest in slight Trendelenburg position
(to reduce pressure on the leakage site),
• broad-spectrum antibiotics and antibiotic ointment over the skin
incision
• and daily puncture and drainage of the subcutaneous collection.
Lumbar catheter CSF drainage
• General information Insertion of a catheter into the lumbar subarachnoid space for
the purpose of draining CSF. Usually connected to a closed drainage system similar to
that for an EVD.
• Generally used for periods of only a few days or so.
• Indications
1. to reduce CSF pressure at a site of CSF leak/fistula. Examples: a) dural breach during
spine surgery or craniotomy (especially posterior fossa) b) for spontaneous CSF
fistula (rare)
2. 2. to reduce intracranial pressure in cases of communicating hydrocephalus: e.g.,
drain test for NPH, or when an infected shunt has been removed
3. 3. to reduce CSF pressure to attempt to increase perfusion of the spinal cord: e.g.,
during surgery for abdominal aortic aneurysm, or following spinal cord injury
Fibrin glue
• One treatment element that seems to be accepted
almost uniformly as being beneficial is the use of fibrin
glue sealants.
• The sealant can be prepared autologously in the
operating room, from cryoprecipitate obtained from the
blood bank, or from commercial kits made from donated
blood products.
• Regardless of the cause, fibrin glue sealants, when
applied in the area of the dural repair, dramatically
increase the rate of healing.
Thank you