Abstract

Background: Our review of 12 articles for this perspective showed the frequency of intraoperative thoracic and/or lumbar CSF fistulas/dural tears (DT) ranged from 2.6% - 8% for primary surgical procedures. Delayed postoperative CSF leak/DT were also diagnosed in 0.83% (17/2052 patients) to 14.3% (2/14 patients) of patients undergoing thoracic and/or lumbar procedures. Further, the rate of recurrent postoperative CSF leaks/DT varied from 13.3% (2/15 patients) to 33.3% (4/12 patients).

Methods: Intraoperative, postoperative delayed, and recurrent postoperative traumatic postsurgical thorac CSF leaks/DT can be limited by performing initially sufficient operative decompressions and/or decompressions/fusions (i.e., utilizing adequate open exposures vs. inadequate minimally invasive (MI) approaches). The incidence of CSF leaks/DT can be further reduced by spine surgeons’ utilization of operating microscopes, and their avoiding routine attempts at total synovial cyst excision and/or complete resection of hypertrophied/ossified yellow ligament in the presence of significant dural adhesions.

Results: Multiple CSF leak/CT repair techniques included; using interrupted, non-resorbable sutures for direct dural repairs (i.e. 7-0 Gore-Tex sutures where the suture is larger than the needle thus plugging needle holes), and adding where needed muscle patch grafts, microfibrillar collagen, the rotation of Multifidus muscle pedicle flaps, fibrin sealants (FS)/fibrin glues (FG), lumbar drains (LD), and/or lumbo-peritoneal (LP) shunts.

Conclusion: Intraoperative, postopertive delayed, and/or recurrent postoperative thorac and/or lumbar traumatic surgical CSF leaks can be reduced by choosing to initially perform the appropriately extensive open operative decompressions and/or decompresssions/fusions. It is critical to use an operating microscope, non-resorbable interrupted sutures, and where necessary, muscle patch grafts, microfibrillar collagen, the rotation of Multifidus Muscle Pedicle Flaps, FS/FG, LD, and/or LP shunts.

Keywords: 7-0 Gore-Tex sutures, Cerebrospinal fluid (CSF) leaks, Direct suture, Dural tears (DT), Microscope, Fibrin glue (FG), Fibrin Sealant (FS), Immediate intraoperative repairs, Delayed repairs, Lumbar and/or thoracic surgery, Lumbar drains (LD), Lumbo-peritoneal shunts (LP), Microfibrillar collagen, Muscle patch graft, Multifidus muscle pedicle flap, Postoperative recurrent DT, Surgical trauma

INTRODUCTION

Intraoperative, postoperative delayed, and recurrent postoperative traumatic surgical thoracic (T) and/or lumbar (L) CSF leaks can be reduced by performing initially sufficient open operative decompressions and/or decompressions/fusions (i.e., adequate original open exposures vs. inadequate minimally invasvie (MI) approaches) in appropriately selected patients. The literature showed that the incidence of CSF leaks/DT was further limited by utilizing an operating microscope, and restricting attempts at gross total resection of synovial cysts and/or ossification of the yellow ligament (OYL) in the presence of dense dural adhesions [ Table 1 ].[ 3 - 5 , 12 ] Traumatic T/L CSF fistulas occurred in 2.6-8% of primary procedures, but were also found on a delayed basis after the initial surgery in 0.83% (17/2052 patients) to 14.3% (2/14 patients) of cases. Additionally, recurrent postoperative CSF leaks were observed in from 13.3% (2/15 patients) to 33.3% (4/12 patients) of cases [ Table 1 ].[ 1 , 2 - 8 , 10 , 12 ] Adequate direct repair of CSF leaks/DT required utilization of interrupted nonresorbable sutures (i.e., typically 7-0 Gore-Tex sutures where the sutures are larger than the needles, thus plugging needle holes). If indicated, additional repair ajuncts included; muscle/dural patch grafts, microfibrillar collagen (non-suturable and suturable), rotation of pedicled Multifidus muscle flaps, fibrin sealant (FS)/fibrin glue (FG), lumbar drains (LD), and/or lumbo-peritoneal (LP) shunts [ Table 1 ].[ 1 - 8 , 10 - 12 ]

Table 1:

Treatment of cerebrospinal fluid leaks in the lumbar spine.

Incidence of CSF Leaks/DT with Thoracic and/or Lumbar Surgery

Incidence of CSF Intraoperative, Delayed Postoperative, and Recurrent Postoperative Traumatic CSF Leaks/DT After Thoracic and/or Lumbar Spine Surgery

Multiple studies documented 2.6-8% frequencies of intraoperative, delayed postoperative, and recurrent postoperative CSF leaks/DT occurring following traumatic thoracic and/or lumbar surgery [ Table 1 ].[ 2 - 4 , 6 , 10 , 12 ] Epstein (2014) observed a 7.14% risk of intraoperative CSF leaks/DT for 336 patients undergoing average 4.7 level lumbar laminecotmies and average 1.4 level non-instrumented fusions. After removing 7 DT due to preopertive epidural steroids injections, and 3 intradural tumor resections from the series, the residual incidence of traumatic CSF leaks/DT was just 4.2% (i.e., due to 6 synovial cysts, 5 ossification of the yellow ligament, and 3 prior operative resection of scar).[ 3 ] From Cureus 2019, Brazdzionis et al. found a 4.4% incidence of CSF leaks/DT occurring in 21 of 384 patients undergoing thoracic and/or lumbar procedures; for both the 9 undergoing direct repair supplemented with adjuncts, and the 12 treated solely with fibrin sealant (FS)/fibrin glue (FG), none developed recurrent postoperative CSF leaks/DT.[ 2 ] Hanna et al. (2022) found just a 2.6% incidence of CSF leaks occurring following 439,220 NIS (Nationwide Inpatient Sample Database) lumbar fusions (2002-2014).[ 6 ] Schmidt et al. (2022) noted that 8% (14 patients) of 176 patients with lumbar synovial cysts developed 12 intraoperative (i.e., all with significant intraoperative dural adhesions), and 2 delayed postoperative CSF leaks (i.e., not recognized at the original surgery); notably, the 12 intraoperative DT were directly repaired, but 33.3% recurred (4/12) postoperatively.[ 12 ] Melcher et al. (2022) documented a 7.5% incidence of intraoperative CSF leaks/DT following 338 lumbar decompressions vs. 100 decompressions/fusions.[ 10 ] Interestingly, CSE leaks/DT comprised 33 of 35 postoperative adverse events (AE). Additional early postoperative AE included; infections, new neurological deficits, and hematomas. Further, 49 of 53 patients developing late AE (> 3 weeks postoperatively) required additional surgery; 28 same level procedures, 10 same plus another level of surgery, and 10 same level plus adjacent level operations.

Incidence and Treatment of Delayed vs. Postoperative Recurrent CSF Leaks/DT After Initial Lumbar Surgery

In two series, the incidence of delayed recognition of CSF leaks/DT following original lumbar procedures ranged from 0.83-14.3%, while the incidence of recurrent postoperative fistulas varied from 13.3-33.3% [ Table 1 ].[ 8 , 12 ] Khazim et al. (2015) in 2052 lumbar cases found a 0.83% (17 patients) incidence of delayed CSF fistulas/DT; 15 were treated with direct DT closure, one received a subarachnoid drain, while another was treated non-operatively.[ 8 ] Further, 2 (13.3%) of the 15 undergoing delayed direct operative repair required secondary surgery to address recurrent CSF fistulas. For Schmidt et al. (2022), the frequency of original postoperative lumbar traumatic CSF leaks/DT attributed to synovial/facet joint cysts was 8% (14/176 patients); 12 (85.7%) of patients were diagnosed and treated during the index surgery, while 2 (14.3%) were recognized/managed in a delayed fashion.[ 12 ] Notably, 12 of the original 14 patients underwent primary CSF leak/DT repairs, and 4 (33.3%) developed recurrent postoperative fistulas.

Risk Factors, Morbidity, and Mortality Associated with Intraoperative CSF Leaks/DT

In 2022, Hanna et al. identified the following risk factors associated with the CSF leaks/DT encountered in 2.6% (11,636 cases) of 439,220 NIS lumbar fusions [ Table 1 ].[ 6 ] These risk factors included; older age, posterior surgery, anemia, obesity, pulmonary or coronary disease that contributed to longer lengths of hospital stay (LOS), higher in-hospital costs, and increased mortality rates [ Table 1 ].[ 6 ]

Techniques for Direct and Indirect Repair of Traumatic Thoracic and/or Lumbar CSF Leaks/DT

Direct Suture Repair with/without Adjuncts vs. Indirect Repair with FS/FG for Traumatic Surgical Thoracic and/or Lumbar CSF Leaks/DT

Out of 21,384 thoracolumbar procedures, Brazdzionis et al. (2019) encountered 21 (0.1%) CSF leaks/DT [ Table 1 ].[ 2 ] Of these, 9 underwent direct sutured repairs with/without adjuncts vs. 12 who had indirect repairs performed with FS/FG. Interestingly, no patients developed a recurrent postoperative CSF leak/DT, and both groups showed comparable infection rates (i.e. 2/9 direct repair vs. 2/12 FS/FG). The only difference between the two groups was the shorter 4 days average length of stay (LOS) for the direct repair vs. the longer 6 day LOS for the indirect repair group.

Direct Mini/Micro Bone Suture-Anchor Repairs of Complex CSF Leaks/DT

Agulnick et al. advocated treating complex CSF leaks/DT where there was no lateral dura to sew to, utilizing a mini/micro bone suture anchor repair technique (2020) [ Table 1 ].[ 1 ] By placing screws into the bony perimeter around a complex CSF leak/DT (i.e., without available dural remnants to sew to), these suture-anchors facilitated direct dural repair. This included potentially attaining a water-tight closure by placing fascia, periosteum, muscle grafts, microfibrillar collagen (i.e., on-lay non suturable vs. suturable) followed by FS/FG.

Pedicle Multifidus Muscle Flap to Treat Inaccessible CSF Leaks/DT after Lumbar Spine Surgery

Policicchio et al. in 2021 advocated using pedicle Multifidus muscle flaps (PMMP) to manage 8 patients (2017-2019) with inaccessible complex CSF leaks/DT following lumbar surgery (i.e., inaccessible defined as could not be treated with typical open direct or adjunctive repair techniques) [ Table 1 ].[ 11 ] Results for these 8 patients were compared to 9 controls (i.e., the latter using standard repair techniques for inaccessible DT). No patients from either group developed postoperative wound or flap-related adverse events; regarding outcomes, 3 of 8 were clinically improved, and 5 were unchanged. The authors concluded that the PMMP only added an average of 20 minutes to the operative procedures, and proved safe and effective in treating complex CSF leaks/DT.

Utility of Fibrin Sealant (FS) and/or Fibrin Glues (FG) for Hemostasis in Addition to Treating CSF Leaks/DT After Lumbar Surgery

Epstein (2014) used FS/FG to treat not only postoperative lumbar CSF leaks/DT, but also to facilitate hemostasis [ Table 1 ].[ 3 ] FS/FG decreased perioperative blood loss, transfusion requirements, and volume as well as duraton of wound driainage. Additionally, FS/FG limited postoperative scar formation, postoperative infections, strengthened CSF leak/DT repairs and shortened the length of stay (LOS).

Use of a Lumbo-Peritoneal Shunt for Recurrent Postoperative CSF Leaks

Johansen et al. (2023) discussed the management of recurrent/refractory postoperative lumbar CSF leaks/DT utilizing lumboperitoneal (LP) (i.e. subarachonid) shunts [ Table 1 ].[ 7 ] LP shunts were typically utilized only following multiple failed attempts at routine and/or augmented direct CSF leak/DT repairs.[ 7 ]

20% Overall Failure Rates for Treating Postoperative CSF Leaks/DT with Epidural Blood Patches (EBP)

In 2023, Epstein et al. discussed the high overall 20% failure rate for treating postoperative lumbar CSF leaks/DT with epidural blood patches [ Table 1 ].[ 5 ] This perspective, reviewing 3 studies utilizing mostly targeted EBP, documented the following failure rates; 0% (0.6 cases) for the 1st study, 10% (1/10 cases) for the 2nd study, and 60% (3/5 cases) for the 3rd study [ Table 1 ].[ 5 ]

Direct Injection of Contrast into Postoperative Pseudomeningocele Facilitated Localization of Postoperative CSF Leaks/DT

Myelo-CT studies classically utilize lumbar punctures to localize traumatic postoperative thorcollumbar CSF leaks/DT. However, Mark et al, (2023) documented that direct injection of contrast into postoperative pseudomeningoceles was not only as efffective, but also avoided the morbidity of lumbar punctures associated with Myelo-CT examinations [ Table 1 ].[ 9 ] Mark et al, (2023) directly injected contrast into a postoperative paraspinal pseudomeningocele and successfully identified the site of the DT while avoiding the morbidity of a lumbar puncture as would be required to perform a Myelo-CT study.[ 9 ]

CONCLUSION

The incidence of traumatic thoracic and/or lumbar CSF fistulas/DT occurring during primary thoracic and/or lumbar operations ranges from 2.6% - 8% [ Table 1 ].[ 4 , 6 , 8 , 10 , 12 ] Additional fistulas may be recognized in a delayed fashion in from 0.83 to 14.3% of cases, while recurrent postoperative CSF leaks/DT occur in from 13.3 to 33% of cases [ Table 1 ].[ 4 , 6 , 8 , 10 , 12 ] Repair strategies for postoperative traumatic surgical thoracic and/or lumbar CSF leaks/DT include; direct application of interrupted non-resorbable sutures (i.e., using 7-0 Gore-Tex where feasible). Additional adjunctive repairs may include; the application of muscle patch grafts, select pedicle Multifidus muscle flaps, microfibrillar collagen, FS/FG, and/or the placement of LD, and/or LP shunts [ Table 1 ].[ 1 - 8 , 10 - 12 ]

Ethical approval

Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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