Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome.

Abstract

Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS). We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n= 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n= 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity. The diseases associated with leak formation included lipomyelomeningocele (n= 16), myelocystocele (n= 4), and myelomeningocele (n= 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n= 15), primary resuturing with local rotation flap of muscle (n= 3), external ventricular drain placement (n= 1), ventriculoperitoneal shunt (n= 3), external ventricular drainage (n= 1), and a combination of techniques (rotation flap with external drain; n= 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications. In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.