Persistent Cerebrospinal Fluid Leak Research Articles

Pediatric Congenital Anterior Skull Base Encephaloceles and Surgical Management: A Comparative Review of 22 Patients Treated With Transnasally, Transcranially, or Combined Approach With a Review of the Literature.

Anterior basal encephaloceles are considered a rare entity and are often associated with midline cerebral abnormalities. Those with a large skull base defect and herniation of brain parenchyma in the neonate or young infant present unique challenges for surgical management. We analyzed the neurosurgical administrative and operative databases between 1986 and 2022 to determine clinical presentation, operative approach, and outcome of basal encephaloceles. Over the 36-year period, 27 pediatric anterior basal encephaloceles were managed, of which 22 had full documentation and images allowing comprehensive review. Mean age at presentation was 5 years (SD 4.94). The majority were transethmoidal encephaloceles (59%), followed by the transsphenoidal-sphenoethmoidal type (32%). Overall, 91% were managed surgically by a transcranial, endoscopic, or combined approach. Four children required subsequent procedures, predominantly for persistent cerebrospinal fluid leak. No significant differences in proportion of patients requiring interval/revision surgery after initial conservative, endoscopic endonasal, or transcranial surgery was identified. Neither age at surgery nor size of the defect on computed tomography scan was associated with the need for revision surgery. Size of cranial defect was significantly smaller in the endoscopic group (P = .01). There was a historic tendency for younger children with larger defects to have a transcranial approach. With the addition of endoscopic skull base expertise, smaller defects in older children were more recently treated endoscopically. Basal encephaloceles are rare and complex lesions and are optimally managed within a skull base multidisciplinary team able to provide multiple approaches. Large skull base defects with brain parenchymal involvement often require a transcranial or combined transcranial-endoscopic approach.

Supraclavicular Artery Island Flap for Treatment of Cervical Wound Defects and Persistent Cerebrospinal Fluid Leaks: A Technical Note and Systematic Review of the Literature

BackgroundSoft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, “supraclavicular artery island flap AND spine” and “supraclavicular AND flap AND spine”. Technical NoteA 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4–C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak. Systematic Literature ReviewSeven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation. ConclusionThe SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

Management of Cerebrospinal Fluid Leakage by Pump-Regulated Volumetric Continuous Lumbar Drainage Following Anterior Cervical Decompression and Fusion for Ossification of the Posterior Longitudinal Ligament.

Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage. We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage. Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed. The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.

Safety of cerebrospinal fluid drainage in descending and thoracoabdominal aortic replacement surgery.

Spinal cord injury (SCI) remains a significant morbidity of surgical repair of descending thoracic aortic aneurysms (DTAA) and thoracoabdominal aortic aneurysms (TAAA). We present our 17-year experience with cerebrospinal fluid drainage (CSFD) as a protective strategy during open surgical repair of descending and thoracoabdominal aortic disease. We conducted a retrospective chart review of 132 patients who underwent open surgical repair of DTAA and TAAA and dissections with concurrent use of CSFD for spinal cord protection. Information regarding survival, postoperative course, and complications related to CSFD use were extracted from electronic health records (EHR) and analyzed. Mean patient age was 65.4±13.0 years, and 82 (62.1%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay after surgery was 12.2±11.2 days, and in-hospital mortality was 7.6%. Postoperative transient paresis was observed in 5 patients (3.8%), and permanent paraplegia was seen in 4 (3.0%). CSFD related complications were reported in 25 patients (19%). Complications included persistent cerebrospinal fluid (CSF) leakage, blood-tinged CSF (with subdural hematoma reported in 3 patients) and spinal cutaneous fistula in 9 (7%), 14 (11%), and 1 (1%), respectively. Long term survival was 50.9% at 15 years. CSFD is associated with minor complications, without major sequalae. It is a safe practice and likely contributes innocuously to decreased SCI in patients undergoing open repair of DTAA and TAAA.

Management of Unilateral TMJ Dislocated Facial Bone Fracture due to an rarely Industrial Accident

Introduction: Traffic accidents commonly cause maxillofacial trauma but rarely industrial accidents. Treatment of multiple maxillofacial traumas needs comprehensive and immediate care to prevent further complications. Objective: Management of a maxillofacial fracture accompanied by dislocation of the right temporomandibular joint due to a fall in a rice mill. Case report: A 20-year-old male patient complained of bleeding and facial fractures due to a rice milling accident approximately one day before admission. The case diagnosis was multiple maxillofacial fractures with condyle dislocation. Emergency oral and maxillofacial surgery was performed immediately and quickly with minimal intervention on the upper jaw to prevent persistent cerebrospinal fluid leakage and prevent infection. Definitive treatment was soft tissue reconstruction, ORIF of the maxillary and mandibular fractures, and repositioning of the condyle dislocation. Conclusion: Multiple facial bone fractures accompanied by TMJ dislocation can result in deformity and loss of facial function affecting the patient's social life. Immediate action and open reduction internal fixation (ORIF) procedure performed in this case were able to restore stomatognathic and facial function. Keywords: Industrial accident, maxillofacial trauma, open reduction internal fixation, temporal mandibular joint dislocation Introduction: Traffic accidents commonly cause maxillofacial trauma but rarely industrial accidents. Treatment of multiple maxillofacial traumas needs comprehensive and immediate care to prevent further complications. Objective: Management of a maxillofacial fracture accompanied by dislocation of the right temporomandibular joint due to a fall in a rice mill. Case report: A 20-year-old male patient complained of bleeding and facial fractures due to a rice milling accident approximately one day before admission. The case diagnosis was multiple maxillofacial fractures with condyle dislocation. Emergency oral and maxillofacial surgery was performed immediately and quickly with minimal intervention on the upper jaw to prevent persistent cerebrospinal fluid leakage and prevent infection. Definitive treatment was soft tissue reconstruction, ORIF of the maxillary and mandibular fractures, and repositioning of the condyle dislocation. Conclusion: Multiple facial bone fractures accompanied by TMJ dislocation can result in deformity and loss of facial function affecting the patient's social life. Immediate action and open reduction internal fixation (ORIF) procedure performed in this case were able to restore stomatognathic and facial function. Keywords: Industrial accident, maxillofacial trauma, open reduction internal fixation, temporal mandibular joint dislocation

Dural Closure Techniques and Cerebrospinal Fluid Leak Incidence After Resection of Primary Intradural Spinal Tumors: A Systematic Review.

This is a systematic review of primary intradural spinal tumors (PIDSTs) and the frequency of postoperative cerebrospinal fluid (CSF) leaks. This study aimed to compare CSF leak rates among techniques for dural watertight closure (WTC) after the resection of PIDSTs. Resection of PIDSTs may result in persistent CSF leak. This complication is associated with infection, wound dehiscence, increased length of stay, and morbidity. Dural closure techniques have been developed to decrease the CSF leak rate. A PubMed search was performed in 2022 with these inclusion criteria: written in English, describe PIDST patients, specify the method of dural closure, report rates of CSF leak, and be published between 2015 and 2020. Articles were excluded if they had <5 patients. We used standardized toolkits to assess the risk of bias. We assessed patient baseline characteristics, tumor pathology, CSF leak rate, and dural closure techniques; analysis of variance and a 1-way Fisher exact test were used. A total of 4 studies (201 patients) satisfied the inclusion criteria. One study utilized artificial dura (AD) and fibrin glue to perform WTC and CSF diversion, with lumbar drainage as needed. The rate of CSF leak was different among the 4 studies (P=0.017). The study using AD with dural closure adjunct (DCA) for WTC was associated with higher CSF leak rates than those using native dura (ND) with DCA. There was no difference in CSF leak rate between ND-WTC and AD-DCA, or with any of the ND-DCA studies. After resection of PIDSTs, the use of autologous fat grafts with ND resulted in lower rates of CSF leak, while use of fibrin glue and AD resulted in the highest rates. These characteristics suggest that a component of hydrophobic scaffolding may be required for WTC. A limitation included articles with low levels of evidence. Continued investigation to understand mechanisms for WTC is warranted. Level 3.

A Comprehensive Analysis of Tobacco Smoking History as a Risk for Outcomes after Endoscopic Transsphenoidal Resection of Pituitary Adenoma.

Objectives This study seeks to comprehensively analyze the impact of smoking history on outcomes after endoscopic transsphenoidal hypophysectomy (TSH) for pituitary adenoma. Design This was a retrospective study. Setting This study was done at the tertiary care center. Participants Three hundred and ninety-eight adult patients undergoing TSH for a pituitary adenoma. Main Outcome Measures Clinical and tumor characteristics and operative factors were collected. Patients were categorized as never, former, or active smokers, and the pack-years of smoking history was collected. Years since cessation of smoking was obtained for former smokers. Specific outcomes included postoperative cerebrospinal fluid (CSF) leak, length of hospitalization, 30-day return to the operating room, and 30-day readmission. Smoking history details were comprehensively analyzed for association with outcomes. Results Any history of smoking tobacco was associated with return to the operating room (odds ratio [OR] = 2.67, 95% confidence interval [CI]: 1.05-6.76, p = 0.039), which was for persistent CSF leak in 58.3%. Among patients with postoperative CSF leak, any history of smoking was associated with need for return to the operating room to repair the CSF leak (OR = 5.25, 95% CI: 1.07-25.79, p = 0.041). Pack-years of smoking was positively associated with a return to the operating room (OR = 1.03, 95% CI: 1.01-1.06, p = 0.048). In all multivariable models, all negative outcomes were significantly associated with the covariate: occurrence of intraoperative CSF leak. Conclusion This is the first study to show smoking may have a negative impact on healing of CSF leak repairs after TSH, requiring a return to the operating room. This effect appears to be dose dependent on the smoking history. Secondarily, intraoperative CSF leak as covariate in multivariable models was significantly associated with all negative outcomes.

Acetazolamide, Short Bed Rest, and Subfascial Off-Suction Drainage in Preventing Persistent Spinal Fluid Leaks from Incidental Dural Tears.

Postoperative cerebrospinal fluid (CSF) leak might occur after the repair of dural tears. Acetazolamide lowers intradural pressure by decreasing CSF production. The aim of this study was to investigate the incidence of persistent CSF leak from incidental dural tears after using acetazolamide, short bed rest, and subfascial off-suction drainage. The medical records at the Ain Shams University hospital were examined retrospectively for this descriptive single-arm cohort study. Adult patients who underwent lumbar degenerative spine surgery from January 2011 through January 2021 were enrolled. The included patients experienced a CSF leak and were administered acetazolamide 1.5 g/d from postoperative day (POD) 1 to POD 7. Subfascial drainage was kept for a maximum of 5 days without suction. Seventy-four patients met the inclusion criteria of the study. Fifty-nine patients (79.7%) had recurrent lumbar surgery. The average age of the patients was 55.7 years. In all patients, the quantity of fluid in the drain decreased on a daily basis. The subfascial drain was kept for 5 days in 26 patients (35.1%). There was no wound infection, collection, or persistent CSF leakage in any of the patients over the 6-month follow-up period. In this study, acetazolamide was well tolerated by the patients and, in addition to short bed rest (72 hours) and off-suction subfascial drainage, did not result in persistent CSF leakage in any patient. A prospective placebo-controlled study is beneficial to confirm the efficacy of acetazolamide in preventing CSF leakage.

Above-The-Hairline Suboccipital Transverse Approach for the Treatment of Chiari I Malformation.

Chiari I malformation is a common pediatric neurosurgical disorder with an established treatment paradigm. Posterior fossa decompression and duraplasty (PFDD) is associated with symptom improvement but it carries postoperative risk, particularly cerebrospinal fluid (CSF) leak and wound complications. In addition, the cosmetic outcomes of PFDD have been overlooked in the literature. To describe a novel approach for PFDD in which the transverse surgical incision is completely hidden above the hairline and to report early outcomes in a prospective patient cohort. Clinical and cosmetic outcomes were recorded for 15 consecutive pediatric patients who underwent PFDD for Chiari I malformation via the above-the-hairline transverse suboccipital approach. The median clinical follow-up time was 6 months (range 1-12 months), and the majority of patients experienced significant improvement of their preoperative symptoms. Three patients (20%) experienced complications associated with surgery, which included injury to the greater occipital nerve, CSF hypotension and subfascial pseudomeningocele, and superficial wound dehiscence that resolved spontaneously with oral antibiotics. Zero patients (0%) returned to the operating room for persistent CSF leak, deep wound infection, or revision decompression. An excellent cosmetic outcome was achieved in 12 patients (80%). No patient had a poor cosmetic outcome. The above-the-hairline transverse suboccipital approach for PFDD in patients with Chiari I malformation offers favorable cosmetic outcomes and fascial closure while permitting adequate decompression.

Neuroprotection is improved by watertightness of fetal spina bifida repair in the sheep model.

A contributing factor to unsuccessful prenatal spina bifida aperta (SBA) repair via an open approach may be incomplete neurosurgical repair causing persistent in-utero leakage of cerebrospinal fluid (CSF) and exposure of the fetal spinal cord to amniotic fluid. We aimed to investigate the neurostructural and neurofunctional efficacy of watertight prenatal SBA repair in a validated SBA fetal lamb model. A well-powered superiority study was conducted in the validated SBA fetal lamb model (n = 7 per group). The outcomes of lambs which underwent watertight or non-watertight multilayer repair through an open approach were compared to those of unrepaired SBA lambs (historical controls) at delivery (term = 145 days). At ∼75 days, fetal lambs underwent standardized induction of lumbar SBA. At ∼100 days, they were assigned to an either watertight or non-watertight layered repair group based on an intraoperative watertightness test using subcutaneous fluorescein injection. At 1-2 days postnatally, as primary outcome, we assessed reversal of hindbrain herniation using magnetic resonance imaging (MRI). Secondary proxies of neuroprotection were: absence of CSF leakage at the repair site; hindlimb motor function based on joint-movement score, locomotor grade and Motor Evoked Potential (MEP); four-score neuroprotection scale, encompassing live birth, complete hindbrain herniation reversal, absence of CSF leakage and joint-movement score ≥ 9/15; and brain and spinal cord histology and immunohistochemistry. As the watertightness test cannot be used clinically due to its invasiveness, we developed a potential surrogate intraoperative three-score skin-repair-quality scale based on visual assessment of the quality of the skin repair (suture inter-run distance ≤ 3 mm, absence of tear and absence of ischemia), with high quality defined by a score ≥ 2/3 and low quality by a score < 2/3, and assessed its relationship with improved outcome. Compared with unrepaired lambs, lambs with watertight repair achieved a high level of neuroprotection (neuroprotection score of 4/4 in 5/7 vs 0/7 lambs) as evidenced by: a significant 100% (vs 14%) reversal of hindbrain herniation on MRI; low CSF leakage (14% vs 100%); better hindlimb motor function, with higher joint-movement score, locomotor grade and MEP area under the curve and peak-to-peak amplitude; higher neuronal density in the hippocampus and corpus callosum; and higher reactive astrogliosis at the SBA lesion epicenter. Conversely, lambs with non-watertight SBA repair did not achieve the same level of neuroprotection (score of 4/4 in 1/7 lambs) compared with unrepaired lambs, with: a non-significant 86% (vs 14%) reversal of hindbrain herniation; high CSF leakage (43% vs 100%); no improvement in motor function; low brain neuron count in both the hippocampus and corpus callosum; and small spinal astroglial cell area at the epicenter. Both watertight layered repair and high (≥ 2/3) intraoperative skin-repair-quality score were associated with improved outcome, but the watertightness test and skin-repair-quality scale could not be used interchangeably due to result discrepancies. Watertight layered fetal SBA repair is neuroprotective since it improves brain and spinal-cord structure and function in the fetal lamb model. This translational research has important clinical implications. A neurosurgical technique that achieves watertightness should be adopted in all fetal centers to improve neuroprotection. Future clinical studies could assess whether a high skin-repair-quality score (≥ 2/3) correlates with neuroprotection. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Epidural Blood Patching in Spontaneous Intracranial Hypotension—Do we Really Seal the Leak?

PurposeEpidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH). Follow-up after EBP primarily relies on clinical presentation and data demonstrating successful sealing of the underlying spinal cerebrospinal fluid (CSF) leak are lacking. Our aim was to evaluate the rate of successfully sealed spinal CSF leaks in SIH patients after non-targeted EBP.MethodsPatients with SIH and a confirmed spinal CSF leak who had been treated with non-targeted EBP were retrospectively analyzed. Primary outcome was persistence of CSF leak on spine MRI or intraoperatively. Secondary outcome was change in clinical symptoms after EBP.ResultsIn this study 51 SIH patients (mean age, 47 ± 13 years; 33/51, 65% female) treated with non-targeted EBP (mean, 1.3 EBPs per person; range, 1–4) were analyzed. Overall, 36/51 (71%) patients had a persistent spinal CSF leak after EBP on postinterventional imaging and/or intraoperatively. In a best-case scenario accounting for missing data, the success rate of sealing a spinal CSF leak with an EBP was 29%. Complete or substantial symptom improvement in the short term was reported in 45/51 (88%), and in the long term in 17/51 (33%) patients.ConclusionNon-targeted EBP is an effective symptomatic treatment providing short-term relief in a substantial number of SIH patients; however, successful sealing of the underlying spinal CSF leak by EBP is rare, which might explain the high rate of delayed symptom recurrence. The potentially irreversible and severe morbidity associated with long-standing intracranial hypotension supports permanent closure of the leak.

P152. Is short segment fracture fixation appropriate for AO spine type B and C injuries?

<h3>BACKGROUND CONTEXT</h3> The AO Spine Classifications are associated with a hierarchical injury severity score. "Type A" fractures represent the most stable injuries and "Type C" represent the most severe and unstable injuries. "Three column" subaxial cervical spine and thoracolumbar injuries are designated as Type B (tension band) and Type C (fracture dislocation). Although the load sharing classification describes burst type fractures, Type B and C injuries are often minimally comminuted but grossly unstable due to "three-column" disruption. Therefore, the load sharing classification may not be appropriate to guide short- or long-segment fixation. <h3>PURPOSE</h3> To identify if construct length affects the rate of surgical complications or instrumentation revision following Type B and C subaxial or thoracolumbar injuries. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> All patients with cervical or thoracolumbar Type B and Type C injuries between 2006-2021 were identified from a prospectively collected database. Only patients who underwent operative intervention were included. <h3>OUTCOME MEASURES</h3> Surgical complications (persistent cerebrospinal fluid leak, wound dehiscence, epidural hematoma, surgical site infection) and reoperations (instrumentation revision and/or exchange). <h3>METHODS</h3> Patients were divided based on the number of levels instrumented above and below the injured level (>2 levels (long-segment) versus < 2 levels (short-segment)). Patient demographics, surgical characteristics and clinical outcomes were collected and compared. Independent t-tests or Mann-Whitney U tests compared continuous variables, while Pearson's chi-square tests compared categorical variables. Bivariate logistic regression measured the effect of fixation construct length (long-segment fixation) on the likelihood of having a surgical complication and reoperation for instrumentation revision and/or exchange. Alpha was set at P<0.05. <h3>RESULTS</h3> A total of 180 patients representative of 187 fractures were included. Of the 187 injuries, 69 (36.9%) underwent long-segment fixation. Patients who underwent long-segment fixation were older (61.1 vs 51.5 years, p=0.005), were more likely to have comorbid ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperosteosis (DISH) (47.8% vs 21.2%, p<0.001), and were more likely to have an injury that involved a thoracic vertebra (53.6% vs 30.5%, p=0.008). Further, patients who underwent long-segment fixation were more likely to undergo posterior-only fixation (85.5% vs 60.2%, p<0.001) in comparison to anterior-only and combined anterior-posterior fixation. There was no significant difference in the proportion of long-segment versus short-segment constructs that included bilateral, unilateral or no pedicle screws within the injured vertebrae (p=0.371). Bivariate logistic regression demonstrated that a long-segment fixation construct had a non-significant increase in complication rates (OR=2.08, p=0.176) and reoperations for instrumentation revision or exchange (OR=2.99, p=0.142). We subanalyzed the 58 fractures with AS/DISH compared to the 129 fractures without AS/DISH. Injuries with AS/DISH had a mean 2.57+ 1.01 and 2.34 + 0.81 levels instrumented above and below the injury compared to injuries without AS/DISH, mean 1.97 + 1.04 and 1.90 + 0.96 levels instrumented above and below the injury (p<0.001), respectively. However, there was no difference in the rate of surgical complications (8.62% vs 7.75%, p=0.780) or instrumentation revision (6.90% vs 3.10%, p=0.256) between the two groups based on construct length. <h3>CONCLUSIONS</h3> Long-segment fixation of Type B or C subaxial cervical spine or thoracolumbar spine injuries resulted in a non-significant increase in complications and spine reoperations for instrumentation revision. Instrumentation technology has improved since the load sharing classification. This exploratory study suggests short segment fixation may be appropriate even for unstable spine fractures. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Efficacy and Safety of Subfascial Epidural Drainage Protocol After Intraoperative Durotomy in Posterior Thoracic and Lumbar Spine Surgery: Reoperation Prevention and Outcomes Among Drained and Undrained Cohorts.

Persistent cerebrospinal fluid (CSF) egress after durotomy in posterior thoracic or lumbar spine surgery may cause devastating complications. Persistent CSF leaks may require reoperation, which confers additional cost and morbidity. To evaluate the efficacy of our subfascial epidural drainage protocol in the setting of durotomy to prevent reoperation. A retrospective cohort study of drained and undrained cohorts was completed to identify factors associated with reoperation for persistent CSF leak-related symptoms. The efficacy and safety of this 7-day subfascial epidural drainage protocol was assessed by comparing reoperation incidence, perioperative complications, rehabilitation necessity, and readmissions. In total, 156 patients underwent subfascial epidural drainage, and 14 were not drained. Subfascial drainage for up to 7 days was associated with a significantly lower incidence of reoperation than no drainage (3.3% vs 14%, respectively; P = .03). Perioperative complication incidence was similar between cohorts (12.8% vs 21.4%, respectively; P = .37), and length of stay was unchanged regardless of drainage (median 7 days). Subfascial drainage conferred a nearly 2-fold relative risk reduction in inpatient rehabilitation requirement (RR 0.55) and 3-fold relative risk reduction in 30-day (RR 0.31) and 90-day readmission (RR 0.36). Factors associated with reoperation among drained patients included drainage longer than 7 days, tobacco use, age younger than 50 years, and longer segment operations. Revision spine surgery was associated with reoperation among undrained patients. When followed after durotomy, our subfascial epidural drainage protocol results in fewer reoperations than in an undrained cohort without prohibitive cost and no added morbidity.

Can Cervical and Lumbar Epidural Blood Patches Help Avoid Revision Surgery for Symptomatic Postoperative Dural Tears?

Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks can be treated with bedrest, subarachnoid lumbar drain, and surgical re-exploration. Another option is an epidural blood patch, which forms a clot over the dural tear in a minimally invasive manner. Our objective was to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies. Patients undergoing spine surgeries at one institution from 2012-2020 were included. Patient charts were reviewed for demographic information, surgical data, rate of dural tear, type of repair, and use of blood patches postoperatively. A total of 1392 patients (726 male, 666 female, average age: 56.3 ± 15.4 years), including 436 cervical and 956 posterior thoracolumbar/lumbar spine surgeries were screened. There were 6 (1.4%) cervical, 64 (6.7%) lumbar, and a total of 70 (5.0%) patients with incidental dural tears/blebs. Of these patients, we identified 2 cervical and 8 lumbar spine patients with persistent CSF leaks who received epidural blood patches postoperatively. Nine of 10 (90%) had resolution of symptoms. One lumbar patient failed both an initial blood patch and subsequent surgical re-exploration, but had successful relief after a second blood patch. The incidence of dural tears/blebs was 1.4% in cervical, 6.7% in lumbar, and 5.0% in all spine surgeries. Of the 10 patients with symptomatic CSF leaks, 9 were successfully treated with blood patches. Targeted epidural blood patch is effective in treating symptomatic CSF leaks and minimizes the morbidity of surgical re-exploration.

A Comparison of Outcomes Using Combined Intra- and Extradural versus Extradural-Only Repair of Tegmen Defects.

Objective Tegmen tympani or tegmen mastoideum defects involve dehiscence of the temporal bone that can be a source of cerebrospinal fluid (CSF) otorrhea. Herein, we compare a combined intra-/extradural repair strategy with an extradural-only repair as it pertains to surgical and clinical outcomes. Design A retrospective review from our institution was performed of patients with tegmen defects requiring surgical intervention. Participants Patients with tegmen defects who underwent surgery (combined transmastoid and middle fossa craniotomy) for repair of tegmen defects between 2010 and 2020 were inclined in this study. Results A total of 60 patients with 40 intra-/extradural (mean follow-up time: 1,060 ± 1,103 days) and 20 extradural-only (mean follow-up time: 519 ± 369 days) repairs were identified. No major differences in demographic factors or presenting symptoms were identified between the two cohorts. There was no difference in hospital length of stay between the two patient cohorts (mean: 4.15 vs. 4.35 days, p = 0.8). In the extradural-only repair technique, synthetic bone cement was more frequently used (100 vs. 7.5%, p < 0.01), whereas in the combined intra-/extradural repair, synthetic dural substitute was used more often (80 vs. 35%, p < 0.01), with similar successful surgical outcomes achieved. Despite disparities in the techniques and materials used for repair, there were no differences in complication rates (wound infection, seizures, and ossicular fixation), 30-day readmission rates, or persistent CSF leak between the two treatment cohorts. Conclusion The results of this study suggest no difference in clinical outcomes between combined intra-/extradural versus extradural-only repair of tegmen defects. A simplified extradural-only repair strategy can be effective, and may reduce the morbidity of intradural reconstruction (seizures, stroke, and intraparenchymal hemorrhage).

805 Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch

INTRODUCTION: Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid (CSF) leak and pseudomeningocele if unrecognized or incompletely repaired. METHODS: A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele. RESULTS: Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and BMI were 60.5±12.6 years and 27.8±4.50 kg/m2, respectively. The most frequent index operation was laminectomy (24.5%) and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (IQR 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases and the median clinical follow-up was 4.3 (IQR 2.4-14.5) months. CONCLUSIONS: This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele.

A novel two-layer, intradural and extradural patch graft approach to treating dural defects and tears: illustrative case.

BACKGROUNDDural tears must be quickly addressed to avoid the development of positional headaches and pseudomeningoceles, among other complications. However, sizeable areas of friable or absent dura create unique challenges when attempting to achieve a watertight seal. We have developed a two-layer subdural and epidural fibrous patch technique to treat expansive or challenging dural tears as a result of our experience treating spinal fluid leaks.OBSERVATIONSThe authors present the treatment of a large necrotic (5 × 1.5 cm) dural defect refractory to initial attempts at standard primary repair with dural patch grafting and requiring a revision with a dual-layer patch to manage persistent cerebrospinal fluid leakage.LESSONSThe use of a two-layer (subdural and epidural) patch is both a safe and effective dural repair technique for creating a watertight seal in challenging large areas in which the dura may be damaged, scarred, or absent. We also propose that this technique may be able to be used for smaller challenging tears, as well as potentially for repairs of large blood vessels or other fluid-filled structures in the body.

Non Spontaneous Cerebrospinal Fluid Rhinorrhoea and Subsequent Bacterial Meningitis: A Case Report

Cerebrospinal Fluid (CSF) protects brain and maintains intracranial pressure which is secreted by choroid plexus. After severe Craniomaxillofacial (CMF) trauma, disruption of meningeal structure leads to CSF leak. About 80-90% of CSF leak in adults is due to head injuries. CSF rhinorrhoea can be classified into spontaneous and non spontaneous. Meningitis is seen in 19% of persistent CSF leakage with 10% of mortality due to delayed and longer duration of the CSF leakage. Post-traumatic CSF leaks are commonly seen in 1-3% of adults among all head injuries. Traumatic CSF leak is reported to be approximately 10-30% of the skull base fractures in adults. Common pathogens of meningitis are Haemophilus influenzae (H. influenzae) and Streptococcus pneumoniae (S. pneumoniae). Present case was of non spontaneous CSF rhinorrhoea and subsequent bacterial meningitis in a 33-year-old male patient, with fever and chills, headache, vomiting, neck stiffness. Kernig sign’s was present. Patient had past history of road traffic accident and found to have CMF injury. Neurosurgery opinion was sought and found to be persistent CSF rhinorrhoea. Haematological and chemical analysis of cerebrospinal fluid was abnormal. CSF and blood sample sent for culture and sensitivity. H. influenzae grown in both culture. H. influenzae is an uncommon cause of adult bacterial meningitis.

Endonasal Free Flap Reconstruction Combined With Draf Frontal Sinusotomy for Complex Cerebrospinal Fluid Leak: A Technical Report &amp; Case Series

Frontal sinus cranialization with closure via bifrontal pericranial flaps is the gold standard for separating the nasofrontal recess from the intracranial cavity for posterior table defects. Despite the high success rate, cerebrospinal fluid (CSF) leak may persist and is particularly challenging when vascularized reconstructive options from the bicoronal incision are exhausted. To assess a novel endonasal technique using an adipofascial radial forearm free flap delivered to the frontal recess through a Draf sinusotomy to repair complex CSF leaks from the frontal sinus. A retrospective review of 3 patients (all male; ages 42, 43, and 69 yr) with persistent CSF leak despite frontal sinus cranialization and repair with bifrontal pericranium was performed. Etiology of injury was traumatic in 2 patients and iatrogenic in 1 patient after anaplastic meningioma treatment. To create space for the flap and repair the nasofrontal ducts, endoscopic Draf III (Case 1, 3) or Draf IIb left frontal sinusotomy (Case 2) was performed. The forearm flap was harvested, passed through a Caldwell-Luc exposure, and placed within the Draf frontal sinustomy. The flap vessels were tunneled to the left neck and anastomosed to the facial vessels by the mandibular notch. Intraoperatively, the flaps were well-seated and provided a watertight seal. Postoperative hospital courses were uncomplicated. There were no new CSF leaks or flap necrosis at 12, 14, and 16 mo. Endoscopic endonasal free flap reconstruction through a Draf procedure is a novel viable option for persistent CSF leak after failed frontal sinus cranialization.

P15. Can cervical and lumbar epidural blood patches help avoid revision surgery for symptomatic postoperative dural tears?

<h3>BACKGROUND CONTEXT</h3> Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks are a known sequela of spine surgeries. Treatments include bedrest, subarachnoid lumbar drain, epidural blood patch, and most commonly, surgical reexploration for durotomy closure. Surgical reexploration carries the inherent consequences of an additional surgical procedure. The theory behind epidural blood patches is to form a clot over the tear in a minimally invasive manner and to allow the dura to heal without the need for additional surgery. Within the literature, there is a paucity of data available evaluating the efficacy of epidural blood patches for CSF leaks secondary to incidental durotomies. <h3>PURPOSE</h3> The purpose of this study is to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series. <h3>PATIENT SAMPLE</h3> All patients undergoing cervical, thoracolumbar, or posterior lumbar spine surgeries at an academic institution between 10/2012 and 12/2020 were included. <h3>OUTCOME MEASURES</h3> Rate of dural tears, type of dural repair, use of blood patches for dural tears, intraoperative/perioperative complications, length of hospital stay, discharge status. <h3>METHODS</h3> Patients undergoing cervical, thoracolumbar, and posterior lumbar surgeries performed by a single surgeon at an academic institution between 10/2012 and 12/2020 were included. Their charts were reviewed retrospectively for demographic information, type of surgery, rate of dural tear, type of repair, and use of blood patches postoperatively. <h3>RESULTS</h3> A total of 1,392 patients (726 males, 666 females, average age: 56.3 ±15.4 years old) were included who received cervical, thoracolumbar, or posterior lumbar surgeries. Of the 436 cervical spine surgeries, there were 236 anterior cervical fusions, 183 posterior cervical surgeries, and 17 anterior and posterior cervical surgeries. Of the 956 thoracolumbar and posterior lumbar spine surgeries, there were 207 laminectomies, 458 fusions and 291 microdiscectomies. There were 6 (1.4%) cervical, 65 (6.8%) lumbar, a total of 71 (5.1%) patients identified with incidental dural tears/blebs. Durotomies were fixed primarily, or if they were inaccessible, then treated with duraseal and/or fat graft. Persistent CSF leaks were indicated by positive beta-2 transferrin or clinical symptoms of positional headaches; these patients were referred to interventional radiology for a blood patch. We identified 2 (2 males) cervical spine and 8 (4 females and 4 males) lumbar spine patients who received blood patches in this study. Nine of 10 patients had resolution of symptoms without reaccumulation of fluid (90%). One lumbar spine surgery patient had a persistent pseudomeningocele after a blood patch and subsequently underwent primary repair with no relief. A second blood patch was then performed, which alleviated his symptomatic pseudomeningocele. Of the10 total patients who received blood patches, the mean length of hospital stay was 10.4 days, and three were discharged to rehabilitation. <h3>CONCLUSIONS</h3> The rate of dural tears/blebs within this series was 1.4% in cervical spine, 6.8% in lumbar spine, and 5.1% in total spine surgeries. Of the 10 patients with symptomatic postoperative CSF leaks, 9 out of 10 were successfully treated with a blood patch. Targeted epidural blood patch is an effective option to treat symptomatic CSF leaks that minimizes the morbidity of surgical reexploration. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.