Persistent Cerebrospinal Fluid Leak Research Articles

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps.

This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)--1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

Pseudomeningocele With Orbital Extension as a Complication of Fronto-Orbital Advancement and Remodeling in Craniosynostosis.

The authors present a series of patients who developed a pseudomeningocele following fronto-orbital advancement and remodeling (FOAR), describing clinical presentation, investigations, and management. Risk factors are identified and preventative strategies suggested. From 2002 to 2012, all patients who underwent FOAR at our unit were identified. Those who developed a pseudomeningocele were selected and case notes, scan imaging and photographs were reviewed. Two hundred thirty-six FOAR operations were carried out over 12 consecutive years. Sixty-one of these patients were syndromic. A pseudomeningocele occurred in 6 patients. All affected cases were syndromic. Clinical features of presentation with orbital pseudomeningocele included orbital swelling, ptosis, proptosis, and/or hypoglobus. Raised intracranial pressure (ICP) was managed before pseudomeningocele repair in 2 patients, at the time of pseudomeningocele repair using an extra-ventricular drain (EVD) or lumbar drain in 4 patients. Decompression of the pseudomeningocele with excision and duraplsty was carried out in 5 patients, 1 patient required excision of gliotic brain and obliteration of dead space. Four patients had a calvarial graft to manage the bony defect and a further 2 had a titanium mesh. None of the patients had a recurrence of the pseudomeningocele or any long-term ocular or aesthetic complications. Pseudomeningocele has not previously been described in FOAR, but in a large series of consecutive patients, we have identified a 2.5% incidence. This incidence increases to 10% in the syndromic population of patients undergoing FOAR. The risk factors include a diagnosis of syndromic craniosynostosis, dural tear, hydrocephalus or raised ICP, infection, persistent cerebrospinal fluid (CSF) leak, or presence of dead space. Preventative strategies include CSF management before or post-FOAR. The ultimate treatment of the pseudomeningocele and growing fracture involves surgical decompression of the collection, a duraplasty, reconstruction of the orbital roof, and temporary CSF diversion.

Postoperative Low-Flow Cerebrospinal Fluid Leak of Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenoma--Wait and See, or Lumbar Drain?

To assess the effectiveness of continuous lumbar drainage (LD) for management of postoperative cerebrospinal fluid leaks after endoscopic endonasal transsphenoidal approach for resection of pituitary adenoma.Three hundred eighty-four medical records of patients who were admitted to our institute during a 2.5-year period were retrospectively reviewed, 33 of them experienced low-flow cerebrospinal fluid leak postoperatively. If LD was used, all patients with low-flow cerebrospinal fluid leak were classified into 2 groups, lumbar drained group and conservatively treated group. The age, sex, management of cerebrospinal fluid leaks, and related complications were reviewed. Statistical comparisons between the 2 groups were made using SPSS 19.0 (IBM Corp, Armonk, NY). The differences were considered statistically significant if the P value was less than 0.05.Thirty-three of 384 (8.6%) experienced low-flow postoperative cerebrospinal fluid leaks. Cured rate of cerebrospinal fluid leak was 94.4% (17/18) in continuous lumbar drained group, and 93.3% (14/15) in control group. There were 2 (11.2%) patients who developed meningitis in the LD group and 1 (5.6%) patient in the control group. One patient required endoscopic repair of skull base because of persistent cerebrospinal fluid leak in both groups, with the rates of 5.6% and 6.7%, respectively. There was no significant difference noted in each rate in both groups.Placement of LD may not be necessary for the management of low-flow postoperative cerebrospinal fluid leak after using endoscopic endonasal transsphenoidal approach to pituitary adenoma.

Pediatric frontal sinus fractures: outcomes and treatment algorithm.

Pediatric frontal sinus fractures are a rare clinical entity. Owing to the large amount of force required to fracture the frontal sinus, it is often associated with severe intracranial and craniofacial injuries. The treatment of frontal sinus fractures is controversial, with many different established algorithms based mainly on the adult population. The authors present their experience with pediatric frontal sinus fractures; they also present a treatment algorithm. A retrospective review of the Cincinnati Children's Hospital Medical Center trauma database was performed. From 1998 to 2010, the authors identified patients between the ages of 0 and 18 with frontal sinus fractures and analyzed demographics, fracture pattern, associated injuries, methods of treatment, and complications. Descriptive statistics and univariate analyses were performed.A total of 39 patients were included in the study with a mean follow-up of 31.2 months. Fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and cerebrospinal fluid leak. There were no differences in short- and long-term complications. Additionally, these patients were more likely to be treated surgically in the form of obliteration or cranialization.Patients without NFOT involvement can be managed with observation only. Patients with NFOT involvement or persistent cerebrospinal fluid leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.

An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications.

Retrospective analysis of inpatient and outpatient data from a single academic trauma center. To test the effectiveness of a conservative treatment algorithm for civilian spinal gunshot wounds (CSGSWs) by comprehensively evaluating neurological status and recovery, fracture type, concomitant injuries, indications for surgery, and complications. Few large studies exist to guide treatment of CSGSWs, and none have been published in nearly 20 years. A search of International Classification of Diseases, Ninth Revision (ICD-9) codes was performed for all hospital patients treated from 2003 to 2011 by either neurosurgery or orthopedic surgery to identify 159 consecutive patients who sustained CSGSWs. Mean follow-up was 13.6 months. American Spinal Injury Association grading was used to assess neurological injury. Fifty percent of patients had neurological deficits from CSGSW. Complete spinal injury was the most common injury grade; thoracic injuries had the most risk of complete injury (P < 0.001). Nearly 80% of patients had concomitant injuries to other organs. Operative treatment was more likely in patients with severe neurological injuries (P = 0.008) but was not associated with improved neurological outcomes (P = 1.00). Nonoperative treatment did not lead to any cases of late spinal instability or neurological deterioration. Overall, 31% of patients had an improvement of at least 1 American Spinal Injury Association grade by final follow-up. Nearly half of patients experienced at least 1 GSW-related complication; risk of complications was associated with neurological injury grade (P < 0.001) and operative treatment (P = 0.04). The vast majority of CSGSWs should be managed nonoperatively, regardless of neurological grade or number of spinal columns injured. Indications for surgery include spinal infection and persistent cerebrospinal fluid leaks. 3.

Extensive Anterior Cranial Base Fractures: Anatomic and Surgical Description of Combination Flaps

Introduction: Traditionally, cerebrospinal fluid (CSF) fistula repair following anterior skull base fractures has been accomplished with the use of exclusive anterior-based pericranial flaps. Over time, limitations have been identified with this technique. Persistent CSF leak rates following initial repairs are 12.5 to 17%, and could potentially be contributed to compromise blood supply resulting from initial cranial insult. In addition, glabellar tissue defects from placement of these flaps can result in poor cosmesis. The limited posterior reach of these flaps can hinder repairs in fractures with a substantial posterior extent. This has led to the addition of lateral temporoparital fascial flap and nasoseptal flap to our repair techniques.

Post Dural Puncture Headache (PDPH) and Associated Factors after Spinal Anesthesia among Patients in University of Gondar Referral and Teaching Hospital, Gondar, North West Ethiopia

Background: Post dural puncture headache (PDPH) has been a problem for patients after dural puncture. It is one of the most frequently occurring complications following spinal anesthesia (SA). It is believed to originate from persistent leakage of cerebrospinal fluid (CSF) through the punctured Dura, greater than the CSF production after lumbar puncture. Although the problem has been widely reported, its magnitude and associated factors has never been studied in our country. Thus, the aim of this study is to assess the magnitude of post dural puncture headache (PDPH) and associated factors after spinal anesthesia among patients in university of Gondar referral and teaching hospital. Methods: An institution based cross sectional study was conducted from February 25-April 10, 2013 in University of Gondar teaching and referral hospital, Gondar, Ethiopia. A total of 116 patients aged 17-74 years were included in the study. Data was collected by interviewing patients using structured and pre-tested questionnaire and reviewing chart. Both bivariable and multivariable logistic regressions were used to determine the association between post dural puncture headache and independent variables. Results: Out of 116 patients who have undergone spinal anesthesia 45 (38.8%) patients developed post dural puncture headache. Sex [AOR=0.2; 95% CI: 0.058, 0.67], repeated attempts [AOR=0.22; 95% CI: 0.09, 0.54], and needle sizes [AOR=5.3; 95% CI: 1.66, 16.93] were found to be significantly associated with Post Dural puncture headache. Conclusion: Prevalence of post dural puncture headache was found to be high among patients in the University of Gondar teaching and referral hospital after spinal anesthesia (SA). The hospital management and the anesthetists of University of Gondar teaching and referal hospital should minimize the incidence of post dural puncture headache by avoiding use of big needles and repeated attempt especially on female patients.

Combat-related intradural gunshot wound to the thoracic spine: significant improvement and neurologic recovery following bullet removal.

The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.

Persistent CSF leak post spinal surgery and cerebrospinal fluid dynamic disturbances: cause or consequence?

Cerebrospinal fluid (CSF) leak following spinal surgery is a relatively common surgical complication. A small group of CSF leak patients require multiple surgical repairs and prolonged hospital admission. Spinal CSF leaks are usually classically associated with symptoms of low intracranial pressure (ICP). However, there is a paucity of literature investigating the associated CSF dynamics.

Surgical technique for repair of complex anterior skull base defects.

Background:Modern microsurgical techniques enable en bloc resection of complex skull base tumors. Anterior cranial base surgery, particularly, has been associated with a high rate of postoperative cerebrospinal fluid (CSF) leak, meningitis, intracranial abscess, and pneumocephalus. We introduce simple modifications to already existing surgical strategies designed to minimize the incidence of postoperative CSF leak and associated morbidity and mortality.Methods:Medical records from 1995 to 2013 were reviewed in accordance with the Institutional Review Board. We identified 21 patients who underwent operations for repair of large anterior skull base defects following removal of sinonasal or intracranial pathology using standard craniofacial procedures. Patient charts were screened for CSF leak, meningitis, or intracranial abscess formation.Results:A total of 15 male and 6 female patients with an age range of 26–89 years were included. All patients were managed with the same operative technique for reconstruction of the frontal dura and skull base defect. Spinal drainage was used intraoperatively in all cases but the lumbar drain was removed at the end of each case in all patients. Only one patient required re-operation for repair of persistent CSF leak. None of the patients developed meningitis or intracranial abscess. There were no perioperative mortalities. Median follow-up was 10 months.Conclusion:The layered reconstruction of large anterior cranial fossa defects resulted in postoperative CSF leak in only 5% of the patients and represents a simple and effective closure option for skull base surgeons.

Reposing the herniated spinal nerves following accidental iatrogenic dural tear in spine surgery-The "no touch hip flexion technique".

Sir, During lumbosacral operations dura may get breached and the cerebrospinal fluid (CSF) with underlying nerve roots immediately come out from the dura vent like a flower vase. These nerves don’t go back easily and also if attempted to push it in, cause physical damage. The treatment of dural tear has evolved through time. There are several methods for the repair of dural tear including primary repair, tissue sealant, blood patch, tissue grafting, gelfoam and glue applications.[1] We report five cases of accidental dural tear after lumbar disc Figure 1: Surgery, its intradural reposition with no-touch hip flexion technique [Table 1]. Figure 1 L5/S1 PIVD Table 1 Relevant cases In all the cases during the operation, we noted that the ventral dura was severely adhered to the surrounding tissue. During dissection, the thinned dura was torn. There was CSF leakage and immediate rootlet herniation. We did not touch the herniated nerve roots, instead we put a cotton patty on the vent. Then semiprone position was made and back towards the operator. Then flexed the hip joint so that the intrathecal stretching of nerves transmitted through the lumbosacral nerves via sciatic nerve caused the herniated nerve roots to go inside spontaneously and immediately. Then water tight duraplasty was done without physical handling of herniated nerve roots. For confirmation of CSF leakage Valsalva maneuver was done before wound closure. Incidental dural tear is a common complication of spinal surgery (incidence from 3.1% to 14%).[2,3,4] The risk of dural tears is increased by conditions such as fibrotic adhesion in chronic cases, scar tissue from prior surgery, eroded dura, redundant dura in patients with large disc herniations,[4] advanced patient age and the surgeon's training level.[5] Good long-term outcomes have been reported when incidental dural tears were recognized intraoperatively and repaired primarily.[3] There are several methods for the repair of dural tear including primary repair, tissue sealant, blood patch, and tissue grafting.[1] Poor clinical outcome[4] have been reported like posttraumatic spinal cord or nerve root herniation through a dural defect site which may cause recurrence of radiating pain also headaches and wound infection in the short term and presence of a pseudomeningocele, persistent CSF leak, neurologic deficits, fistula formation, meningitis, arachnoiditis, or an epidural abscess in the long term. In addition, a pseudomeningocele may entrap nerve roots or the spinal cord and cause radicular symptoms. Nerve root herniation is an infrequent complication of incidental dural tear. Unrecognized or incidental dural tear was repaired using Gelfoam and fibrin glue. Treatment with gelfoam and fibrin glue alone may not prevent persistent CSF leakage.[6] Surgically the dorsal dural vent is primarily repaired by increasing the vent and then manually reposing the herniated nerves with non-toothed fine forceps. Although conservative treatments such as bed rest and closed subarachnoid drainage have been attempted, midline durotomy and meticulous surgical dural repair remain the definitive treatment for ventral dural vents. One study reported that bed rest is not a definitive treatment; in this study, the patients who did not undergo dural repair developed complications.[7] These patients eventually underwent dural repair. Another study reported that the Valsalva maneuver may help identify the dural tear in suspected cases.[8] In dural dorsal or ventrolateral vents the physical handling of the herniated nerve roots thus iatrogenic damage may be avoided by a very simple maneuver. We operate these patients usually in prone position. Immediately after incidental dural tear we put a cotton patty on the herniated nerves. Do not touch the nerves with any instrument, make semi-prone position and flex the hip joint so that the various lumbosacral plexus’ nerves stretch which in turn stretches the intrathecal nerve root causes them to go inside without increasing the vent and physical handling of the nerves. Iatrogenic dural vent causes rootlet herniation and a simple “no touch hip flexion technique” reposes the nerve roots effectively without physical handling to prevent nerve rootlet entrapment and other complications. Valsalva maneuver should be performed before and after the wound closure.

Control of cerebrospinal fluid otorrhea via C-arm-guided reduction of the zygomatic arch as a part of the temporal bone: interdisciplinary approach to an unusual craniomaxillofacial fracture

Maxillofacial fractures are often associated with blunt head injuries, of which skull base trauma is a common component. However, most oral and maxillofacial surgeons do not provide definitive management of temporal bone fractures involving the skull base and their sequelae. Persistent cerebrospinal fluid (CSF) leakage that is refractory to conservative measures usually requires surgical closure to decrease the risk of meningitis. In general, reduction of the displaced fragment of the skull base in temporal bone fractures is not considered a priority. We describe an unusual case of craniomaxillofacial injury exhibiting CSF otorrhea because of a temporal bone fracture with a fragment that included the zygomatic arch. The persistent traumatic leakage was stopped after C-arm-guided reduction of the depressed zygomatic arch. This technique facilitated minimal and only necessary manipulation, without overcorrection, thereby avoiding additional damage to the surrounding tissues. The present case illustrates the definitive contribution of therapeutic measures based on maxillofacial surgery as part of an interdisciplinary approach to the management of the complications of severe head injuries; more invasive neurosurgery was thus avoided.

Subdural Hematoma and Postdural Puncture Headache from Intrathecal Pump Placement Resolved with Lumbar Epidural Blood Patch

Intrathecal drug delivery systems are commonly used in the management of chronic pain, cancer pain and neuromuscular disorders with muscle spasticity. The complications associated with in-trathecal pump placement include persistent cerebrospinal fluid (CSF) leak, hygroma, meningitis, and granuloma formation. A severe persistent CSF leak may cause postdural puncture headache along with acute intracranial subdural hematoma, which can be potentially life threatening. Surgical exploration with dural repair is required to treat this severe complication when conservative treatments fail. We present a case report of severe persistent CSF leak after intrathecal pump revision that resulted in a subdural hematoma and postdural puncture headache. In this case, an epidural blood patch was performed using epidural catheter under fluoroscopic guidance to target the site of CSF leak and to avoid damaging the intrathecal catheter. This patient’s headache was resolved and intrathecal catheter remained intact after this blood patch.

Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases

ABSTRACTCerebrospinal fluid rhinorrhea results from a breakdown of barriers between the subarachnoid space and aerodigestive tract. Because of the risk of potential intracranial complications, all persistent cerebrospinal fluid (CSF) leaks should be repaired. Over the past few decades, with the advances in endoscopic techniques, the surgical management of CSF rhinorrhea has changed significantly. CSF leak repair has advanced from the conventional open intracranial approaches by neurosurgeons to the transnasal endoscopic ones by otorhinolaryngologists. In this study, 35 patients with CSF leaks underwent endoscopic repair with a 94.3% first attempt success rate, and 100% overall success rate. There were no major intraoperative or postoperative complications. To conclude, the endoscopic approach has a high success rate with minimal morbidity and has therefore, become the preferred method.How to cite this articleJain A, Singhal P, Sharma MP, Singh SN, Grover M. Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases. Clin Rhinol An Int J 2014;7(2):47-51.

Sternocleidomastoid Muscular Flap

Retrospective review. To describe a novel application of rotational sternocleidomastoid (SCM) muscle flap in management of ventral cervical durotomy. Even for the most experienced surgeons, incidental durotomy is a common occurrence in spine surgery. Primary direct suture repair is indicated to avoid possible complications such as pseudomeningocele or spinocutaneous fistula formation. Significant secondary effects of these complications have been described, including airway compromise, radiculopathy, myelopathy, and infection. When primary repair is not feasible, surgeons have used alternative management techniques based on their clinical judgment. In the setting of persistent symptomatic cerebrospinal fluid leak after repair, reoperation is warranted. A retrospective review was conducted of clinical records and radiographic data for 2 patients who underwent reoperation for management of ventral cervical durotomy encountered during anterior cervical spine surgery. SCM muscular flap was used to augment durotomy repair. Both patients did not have any persistent cerebrospinal fluid leak after repair with pedicled SCM muscle flap, and did not require any further surgical procedures related to the cervical spine. The use of a rotational SCM muscular flap may be useful in cases of ventral cervical durotomy refractory to conventional management.

Case Report

A 55-year-old woman with recurrent glioblastoma multiforme on palliative chemotherapy including Avastin, an angiogenesis inhibitor, presents with several episodes of bacterial meningitis secondary to a persistent cerebrospinal fluid (CSF) leak. Anastomotic dehiscence of the dura mater in the region of the previous craniotomy sites was evident. Attempts to repair the cranial CSF leak with external ventricular drain and ventriculoperitoneal shunt were unsuccessful. This patient underwent repair of the dural defects with a radial forearm free fascial flap, with consequent resolution of the CSF leak.A literature search was performed, and the available data on angiogenesis inhibitors and anastomotic dehiscence was reviewed, specifically focusing on delayed anastomotic dehiscence in patients receiving Avastin (bevacizumab). Although the potential complications of anastomotic dehiscence in patients receiving angiogenesis inhibitors are well documented, there is comparatively little documentation in the literature regarding delayed wound or anastomotic dehiscence. Twenty such cases were found cited in the literature; however, only one study was found which specifically considered angiogenesis inhibitors within the context of central nervous system malignancies.

Simulated Spinal Cerebrospinal Fluid Leak Repair

In the era of surgical resident work hour restrictions, the traditional apprenticeship model may provide fewer hours for neurosurgical residents to hone technical skills. Spinal dura mater closure or repair is 1 skill that is infrequently encountered, and persistent cerebrospinal fluid leaks are a potential morbidity. To establish an educational curriculum to train residents in spinal dura mater closure with a novel durotomy repair model. The Congress of Neurological Surgeons has developed a simulation-based model for durotomy closure with the ongoing efforts of their simulation educational committee. The core curriculum consists of didactic training materials and a technical simulation model of dural repair for the lumbar spine. Didactic pretest scores ranged from 4/11 (36%) to 10/11 (91%). Posttest scores ranged from 8/11 (73%) to 11/11 (100%). Overall, didactic improvements were demonstrated by all participants, with a mean improvement between pre- and posttest scores of 1.17 (18.5%; P = .02). The technical component consisted of 11 durotomy closures by 6 participants, where 4 participants performed multiple durotomies. Mean time to closure of the durotomy ranged from 490 to 546 seconds in the first and second closures, respectively (P = .66), whereby the median leak rate improved from 14 to 7 (P = .34). There were also demonstrative technical improvements by all. Simulated spinal dura mater repair appears to be a potentially valuable tool in the education of neurosurgery residents. The combination of a didactic and technical assessment appears to be synergistic in terms of educational development.

Successful Endoscopic Repair of Persistent Cerebrospinal Fluid Leak Following Attempted Transcranial Repair

Endoscopic techniques have become the preferred approach to address cerebrospinal fluid (CSF) leaks in the skull base, as they offer a minimally invasive method to directly visualize and repair the defect. The alternative technique of open craniotomy can still be considered for cases refractory to endoscopic repair; however, few studies have investigated the potential benefits of endoscopic repair for cases of persistent leaks after attempted transcranial repair. We report two such cases of successful long-term endoscopic repair of a persistent CSF leak, and demonstrate that endoscopic repair is a viable option to salvage an unsuccessful intracranial repair.

When does a spinal surgeon need a plastic surgeon?

Discussions with colleagues at meetings indicate that some spine surgeons often ask plastic surgery to close both primary and secondary adult instrumented spinal fusions (ISFs). This raises a major concern; if plastic surgeons rotate complex muscle flaps, the prolonged use of multiple drains will increase infection rates. Thus, I would assume that most spine surgeons still routinely close their own primary and secondary ISF, with the rare exceptions of; infection, multiple revisions, prior radiation therapy, or other factors that have contributed to compromised skin. To test this hypothesis, I polled the spine surgeons on the Editorial Board of Surgical Neurology International (SNI) Spine Supplement, and asked two questions: Do you utilize plastic surgery to close primary ISF? Do you utilize plastic surgery to close secondary ISF? I also invited them to comment on the role of plastic surgery in primarily or secondarily closing ISF. Additionally, I reviewed pertinent literature. Nineteen spine surgeons from the Editorial Board answered the questionnaire. The 12 neurosurgeons and 7 orthopedic surgeons were from 9 different US states, and 2 were from Japan. Sixteen of the 19 who responded practice spine surgery in university settings, and 7 were chairman of departments. This is what I learned. The cumulative data revealed that no one routinely used a plastic surgeon to close adult primary or secondary ISF wounds. Only 2 of 19 surgeons advocated utilizing plastic surgeons to perform primary ISF wound closures (e.g., for infected or irradiated wounds). For secondary ISF closures, 12 of 19 surgeons rarely asked plastic surgeons to close their wounds, while 7 never asked plastic surgeons to be involved. The rare secondary indications for plastic surgeons to rotate complex muscle flaps included: infections, a history of radiation, multiple wound revisions (particularly posterior cervical), persistent cerebrospinal fluid leaks, pediatric spina bifida, and wide tissue defects. The 19 surgeons had various comments. One surgeon commented, “I do not use plastics to close any of my incisions/wounds. We do all our own closures. The only time we might use them is in pediatrics for closing a spina bifida.” Another commented, “On very rare occasions, maybe once every 3-4 years I may ask for help in a multioperated, radiated tumor patient because of poor tissue. In these cases we need a flap rotated. Very very rare situation.” Another stated “Kind of odd. I just never thought about needing to have this done by them (plastic surgeons). I have had some wound infections where they raise some local flaps, and have needed them on some occipital cervical infections in rheumatoids, but do not use them routinely.” Yet another surgeon responded, “We never ask anyone to close our wounds, with or without instrumentation, primary or secondary incisions. My orthopedic colleagues close their own wounds as well. They’re our wounds, and our responsibility to close them. Our wound infection rate is below the University Health System Consortium (UHC) standard, which we use as our benchmark. Also, if I were an insurer, I would not routinely pay extra for this, so it will probably come out of our reimbursement for the procedure.” I found four studies in the literature in which plastic surgeons closed secondary ISF wounds to address infection, irradiated skin, multiple revisions, and other factors requiring the rotation of complex muscle flaps to obtain closure.[1,2,3,4] Only one of these studies involved plastic surgeons to “prophylactically” close primary infected or irradiated ISF wounds.[1] In summary, there appears to be little precedent for spine surgeons to routinely request the assistance of plastic surgeons to close adult primary or secondary wounds for ISF. However, in rare secondary ISF cases, plastic surgeons may rotate complex muscle flaps in the presence of infection, prior radiation therapy, persistent cerebrospinal fluid leak, multiple revisions (including posterior cervical wounds), and other factors compromising skin closure.

Management of acute intraoperative cerebrospinal fluid leaks

Incidental durotomy in spinal surgery has been reported with incidences varying between 1 and over 16%, depending on the type of surgery and the region of the spine. When a dural tear occurs, immediate and meticulous repair is advised in order to minimize the risk of complications secondary to persistent leakage of cerebrospinal fluid (CSF). These complications include intracranial hypotension, pseudomeningocele formation and the development of a CSF fistula with secondary wound infection and meningitis. Most dural tears are caused during biting actions by Kerrison rongeurs, and dural adhesions, dural redundancy and thinned dura are known risk factors. Accurate visualization and thorough preparation of the surgical field are key steps in dural tear repair. Those tears that are amenable to it should be carefully sutured. Large defects may require a patch of dural substitute to be sewed in. Autologous fat has proven to be useful as onlay or plugin graft. The use of fibrin glue has become a widespread practice and its effectiveness as an adjunct to primary suturing and graft constructions has been well demonstrated. Hydrogel sealants and collagen matrix onlay grafts have become available to the surgeon as additional tools in dural tear repair. However, primary suturing — if possible — is still considered to be the most effective way of reducing the chance of persistent CSF leakage. Tight closure of the fascial layer is imperative. After lumbar durotomy repair, bed rest is advised. Postoperative lumbar or ventricular CSF drainage can also help as an additional protective measure. While numerous measures and tools are available, the key message is that the surgeon confronted with a dural tear should take his time and apply all intraoperative and postoperative means required to secure watertight closure.