Persistent Cerebrospinal Fluid Leak Research Articles

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.

Intracranial subdural hematoma coexisting with improvement in spontaneous intracranial hypotension after an epidural blood patch

A 36-year-old male had spontaneous intracranial hypotension (SIH) presenting with refractory headache for 4 months. Multiple epidural blood patches (EBPs) yielded relief of symptoms, but the course was complicated, with asymptomatic intracranial subdural hematoma (SDH). Except for SDH, other radiological diagnostic signs of SIH were resolved and the patient’s headaches improved after EBP. Owing to a mass effect and persistent cerebrospinal fluid (CSF) leakage, surgical repair of the spinal leakage was performed, but no cranial procedures were carried out. Postoperatively, the SDH completely resolved, but there was still CSF leakage at the level where surgery was performed. The patient has remained free of headache or other events for 3 years. It was reduction rather than elimination of the spinal CSF leak that yielded remission of SIH. In summary, intracranial SDH can be a complication of inadequately treated SIH (i.e. persistent minor CSF leakage). Management of SDH should focus on correction of the underlying SIH rather than craniotomy for hematoma evacuation.

Salvage endoscopic nasoseptal flap repair of persistent cerebrospinal fluid leak after open skull base surgery

PurposePersistent cerebrospinal fluid (CSF) rhinorrhea after open skull base surgery can be challenging to manage due to the risk of meningitis, brain abscess, surgical morbidity associated with revision craniotomy, and the lack of available healthy autologous tissue after failure of a pericranial flap. Given the recent success of the vascularized pedicled nasoseptal flap (PNSF) for reconstruction after endoscopic skull base surgery, we have adopted this technique as a salvage method to treat recalcitrant CSF rhinorrhea after previous open skull base surgery in order to avoid revision craniotomy. To our knowledge, use of the PNSF in this setting has not been previously described in the literature. MethodsA retrospective analysis was performed on 4 patients who underwent endoscopic endonasal PNSF repair of persistent CSF rhinorrhea after having undergone previous open transcranial skull base operation. Pathologies consisted of one sinonasal anterior skull base squamous cell carcinoma, one recurrent petrosal skull base meningioma, and 2 traumatic gunshot wounds to the head. ResultsAll 4 patients underwent successful repair of CSF rhinorrhea without complications using the salvage endoscopic endonasal PNSF technique after a mean follow-up of 21.5 months. ConclusionsIn patients who have undergone previous open skull base surgery as the primary approach, persistent CSF rhinorrhea can be safely repaired using the vascularized PNSF via an endoscopic endonasal approach. This minimally invasive strategy has the advantage of providing new healthy vascularized tissue for skull base reconstruction while avoiding revision craniotomy.

Symptomatic Postlaminectomy Cerebrospinal Fluid Leak Treated With 4-Dimensional Ultrasound-guided Epidural Blood Patch

A persistent cerebrospinal fluid leak after spinal surgery can be associated with both meningitis and/or pneumocephalus. Therefore, early active intervention is recommended with surgical exploration, lumbar subarachnoid drain, and less commonly epidural blood patch. In the absence of a ligamentum flavum, the use of high-resolution ultrasound (US) spine imaging enables real-time advancement of a Tuohy needle towards the dura and the precise injection of blood to cover the dural defect. Six patients, after lumbar spine surgery with instrumentation and primary closure was complicated by incidental dural tears, developed severe symptomatic headaches that failed conservative therapy. All patients underwent US-guided epidural blood patch. Precise needle advancement to the dura was observed with US guidance, and 4-dimensional US scanning was used to confirm the expansion of blood over the dura in real time. All patients had symptomatic relief of their headaches and successful treatment of dural leaks using US-guided blood patch. Real-time US guidance allowed accurate positioning of the Tuohy needle and deposition of the epidural blood patch in the setting of a surgically removed ligamentum flavum. Further investigations are needed to confirm that an US-guided epidural blood patch may offer reliable symptomatic relief to postsurgical persistent cerebrospinal fluid leak and may serve as an intermediate step along a spectrum between conservative initial management and surgical reexploration.

Management of Cerebrospinal Fluid Leakage After Anterior Decompression for Ossification of Posterior Longitudinal Ligament in the Thoracic Spine

Retrospective review To determine the efficacy of management of cerebrospinal fluid (CSF) leakage after the anterior thoracic approach. CSF leakage after incidental durotomy commonly occurs after anterior thoracic ossification of posterior longitudinal ligament (OPLL) surgery. Pseudomeningocele will invariably form under such circumstances. Among them, uncontrolled CSF leakage with a fistulous condition is problematic. As a solution, we have managed these durotomies with chest drains alone without any CSF drainage by the concept of a "volume-controlled pseudomeningocele." Between 2001 and 2009, CSF leakage occurred in 26 patients (37.7%) of the total 69 patients who underwent anterior decompression for thoracic OPLL. In the initial 11 cases, subarachnoid drainage was utilized as an augmentive measure in combination with chest tube drainage in the postoperative period (group A). In the subsequent 15 cases, the durotomy was managed in a similar manner but in the absence of any subarachnoid drainage (group B). Various parameters such as the duration of postoperative hospital stay, clinical outcome score, drainage output, resolution of CSF leakage, complications, and additional surgery performed were analyzed and compared between the 2 groups. A resolution of the CSF leakage grading system was also proposed for the residual pseudomeningocele that formed in each group. There were statistically no significant differences in the outcome parameters between the 2 groups and also in patients with grade I or grade II residual pseudomeningocele of the new grading system. Two complications occurred in group A. No reexploration for persistent CSF leakage was required in both groups. CSF leakage managed with controlled chest tube drainage can produce a comparable result with those with additional subarachnoid drainage when watertight dural repair is impossible. The concept of controlled pseudomeningocele may be a useful and practical technique for the treatment of CSF leakage after anterior thoracic OPLL surgery.

Transmastoid approach to temporal bone cerebrospinal fluid leaks

PurposeThe aim of the study was to evaluate various presentations and treatment options for spontaneous cerebrospinal fluid (CSF) leakage originating in the temporal bone. Materials and MethodsClinical data and imaging results for 18 ears (15 patients) presenting with spontaneous CSF leakage originating in the temporal bone were reviewed. Average follow-up period was 13.5 months. The main outcome measure was presence of persistent CSF leak postoperatively. A standard postauricular mastoidectomy was performed. ResultsFifteen patients diagnosed with spontaneous CSF leakage over an 8-year period including 3 treated for bilateral disease were included in the study. The age ranged between 33 and 83 years. Presenting symptoms included serous otitis media (44%), persistent otorrhea after tympanostomy tube placement (28%), and meningitis (28%). Preoperative diagnosis was made using imaging studies and was substantiated by observation of CSF leakage and dural herniation intraoperatively. Treatment was eustachian tube plugging (5%), mastoidectomy with fat obliteration (61%), middle fossa approach with extradural (17%), intradural repair (5%), or combined middle fossa and transmastoid (TM) approach (11%). Successful treatment was obtained in 17 of the 18 cases. The last 9 patients in the series underwent TM approach alone for repair with no treatment failures. ConclusionsRepair of defects in tegmen mastoideum and posterior fossa can be successfully achieved on an outpatient basis without regard to size and multitude of defects via TM approach. This approach obviates the need for a craniotomy or lumbar drain.

Headache and Meningismus Following Lumbar Puncture

Post-lumbar puncture headache is the most common complication of lumbar puncture. This condition is thought to be the result of persistent cerebrospinal fluid leakage at the puncture site, leading to low cerebrospinal fluid pressure and traction on the meninges and intracranial veins. Associated symptoms may include nausea, vomiting, auditory and vestibular symptoms. Meningeal irritation signs are unexpected as clinical findings unless serious medical conditions such as subarachnoid hemorrhage or meningitis occur. We are present a case of headache and meningismus following by lumbar puncture. A 17-year-old female presented to the emergency department suffering from headache, nausea and vomiting, starting one day after a lumbar puncture procedure. The characteristics of the headache were different and more severe than the previous form. Her vital signs and physical and detailed neurological examination were normal, except meningismus findings such as neck stiffness and Brudzinksy’s sign. Since the meningismus findings were unexpected, lumbar puncture was performed again to diagnose meningitis and subarachnoid hemorrhage. Cerebrospinal fluid pressure, protein, glucose, microscopic examination, blood and cerebrospinal fluid cultures were normal. Finally, magnetic resonance imaging of the brain revealed no pathological meningeal enhancement. In patients harboring uncontrollable factors, variables such as needle size, bevel orientation and the avoidance of traumatic lumbar puncture should be taken into consideration more seriously than ever. Furthermore, since, meningeal irritation signs such as neck stiffness and Brudzinksy’s and Kernig’s signs are not the expected clinical findings of post-lumbar puncture headache, serious medical conditions such as subarachnoid hemorrhage and meningeal infections should be investigated in the emergency setting.

Primary Closure of Inadvertent Durotomies Utilizing the U-Clip in Minimally Invasive Spinal Surgery

Retrospective clinical cohort study. To examine performance of the U-Clip for the closure of inadvertent durotomy occurring during minimally invasive spinal surgery. Primary closure of inadvertent durotomies that occur during minimally invasive spinal surgery can be technically difficult to accomplish when using standard knot-tying and suture management techniques, owing to the narrow and deep surgical corridor afforded by tubular retraction systems. The U-Clip is a novel device that can achieve tight tissue approximation without the need for knot-tying and excessive suture manipulation, making it ideally suited for use in minimally invasive spinal surgeries. We performed a retrospective review of patients who underwent minimally invasive decompressive procedures complicated by durotomy and repaired using U-Clips for the period January 2008 to January 2010. A total of seven patients were identified. Four of the seven patients were male. Six patients underwent lumbar laminectomy or discectomy. One patient underwent resection of a cervical synovial cyst. In each patient, the durotomy was repaired primarily using U-Clips. All six lumbar patients were discharged home on the same day, and the remaining patient was discharged the following morning. Mean follow-up was 6.3 months. No patient experienced symptoms related to persistent cerebrospinal fluid leakage. Primary closure of an inadvertent durotomy occurring during minimally invasive spinal surgery can be effectively achieved using the self-closing U-Clip device.

Endoscopic Removal of a Bullet Penetrating the Middle Cranial Fossa

Reports of intracranial retained foreign bodies are relatively rare in the literature. Such objects can cause numerous complications requiring removal, such as infection, persistent cerebrospinal fluid (CSF) leak, or new-onset seizures. The transnasal endoscopic approach provides an excellent alternative to craniotomy for repairing middle cranial fossa (MCF) defects. We describe a case of a 57-year-old woman with a self-inflicted bullet piercing the MCF, creating a persistent CSF leak. The details regarding the removal of this penetrating foreign body from the MCF, including the unique management in the setting of a contralateral spontaneous CSF leak, are discussed.

Catheter-over-needle typeのくも膜下カテーテルへの入れ替えにより髄液漏が改善した症例

Catheter-over-needle typeのくも膜下カテーテルへの入れ替えにより髄液漏が改善した症例

Postoperative pseudomeningocele in a 40-year-old man

Postoperative pseudomeningocele is a relatively rare complication of spinal surgery. In addition to patient inconvenience and apprehension, it is also associated with other morbidities, such as headache, lumbar discomfort, and radiculopathy. The word ‘‘pseudo-’’ means that the lesion does not possess of a true meningeal layer lining the cyst wall, which is not a complete sac or cyst and communicates with the arachnoid space. Herein we present a patient who suffered pseudomeningocele formation after lumbar surgery, and was treated successfully with reoperation. This 40-year-old man had a L4–L5 laminectomy, pedicle screw fixation, and intervertebral bone graft fusion for low back pain on March 2004 at a local hospital. During the operation, a cerebrospinal fluid (CSF) leak had occurred. After 1.5 months without symptoms, he came to our hospital for recurrent legs pain and postural headache. On physical examination, there was a palpable fluctuating mass under the previous surgical scar. Magnetic resonance imaging (MRI) revealed an oval-like cystic collection lying posterior to L3–L5 vertebrae. The lesion was about 5 9 8 cm and isointense compared with the CSF signal on both T1and T2-weighted images (Fig. 1). A diagnosis of postoperative pseudomeningocele was highly suspected. Because of failure of conservation treatment, the wound was reopened on February 2005. The entire cyst was visualized and followed deep into the durotomy site. It was fluctuant and tense, and the walls were thin, shiny, and pinkish white. About 100 mL translucence fluid fluxed when incised it. A tiny communication between the dural sac and the pseudomeningocele was seen with the aid of a Valsalva maneuver. After freeing and returning all nerve roots into the intradural space, the defect was sealed. Subcutaneous fat was placed loosely over the site of the dural repair. Paraspinal muscles and overlying fascia were closed in two layers with sutures placed 3–4 mm apart. Drainage tube was not used routinely because we considered that it might lead to the persistence of communication between the intraand extradural spaces and serve as nidus for infection. Postoperatively, he had a good recovery. Postural headache and legs pain were resolved immediately. With a 4-year follow-up, he was still free of symptom. Postoperative pseudomeningocele is described as ‘‘ugly bulging wounds filled with fluid’’ lying dorsal to the thecal canal. It has been postulated occurring mostly by CSF fistula, and these two can be considered to be on a continuum. It may or may not be associated with an arachnoid tear, but a dural tear is necessary for one to form. In this case, it seemed likely, in the presence of a dural defect, that the intradural pressure of the CSF caused a constant outflow of CSF, which kept the tiny defect opening and prevented healing. On the other hand, as a consequence of paravertebral muscle atrophy after previous procedures, there was less soft tissue to tamponade the CSF leak. The resultant paravertebral dead space became filled with CSF and subsequently formed the pseudomeningocele cavity. Although persistent CSF leakage existed, it still took times (more than 1 month) to become large enough to cause the signs and symptoms. C. Liu H.-X. Cai S.-W. Fan (&) Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China e-mail: srrshspine@hotmail.com

Transpalpebral Orbitofrontal Craniotomy: A Minimally Invasive Approach to Anterior Cranial Vault Lesions

To describe a minimally invasive approach to anterior cranial vault pathology using a transpalpebral exposure with a miniorbitofrontal craniotomy. Case series. Tertiary referral hospital with multidisciplinary skull base program. Participants include patients with intra-axial and extra-axial anterior skull base lesions who underwent the transpalpebral minicraniotomy approach. Feasibility of the approach to permit adequate exposure of targeted lesion. We applied this approach in seven patients for the repair of persistent cerebrospinal fluid leaks, pneumocephalus, and the biopsy or resection of midline brain tumors along the anterior cranial base. The approach allowed bimanual instrumentation working with either endoscopic or microscopic visualization for tumor resection and repair of dural and cranial base defects. We measured an average working distance of 4 cm to the sella. The transpalpebral miniorbitofrontal craniotomy approach to the anterior cranial base is quick, adequate, and safe and should be considered as an alternative to extended bifrontal approaches and/or pterional craniotomies for select anterior cranial vault pathology.

Reconstruction After Posterior Cranial Fossa Surgery—Case Report of Application of a Synthetic Tissue Sealant to Augment Dural Closure

Cerebrospinal fluid (CSF) leakage following cranial surgery is a well-described and potentially devastating complication, particularly in posteriorcranial fossa surgery. If untreated, a persistent CSF leak can evolve into wound breakdown, a surgical-site infection, and meningitis. Themorbidity of a complication following a cranial operation is harmful to the patient. Additionally, complications are a source of elevated medicalcosts. Numerous reconstruction strategies have been developed to thwart the ill effects of CSF leaks on patient outcomes and healthcarefinances. This case report illustrates the method employed at our institution to repair posterior fossa defects following surgery in thecerebellopontine angle.

Endoscopic transnasal management of cerebrospinal fluid leaks of the sphenoid sinus

The authors reviewed the medical records of patients who had undergone endoscopic management of sphenoid sinus (SS) cerebrospinal fluid (CSF) leaks in our department between 2005 and 2007. Eight patients were included in this study: 4 males and 4 females. CSF fistulae were due to trauma, surgery, and some were idiopathic. In all the patients, a multilayer skull base closure was performed. No SS obliteration was carried out. One patient required revision surgery for persistent CSF leak. Multilayer skull base closure is confirmed as the preferred option in sphenoid CSF leaks. The limited morbidity and high success rate fit well with the data in the literature and make this treatment option advisable.

Median Facial Cleft with a Frontoethmoidal Encephalocele Treated with Craniofacial Bipartition and Free Radial Forearm Flap: A Case Report

We describe a patient with a median facial cleft with a frontoethmoidal encephalocele, hypertelorism, hydrocephalus, and cerebrospinal fluid (CSF) leakage referred to our department due to numerous complications after previous surgical treatments. An 8-year-old girl, born with median cleft syndrome, underwent neurosurgical repair of the encephalocele at another hospital and cleft lip/palate repair later in the same year. Her hydrocephalus was treated with a ventriculoperitoneal shunt, but she underwent numerous shunt revisions due to recurrent intracerebral infections. In 2008, she was rehospitalized due to a gram-negative meningitis and cerebral abscess. She underwent surgery where part of her frontal bone was removed due to osteomyelitis. She was referred to our department due to persistent CSF leakage, recurrent infections, and significant dura defect. In addition, she had hypertelorism and a strongly reduced vision. We performed a monobloc and facial bipartition osteotomy where 15 mm of her frontal and nasal bone was removed after facial bipartiton. The dura defect was closed using a free fasciocutanous flap. The patient had no CSF leakage or infections postoperatively, and her hypertelorism was reduced. The case represents the first monobloc and facial bipartition osteotomy performed in Norway as a part of the treatment of median cleft syndrome with a nasoethmoidal encephalocele.

Fallopian Canal Meningocele

The purpose of this study is to report 2 rare cases of congenital fallopian canal meningoceles. Magnetic resonance imaging, computed tomography (CT) of the temporal bone, CT-cisternogram, and combined transmastoid approach with middle fossa craniotomy in 2 patients. Radiologic and operative diagnosis of congenital fallopian canal meningoceles. Presentations included spontaneous cerebrospinal fluid (CSF) otorrhea and recurrent meningitis with intracranial hypertension. Postoperative complications included facial nerve palsy and persistent CSF leaks that necessitated ventriculoperitoneal shunt and lumbar drain placement. Use of CT of the temporal bone in combination with CT-cisternogram may define sites of active CSF leak. Intraoperative use of fluorescein may assist identification of cranial base defects to lower rates of recurrence, and intraoperative use of cranial nerve monitoring can minimize the risk of nerve injury during repair.

Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery

Approximately one million spinal surgeries are performed in the United States each year. The risk of an incidental durotomy (ID) and resultant persistent cerebrospinal fluid (CSF) leakage is a significant concern for surgeons, as this complication has been associated with increased length of hospitalization, worse neurological outcome, and the development of CSF fistulae. Augmentation of standard dural suture repair with the application of fibrin glue has been suggested to reduce the frequency of these complications. This study examined unintended durotomies during lumbar spine surgery in a large surgical patient cohort and the impact of fibrin glue usage as part of the ID repair on the incidence of persistent CSF leakage. A retrospective analysis of 4,835 surgical procedures of the lumbar spine from a single institution over a 10-year period was performed to determine the rate of ID. The 90-day clinical course of these patients was evaluated. Clinical examination, B-2 transferrin assay, and radiographic imaging were utilized to determine the number of persistent CSF leaks after repair with or without fibrin glue. Five hundred forty-seven patients (11.3%) experienced a durotomy during surgery. Of this cohort, fibrin glue was used in the dural repair in 278 patients (50.8%). Logistic models evaluating age, sex, redo surgery, and the use of fibrin glue revealed that prior lumbar spinal surgery was the only univariate predictor of persistent CSF leak, conferring a 2.8-fold increase in risk. A persistent CSF leak, defined as continued drainage of CSF from the operative incision within 90 days of the surgery that required an intervention greater than simple bed rest or over-sewing of the wound, was noted in a total of 64 patients (11.7%). This persistent CSF leak rate was significantly higher (P < 0.001) in patients with prior lumbar surgery (21%) versus those undergoing their first spine surgery (9%). There was no statistical difference in persistent CSF leak between those cases in which fibrin glue was used at the time of surgery and those in which fibrin glue was not used. There were no complications associated with the use of fibrin glue. A history of prior surgery significantly increases the incidence of durotomy during elective lumbar spine surgery. In patients who experienced a durotomy during lumbar spine surgery, the use of fibrin glue for dural repair did not significantly decrease the incidence of a persistent CSF leak.

Duraplasty Using Autologous Fascia Lata Reenforced by On-site Pedicled Muscle Flap: Technical Note

Postoperative cerebrospinal fluid (CSF) leak is a common complication in the practice of neurosurgery, and various surgical techniques were described to overcome and manage this problem. Besides not applying watertight closure of the duraplasty, the inviability and the poor vascularization of the graft and/or the dura (eg, reoperations, multiple operations, or cranial radiotherapy) may lead to delayed healing of the suture site and resultant persistent CSF leaks. We present a simple technique that uses on-site muscle flap with pedicle to supply and vascularize the autologous fascia lata, preserving the viability of the graft and reenforcing its healing ability. We applied this technique in 6 patients with postoperative CSF leaks. After harvesting a fascia lata graft with appropriate size from the patients, the graft was sutured to dural defect in watertight fashion. The suboccipital, temporal, and temporal muscles in 4 patients who had posterior fossa duraplasty, in 1 patient who had pterional craniotomy, and in 1 patient who had subtemporal craniotomy, respectively, were dissected, stretched, and sutured to the fascia graft covering the dura graft suture site and then reinforced by Tisseel fibrin glue (Baxter Healthcare Corporation, Deerfield, IL). Postoperatively, CSF lumbar drain was kept open for 72 hours with pressure wound dressing. The technical nuances are illustrated. Cerebrospinal fluid leaks were controlled successfully in 5 patients without recurrence. One patient with posterior fossa duraplasty had recurrence of CSF leak that required reexploration 21 days after the first surgery and a second dural repair in a site distant from the fascia lata attachment. During reexploration intraoperatively, the fascia lata graft was inspected and studied, which has shown the healing of the dura graft site and the graft neovascularization. Duraplasty using autologous fascia lata reenforced by on-site pedicled muscle flap is an effective technique to control CSF leak, especially when dura is poorly vascularized and less viable. The unfortunate recurrence of CSF leak and reexploration in the seventh patient helped us to observe the effectively healed dural defect with profound early postoperative vascularization of the graft, supporting our idea about the effectiveness of this technique.

Pediatric Orbital Fractures: Classification, Management, and Early Follow-Up

Scarce literature exists addressing the presentation, classification, and management of pediatric orbital fractures. The aim of this study is to review the authors' experience with the presentation, management, and early follow-up of pediatric orbital fractures. A retrospective review of pediatric orbital fractures presenting to the Children's Hospital of Pittsburgh between 2003 and 2007 was performed. Demographics, associated injuries, computed tomographic scan findings, management, and follow-up were collected. From these data, a pediatric orbital fracture classification system was devised. Seventy-four patients (81 orbits) were reviewed. Average age at presentation was 8.6 years. Fractures were distributed as follows: type 1, 40.7 percent; type 2, 33 percent; and type 3, 25.9 percent. Twenty-three orbits were treated surgically and 58 were treated nonoperatively. The operative rates were as follows: type 1, 9.1 percent; type 2, 14.8 percent; and type 3, 76.2 percent. Complications included minor enophthalmos in seven patients, and persistent cerebrospinal fluid leak in two growing skull fractures. For type 1 (pure orbital) fractures, three (12 percent) underwent surgical treatment for acute enophthalmos, vertical orbital dystopia, or muscle entrapment. Twenty-two orbits (88 percent) were managed nonoperatively. At an average follow-up of 13 months, minimal enophthalmos (1 to 2 mm) was found in one of the surgically treated fractures (33 percent) and in three of the conservatively managed fractures (13.6 percent). For type 1 (pure orbital) fractures, unless there is evidence of acute enophthalmos, vertical orbital dystopia, or muscle entrapment, a nonoperative approach is advocated. Type 2 (craniofacial) fractures should be followed with serial computed tomographic scans; and type 3 (common fracture patterns) fractures have a greater chance of requiring surgery.

Management of Pericatheter Cerebrospinal Fluid Leak After Intrathecal Implantation of a Drug Delivery System

Persistent cerebrospinal fluid leak is a known complication of intrathecal pump system insertion for drug delivery. Various treatment modalities, such as an epidural blood patch, use of glue, removal of catheter, and surgical closure of dura and subdural blood patch, have been reported previously. This report presents a 35-year-old woman in whom an intrathecal pump system was inserted for cancer pain management with intrathecal morphine. This was complicated by a persistent cerebrospinal fluid leak that was successfully managed by purse-string sutures over the dura around the catheter, without removing the intrathecal implant. The cause of the cerebrospinal fluid leak and different treatment approaches are discussed.