Computed tomography–guided epidural patching of postoperative cerebrospinal fluid leaks

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Cerebrospinal fluid leaks due to unrecognized durotomy during spinal surgery are often managed with a second surgery for dural closure. CT-guided percutaneous patching targeted to the dural defect offers an alternative to surgery since it can be performed in a minimally invasive fashion without the need for general anesthesia. This case series describes the authors' experience using targeted CT-guided percutaneous patching to repair incidental durotomies incurred during spinal surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>This investigation is a retrospective case series involving patients who underwent CT-guided percutaneous patching of surgical incidental durotomies and were referred between January 2007 and June 2013. Their presenting clinical history, myelographic findings, and clinical outcomes, including the need for eventual surgical duraplasty, were reviewed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Nine cases were identified, including 7 durotomies incurred during lumbar discectomy, one due to a medial transpedicular screw breach, and one incurred during vertebrectomy for spinal osteosarcoma. All patients who had favorable outcomes with percutaneous intervention alone had 2 common features: dural defect of 4 mm or smaller and absence of a pseudomeningocele. Patients with CSF leaks complicated by pseudomeningocele and those with a dural defect of 6 mm or more all required eventual surgical management.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The authors' results suggest that findings on CT myelography may help predict which patients with postsurgical durotomy can be treated with percutaneous intervention. In particular, CT-guided patching may be more likely to be successful in those patients with dural defects of less than 5 mm and without pseudomeningocele. In patients with larger dural defects or pseudomeningoceles, percutaneous blood patching alone is unlikely to be successful.</jats:p></jats:sec>

The New Strategy for the Treatment of Cerebrospinal Fluid Leak Following Lumbar Surgery

“…Several methods are used for the management of CSF leak including direct suturing 1,6) , percutaneous injection 7,8) , drainage therapy [9][10][11] , and blood patch 9,[12][13][14] . One well-known and widely accepted management option is surgical repair by either meticulous direct primary closure of the dura or augmented closure by means of fat, muscle tissue, or a fascia graft.…”

Incidence and management of cerebrospinal fluid fistulas in 336 multilevel laminectomies with noninstrumented fusions

“…evaluated the efficacy of repairing postoperative CSF fistulas utilizing MI, percutaneous CT-guided epidural patching. [ 12 ] The study retrospectively identified 9 such cases utilizing CT myelography; those effectively treated percutaneously had dural defects of 4 mm or less without pseudomeningoceles, while those with larger defects and pseudomeningocele could not be managed with this percutaneous strategy.…”

Liquorverlustsyndrom

“…Bei Leckagen bis zu einer maximalen Grö-ße von 5 mm ist der "blood patch" meist erfolgreich, bei größeren Leckagen kann eine offene operative Versorgung erforderlich werden [14]. Sollte der "blood patch" bei kleineren Leckagen auch nach der dritten Anwendung noch nicht suffizient sein, besteht als weitere Therapieoption die CTAbb.…”

“…Der erste "blood patch" ist in bis zu 85% der Fälle wirksam, nach einmaliger Wiederholung wird bereits eine Wirksamkeitsrate von bis zu 98% erreicht [1,2,4,5,9,12,14,18,21,23,28]. Da manche Patienten mit spontanem Liquorverlustsyndrom auf mehreren Höhen Liquorlecks aufweisen, können mehrere "blood patches" auf verschiedenen Höhen erforderlich sein.…”