gms | German Medical Science

Objective: Posterior Lumbar Interbody Fusion (PLIF) is increasingly applied for the treatment of spinal stenosis and spondylolisthesis. A known complication is injury of the dura and CSF fistula. In this retrospective study we evaluated risk factors for intraoperative CSF fistulas and its impact on the postoperative course.

Method: A cohort of 541 patients, who underwent primary PLIF surgery at our department between 2005 and 2015 was analyzed. Use of microsurgical technique, previous lumbar surgery, preoperative clinical symptoms, age and number of operated levels were assessed and the risk for intraoperative CSF fistula was estimated using the Log-likelihood test and Wald-test, respectively. The association of CSF-fistula and postoperative parameters, such as duration of hospital stay, duration of bed rest, postoperative antibiotic use and follow-up surgery were analyzed using the quantile regression model.

Results: Median age of patients was 68 years. 77 (14.2%) patients with intraoperative CSF fistula were observed. Previous lumbar surgery (10.16 vs. 24.2%, p<0.001) and number of operated levels (single level vs. multiple levels, p=0.03) were shown to be significantly associated with the occurrence of intraoperative CSF fistula. Age, the use of microsurgical technique and preoperative clinical symptoms did not have significant impact on intraoperative CSF fistula. The occurrence of a CSF fistula was significantly associated with a prolonged bed rest (p<0.001) and hospital stay (p=0.041), increased use of prophylactic postoperative antibiotics (p<0.001) and a higher risk for follow-up surgery (17.6% vs. 27.2%, p=0.043). Nine out of 77 patients (11.7%) with an intraoperative CSF leak needed revision surgery for the CSF fistula, whereas 12 patients (15.5%) had follow-up surgery for other indications.

Conclusions: In the present study, we were able to identify important parameters associated with a higher risk for intraoperative CSF fistula. Especially in patients, who had undergone previous lumbar surgery and those with multi-level disease, particular precaution is required. On the other hand, the use of microsurgery had no impact on CSF fistula. Furthermore, we were able to verify the morbidity associated with CSF fistula as shown by increased immobilization and follow-up surgeries which emphasizes the importance of developing strategies to minimize the risk of intraoperative CSF fistula.