Article
Minimally invasive surgery for spinal CSF-leaks in spontaneous intracranial hypotension
Minimal-invasive Chirurgie als Behandlung spinaler Liquorlecks bei Patienten mit spontaner intrakranieller Hypotension
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Authors
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Christian Fung
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Ulrich Hubbe
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Jan-Helge Klingler
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Roland Rölz
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Florian Volz
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Petros Evangelou
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Horst Urbach
- Universitätsklinikum Freiburg, Neuroradiologische Klinik, Freiburg, Deutschland
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Jürgen Beck
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
| Published: | June 4, 2021 |
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Outline
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Objective: Spinal cerebrospinal fluid (CSF)-leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF-leaks is the treatment of choice after conservative therapy and blood patching have failed. The objective of the study was to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal dural CSF-leaks using tubular retractors.
Methods: Since April 2019 we included all consecutive patients with SIH undergoing surgery for a spinal CSF-leak. Dynamic myelography studies were used to localize the leak. Surgery was performed under general anesthesia in the prone position via a 2.5 cm dorsal midline incision using 18-20 mm tubular retractors. After microsurgical unilateral hemilaminotomy ventral leaks were sealed via a transdural route while cutting the dentate ligament. Intraoperative neuromonitoring was used for ventral leaks in the first 16 cases. The primary outcome was the successful achievement of minimally invasive dura sealing; secondary outcome was the occurrence of complications.
Results: 45 patients, mean age 48.4 years (SD 13.5), 30 female and 15 male patients, with the diagnosis of SIH and Superficial Siderosis have been included. We diagnosed 29 ventral leaks, 14 dorsal/lateral leaks, 1 CSF-venous fistulas. In all but one patients (98%) the leak could be approached, identified and closed via the tubular retractor. In 1 (2%) patient the leak was missed due to misinterpretation of imaging studies. Microspurs were removed or drilled and leaks were either closed by suturing (6-0) or by sandwich patch using a fibrin sealant patch (TachoSil).
Imaging signs of SIH (brain or spine MR) improved in all cases. Despite surgical closure of the leak, clinical outcome was mixed, all patients improved to some extent, but a significant number of patients was still symptomatic and needed prolonged recovery. There were no permanent neurological deficits. There was one reoperation for wound healing and one for dorsal suture deficiency.
Conclusion: Minimally invasive surgery using tubular retractors of 18-20mm diameter can be safely and effectively performed for closure of spinal dural CSF-leaks in specialized centers.
