Article
Outcome after surgical treatment of cerebrospinal fluid leaks in spontaneous intracranial hypotension – a matter of time
Ergebnisse der chirurgischen Behandlung von Liquorlecks bei spontaner intrakranieller Hypotension – eine Frage der Zeit
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Authors
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Levin Häni
- Inselspital, Universitätsspital Bern, Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Bern, Schweiz
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Christian Fung
- Universitätsklinikum Freiburg, Klinik für Neurochirurgie, Freiburg, Deutschland
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Christopher Marvin Jesse
- Inselspital, Universitätsspital Bern, Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Bern, Schweiz
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Christian Thomas Ulrich
- Lindenhofspital, Neurochirurgie, Bern, Schweiz
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Tomas Dobrocky
- Inselspital, Universitätsspital Bern, Diagnostische und Interventionelle Neuroradiologie, Bern, Schweiz
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Eike Imo Piechowiak
- Inselspital, Universitätsspital Bern, Diagnostische und Interventionelle Neuroradiologie, Bern, Schweiz
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Andreas Raabe
- Inselspital, Universitätsspital Bern, Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Bern, Schweiz
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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) leaking causes spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is a mainstay in the management of these patients. Despite surgical closure of the leak, some patients suffer from residual symptoms. Aim of the study was to assess predictors for favorable outcome after surgical treatment of SIH.
Methods: We included consecutive patients with SIH treated surgically from January 2013 to May 2020. Subjects were surveyed by a specifically designed questionnaire at a mean of 2.1 years after treatment. Primary outcome was resolution of symptoms rated by the patient as complete, partial or unchanged. Secondary outcome was postoperative headache intensity on the numeric rating scale 0-10. Association between variables and outcome was assessed using univariate ordinal logistic regression for the primary and univariate linear regression for the secondary outcome. Any variable with a p-value ≤ 0.15 was integrated into a multivariate model. We converted symptom duration to a logarithmic scale, since the data had a right skew. In order to define a cut-off value for continuous variables, we performed an ROC analysis using complete resolution of symptoms as a positive result.
Results: Eighty-six patients were identified, of which 69 (80.2%) returned the questionnaire and were analyzed. Mean age was 46.7 years and 65.2% of the patients were female. Mean pre- and postoperative headache intensity was 8.33 and 1.45 on the numeric rating scale. Neither sex, age, type of pathology (ventral vs lateral leak), lumbar opening pressure, nor initial presentation were associated with the primary outcome. A significant association with the primary outcome was found only for symptom duration (p=0.001), whereby a shorter symptom duration was associated with better outcome. Symptom duration remained the only significant predictor in a multivariate model (p=0.011). Similarly, only symptom duration was associated with the secondary outcome (p<0.001). ROC analysis of symptom duration yielded 9.1 weeks as reasonable cut-off with a false positive rate of 0.192.
Conclusion: Shorter duration of preoperative symptoms is the most powerful predictor of favorable outcome after surgical treatment of SIH. While an initial attempt of conservative treatment is justified, we advocate early surgical treatment within 9.1 weeks in case of persisting symptoms and a proven spinal CSF leak.
