Subfascial drainage and clipping technique for treatment of cerebrospinal fluid leak following spinal surgery

Objectives:To investigate the treatment of iatrogenic cerebrospinal fluid (CSF) leak that develops after degenerative lumbar spinal surgery with a subfascial drainage and clipping (SDC) technique.Methods:This study retrospectively reviewed the medical records of 46 patients who developed iatrogenic CSF leak after surgery for lumbar degenerative spine disease from 2007 to 2019. Twenty-five patients were treated with the SDC procedure (SDC group), whereas 21 were not (control group). Outcomes were compared between the two groups.Results:CSF leakage ceased within 6–9 days (average 7.4±1) after the procedure in the SDC group. In the control group, CSF leakage was controlled with conservative measures in 14 patients, and in 7 patients, lumbar external drainage was performed. Among these 7, the CSF leak was controlled by lumbar external drainage in 3, and 4 required reoperation to repair the dural defect. No infection occurred in either group. Length of hospital stay was also shorter in SDC group (8.4±1 vs 10.0±1.3 days, p < 0.001).Conclusion:The SDC technique is effective for the treatment of iatrogenic CSF leak that develops after degenerative lumbar spinal surgery.

Iatrogenic cerebrospinal fluid (CSF) leaks are one of the most common surgical complications of spinal surgery. Incidental dural injury is common during spinal surgery, epidural injection, and myelography. Previous studies have reported incidence rates ranging between 1% and 17% for incidental durotomy during surgery,¹ and Gerardi et al² reported a 6.8% incidence of intraoperatively undiagnosed CSF leak. As many patients with this condition are asymptomatic, it is difficult to predict CSF leaks that are not diagnosed at the time of surgery. Patients with symptomatic CSF leaks may suffer intracranial hypotension-related vertigo, posture-related headache, photophobia, double vision, neck stiffness and dizziness.Patients who are not diagnosed at the time of surgery or undergo inadequate dural repair may develop a postoperative dural leakage or pseudomeningocele.³In 1983, Teplick and Haskin⁴ reported a pseudomeningocele incidence of 1.6% detected by computerised tomography imaging among 750 patients who underwent lumbar spinal surgery and remained free of dural leak. When they occur, cutaneous leakage usually develop between the first and seventh days after surgery.In spinal CSF leaks, oversuturing the incision and application of a pressure dressing may suffice in most cases. When these measures fail, bed rest in the semi-Fowler’s position is recommended. The main target of bed rest is to reduce the CSF hydrostatic pressure in the lumbar region. In 2 previous studies, Wang et al² systematically prescribed short-term (2.9 days) bed rest, and Camisa et al² prescribed bed rest for 3–5 days. In addition, acetazolamide,⁵ repair with blood patch, and closed lumbar subarachnoid CSF drainage can be used. Kitchel et al reported that closed subarachnoid CSF drainage is an effective technique for treatment of postoperative CSF leaks and can prevent a repeat surgical intervention.⁶ Despite this, the outcomes are not always favourable. When these measures fail, a second surgery for primary dural repair can be performed.Cain et al⁷ examined the biology of a dural CSF leak repair in a canine model. They reported that fibroblastic bridging started on the 6th day and dural defects were healed on the 10th day.We did not encounter any other study in the literature that described the subfascial drainage and clipping (SDC) technique that we perform to treat CSF leaks after degenerative lumbar spinal surgery and report our experience herein.