16.5. Cerebrospinal fluid leakage
@ProfFishchenkoCerebrospinal fluid leakage may occur after BESS/UBE following recognized or unrecognized intraoperative dural injury. This complication is also possible after other spinal operations. The strategy depends on the defect, quality of closure, and postoperative symptoms.
Incidence:
The incidence of dural tears and clinically significant postoperative cerebrospinal fluid leakage varies according to the operation, patient group, and definition used.
Why does cerebrospinal fluid leakage occur?
Leakage occurs when dural integrity is disrupted and cerebrospinal fluid (CSF) escapes from the subarachnoid space:
Cause: Most often, an intraoperative dural tear that was not completely closed or became apparent after surgery (for example, due to increased cerebrospinal fluid pressure).
Types of cerebrospinal fluid leakage after UBE:
External cerebrospinal fluid leakage:
- CSF leaks externally through the surgical wound. Small portal size does not exclude an external leak.
- If a drain has already been placed in the presence of an unrecognized defect, CSF may pass through it. Clear fluid and rapid reservoir filling raise suspicion, but color alone does not confirm CSF leakage.
Contained CSF collection (pseudomeningocele):
- CSF accumulates in soft tissues, forming a localized collection.
Occult cerebrospinal fluid leakage:
- A small leak with no external manifestation that causes symptoms through reduced CSF pressure (hypotension).
Symptoms:
Direct signs:
- Clear fluid leakage from the puncture site (rare, but possible with a substantial tear).
- Soft, tender swelling at the surgical site (pseudomeningocele).
Indirect signs (CSF hypotension syndrome):
- Headache: Postural, worsening when upright and relieved by lying down.
- Nausea, vomiting, and dizziness.
- Tinnitus or hearing impairment (due to altered inner ear pressure).
Severe manifestations (rare): infection (meningitis) if leakage persists and provides an entry route for infectious agents.
Diagnosis:
Clinical assessment: Postural headache or swelling at the surgical site first raises suspicion.
Imaging:
- MRI: identifies a CSF collection (pseudomeningocele) as a hyperintense area on T2 images.
- CT: Shows a dural defect or fluid in the epidural space.
Laboratory analysis: If there is leakage through the skin, the fluid is tested for beta-2 transferrin — a specific marker of cerebrospinal fluid.
Treatment:
Conservative (for a small or occult CSF leak):
- In our practice, after secure suturing of a dural defect, mobilization may begin earlier than 24 hours, depending on the patient’s condition. If the defect is closed with TachoSil without suturing, we begin mobilization no earlier than 24 hours. In both cases, we prescribe additional antibiotic therapy and monitor the wound for CSF leakage during the first week.
- Adequate oral or intravenous hydration according to the patient’s condition.
- Analgesics (paracetamol, ibuprofen) for headache control.
- In our practice, we do not place an operative drain after recognized dural injury. Suspected CSF leakage through a previously placed drain requires assessment by the surgeon and adjustment of the strategy.
Surgical closure of the defect
When a dural defect is identified intraoperatively, we lower the irrigation height and inspect the defect and neural structures. In our practice, we close tears up to and including 5 mm with TachoSil and suture those larger than 5 mm with VICRYL 4-0 (RB-1 Plus needle, 17 mm, 1/2 circle). We also consider the shape and location of the defect and involvement of neural structures. Persistent or symptomatic postoperative CSF leakage requires reassessment and, when indicated, endoscopic or open revision and sealing.
Conclusion:
Persistent wound leakage, a symptomatic or enlarging pseudomeningocele, neurological deterioration, or signs of infection require timely reassessment and targeted treatment.
References
1. Kim JE, Choi DJ, Park EJ. Risk factors and options of management for an incidental dural tear in biportal endoscopic spine surgery. Asian Spine J. 2020;14(6):790–800.
2. Kinaci A, Moayeri N, van der Zwan A, van Doormaal TPC. Effectiveness of sealants in prevention of cerebrospinal fluid leakage after spine surgery: a systematic review. World Neurosurg. 2019;127:567–575.e1.
DOI: 10.1016/j.wneu.2019.02.236
3. Gomes FC, Larcipretti ALL, Elvir FAR, et al. Early ambulation versus prolonged bed rest for incidental durotomies in spine procedures: a systematic review and meta-analysis. Neurosurg Rev. 2023;46(1):310.
DOI: 10.1007/s10143-023-02201-2
4. European Medicines Agency. TachoSil: official product information.