Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach, is safe and effective for the treatment of spinal cerebrospinal fluid leaks (CSFs), new research has found.
Published in the Journal of Neurosurgery: Spine by Christian Fung (University of Freiburg, Freiburg, Germany) et al, the study sought to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using non-expandable tubular retractors.
The results suggest performing a minimally invasive closure of spinal CSF leaks in specialized centres, say the study authors.
Consecutive patients with spontaneous intracranial hypotension and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study.
Surgery was performed via a dorsal 2.5cm skin incision using non-expandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications.
A total of 58 patients, 65.5% of whom were female (median age 46 years [interquartile range 36–55 years]), with 38 ventral leaks, 17 lateral leaks, and two CSF venous fistulas were included.
In 56 (96.6%) patients, the leak could be closed, and in two (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak.
The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% of patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension.
Speaking to Spinal News International, Fung said: “This study is another milestone in the treatment of patients with SIH. Up to now patients are often treated by means of large and invasive surgical approaches including corpectomies.
“Throughout the recent years, we could show that we are able to reach the whole 360° circumference of the thecal sack by a standard dorsal interlaminar approach and with this recent study we minimalized this technique even further. A precise neuroradiological workup is the prerequisite for this highly targeted surgical therapy.
“In the end our good clinical results, even in the long term, are the best indicator for the successful treatment. This technique, i.e. the transdural surgical approach, manipulation of the spinal cord and the diagnostic workup, is demanding and therefore should be performed in specialised centres with a high case load.”