Elsevier

World Neurosurgery

Volume 81, Issues 3–4, March–April 2014, Pages 634-640
World Neurosurgery

Peer-Review Report
Comparison of Symptomatic Cerebral Spinal Fluid Leak Between Patients Undergoing Minimally Invasive versus Open Lumbar Foraminotomy, Discectomy, or Laminectomy

https://doi.org/10.1016/j.wneu.2013.11.012Get rights and content

Objective

Minimally invasive spine surgery (MISS) techniques have similar long-term outcomes compared to open surgery for patients undergoing 1- or 2-level discectomy, foraminotomy, or laminectomy. However, the rate of cerebrospinal fluid (CSF) leaks with both techniques has not been well established in the literature. This study sought to compare the rate and clinical impact of CSF leak in open lumbar foraminotomy, discectomy, or laminectomy with comparable MISS approaches.

Methods

A total of 863 patients undergoing 1- or 2-level discectomy, foraminotomy, or laminectomy by either MISS an open technique were evaluated for CSF leaks. Variables assessed included operative time, blood loss, CSF leaks, hospital stay, days with lumbar drain, days of postoperative flat bed rest, and postoperative intervention. Statistical analyses include univariate analysis (Student t test, analysis of variance, odds ratio, χ2) and bivariate analysis (logistic regression).

Results

In the MISS group there were 15 CSF leaks (4.7%), and 49 CSF leaks (9.0%) in the open group. Eight patients in the open group required lumbar drainage, compared to zero patients in the MISS group. Twelve patients required reoperation for persistent CSF leak in the open group, compared to zero patients in the MISS group. Patients undergoing open spine surgery were 2 times more likely to have a CSF leak (odds ratio = 2.3, 95% confidence interval = 1.2 to 3.7, P = .01). Patients undergoing MISS had significantly lower reoperation rates for CSF leak repairs (open = 25% of open CSF leak cases, MISS = 0%, P < .01).

Conclusions

In this study, there was a statistically significant decreased rate of CSF leak between an MISS approach and an open surgical approach. Furthermore, CSF leaks in open surgery have a higher probability of requiring lumbar drainage or reoperation to repair the durotomy.

Introduction

Degenerative disease of the lumbar spine, leading to central or neuroforaminal compression, can lead to symptoms of neurogenic claudication, radicular pain, lower extremity weakness, and bladder or bowel incontinence. Surgical decompression (foraminotomy, discectomy, laminectomy) for lumbar compression is the most common spine surgery in patients more than 65 years of age (11). One of the major complications that may happen in any decompressive lumbar surgery is an unintentional durotomy leading to a cerebrospinal fluid (CSF) leak.

There are a number of potential sequelae associated with dural tears. Patients with CSF leaks may develop postoperative postural headaches, a pseudomeningocele at the surgical site, or CSF leakage beyond the skin with the potential to develop meningitis. Furthermore, a known intraoperative CSF leak can lead to additional surgical interventions with associated complications. These postoperative interventions and their associated potential complications include prolonged flat bed rest (immobility and risk of deep venous thrombosis), placement of a lumbar drain (injury to neurologic elements), interventional radiology placement of a blood patch (mass effect from hematoma or arachnoiditis), or revision surgery for CSF leak repair (infection).

Prior studies report that CSF leaks occur in 5.5% to 9% of primary lumbar spine surgeries 15, 16, 25 and in 13.2% to 21% of revision lumbar spine surgeries 15, 16, 25. Approximately 1.8% to 8.0% of cases with reported CSF leaks require a secondary operation for exploration and repair of the durotomy 15, 16. Traditionally, the best treatment for intraoperative CSF leak is a water-tight primary repair of the dura. However, technological advances in minimally invasive surgery have shifted opinions on surgical approaches and treatment of intraoperative CSF leak.

Minimally invasive spine surgery (MISS) techniques have been introduced over the last 10 to 15 years with success 12, 28. Recent studies have shown MISS to be associated with decreased intraoperative blood loss, postoperative pain, and duration of hospitalization, with similar improvement in functional outcomes when compared to open procedures 2, 10, 13, 14, 20, 21, 28, 29. MISS techniques also have been associated with a reduction in the incidence of postoperative wound infection in lumbar spine surgery (19).

Despite the reported benefits of MISS approaches to lumbar spine pathology, there are limited data on the incidence of CSF leaks with MISS procedures when compared to open procedures 2, 4, 7, 10, 13, 14, 19, 20, 22, 23, 26, 28, 29. To date, only a small case series comparing open and minimally invasive surgeries suggests that MISS approaches may have a lower incidence of CSF leaks compared to open cases (20). For MISS approaches, we hypothesize that the smaller working channel and integrity of the surrounding muscles limit the potential dead-space for accumulation of CSF, which decreases the probability of postoperative symptomatic CSF leak.

Section snippets

Methods

A retrospective review of prospectively collected databases of patients undergoing MISS procedures vs. comparable open lumbar foraminotomy, discectomy, or laminectomy over a 5-year period from August 2005 to July 2010 at a single institution was performed. Approval from the institutional review board was obtained before conducting the study. Patients were identified by querying departmental billing records for Current Procedural Terminology codes for lumbar foraminotomy/facetectomy, lumbar

Results

The study included 863 consecutive patients who were operated on at a single academic hospital from August 2005 to July 2010 and enrolled in the study. There were 498 (57.7%) men and 365 (42.3%) women in the study, with a mean age of 52.5 years (range 18 to 89 years). Eleven neurosurgeons were involved in this retrospective review; 7 surgeons performed primarily open spinal decompressions and 4 surgeons performed primarily MISS decompressions (Table 2). CSF leaks were significantly less

Discussion

In this study, CSF leaks occurred less frequently in MISS procedures, required minimal alterations from routine postoperative care, and resulted in fewer long-term sequelae than decompressive procedures utilizing open surgical techniques. Our results suggest that CSF leaks are twice as likely to occur in open lumbar spine surgeries compared to MISS procedures, and significantly increase the total hospitalization time. Furthermore, open procedures were more likely to have postoperative

Conclusions

This study demonstrates a decreased incidence of CSF leak with MISS vs. open surgery in lumbar foraminotomy, discectomy, or laminectomy. Furthermore, indirect repair of intraoperative CSF leaks with dural sealant fibrin glue and Gelfoam was sufficient to prevent postoperative symptomatic CSF leaks. Moreover, the reoperation rate for postoperative CSF leak repair in patients undergoing MISS approaches was significantly decreased compared to open surgical approaches.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Albert P. Wong and Patrick Shih are co first authors.

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