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