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Endoscopic Approach to Type 1 Spontaneous Cerebrospinal Fluid Leak in the Thoracic Spine: Technical Considerations and Literature Review

  • International Journal of Spine Surgery
  • December 2025,
  • 8838;
  • DOI: https://doi.org/10.14444/8838

Abstract

Cerebrospinal fluid (CSF) leaks of spinal origin present unique diagnostic and therapeutic challenges. Ventral leaks in particular are technically demanding due to limited exposure, proximity to the spinal cord, and the need for precise dural repair. Traditional management strategies, ranging from laminectomy-based approaches to thoracotomy, carry significant morbidity. Recent advances in full endoscopic spine surgery provide a minimally invasive alternative that allows surgeons to access ventral pathology, remove osteophytes, and perform direct dural closure under continuous irrigation. This article reviews treatment challenges, highlights conventional and emerging strategies, and discusses the role of full endoscopic repair of spinal CSF leaks. Technical considerations unique to endoscopic repair of Type 1 CSF leaks in the thoracic spine are described.

Introduction

Spinal cerebrospinal fluid (CSF) leaks can result in debilitating intracranial hypotension, postural headaches, radiculopathy, and neurological decline.1,2 While iatrogenic leaks occur after surgery or trauma, spontaneous leaks are increasingly recognized, often associated with ventral dural tears caused by degenerative osteophytes or calcified discs.3,4 Ventral leaks represent a particularly difficult subset: their deep, anterior location within the spinal canal makes exposure technically challenging and limits direct visualization. Conventional repair strategies typically involve open transdural, posterior transpedicular, costotransversectomy, or anterior thoracotomy/lateral approaches.5–8 These techniques allow for the removal of disc-osteophyte complexes and direct dural repair but at the cost of extensive soft tissue dissection, destabilization, high perioperative morbidity, and the potential need for spinal fusion.9–11 Nonoperative measures, including epidural blood patches, fibrin sealants, or lumbar drainage, may achieve temporary relief but frequently fail to address the underlying dural defect or mass effect from osteophytes.12–14 Minimally invasive tubular techniques have been explored as alternatives, but visualization remains limited, especially in ventral or far-lateral locations.15,16 Endoscopic spine surgery offers a unique solution, using continuous irrigation, angled optics, and high-definition visualization to achieve a flat working trajectory, directly access ventral pathology, and perform both decompression and dural repair with minimal to no spinal cord manipulation.17–20 Endoscopic CSF leak repairs have unique challenges, and technical considerations specific to Type 1 CSF leaks in the thoracic spine are described in this article along with an illustrative case.

Illustrative Case and Technical Considerations

Case

A 51-year-old man had a sudden onset of intense headaches after strenuous physical activity. For approximately 1 year, the patient had symptoms of feeling like his “head was underwater” and had flare-ups of neck pain that required emergency room visits multiple times. He described these flare-ups as “head rushes” along with ringing in the ears and neck rigidity. He was worked up comprehensively for other causes of his symptoms, including meningitis, which was ultimately ruled out. He described his headaches as positional, as they improved while laying down and worsened with activity, especially from a sitting to standing position, and he felt fullness in his eyes with rapid changes in focus. He has had to significantly adapt his lifestyle to keep from having symptoms. Further workup included magnetic resonance imaging (MRI) of the brain and thoracic spine and prone computed tomography (CT) myelography. MRI of the brain revealed findings suggestive of intracranial hypotension, revealing pachymeningeal enhancement. The MRI of the thoracic spine revealed extradural spinal fluid over multiple levels of the thoracic spine. A prone CT myelogram was completed, which revealed a type 1 spontaneous CSF leak at the level of T11 to T12 at the midline ventral dura. This was associated with a disc osteophyte complex seen on the MRI as well as the CT scan (Figure 1). The patient was deemed appropriate for a left-sided endoscopic transpedicular approach for disc-osteophyte complex removal and repair of CSF leak. Institutional Review Board approval was obtained for this technique guide and patient review (1194051-18).

Preoperative imaging and workup. (A) T1-weighted image with gadolinium revealing pachymeningeal enhancement and subtle subdural collections. (B) Axial T2-weighted magnetic resonance imaging revealing extradural cerebrospinal fluid (CSF) dorsally. (C) Axial T2-weighted sequence at T11–T12 revealing a small central disc osteophyte complex at the. (D) Prone computed tomography myelogram revealing evidence of Type 1 CSF leak at the level of T11–T12.
Figure 1

Preoperative imaging and workup. (A) T1-weighted image with gadolinium revealing pachymeningeal enhancement and subtle subdural collections. (B) Axial T2-weighted magnetic resonance imaging revealing extradural cerebrospinal fluid (CSF) dorsally. (C) Axial T2-weighted sequence at T11–T12 revealing a small central disc osteophyte complex at the. (D) Prone computed tomography myelogram revealing evidence of Type 1 CSF leak at the level of T11–T12.

Approach Considerations

Studying preoperative imaging is critical to ensure endoscopic access to the ventral midline dural defect. High-resolution MRI and CT images are reviewed to plan for a safe trajectory. Due to the disc osteophyte complex and the ventral leak having a direct midline position, a flat trajectory is favorable to ensure adequate reach and visualization of the offending pathology and the ventral dural defect. It is important to measure distances from the midline to approximate incision and reach an appropriate trajectory to enter the epidural space ventral to the canal safely. The disc space is marked with an inline anteroposterior fluoroscopic image, as the endoscopic working trajectory will be parallel to the disc space (Figure 2). Once the appropriate level is identified, a spinal needle is placed on the contralateral pedicle of the inferior vertebral body to keep a constant marker throughout the case for reference. At the level of T11 to T12, it is important to note that the costovertebral joint will be caudal to the disc space, and the foramen will be large enough for safe docking. A large foramen, however, can cause difficulty and introduce risk when passing instruments such as dilators down to the disk space, as these instruments may inadvertently enter the spinal canal if one is not progressing with a reasonable degree of care and trepidation.

Counting levels and marking. (A) Marking the disc space at T11–T12. (B) Entry with spinal needle on the contralateral pedicle of the caudal vertebral body (T12).
Figure 2

Counting levels and marking. (A) Marking the disc space at T11–T12. (B) Entry with spinal needle on the contralateral pedicle of the caudal vertebral body (T12).

Discectomy and Osteophyte Removal

To adequately treat the pathology, the offending disc osteophyte complex must be removed. Removing the disc osteophyte complex accomplishes 2 main goals: (1) it creates enough ventral space to the thoracic dura, and (2) it removes the causative pathology to mitigate chances of postoperative recrudescence. It is important to note a distinct technical consideration of not creating a large ventral defect on the floor of the canal. A discectomy and osteophyte removal is done modestly. Moreover, the posterior longitudinal ligament and any dorsal annulus should be kept intact. This allows for adequate coverage of this space and tamponade effect when the dural substitute and fibrin sealant are applied in the later part of the case for the dural repair.

In this case, after the ventral approach was obtained and the floor of the canal was identified (Figure 3), a modest discectomy revealed a disc fragment violating the ventral dura at the index level, which was notably the causative intradural disc herniation (Figure 4a). An anteroposterior fluoroscopic image was taken as this disc fragment was removed with pituitary graspers, showing and reaching past midline (Figure 4b). Once the intradural disc fragment was removed from the ventral dural defect, the ventral dural defect’s edges were carefully explored to ensure complete exposure of its margins (Figure 4c).

(A) Preparation for discectomy with spinal cord peridural membranes visualized. (B) Ventral peridural membranes after most of the discectomy maintaining a canal floor to help with later dural repair.
Figure 3

(A) Preparation for discectomy with spinal cord peridural membranes visualized. (B) Ventral peridural membranes after most of the discectomy maintaining a canal floor to help with later dural repair.

Pathology identification. (A) Modest discectomy revealed a disc fragment violating the ventral dura at the index level. (B) Midline reach with a pituitary grasper while removing the offending intradural disc herniation. (C) Exploration of the dural defect edges at the central ventral thoracic dura at T11–12.
Figure 4

Pathology identification. (A) Modest discectomy revealed a disc fragment violating the ventral dura at the index level. (B) Midline reach with a pituitary grasper while removing the offending intradural disc herniation. (C) Exploration of the dural defect edges at the central ventral thoracic dura at T11–12.

Repair of the Dural Defect

After the margins of the dural defect were explored and identified, attention was placed on the dural repair. Using a curved ball-tipped probe, the reach into the dural defect was tested prior to any placement of any dural substitute. This ensures the feasibility of subsequent placement of a dural substitute within the dural defect. A DuraGen (Integra Life Sciences, USA) was cut to approximately 0.5 cm × 0.25 cm and placed into the working channel and guided to the ventral canal with a small pituitary grasper. Once placed in position, a ball-tipped probe was used to guide the DuraGen into the dural defect (Figure 5A). A dumbbell orientation—half of the dural substitute placed intradurally and half extradurally—was the goal of this placement. Irrigation was maintained throughout these maneuvers. Care should be taken with specific consideration of neurovascular elements during these maneuvers to prevent spinal cord infarct or direct injury. Intraoperative neuromonitoring is used in all cases to assist with surgery and help prevent spinal cord injury. If any changes are noted, the patch can be promptly removed under direct visualization through the endoscope. A small piece of TachoSil (Linz, Austria) was cut to a similar size and placed ventral to the dural defect. The TachoSil was placed with the yellow adhesive face on the ventral dura. Care was taken to cross contralaterally past the defect dorsal to the intact posterior longitudinal ligament (Figure 5B). This ensured adequate coverage over the ventral defect. Additional TachoSil pieces were placed cranial and caudal to completely cover the ventral defect and the dead space created by the surgical approach (Figure 5C). After this was completed, fibrin glue was placed over the dural substitute pieces to complete the seal. Reduction of the dead space created by the partial vertebral body section and pedicle section is also accomplished here with the application of additional TachoSil pieces and fibrin glue.

Dural repair. (A) A ball-tipped probe was used to guide the duragen into the dural defect. (B) TachoSil placed past the defect dorsal to the intact posterior longitudinal ligament. (C) Additional TachoSil pieces were placed cranial and caudal to completely cover the ventral defect and the dead space created by the surgical approach.
Figure 5

Dural repair. (A) A ball-tipped probe was used to guide the duragen into the dural defect. (B) TachoSil placed past the defect dorsal to the intact posterior longitudinal ligament. (C) Additional TachoSil pieces were placed cranial and caudal to completely cover the ventral defect and the dead space created by the surgical approach.

Discussion

Key Notes Specific to Endoscopic Repair of Type 1 CSF Leaks

During placement of the dural substitute inlay, it is important to continue the irrigation to keep the graft from pushing out of the dura after placement. This is a technical challenge specific to unit portal spinal endoscopy, as careful manipulation of the ventral dura and the dural substitute is required for precise placement without spinal cord injury.

A basic understanding of fluid management in any uniportal endoscopic spine case with a dural defect, spontaneous or otherwise, is paramount. It is important to ensure that adequate fluid egress is maintained throughout the case, especially when the dural defect is in clear view. The goal would be to avoid any inadvertent fluid entry into the intradural space unnecessarily and for an unwanted amount of time. Once the dural defect is exposed, it is important to only use irrigation when necessary. Constant communication with the anesthesia team is important so that the surgeon is notified of any vital sign changes during dural defect repair.

Hemostasis throughout the procedure must be maintained. In a typical endoscopic case, continuous irrigation is maintained for adequate visualization. Significant time is spent with the irrigation stopped for these dural repairs. To effectively and safely execute the dural patch technique, meticulous hemostasis is required to maintain appropriate visualization when the fluid is stopped. Moreover, thorough hemostasis is critical for preventing postoperative hematomas around the spinal cord.

TachoSil is a special collagen patch that has exclusive properties favorable for this specific procedure. Under a fluid-filled medium, it can adhere to the ventral dura and maintain position to ensure purposeful placement. A fibrin clot seals the dural defect as the fibrinogen and thrombin on the patch react with the patient’s own blood components. The patch provides a scaffold for tissue regeneration, and since it is biodegradable, tissue replaces it over time. The adherence provides an additional advantage with unimportant techniques and allows multiple layers to be firmly placed to cover the dural defect.

Fat grafts and muscle grafts have been previously described,21 but with the consideration of the minimal dead space and minimal incision, along with the use of the dural substitutes and the fibrin sealant, these methods have not been felt to be necessary in our recent experience.

Ventral leaks are difficult to repair because of their anatomical location adjacent to the spinal cord. Barber et al and Sofoluke et al recently reported successful full-endoscopic repairs of ventral CSF leaks, establishing feasibility and early efficacy.21,22 Posterior approaches require spinal cord manipulation, whereas anterior approaches such as thoracotomy expose patients to pulmonary morbidity, pain, and longer recovery.23,24 CSF dynamics further complicate repair: persistent leakage, arachnoid herniation, and fragile dura may predispose a patient to recurrence.25

Open posterior or posterolateral approaches (laminectomy, transpedicular, or costotransversectomy) provide direct visualization but often require extensive bone removal and can destabilize the spine.26–28 Thoracotomy or lateral extracavitary procedures offer ventral exposure but carry high cardiopulmonary risk.29 Microsurgical repair techniques include suturing, patch grafting (muscle, fat, and fascia lata), fibrin glue reinforcement, and CSF diversion.30–32 The advent of full-endoscopic spine surgery has changed this paradigm. Endoscopes allow a flat, oblique working trajectory, enabling ventral access without spinal cord retraction. Continuous irrigation not only improves visualization by clearing blood but also maintains a tamponade effect on minor venous bleeding, though fluid pressure management is critical to prevent increased intracranial pressure or neural injury.33–35 Osteophyte or disc removal under endoscopic guidance facilitates identification of the dural defect and its underlying cause. Barber et al21 systematically reviewed surgical options and presented an illustrative case of endoscopic ventral CSF leak repair. Sofoluke et al22 described full endoscopic resection of a ventral thoracic osteophyte with successful dural repair. These cases demonstrate that endoscopy not only achieves decompression but also enables targeted dural closure, something previously limited to open exposures. Although long-term outcome data remain limited, early results suggest lower morbidity, shorter hospital stays, and successful leak resolution with endoscopy compared to traditional open approaches.36–38 Recurrence rates, complication profiles, and repair durability are areas for further study. Endoscopy may also offer an option in patients who have failed nonoperative management or prior open surgery.

An important consideration should be made regarding postoperative adhesive arachnoiditis after potential exposure of dural substitutes within the subarachnoid space. This has been described,39 and close follow-up after the application of this dural closure technique should be maintained to determine the long-term effects and clinical outcomes of this potential downstream sequela. Ongoing innovation in endoscopic instrumentation, dural closure devices, and biological sealants will likely expand the role of full endoscopic repair. Various techniques have been described extensively for endoscopic repair of dural tears in lumbar spine surgery.40,41 Techniques can include direct repair using sutures for dorsal defects in the lumbar spine and have been shown to have good results. Prospective trials and multi-institutional registries are needed to validate efficacy, define complication rates, and establish standardized protocols for fluid and pressure management.

Conclusion

Ventral spinal CSF leaks remain among the most technically demanding pathologies warranting complex treatments. A flat trajectory for access, ventral visualization, irrigation management, decompression, and direct dural repair is a noteworthy technique in full endoscopic CSF leak repairs. These technical considerations offer a safe and effective minimally invasive solution for these complex problems.

Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

  • Disclosures Sanjay Konakondla reports royalties/licenses from Spineology; consulting fees from Arthrex; and payment/honoraria from Globus, Elliquence, and Arthrex. The remaining authors have nothing to disclose.

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International Journal of Spine Surgery

Vol. 19, Issue 6

1 Dec 2025

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    Endoscopic Approach to Type 1 Spontaneous Cerebrospinal Fluid Leak in the Thoracic Spine: Technical Considerations and Literature Review
    • International Journal of Spine Surgery
    • Dec 2025,
    • 8838;
    • DOI: 10.14444/8838

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Keywords

thoracic disc herniation, Type 1 CSF leak, endoscopic CSF leak repair