Sinonasal Packing is Not a Requisite for Successful Cerebrospinal Fluid Leak Repair

2021 ◽  
Author(s):  
Karam Asmaro ◽  
Frederick Yoo ◽  
Abdulkader Yassin-Kassab ◽  
Michael Bazydlo ◽  
Adam M. Robin ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cerebrospinal Fluid ◽  
Operating Room ◽  
Case Series ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Secondary Outcome ◽  
Defect Sites ◽  
Snot 22 ◽  
Csf Leaks

Abstract Background Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%. Objective This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing. Methods A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes. Results Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time. Conclusion Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity.

scholarly journals Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series

2020 ◽  
Vol 2020 (12) ◽  
Author(s):  
Clifford L Crutcher ◽  
John M Wilson ◽  
Kevin D Morrow ◽  
Jessica A Shields ◽  
Lindsay M Lasseigne ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
External Ventricular Drain ◽  
Treatment Algorithm ◽  
Case Series ◽  
Cerebrospinal Fluid Leak ◽  
Gunshot Wounds ◽  
External Ventricular Drainage ◽  
Csf Leak ◽  
Fluid Leak ◽  
Csf Leaks

Abstract Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author’s knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.

Endonasal Free Flap Reconstruction Combined With Draf Frontal Sinusotomy for Complex Cerebrospinal Fluid Leak: A Technical Report & Case Series

2021 ◽  
Author(s):  
Jake J Lee ◽  
Elizabeth H Wick ◽  
Michael R Chicoine ◽  
Joshua L Dowling ◽  
Eric C Leuthardt ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Free Flap ◽  
Frontal Sinus ◽  
Case Series ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
Endoscopic Endonasal ◽  
Csf Leaks

Abstract BACKGROUND Frontal sinus cranialization with closure via bifrontal pericranial flaps is the gold standard for separating the nasofrontal recess from the intracranial cavity for posterior table defects. Despite the high success rate, cerebrospinal fluid (CSF) leak may persist and is particularly challenging when vascularized reconstructive options from the bicoronal incision are exhausted. OBJECTIVE To assess a novel endonasal technique using an adipofascial radial forearm free flap delivered to the frontal recess through a Draf sinusotomy to repair complex CSF leaks from the frontal sinus. METHODS A retrospective review of 3 patients (all male; ages 42, 43, and 69 yr) with persistent CSF leak despite frontal sinus cranialization and repair with bifrontal pericranium was performed. Etiology of injury was traumatic in 2 patients and iatrogenic in 1 patient after anaplastic meningioma treatment. To create space for the flap and repair the nasofrontal ducts, endoscopic Draf III (Case 1, 3) or Draf IIb left frontal sinusotomy (Case 2) was performed. The forearm flap was harvested, passed through a Caldwell-Luc exposure, and placed within the Draf frontal sinustomy. The flap vessels were tunneled to the left neck and anastomosed to the facial vessels by the mandibular notch. RESULTS Intraoperatively, the flaps were well-seated and provided a watertight seal. Postoperative hospital courses were uncomplicated. There were no new CSF leaks or flap necrosis at 12, 14, and 16 mo. CONCLUSION Endoscopic endonasal free flap reconstruction through a Draf procedure is a novel viable option for persistent CSF leak after failed frontal sinus cranialization.

Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair

2019 ◽  
Vol 161 (3) ◽  
pp. 522-528 ◽  
Author(s):  
Lauren J. Luk ◽  
Allison Ikeda ◽  
Sarah K. Wise ◽  
John M. DelGaudio
Keyword(s):  
Cerebrospinal Fluid ◽  
Primary Repair ◽  
Tertiary Care ◽  
Middle Turbinate ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Secondary Outcome ◽  
Free Graft ◽  
Fluid Leak ◽  
Csf Leaks

ObjectiveTo compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects.Study DesignA retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years.SettingTertiary care rhinology practice.SubjectsAdult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic).MethodsPatients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate.ResultsOf 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed ( P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%.ConclusionsWe present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.

Recurrent Spontaneous Spinal Cerebrospinal Fluid Leak Associated with “Nude Nerve Root” Syndrome: Case Report

Neurosurgery ◽  
2003 ◽  
Vol 53 (5) ◽  
pp. 1216-1219 ◽  
Author(s):  
Wouter I. Schievink ◽  
Line Jacques
Keyword(s):  
Cerebrospinal Fluid ◽  
Nerve Root ◽  
Intracranial Hypotension ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Magnetic Resonance Imaging Examination ◽  
Computed Tomographic ◽  
Computed Tomographic Myelography ◽  
Increased Risk ◽  
Csf Leaks

Abstract OBJECTIVE AND IMPORTANCE Spontaneous spinal cerebrospinal fluid (CSF) leaks have been noted occasionally at multiple sites in the same patient, but recurrent spontaneous spinal CSF leaks have not been documented. We describe a patient with a recurrent CSF leak who was found at surgery to have an absence of the entire nerve root sleeve at multiple thoracic levels. CLINICAL PRESENTATION A 29-year-old woman bodybuilder noted an excruciating orthostatic headache associated with nausea. The neurological examination was unremarkable, and a magnetic resonance imaging examination showed the typical changes of intracranial hypotension. Computed tomographic myelography showed an extensive bilateral lower cervical CSF leak. INTERVENTION The patient underwent bilateral lower cervical nerve root explorations, and several small dural holes were found. The CSF leaks were repaired, but 3 months later, computed tomographic myelography showed a new CSF leak in the midthoracic area. A thoracic laminectomy was performed, and several nerve roots were found to be completely devoid of dura. After the CSF leaks were repaired, there was significant improvement in her headaches. CONCLUSION A recurrent spontaneous spinal CSF leak may occur in patients with intracranial hypotension at a site previously documented not to be associated with a CSF leak. Absent nerve root sleeves may be found in patients with spontaneous spinal CSF leaks (“nude nerve root” syndrome), and these patients may be at increased risk of developing a recurrent CSF leak.

Spinal Cerebrospinal Fluid Leak in the context of Pars Interarticularis Fracture: A Case Series

2020 ◽  
Author(s):  
Tommy Lik Hang Chan ◽  
Robert Cowan ◽  
Nada Hindiyeh ◽  
Syed Hashmi ◽  
Bryan Lanzman ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Fibrin Sealant ◽  
Intracranial Hypotension ◽  
Case Series ◽  
Cerebrospinal Fluid Leak ◽  
Sudden Onset ◽  
Fracture Site ◽  
Csf Leak ◽  
Retrospective Case ◽  
Pars Interarticularis

Abstract Introduction: Spinal Cerebrospinal fluid (CSF) leak can lead to intracranial hypotension and is an important differential diagnosis to consider in patients with sudden onset chronic daily headaches. Pars interarticularis (PI) fracture is a potential rare cause of suspected spinal CSF leak. Methods: This is a retrospective case series of 6 patients with suspected spinal CSF leak evaluated at the Stanford CSF leak headache clinic between January 2016 and September 2019. All cases were presented at the combined neuroradiology/headache neurology CSF leak conference. All patients received a magnetic resonance imaging (MRI) of the brain with and without gadolinium, MRI whole spine and full spine computed tomography (CT) myelogram. All targeted epidural patches with fibrin sealant were performed by a team member board-certified in Headache, Anesthesiology, and Pain Medicine. Treatment response at return visit (3 months post patch) was reported based on a pain intensity scale from 0 to 10, 10 being the most severe. Results: Six patients (4 females, 2 males) were diagnosed with a suspected spinal CSF leak and PI fracture. Mean age at the time of onset of headache was 39 years old, ranges from 32 to 50 years old. Mean time to targeted epidural patches with fibrin sealant was 4.5 years. All 6 patients had PI fractures identified on CT myelogram and received targeted epidural patches with fibrin sealant at the site of the PI fracture. All patients had significant improvement in their headache intensity. Conclusion: Our study highlights: 1) the importance of PI fracture as a possible culprit of suspected spinal CSF leak in patients with intracranial hypotension; 2) the added benefit of CT imaging for detecting bony abnormalities such as fractures in patients with intracranial hypotension; and 3) the successful treatment of suspected spinal CSF leak when targeting the fracture site.

scholarly journals Rapid Diagnostic Test Kit for Point-of-Care Cerebrospinal Fluid Leak Detection

2019 ◽  
Vol 25 (1) ◽  
pp. 67-74
Author(s):  
Daniel W. Bradbury ◽  
Ashley E. Kita ◽  
Kensuke Hirota ◽  
Maie A. St. John ◽  
Daniel T. Kamei
Keyword(s):  
Cerebrospinal Fluid ◽  
Diagnostic Test ◽  
Rapid Diagnostic Test ◽  
Point Of Care ◽  
Cerebrospinal Fluid Leak ◽  
Leak Detection ◽  
Csf Leak ◽  
Medical Provider ◽  
Test Kit ◽  
Csf Leaks

Cerebrospinal fluid (CSF) leaks can occur when there is communication between the intracranial cavities and the external environment. They are a common and serious complication of numerous procedures in otolaryngology, and if not treated, persistent leaks can increase a patient’s risk of developing life-threatening complications such as meningitis. As it is not uncommon for patients to exhibit increased secretions postoperatively, distinguishing normal secretions from those containing CSF can be difficult. Currently, there are no proven, available tests that allow a medical provider concerned about a CSF leak to inexpensively, rapidly, and noninvasively rule out the presence of a leak. The gold standard laboratory-based test requires that a sample be sent to a tertiary site for analysis, where days to weeks may pass before results return. To address this, our group recently developed a semiquantitative, barcode-style lateral-flow immunoassay (LFA) for the quantification of the beta-trace protein, which has been reported to be an indicator of the presence of CSF leaks. In the work presented here, we created a rapid diagnostic test kit composed of our LFA, a collection swab, dilution buffers, disposable pipettes, and instructions. Validation studies demonstrated excellent predictive capabilities of this kit in distinguishing between clinical specimens containing CSF and those that did not. Our diagnostic kit for CSF leak detection can be operated by an untrained user, does not require any external equipment, and can be performed in approximately 20 min, making it well suited for use at the point of care. This kit has the potential to transform patient outcomes.

Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series

2021 ◽  
Author(s):  
Majid Aljoghaiman ◽  
Yosef Ellenbogen ◽  
Radwan Takroni ◽  
Kaiyun Yang ◽  
Forough Farrokhyar ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Minimally Invasive ◽  
Spine Surgery ◽  
Subdural Hematoma ◽  
Case Series ◽  
Early Mobilization ◽  
Cerebrospinal Fluid Leak ◽  
Minimally Invasive Spine Surgery ◽  
Csf Leak ◽  
Minimally Invasive Spine

Abstract BACKGROUND Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear. OBJECTIVE To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS. METHODS A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma. RESULTS A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported. CONCLUSION Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.

Risk Factors and Reconstruction Techniques for Persistent Cerebrospinal Fluid Leak in Patients Undergoing Endoscopic Endonasal Approach to the Posterior Fossa

2021 ◽  
Author(s):  
Sergio Torres-Bayona ◽  
Nathalia Velasquez ◽  
Ana Nakassa ◽  
Aldo Eguiluz-Melendez ◽  
Vanessa Hernandez ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Control Group ◽  
Endoscopic Endonasal ◽  
Increased Risk ◽  
Dural Defects ◽  
Csf Leaks

Abstract Background High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. Objective This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Methods Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Results Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) (p = 0.02). All patients with a persistent CSF leak developed meningitis (p = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Conclusion Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial–pericranial flaps, should be considered as an early rescue option in obese patients.

A Simple Onlay Sellar Reconstruction Does not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

2020 ◽  
Author(s):  
Mark B. Chaskes ◽  
Judd H. Fastenberg ◽  
Swar Vimawala ◽  
Gurston F. Nyquist ◽  
Mindy R. Rabinowitz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Care Center ◽  
Tertiary Care ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Oxidized Cellulose ◽  
Repair Technique ◽  
Sellar Reconstruction ◽  
Csf Leaks

Abstract Objectives A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm3. No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 (p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

scholarly journals Use of Zipper Ratcheting Straps as a Bailout for Postoperative Cerebrospinal Fluid Leaks: Our Experience

2019 ◽  
Vol 10 (4) ◽  
pp. 443-447
Author(s):  
Arvind G. Kulkarni ◽  
Sandeep Tapashetti ◽  
Priyank M. Patel
Keyword(s):  
Cerebrospinal Fluid ◽  
Case Series ◽  
Good Alternative ◽  
Technical Note ◽  
Csf Leak ◽  
Skin Closure ◽  
Retrospective Case ◽  
Dural Tears ◽  
Csf Leaks

Study Design: Technical note. Objectives: Management of postoperative cerebrospinal fluid (CSF) leaks is a challenge. Reexploration increases the morbidity risks. The main objective was to evaluate the outcomes of noninvasive zipper-like system (Zip surgical skin closure system, ZipLine Medical, Inc, Campbell, CA, USA) as a bailout technique for postoperative CSF leaks. Methods: Retrospective case series. Consecutive patients with postoperative CSF leaks that occurred secondary to spinal surgeries performed between January 2017 and September 2018 were part of the study. All these patients were managed conservatively by reinforcement with zipper ratcheting straps over the sutured surgical wound. Successful clinical outcomes included cessation of CSF leaks and adequate wound healing in the postoperative period and at follow-up. Results: Ten patients underwent the application of zipper ratcheting straps. The mean follow-up was 6 months (range 6 months to 1 year). In 7 cases, the dural tears were recognized postoperatively and in 3 cases, the tears were noted intraoperatively and repaired and reinforced with fibrin sealants. None of the patients developed wound soakage or subsequent CSF leak from the wound after the application of zipper ratcheting straps. Conclusions: Zipper ratcheting straps as augmentation to sewing of the wound seem to be a good alternative and bailout in treating patients with postoperative CSF leaks. The ease of its application, the ability in minimizing the complications associated with CSF leaks, and negating the need of surgical reexploration makes it a worthy option.

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