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.

Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

1998 ◽  
Vol 88 (2) ◽  
pp. 243-246 ◽  
Author(s):  
Wouter I. Schievink ◽  
Vittorio M. Morreale ◽  
John L. D. Atkinson ◽  
Fredric B. Meyer ◽  
David G. Piepgras ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Treatment ◽  
Intracranial Hypotension ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Content Type ◽  
Surgical Exploration ◽  
Fine Print ◽  
Csf Leaks

Object. Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. Methods. Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22–61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. Conclusions. All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3–58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

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 Opening and closure of intraventricular neuroendoscopic procedures in infants under 1 year of age: institutional technique, case series and review of the literature

2020 ◽  
Vol 37 (1) ◽  
pp. 101-105 ◽  
Author(s):  
M. D. Cearns ◽  
M. Kommer ◽  
A. Amato-Watkins ◽  
E. Campbell ◽  
T. Beez ◽  
...  
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Case Series ◽  
Csf Leak ◽  
Third Ventriculostomy ◽  
Retrospective Case ◽  
Infantile Hydrocephalus ◽  
Wound Breakdown ◽  
Csf Leakage ◽  
Clinical Records

Abstract Purpose Intraventricular neuroendoscopic techniques, particularly third ventriculostomy, are employed increasingly in the management of infantile hydrocephalus. However, surgical access to the ventricular cavities is associated with a risk of post-operative cerebrospinal fluid (CSF) leak. Here, we describe a structured, multi-layered approach to wound opening and closure which aims to maximise the natural tissue barriers against CSF leakage. We present a series of patients undergoing this technique and subsequently review the literature regarding opening and closure techniques in paediatric intraventricular neuroendoscopic procedures. Methods We performed a retrospective case series analysis of patients under 1 year of age who underwent intraventricular neuroendoscopic procedures in a single institution over a 5-year period. Patients were identified from an institutional operative database, and operation notes and clinical records were subsequently reviewed. Results 28 patients fulfilled the inclusion criteria for this study. The mean age at operation was 9 weeks. 27 patients underwent endoscopic third ventriculostomy whilst 1 underwent endoscopic septostomy, and all patients underwent our structured, multi-layered opening and closure technique. Follow-up ranged from 4 months to 5 years. There were no cases of post-operative CSF leak, infection or wound breakdown. 12 patients remained shunt-free at the last follow-up, with the remaining 16 requiring shunt insertion for progressive hydrocephalus at a mean of 24 days post-operatively. Conclusion Various methods aiming to prevent post-operative CSF leak have been reported in the literature. We propose that our institutional technique may be of benefit in minimising this risk in infants undergoing endoscopic third ventriculostomy and similar intraventricular neuroendoscopic procedures.

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.

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 Intradural extraarachnoid sutureless technique combined with laminoplasty for indirect repair of ventral dural defects in spontaneous intracranial hypotension: technical note and case series

2021 ◽  
Author(s):  
M. Kamenova ◽  
S. Schaeren ◽  
M-G. Wasner
Keyword(s):  
Surgical Technique ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Treatment Strategies ◽  
Case Series ◽  
Technical Note ◽  
Csf Leak ◽  
Sutureless Technique ◽  
Dural Defects ◽  
Csf Leaks

Abstract Background There is a significant variance in surgical treatment strategies of ventral cerebrospinal fluid (CSF) leaks causing spontaneous intracranial hypotension (SIH). Posterior approaches might represent a preferable alternative to the more invasive anterior and lateral routes, as long as the spinal cord is not exposed to harmful manipulation. The aim of this technical note is to report and illustrate a new surgical technique using an intradural extraarachnoid sutureless technique via laminoplasty for indirect repair of ventral CSF leaks causing intractable SIH symptoms. Methods The surgical technique is described in a step by step fashion. Between May 2018 and May 2020, five patients with ventral spinal CSF leaks were operated on, utilizing this technique. All dural defects were located at the level of the thoracic spine. A retrospective review on demographic and radiological findings, symptoms, outcome, and follow-up was performed. Results The intra- and postoperative course was uneventful in all patients with no surgery-related complications. Three patients recovered completely at discharge, while neurological symptoms significantly improved in two patients. A postoperative MRI of the spine was obtained for all patients, demonstrating regressive signs of CSF leak. Conclusion Based on the presented case series, this intradural extraarachnoid sutureless technique combined with laminoplasty seems to be a safe and effective option for indirect repair of ventral dural defects in SIH. In our opinion, it represents a valid alternative to traditional more aggressive approaches.

scholarly journals 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 ◽  
Sudden Onset ◽  
Fracture Site ◽  
Csf Leak ◽  
Retrospective Case ◽  
Headache Onset ◽  
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 between January 2016 and September 2019. 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. Targeted epidural patches with fibrin sealant were performed. Treatment response at return visit (3 months post patch) was documented. Results: Six patients (4 females, 2 males) were diagnosed with a suspected spinal CSF leak and PI fracture. Mean age at the time of headache onset was 39 years old, and a range 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.

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.

scholarly journals Optimising outcomes in the management of spontaneous cerebrospinal fluid rhinorrhoea

2013 ◽  
Vol 51 (3) ◽  
pp. 268-274
Author(s):  
J.S Virk ◽  
B. Elmiyeh ◽  
C. Stamatoglou ◽  
H.A. Saleh
Keyword(s):  
Body Mass Index ◽  
Cerebrospinal Fluid ◽  
Body Mass ◽  
Surgical Approach ◽  
Case Series ◽  
Operative Management ◽  
Csf Leak ◽  
Tertiary Referral Centre ◽  
Csf Rhinorrhoea

Background: To describe our experience of the management of spontaneous cerebrospinal fluid (CSF) rhinorrhoea in a large case series focusing on surgical approach, peri-operative management and outcomes; to evaluate the efficacy of endoscopic CSF leak repairs. Methodology: Retrospective chart review was performed for all patients with spontaneous CSF rhinorrhoea managed from 2003 to 2011 at a tertiary referral centre. Data regarding demographics, presentation, site of leak, peri-operative management, surgical approach, body mass index (BMI), follow up and success rates was collated. Results: Thirty-six patients were identified: 9 male and 27 female with a mean age of 50.4 years. Eight patients had previous failed repairs in other units. Success rate after first surgery was 89 % and after second surgery was 100 %. Four patients had recurrences, 3 underwent successful revisions and the fourth had complete cessation of the leak after gastric bypass surgery and weight reduction. All failures were before 2004 prior to instigation of an anatomic three-layered repair with no further failures in the following 7 years. Mean follow up was 21.5 months. Mean body mass index was 34.0 kg/m2. Fifty percent of spontaneous leaks were from the cribriform plate, 22 % sphenoid, 14 % ethmoid and 14 % frontal sinus. Conclusion: Endoscopic CSF fistula closure has become the gold standard of care. In order to optimise the outcome, we recommend a multidisciplinary approach to manage the associated idiopathic intracranial hypertension and an anatomic three-layered closure technique for recalcitrant cases.

Combined Posteromedial and Posterolateral Approaches for 2-Part Posterior Malleolar Fracture Fixation

2020 ◽  
Vol 41 (10) ◽  
pp. 1234-1239 ◽  
Author(s):  
Yunfeng Yang ◽  
Wenbao He ◽  
Haichao Zhou ◽  
Jiang Xia ◽  
Bing Li ◽  
...  
Keyword(s):  
Case Series ◽  
Good Alternative ◽  
Retrospective Case ◽  
Malleolar Fracture ◽  
Level Of Evidence ◽  
Malleolar Fractures ◽  
Posterior Malleolar Fracture ◽  
The Mean ◽  
Mean Time

Background: This study investigated the clinical efficacy of combined posteromedial and posterolateral approaches for repair of 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. Methods: This case series report included 27 Weber B with Haraguchi type II patients with medial and lateral malleolar fractures combined with 2-part posterior malleolar fractures. Patients were treated with open reduction and internal fixation through a combination of posteromedial and posterolateral approaches from January 2015 to January 2018. There were 11 males and 16 females, with an average age of 61.5 years (range, 53-67 years). The procedures were performed on prone patients under spinal anesthesia. The medial, lateral, and posterior malleolar fractures were exposed through posteromedial and posterolateral approaches performed at the same time. The lateral malleolar fracture was fixed using a plate, the medial malleolar fracture was fixed using screws, and the posterior malleolar fracture was fixed using a plate or cannulated screws according to the size of the fragments. We performed follow-up on 22 patients for an average of 30 months (range, 18-48 months). Results: Primary healing of the incisions was achieved in all cases, and no infection was found. The mean time of bone union was 12.5 weeks (range, 10-15 weeks). The mean time from the operation to full weightbearing was 13 weeks (range, 11-16 weeks). We used the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale to score patient outcomes; the mean score was 85.4 (range, 80-92) at the final follow-up. No significant pain was found at the final follow-up. Conclusion: This study showed that satisfactory outcomes were achieved with combined posteromedial and posterolateral approaches. Therefore, we believe this approach was a good alternative strategy to repair 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. Level of Evidence: Level IV, retrospective case series.

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