Cerebrospinal fluid leaks following spinal or posterior fossa surgery: use of fat grafts for prevention and repair

2000 ◽  
Vol 9 (1) ◽  
pp. 1-4 ◽  
Author(s):  
Perry Black
Keyword(s):  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Effective Means ◽  
Fat Graft ◽  
Posterior Fossa Surgery ◽  
Dural Tear ◽  
Fat Grafts ◽  
Csf Leakage ◽  
Dural Tears ◽  
Csf Leaks

Cerebrospinal fluid (CSF) leaks are relatively common following spinal or posterior fossa surgery. A midline dural tear in the spine is readily repaired by direct application of a suture. However, far-lateral or ventral dural tears are problematic. Fat is an ideal sealant because it is impermeable to water. In this paper the author reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventra1 dural leak. Leaks in the posterior fossa are managed similarly to those in the spine. Dural suture lines, following suboccipital or spinal intradural exploration, are prophylatically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 150 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following posterior fossa and spinal surgery.

Cerebrospinal fluid leaks following spinal surgery: use of fat grafts for prevention and repair

2002 ◽  
Vol 96 (2) ◽  
pp. 250-252 ◽  
Author(s):  
Perry Black
Keyword(s):  
Cerebrospinal Fluid ◽  
Spinal Surgery ◽  
Effective Means ◽  
Fat Graft ◽  
Dural Tear ◽  
Disc Space ◽  
Fat Grafts ◽  
Csf Leakage ◽  
Dural Tears ◽  
Csf Leaks

✓ Cerebrospinal fluid (CSF) leaks are relatively common following spinal surgery. A midline dural tear in the spine is readily repaired by direct application of sutures; however, far-lateral or ventral dural tears are problematic. Fat is an ideal sealant because it is impermeable to water. In this paper the author reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventral dural leak. Dural suture lines following spinal intradural exploration are prophylatically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 140 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following spinal surgery.

scholarly journals Sandwich wound closure reduces the risk of cerebrospinal fluid leaks in posterior fossa surgery

2016 ◽  
Vol 6 (2) ◽  
Author(s):  
Verena Heymanns ◽  
Abidemi W. Oseni ◽  
Ameer Alyeldien ◽  
Homajoun Maslehaty ◽  
Richard Parvin ◽  
...  
Keyword(s):  
New York ◽  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Wound Closure ◽  
Posterior Fossa Surgery ◽  
Dural Closure ◽  
Csf Leakage ◽  
Cerebrospinal Fluid Leaks ◽  
Closure Method ◽  
Csf Leaks

Posterior fossa surgery is demanding and hides a significant number of obstacles starting from the approach to the wound closure. The risk of cerebrospinal fluid (CSF) leakage in posterior fossa surgery given in the literature is around 8%. The present study aims to introduce a sandwich closure of the dura in posterior fossa surgery, which reduces significantly the number of CSF leaks (3.8%) in the patients treated in our department. Three hundred and ten patients treated in our hospital in the years 2009-2013 for posterior fossa pathologies were retrospectively evaluated. The dura closure method was as following: lyophilized dura put under the dura and sealed with fibrin glue and sutures, dura adapting stitches, TachoSil® (Takeda Pharma A/S, Roskilde, Denmark), Gelfoam® (Pfizer Inc., New York, NY, USA) and polymethylmethacrylate (osteoclastic craniotomy). The incidence of postsurgical complications associated with the dural closure like CSF leakage, infections, bleeding is evaluated. Only 3.8% of patients developed CSF leakage and only 0.5% needed a second surgery for CSF leakage closure. Two percent had a cerebellar bleeding with no need for re-operation and 3% had a wound infection treated with antibiotics. The sandwich wound closure we are applying for posterior fossa surgery in our patients correlates with a significant reduction of CSF leaks compared to the literature.

Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery

2006 ◽  
Vol 5 (3) ◽  
pp. 224-227 ◽  
Author(s):  
Anthony H. Sin ◽  
Gloria Caldito ◽  
Donald Smith ◽  
Mahmoud Rashidi ◽  
Brian Willis ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Fat Graft ◽  
Csf Leak ◽  
Dural Tear ◽  
Lumbar Surgery ◽  
History Of Surgery ◽  
Csf Leakage ◽  
History Of ◽  
Group A ◽  
Group B

Object A dural tear resulting in a cerebrospinal fluid (CSF) leak is a well-known risk of lumbar spinal procedures. The authors hypothesized that the incidence of CSF leakage is higher in cases involving repeated operations and those in which the surgeon performing the surgery is less experienced; however, they postulated that the overall outcome of the patient would not be adversely affected by a dural tear. Methods An institutional review board–approved protocol at Louisiana State University Health Sciences Center, Shreveport, was initiated in August 2003 to allow prospective comparison of data obtained in patients in whom a CSF leak occurred (Group A) and those in whom no CSF leak occurred (Group B) during lumbar surgery. Basic demographic information, descriptive findings regarding the tear, history of other surgeries, hospital length of stay (LOS), and immediate disposition at the time of discharge were compared between the two groups. Seventy-seven patients were eligible for this study. One patient refused to participate. In 12 (15.8%) of 76 patients CSF leakage developed. In three patients the presence of a tear was questioned, and the patients were clinically treated as if a tear were present. The patients in Group A were older than those in Group B (59.8 ± 16.9 and 49.4 ± 13.6 years of age, respectively; p = 0.02, Fisher exact test). In terms of those with a history of surgery, there was no significant difference between patients with and patients without a CSF leak (three [25%] of 12 patients [Group A] compared with 28 [43.8%] of 64 patients [Group B]; p = 0.34, two-sample t-test). In the 12 patients with dural tears, nine (75%) were caused by a resident-in-training, and the Kerrison punch was the instrument most often being used at the time (55%). This is significantly greater than 50% at the 5% level (p = 0.044, binomial test). The authors were able to repair the tear primarily with suture in all but one patient, whose tear was along the nerve root sleeve. In all cases fibrin glue and a muscle/fat graft were used to cover the tear, and all patients were assigned to bed rest from 24 to 48 hours after the operation. In Group A one patient required rehabilitation at discharge. The LOS in Group A was greater than that in Group B (median 5 days compared with 3 days), but no additional complication was noted. Conclusions The incidence of CSF leakage was 16% in 76 patients, and there were no other complications. Older patient age and higher level of the surgeon’s training were factors contributing to the incidence, but the history of surgery was not.

LOCALIZATION OF CEREBROSPINAL FLUID LEAKS BY GADOLINIUM-ENHANCED MAGNETIC RESONANCE CISTERNOGRAPHY

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 584-589 ◽  
Author(s):  
Kubilay Aydin ◽  
Ege Terzibasioglu ◽  
Serra Sencer ◽  
Altay Sencer ◽  
Yusufhan Suoglu ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Vital Signs ◽  
Imaging Method ◽  
Csf Rhinorrhea ◽  
Mr Cisternography ◽  
Csf Leakage ◽  
Dural Tears ◽  
Magnetic Resonance Cisternography ◽  
Csf Leaks

Abstract OBJECTIVE Intrathecal gadolinium (Gd)-enhanced magnetic resonance (MR) cisternography is a newly introduced imaging method. Two main objectives of this study were to investigate the sensitivity of Gd-enhanced MR cisternography for presurgical localization of cerebrospinal fluid (CSF) leaks in patients with CSF rhinorrhea and to study the potential long-term adverse effects of intrathecal Gd application. METHODS Fifty-one patients (19 women; mean age, 36.2 yr) with CSF rhinorrhea were included in the study. A total of 0.5 ml of Gd was injected into the lumbar subarachnoid space. T1-weighted MR cisternographic images were obtained to detect CSF leakage. The patient's neurological states and vital signs were recorded for the first 24 hours after the procedure. Neurological evaluations were repeated 1, 3, and 12 months after the procedure. The patients were followed for at least 3 years with annual neurological examinations. RESULTS Gd-enhanced MR cisternography demonstrated CSF leaks in 43 of the 51 patients. The sensitivity of Gd-enhanced MR cisternography for localization of CSF leaks was 84%. Forty-four patients underwent surgery to repair dural tears. Surgical findings confirmed the results of Gd-enhanced cisternography in 43 of the 44 patients who underwent surgery (98%). Eight patients with negative Gd-enhanced MR cisternography had no active rhinorrhea at the time of procedure, and seven of them did not need surgery. None of the patients developed an acute adverse reaction that could be attributed to the procedure. None of the patients developed any neurological symptoms or signs caused by intrathecal Gd injection during a mean follow-up period of 4.12 years. CONCLUSION Gd-enhanced MR cisternography is a sensitive and safe imaging method for detection of CSF leaks in patients with rhinorrhea.

Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas

2012 ◽  
Vol 116 (6) ◽  
pp. 1299-1303 ◽  
Author(s):  
Gautam U. Mehta ◽  
Edward H. Oldfield
Keyword(s):  
Cerebrospinal Fluid ◽  
Transsphenoidal Surgery ◽  
Surgical Repair ◽  
Fat Graft ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Cerebrospinal Fluid Drainage ◽  
Csf Drainage ◽  
Csf Leakage ◽  
Csf Leaks

Object Cerebrospinal fluid leakage is a major complication of transsphenoidal surgery. An intraoperative CSF leak, which occurs in up to 50% of pituitary tumor cases, is the only modifiable risk factor for postoperative leaks. Although several techniques have been described for surgical repair when an intraoperative leak is noted, none has been proposed to prevent an intraoperative CSF leak. The authors postulated that intraoperative CSF drainage would diminish tension on the arachnoid, decrease the rate of intraoperative CSF leakage during surgery for larger tumors, and reduce the need for surgical repair of CSF leaks. Methods The results of 114 transsphenoidal operations for pituitary macroadenoma performed without intraoperative CSF drainage were compared with the findings from 44 cases in which a lumbar subarachnoid catheter was placed before surgery to drain CSF at the time of dural exposure and tumor removal. Results Cerebrospinal fluid drainage reduced the rate of intraoperative CSF leakage from 41% to 5% (p < 0.001). This reduction occurred in macroadenomas with (from 57% to 5%, p < 0.001) and those without suprasellar extension (from 29% to 0%, p = 0.31). The rate of postoperative CSF leakage was similar (5% vs 5%), despite the fact that intraoperative CSF drainage reduced the need for operative repair (from 32% to 5%, p < 0.001). There were no significant catheter-related complications. Conclusions Cerebrospinal fluid drainage during transsphenoidal surgery for macroadenomas reduces the rate of intraoperative CSF leaks. This preventative measure obviated the need for surgical repair of intraoperative CSF leaks using autologous fat graft placement, other operative techniques, postoperative lumbar drainage, and/or reoperation in most patients and is associated with minimal risks.

Use of ligamentum nuchae graft for dural closure in posterior fossa surgery

1998 ◽  
Vol 89 (1) ◽  
pp. 155-156 ◽  
Author(s):  
Edward J. Kosnik
Keyword(s):  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leakage ◽  
Posterior Fossa Surgery ◽  
Content Type ◽  
Fluid Leakage ◽  
Dural Closure ◽  
Fine Print

✓ The technique of harvesting the ligamentum nuchae and its use in posterior fossa surgery are discussed. By using this technique the author has avoided postoperative cerebrospinal fluid leakage in more than 200 procedures.

Use of Autologous Fat Grafts for the Endoscopic Reconstruction of Skull Base Defects: Indications, Outcomes, and Complications

2018 ◽  
Vol 32 (4) ◽  
pp. 310-317 ◽  
Author(s):  
Kent Lam ◽  
Amber U. Luong ◽  
William C. Yao ◽  
Martin J. Citardi
Keyword(s):  
Skull Base ◽  
Tertiary Care ◽  
Anterior Skull Base ◽  
Fat Graft ◽  
Skull Base Reconstruction ◽  
Autologous Fat ◽  
Fat Grafts ◽  
Autologous Fat Graft ◽  
Skull Base Defects ◽  
Csf Leaks

Background The use of abdominal free fat is a traditional surgical method for the repair and reconstruction of the anterior skull base. Our objective is to assess the outcomes associated with the autologous fat graft to endoscopically repair anterior skull base defects at a single tertiary care center. Methods All patients, who underwent endoscopic skull base repair utilizing abdominal free fat from September 2009 to June 2016, were included for retrospective chart review. Evaluated outcome measurements included (1) the successful closure of preoperative and intraoperative cerebrospinal fluid (CSF) leaks and (2) complications at both donor and recipient graft sites during the postoperative periods. Four representative clinical cases have additionally been selected to highlight the common indications for which the fat graft may be effective in skull base reconstruction. Results Of the 27 patients who were identified for inclusion in this review, 25 (92.6%) demonstrated successful repair of preoperative or intraoperative CSF leaks following primary skull base repair. Two patients developed recurrent CSF leaks occurring about 1 week after their primary closures, and a secondary closure rate of 96.3% was achieved with use of fat grafts. Other complications included seroma and hematoma formation at the abdominal donor sites, each occurring in 1 patient. Conclusions The use of autologous fat remains a viable option for grafting material during endoscopic skull base reconstruction. Despite the wide variety of closure techniques in skull base surgery, autologous fat provides safe and easily accessible material to repair CSF leaks.

scholarly journals Accidental Dural Tears in Minimally Invasive Spinal Surgery for Degenerative Lumbar Spine Disease

2021 ◽  
Vol 8 ◽  
Author(s):  
Stefan Aspalter ◽  
Wolfgang Senker ◽  
Christian Radl ◽  
Martin Aichholzer ◽  
Kathrin Aufschnaiter-Hießböck ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Minimally Invasive ◽  
Dead Space ◽  
Spinal Surgery ◽  
Surgical Techniques ◽  
Csf Leak ◽  
Previous Surgery ◽  
Minimally Invasive Spinal Surgery ◽  
Csf Leakage ◽  
Dural Tears

Background: One of the most frequent complications of spinal surgery is accidental dural tears (ADTs). Minimal access surgical techniques (MAST) have been described as a promising approach to minimizing such complications. ADTs have been studied extensively in connection with open spinal surgery, but there is less literature on minimally invasive spinal surgery (MISS).Materials and Methods: We reviewed 187 patients who had undergone degenerative lumbar spinal surgery using minimally invasive spinal fusions techniques. We analyzed the influence of age, Body Mass Index (BMI), smoking, diabetes, and previous surgery on the rate of ADTs in MISS.Results: Twenty-two patients (11.764%) suffered from an ADT. We recommended bed rest for two and a half to 5 days, depending on the type of repair required and the amount of cerebrospinal fluid (CSF) leakage. We could not find any statistically significant correlation between ADTs and age (p = 0.34,), BMI (p = 0.92), smoking (p = 0.46), and diabetes (p = 0.71). ADTs were significantly more frequent in cases of previous surgery (p &lt; 0.001). None of the patients developed a transcutaneous CSF leak or post-operative infection.Conclusions: The frequency of ADTs in MISS appears comparable to that encountered when using open surgical techniques. Additionally, MAST produces less dead space along the corridor to the spine. Such reduced dead space may not be enough for pseudomeningocele to occur, cerebrospinal fluid to accumulate, and fistula to form. MAST, therefore, provides a certain amount of protection.

scholarly journals Cerebrospinal Fluid Leaks and Pseudomeningocele after Posterior Fossa Surgery: Effect of an Autospray Dural Sealant

Cureus ◽  
2020 ◽  
Author(s):  
Young M Lee ◽  
Angel Ordaz ◽  
Beata Durcanova ◽  
Jennifer A Viner ◽  
Philip V Theodosopoulos ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Posterior Fossa Surgery ◽  
Cerebrospinal Fluid Leaks

Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

2020 ◽  
Author(s):  
Stephen Ahn ◽  
Jae-Sung Park ◽  
Do H. Kim ◽  
Sung W. Kim ◽  
Sin-Soo Jeun
Keyword(s):  
Pituitary Adenomas ◽  
Case Series ◽  
Abdominal Fat ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Tertiary Referral Center ◽  
Fat Grafts ◽  
Sellar Floor ◽  
Csf Leaks

Abstract Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.

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