Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management

Abstract

Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.

Keywords: Durotomy; cerebrospinal fluid leak; dural repair; duraplasty; spine tumor.

Figure 1

Pre- (A,B) and post-operative (C-F) films of a patient with a thoracic epidural mass who underwent a circumferential approach for tumor resection and posterior instrumentation. The anterior portion of the surgery was complicated by unintended durotomy, although the site of durotomy was not easily visible/accessible at the time of surgery and was not primarily repaired. Post-operatively the patient developed a large right-sided pleural effusion requiring chest tube placement (E, asterisk; F, arrow). Chest tube drainage was positive for beta-2-transferrin. The patient subsequently underwent re-exploration and durotomy repair with a favorable long-term outcome.

Figure 2

An illustration depicting the use of subfascial drainage in the prevention of post-operative CSF leaks. The subfascial drain is connected to a Becker bag or other form of gravity drainage, and the output is closely monitored and the bag height titrated to avoid overdrainage. Prolonged subfascial diversion of spinal fluid provides time for the thoracodorsal fascia and skin to heal. After drain removal, epidural and subarachnoid pressure are said to equalize, arresting flow through the dural defect and allowing the dural defect to heal secondarily. CSF, cerebrospinal fluid.