Perspective: Early direct repair of recurrent postoperative cerebrospinal (CSF) fluid leaks: No good evidence epidural blood patches (EBP) work

Abstract

Background: "Targeted" epidural blood patches (EBP)" successfully treat "focal dural tears (DT)" diagnosed on thin-cut MR or Myelo-CT studies. These DT are largely attributed to; epidural steroid injections (ESI), lumbar punctures (LP), spinal anesthesia (SA), or spontaneous intracranial hypotension (SICH). Here we asked whether "targeted EBP" could similarly treat MR/Myelo-CT documented recurrent post-surgical CSF leaks/DT that have classically been effectively managed with direct surgical repair.

Methods: Utilizing ultrasound, fluoroscopy, or O-arm guidance, "targeted EBP" effectively manage "focal DT" attributed to ESI, LP, SA, or SICH. Here we reviewed the literature to determine whether similar "targeted EBP" could effectively manage recurrent postoperative CSF leaks/DT.

Results: We were only able to identify 3 studies involving just 20 patients that attempted to utilize EBP to control postoperative CSF fistulas/DT. EBP controlled CSF fistulas/DT in 6 patients in the first study, and 9 of 10 patients (i.e. 90%: 2/2 cervical; 7/8 lumbar) in the second study. However, in the third study, 3 (60%) of 5 EBP failed to avert recurrent CSF leaks/DT in 4 patients (i.e. 1 cervical patient (2 EBP failed attempts), 3 lumbar patients (1 failed EBP)).

Conclusion: Early direct surgical repair of recurrent postoperative spinal CSF leaks/DT remains the treatment of choice. Our literature review revealed 3 underpowered studies including just 20 patients where 20% of EBP failed to control recurrent postoperative fistulas (range of failure from 0-60% per study). Although there are likely other studies we failed to identify in this review, they too are likely insufficiently powered to document significant efficacy for performing EBP over direct surgical repair for recurrent postoperative CSF leaks/DT.

Keywords: Cerebrospinal fluid (CSF) leak; Dural repair; Dural tear (DT); Epidural blood patch (EBP); Fluoroscopy; Insufficient evidence; MR; Myelo-CT; Postoperative recurrent lumbar CSF leaks; Spontaneous intracranial hypotension (SICH); Targeted EBP.