Management of iatrogenic spinal cerebrospinal fluid leaks: A cohort of 124 patients

Objectives: Cerebrospinal fluid leaks are a frequent complication of spinal surgery, with reported rates between 2 and 20%. Management is highly variable and dependent on comorbidities, complexity of the index procedure, and surgeons' experience. Treatment options include primary or delayed repair, with or without spinal drainage. Using a retrospective cohort, the authors aim to identify the appropriate management of iatrogenic spinal cerebrospinal fluid (CSF) leaks. Patients and Methods: We queried our institutional database for postoperative spinal CSF leaks between 1/1/2007 and 3/14/2017 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes. Excluded were patients who had primarily intradural procedures such as tethered cord release, tumor resection, and posterior fossa decompression. Information regarding patient demographics, surgical characteristics, and postoperative course was gathered, including whether primary closure (with nonabsorbable suture) was achieved, lumbar drain placement at initial surgery, use of fibrin sealant, number of subsequent explorations, rate of infection, length of stay, and number of hospital admissions. Results: Our cohort consisted of 124 patients who suffered intraoperative iatrogenic CSF leak out of 3965 procedures, for a rate of 3.1%. Primary dural closure ( +/- lumbar drain) was attempted in 64 patients, with successful repair in 47 (73.4%). Lumbar drain placement ( +/- primary closure) was performed in 49, with success in 43 (87.8%). Delayed exploration of the surgical wound was required in 34 patients. Patients in whom primary closure could not be achieved and did not have a lumbar drain placed had a 39.5% reexploration rate. Patients who were treated with delayed exploration had statistically significant increase in length of stay (19.6 vs. 7.8 days), hospital admissions (2.1 vs. 1.0), and infections (15 vs. 0). Conclusion: CSF leaks are fraught with complications requiring reexploration for repair in 27.4% of cases. Primary repair of the leak and use of fibrin sealant upon discovery, with consideration of lumbar drain, should be performed whenever possible, as they are associated with shorter hospital stays, fewer hospital admissions, and lower rates of reoperation and infection.