Identification and surgical ligation of spinal CSF-venous fistula

Abstract

Background: CSF-venous fistulas (CVF) may cause incapacitating positional headaches resulting from spontaneous intracranial hypotension/hypovolemia (SIH). Their etiology remains unknown, although unrecognized local trauma may precipitate SIH. In addition, they are diagnostically challenging despite various imaging tools available. Here, we present CVF identification using magnetic resonance myelography (MRM) and elaborate on their surgical management techniques. Methods: Retrospective charts of confirmed and treated CVF patients with attention to their diagnostic imaging modalities and management techniques were further reviewed. Results: Six cases were identified of which three are presented here. There were two females and one male patient. All had fistulas on the left side. Two were at T7-T8 while the third was at T9-T10 level. Two underwent hemilaminotomies at the T7-T8 while the third underwent a foraminotomy at T9 level to access the fistula site. All CVF were closed with a combination of an aneurysm clip and a silk tie. On follow-up, all had complete resolution of symptoms with no evidence of recurrence. Conclusion: Of the various imaging modalities available, MRM is particularly sensitive in localizing CVF spinal nerve level and their laterality. In addition, the technique of aneurysm clip ligation and placement of a silk tie is curative for these lesions.

Minimally invasive surgery for spinal cerebrospinal fluid–venous fistula ligation: patient series

“…Wang et al 9 performed open CVF ligation in 20 patients with consecutive reduction of symptoms in all patients and in absence of surgical complications. Another study, by Majeed et al, 14 demonstrated similarly positive results in a series of 6 patients who underwent open surgical ligation of CVF via clipping. All patients showed resolution of their symptoms by applying the same clipping technique as described in our study.…”

“…Beyond this surgical technique, there are standard treatment options for CVF, including EBP, endovascular embolization, and open surgery. 4 , 9 , 14 , 16 Given the novelty of CVF and the lack of randomized controlled trials, the treatment of choice relies on the physician’s preference and expertise or the center’s available modalities. As observed in our cohort, some patients do not respond to interventional measures such as EBP or endovascular embolization and remain symptomatic.…”

“…[11][12][13] Ligation of the fistula under direct visualization confirms the successful elimination of the CVF and is usually performed as an open surgical approach with a high success rate. 12,14 We herein describe our experience and observations with a percutaneous, minimally invasive approach for surgical ligation of CVFs using a conventional tubular retractor system.…”

Surgical management of spontaneous intracranial hypotension syndrome: a literature review

“…Case series and clinical studies reporting the outcomes after surgery for SIH are presented in Table 5. Most patients after neurosurgical treatment remained asymptomatic, and the successful rate for operation of SIH varied between 82.6-100% [1,27,43,47,51,54,56,[58][59][60]. Only one case series presented a successful rate of 50% for SIH symptom relief [51].…”

“…In most studies, most of the affected individuals who underwent surgery were women, and the female-to-male ratio was almost 2:1 [1,43,51,54,[58][59][60]. The patients operated for SIH were in their fourth or fifth decades of life [1,6,11,54,59,60]. In almost all cases, MRI was used to diagnose SIH, which remains the basic diagnostic tool [1,5,54,61,62].…”