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

Abstract

BACKGROUND Cerebrospinal fluid–venous fistulas (CVFs) may cause cerebrospinal fluid leaks resulting in spontaneous intracranial hypotension (SIH). Surgical treatment of CVFs aims to eliminate abnormal fistulous connections between the subarachnoid space and the epidural venous plexus at the level of the nerve root sleeve. The authors propose a percutaneous minimally invasive technique for surgical ligation of CVF as an alternative to the traditional open approach using a tubular retractor system. OBSERVATIONS Minimally invasive surgical (MIS) ligation of spinal CVF was performed in 5 patients for 6 CVFs. The definite disconnection of the CVF was achieved in all patients by clipping and additional silk tie ligation of the fistula. None of the patients experienced surgical complications or required transition to an open procedure. One patient underwent 2 MIS procedures for 2 separate CVFs. Postoperative clinical follow-up and cranial magnetic resonance imaging confirmed resolution of symptoms and radiographic SIH stigmata. LESSONS MIS ligation of CVFs is safe and efficient. It represents an elegant and less invasive procedure, reducing the risk of wound infections and time to recovery. However, preparedness for open ligation is warranted within the same surgical setting in cases of complications and difficult accessibility.

Don’t delay, but don’t despair: symptom duration, comorbidity and outcome after closure of spinal cerebrospinal fluid leaks

“…Cheema et al report a median time from symptom onset to the correct diagnosis of 2 months with a range of 0–180 months, and after that, a median period of 10 weeks until surgery [ 3 ]. Before surgical treatment of CSF-venous fistulas, Wang et al report an average duration of symptoms of around 40 months [ 11 ] and Lohkamp et al a symptom duration between 1.5 and 3 years [ 31 ]. Notably, neither study reports an impact of symptom duration on the outcome.…”

Commentary: Keyhole Fenestration for Cerebrospinal Fluid Leaks in the Thoracic Spine: Quantification of Bone Removal and Microsurgical Anatomy

“…6 When conservative treatment or blood patches fail, opting for a minimally invasive CSF leak repair should be a safe and reasonable approach as an alternative to open procedures, reducing the risk of wound infections and time to recovery. 7,8 In cases where the medial fistula point is located directly at the exit of the nerve root or at the medial dura, endoscopic techniques may be more useful because of the improved visualisation. 7 Surgeons, therefore, need to judiciously weigh the risk, benefits, and surgeon comfort with either a tubular or endoscopic approach, and we encourage surgeons to do what is safest in their hands.…”