Unique Bone Suture Anchor Repair of Complex Lumbar Cerebrospinal Fluid Fistulas

Abstract

Background: Spine surgeons encounter occasional complex cerebrospinal fluid fistulas/dural tears (CSF/DT) during lumbar spinal surgery. In some cases, these leaks are found during the index procedure, but others may appear postoperatively, or in the course of successive procedures. Here we asked, whether these complex CSF fistulas/DT could be more readily repaired utilizing a “bone suture anchor” technique, particularly where there is no residual dural margin/remnant. Methods: With the combined expertise of the orthopedist and neurosurgeon, mini/micro bone suture anchors, largely developed for hand surgery, facilitated repair of complex DT occurring during lumbar spine surgery. This technique was utilized to suture in place fascia, periosteal, or muscle grafts, and was followed by the application of microfibrillar collagen, and a fibrin sealant. Results: This mini/micro suture anchor technique has now been utilized to repair multiple significant intraoperative and/or postoperative recurrent DT, largely avoiding the need to place lumbar drains and/or lumbo- peritoneal shunts. Conclusions: Here, we reviewed how to directly suture dural grafts utilizing a mini/micro bone suture anchor technique to repair complex intraoperative primary/recurrent DT occurring during lumbar spine surgery. The major advantages of this technique, in addition to obtaining definitive occlusion of the DT, largely avoids the need to place lumbar drains and/or lumbo-peritoneal shunts with their attendant risks and complications.

Perspective: Early diagnosis and treatment of postoperative recurrent cerebrospinal fluid fistulas/ dural tears to avoid adhesive arachnoiditis

“…More complex repairs may also warrant muscle/dural patch grafts, and/or suture anchors. [ 1 ] Mini/micro bone suture anchors can be tapped directly into the bone surrounding a lumbar decompression/ fistula site where there is no residual dural edge for suturing; with these suture anchors, a spine surgeon can attain a water-tight dural closure, and avoid lumbar drains and/or lumboperitoneal shunts [ Table 1 ]. [ 1 ] In almost all cases, the closure or primary and secondary lumbar CSF fistula/DT repairs should be routinely supplemented by the application of microfibrillar collagen, and a fibrin sealant/fibrin glue (FS/FG).…”

“…As noted above, it can also be placed dorsal to repairs performed with suture anchors. [ 1 ] Further, as the packaging insert states: “FG may be used to augment repair especially if used in skull base procedures or intradural spinal surgery.” Additionally the insert states: “Closed suction wound drainage is recommended for 1–3 days postoperatively.”…”

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

“…Patients may present with classical symptoms/signs of intracranial hypotension (ICH) due to newly occurrent or recurrent CSF leaks/DT [Table 1]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] ese symptoms typically include; postural headaches, nausea/vomiting, visual complaints/double vision, difficulty concentrating, lumbar radiculopathy/cauda equina syndromes, sphincter dysfunction, and/or sexual dysfunction. [2][3][4][5][6][7][8][9] CSF leaks/ DT are largely documented on thin-cut MR or Myelo-CT studies following prior epidural spinal injections (ESI), lumbar punctures (LP), spinal anesthesia (SA), spontaneous intracranial hypotension (SICH), or trauma due to surgery.…”

“…In multiple studies, patients underwent primary intraoperative and/or recurrent postoperative direct surgical repair of CSF leaks/DT [Tables 1 and 2]. [1,[3][4][5]7,8] Khan et al (2006) successfully treated intraoperative CSF leaks/DT occurring in 7.6% primary (no prior surgery) vs. 15.9% revision-procedure CSF leaks/DT, and 6 recurrent postoperative DT (1.8%: 2 after primary, and 4 after revision surgery) utilizing 4-0 Silk sutures. [8] Guerin et al (2012) advocated direct dural repairs for 51 of 1326 (3.8%) primary surgical, and 9 secondary repairs (i.e.…”

“…"Focal cerebrospinal fluid (CSF) leaks/dural tears (DT)" identified on Myelo-CT and/or thin-cut MR studies are largely attributed to; epidural steroid injections (ESI), lumbar punctures (LP), spinal anesthesia (SA), or spontaneous intracranial hypotension (SICH) [Table 1]. [1,[3][4][5][6][7][8][9][10]12,13] ese "focal leaks" have long been successfully treated with "targeted epidural blood patches (EBP)" utilizing ultrasound, fluoroscopy, or O-arm guidance […”