dural tear1

Dr. Shankar Vadapatil discusses the necessity of re-exploring cases of CSF leak following spinal surgery. CSF leaks can occur during surgery and if left untreated, can lead to complications such as nerve entrapment or brain abscess. The optimal method of managing CSF leaks is still debated. Dr. Vadapatil conducted a retrospective study and found that diversion drains, zipper ratcheting straps, and strategic removal of wound drains were effective in managing CSF leaks. These techniques can help avoid re-exploration and reduce morbidity and costs associated with the surgery. Hello everyone, my topic is, is it always necessary to re-explore a case of CSF leak following spinal surgery? Myself Dr. Shankar Vadapatil. Incidental durotomy is inevitable. Durotomy induced CSF leak is a common complication during spine surgery with incidence of 3 to 16%. A tear in the dura followed by CSF leak can also occur in dead fashion in an extra-dural operation if the dura is very thin or the margin along the laminated effect have a bone spikule. When CSF outflow exceeds the strength of the socio-tissue, there is a persistent CSF connection between the intra-dural and outside the incision. It leads to persistent CSF leak, and if untreated, it may pose risks such as nerve entrapment, meningitis, brain abscess, or even intra-cranial hemorrhage. The optimal method of managing CSF leak remains controversial. How such patient presents with? One is swelling over the back or repeated soakage of dressing. How to proceed? Should we re-explore all such cases? Today, my objective is to establish if it is always necessary to re-explore a case of CSF leak following spinal surgery. We retrospectively studied from 2016 to 2022. The patients with CSF leaks recognized post-operatively are those that persisted in spite of an attempt at repair intraoperatively were reviewed. We excluded MIS cases as the principal is different entity. We came to our treatment strategy where if CSF leak presents with continuous profuse leak or pseudomeningocele, then we applied diversion drain. If there is a droplet of CSF leak from incision site, then we applied zipper ratcheting straps. If leak noticed post-operatively with wound drain in-situ, then statistically removal of wound drain done. We noticed CSF leak in 3.63 percentage. The average age is 53 years, male to female ratio is 4.2 to 5.8. We applied diversion drain in 7 cases, strategic wound drain in 2 cases, and zipper ratcheting straps were applied in 7 cases. All patients were followed up for 6 months. Majority leaks were seen in lumbar cases around 85, then thoracic, and least in cervical. Majority incidents of duralty were noticed during decompression, t-leaf, and deformity correction, and last is residence surgery. There were no recurrence of CSF leak noted in our study. Why you are hesitant to re-explore? Because in cases such as the dura is irreparable, such as lacerated or ragged edges, it's endosurgery, economic burden due to social morbidity, longer hospital stay, psychological impact on patient and its attenders, every revision surgery leads to wound infection and due to delayed wound healing, and what special will you do this time? The treatment approaches were classified into two groups based on fluid flow mechanics. One is stoppage of CSF leak by direct suture or augmented closure with dural substitute, and second one is retarding CSF leak by reducing subaltern fluid pressure or increasing the epidural space pressure. CSF leak percentage is a method of CSF sent in by the subaltern catheter which in turn reduces the subaltern fluid pressure. Can be used prophylactically or therapeutically. The patient placed in lateral position with 14 standard lumbar puncture needle, needle directed superiorly after encountering CSF leak, it should advance at least 20 cm inside, one end is connected to back which have a rate controller, and the drainage bag is always kept lower, around 5 cm lower than the catheter enter point. The first in five days, the drainage was kept at 8 ml per hour. The patient was on IV antibiotic throughout the procedure till drain removal. This is a schematic representation of diversion drain. It was closely monitored in the neuromonitoring ICU. Some cases where the complete cessation of pseudomeningocele seen in repeated MRI. Many literature shows that diversion drain have high success rate around 85 to 94%. It was widely used in CSF leak with unrecognized site of fistula. The second one is application of zipper ratcheting strap. Once the droplet CSF leak identified in post-operative period, we applied zipper ratcheting straps. It has a set of ratcheting strap made of adjustable polyurethane that lock into place to preserve the tension. A tight facial closure will increase the abdominal fluid pressure in trans-retard CSF flow, and help dura flap to adhere. Previously, we have published our own paper in Global Spine Journal. It has advantages of ease of its application and ability to minimize the complications associated with CSF leak. Third one is strategic removal of sub-facial wound drain. There is epidural CSF fluid may be developed secondary to durotomy, which is wrapped up by the incisional tissue. When CSF outflow beyond the strength of the social tissue, it leads to persistent CSF leak. A tight facial closure will increase the epidural fluid pressure, retard CSF flow, and it makes the dura flap to adhere. Meantime, the sub-facial wound drain will discharge excessive CSF, which in turn eliminates the dead space. This is a symmetric representation of sub-facial wound drain. Many literatures were published on sub-facial wound drain. Our studies have limitations such as infection, excessive fluid drainage, persistence of pseudomeningocele facial along the cataract, and pneumocephalus. Clinical practice is always an evolution. There may be situations that might force us to re-explore. We conclude that diversion drain, strategic removal of wound drain, and collapsing dead space with zipper ratcheting steps are simple effective modes of managing preventing post-operative CSF leak. These techniques will help in avoiding re-exploration, thus minimizing the wound-related morbidity and economic burden. Thank you.