Management Of Resistant CSF Leak After Lumbar Spine Surgery By None Suction Drain Only ( Simple And Cheap Approach In A Developing Country )

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Ahmed Koheil MD, Mostafa Elmaghraby MD

Abstract

BACKGROUND:
Spinal dural tear is a relatively common situation in every day lumbar procedures. Previous studies have shown that potentially serious problems such as pseudomeningocele, external CSF fistula, meningitis and arachnoiditis with subsequent chronic pain are possible problems of dural tears and CSF leakage after spinal surgery [1]. For cases of dural tears located at the nerve root shoulder or axilla however, the direct dural repair with stitches as a treatment options less appealing because they are associated with a higher morbidity rate. Oversewing the wound with a running locked suture can sometimes stop an external minor leak in a relatively healthy patient. Lumbar drainage system and blood patch have also been used for this situation [1]
Objective:
The main object from this study is to assess the simple suturing, valsava maneuver plus the use of the none suction drain for 7 days at least until the skin wound in the lumbar region get about to heal optimally and then it will prevent the further CSF leak again by its own passive counter coup pressure.
Material and Method:
A series of patients underwent lumbar spinal surgery were retrospectively reviewed in multicenteric study in the period between 2017 – 2021. Some types of the tears were iatrogenic, seen, reported in the operative note and others were occult. Appeared after the surgery by hours to days. In addition some patients had previous lumbar surgery. Surgeries included 116 patients. Each type of the surgery in the lumbar spine was mentioned. All wounds were managed by the same dressing material and the dura was closed in the same simple sutures fashion using vicryl 0/4 round needle. The drain was put in all cases in the subfacial space and in a none suction state. Management against low tension headache was initiated. Complete bed rest was applied. Finally the follow up period was about one month after surgery.
Results: Among total of 116 cases CSF leak occurred in 18 cases which represent 15.5% of the total number of surgeries included in the study. in the early 3 days after the surgery and appeared in the drain. The period between primary surgery and the diagnosis of CSF leak was an average of ( Mean 2 days ) (range 1 – 3 days) after surgery. Discectomy in 45 cases and post operative leak occurred in 4 . Decompression laminectomy of the lumbar spine included in 53 and the post operative leak occurred in 7 cases. Recurrent lumbar disc surgery were 12 cases and the post operative leak occured in 5 cases. Meningocele was done in other 6 and the post operative leak occurred in 2 cases.
Conclusions: Although the incidence of the CSF leak after dural tear with spinal surgery is not high, caution must be taken in mind not to progress to fistula or infective meningitis. Also, not to remove the submascular drain early as usual but to keep it in place to help in skin wound healing. Finally, the recurrent surgery carries a high risk of dural tear that indicated preoperative availability of graft or sealant like fibrin glue.

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