Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks

Aaron A. Cohen-Gadol, Bahram Mokri, David G. Piepgras, Fredric B. Meyer, John L D Atkinson

Research output: Contribution to journalReview article

39 Citations (Scopus)

Abstract

OBJECTIVE: Spontaneous intracranial hypotension is typically caused by a spontaneous spinal cerebrospinal fluid (CSF) leak. The configuration of the related dural defects can be complex. We describe our experience with the surgical anatomy of these defects. METHODS: Thirteen consecutive patients with spontaneous spinal CSF leaks who underwent surgical exploration at Mayo Clinic between 1994 and 2003 were studied. All patients' records, imaging studies, detailed intraoperative findings, and outcomes were reviewed. RESULTS: There were four men and nine women with an average age of 40 years (range, 12-62 yr). Preoperative imaging studies revealed a single site of CSF leak in eight patients, two sites in three patients, and multiple sites in two patients. Intraoperatively, the exact site of leakage could not be found in four patients. Among the other nine patients, primary closure of a meningeal diverticulum was achieved in one patient. Significant regional attenuation of the dura prevented primary repair of the leak site in eight patients. Muscle, fibrin glue, and Gelfoam (Upjohn Co., Kalamazoo, MI) soaked in patient's own blood were commonly used to pack the epidural space in an attempt to seal the site of the leak. Ligation of two nonappendicular nerve roots allowed closure of the leak in one of these patients. Postoperatively, resolution of symptoms occurred in eight patients, significant improvement was noted in three patients, and only transient resolution in two. The mean duration of follow-up was 20.5 months. CONCLUSION: Surgery for closure of spontaneous spinal CSF leaks may not be straightforward. Even when extradural CSF leakage is discovered preoperatively by imaging studies, it may not always be possible to identify the exact site of the leakage intraoperatively. Furthermore, the anatomy of the dural defects may be complex and not amenable to primary closure. In such cases, the use of adjuvant techniques during surgical exploration may be effective.

Original languageEnglish (US)
JournalNeurosurgery
Volume58
Issue numberSUPPL. 2
DOIs
StatePublished - Apr 2006

Fingerprint

Anatomy
Cerebrospinal Fluid Leak
Intracranial Hypotension
Absorbable Gelatin Sponge
Epidural Space
Fibrin Tissue Adhesive
Diverticulum
Ligation
Muscles

Keywords

  • Cerebrospinal fluid leaks
  • Intracranial hypotension
  • Laminectomy
  • Meningeal diverticula
  • Orthostatic headaches

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Cohen-Gadol, A. A., Mokri, B., Piepgras, D. G., Meyer, F. B., & Atkinson, J. L. D. (2006). Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks. Neurosurgery, 58(SUPPL. 2). https://doi.org/10.1227/01.NEU.0000204712.16099.FB

Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks. / Cohen-Gadol, Aaron A.; Mokri, Bahram; Piepgras, David G.; Meyer, Fredric B.; Atkinson, John L D.

In: Neurosurgery, Vol. 58, No. SUPPL. 2, 04.2006.

Research output: Contribution to journalReview article

Cohen-Gadol, AA, Mokri, B, Piepgras, DG, Meyer, FB & Atkinson, JLD 2006, 'Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks', Neurosurgery, vol. 58, no. SUPPL. 2. https://doi.org/10.1227/01.NEU.0000204712.16099.FB
Cohen-Gadol, Aaron A. ; Mokri, Bahram ; Piepgras, David G. ; Meyer, Fredric B. ; Atkinson, John L D. / Surgical anatomy of dural defects in spontaneous spinal cerebrospinal fluid leaks. In: Neurosurgery. 2006 ; Vol. 58, No. SUPPL. 2.
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abstract = "OBJECTIVE: Spontaneous intracranial hypotension is typically caused by a spontaneous spinal cerebrospinal fluid (CSF) leak. The configuration of the related dural defects can be complex. We describe our experience with the surgical anatomy of these defects. METHODS: Thirteen consecutive patients with spontaneous spinal CSF leaks who underwent surgical exploration at Mayo Clinic between 1994 and 2003 were studied. All patients' records, imaging studies, detailed intraoperative findings, and outcomes were reviewed. RESULTS: There were four men and nine women with an average age of 40 years (range, 12-62 yr). Preoperative imaging studies revealed a single site of CSF leak in eight patients, two sites in three patients, and multiple sites in two patients. Intraoperatively, the exact site of leakage could not be found in four patients. Among the other nine patients, primary closure of a meningeal diverticulum was achieved in one patient. Significant regional attenuation of the dura prevented primary repair of the leak site in eight patients. Muscle, fibrin glue, and Gelfoam (Upjohn Co., Kalamazoo, MI) soaked in patient's own blood were commonly used to pack the epidural space in an attempt to seal the site of the leak. Ligation of two nonappendicular nerve roots allowed closure of the leak in one of these patients. Postoperatively, resolution of symptoms occurred in eight patients, significant improvement was noted in three patients, and only transient resolution in two. The mean duration of follow-up was 20.5 months. CONCLUSION: Surgery for closure of spontaneous spinal CSF leaks may not be straightforward. Even when extradural CSF leakage is discovered preoperatively by imaging studies, it may not always be possible to identify the exact site of the leakage intraoperatively. Furthermore, the anatomy of the dural defects may be complex and not amenable to primary closure. In such cases, the use of adjuvant techniques during surgical exploration may be effective.",
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N2 - OBJECTIVE: Spontaneous intracranial hypotension is typically caused by a spontaneous spinal cerebrospinal fluid (CSF) leak. The configuration of the related dural defects can be complex. We describe our experience with the surgical anatomy of these defects. METHODS: Thirteen consecutive patients with spontaneous spinal CSF leaks who underwent surgical exploration at Mayo Clinic between 1994 and 2003 were studied. All patients' records, imaging studies, detailed intraoperative findings, and outcomes were reviewed. RESULTS: There were four men and nine women with an average age of 40 years (range, 12-62 yr). Preoperative imaging studies revealed a single site of CSF leak in eight patients, two sites in three patients, and multiple sites in two patients. Intraoperatively, the exact site of leakage could not be found in four patients. Among the other nine patients, primary closure of a meningeal diverticulum was achieved in one patient. Significant regional attenuation of the dura prevented primary repair of the leak site in eight patients. Muscle, fibrin glue, and Gelfoam (Upjohn Co., Kalamazoo, MI) soaked in patient's own blood were commonly used to pack the epidural space in an attempt to seal the site of the leak. Ligation of two nonappendicular nerve roots allowed closure of the leak in one of these patients. Postoperatively, resolution of symptoms occurred in eight patients, significant improvement was noted in three patients, and only transient resolution in two. The mean duration of follow-up was 20.5 months. CONCLUSION: Surgery for closure of spontaneous spinal CSF leaks may not be straightforward. Even when extradural CSF leakage is discovered preoperatively by imaging studies, it may not always be possible to identify the exact site of the leakage intraoperatively. Furthermore, the anatomy of the dural defects may be complex and not amenable to primary closure. In such cases, the use of adjuvant techniques during surgical exploration may be effective.

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KW - Meningeal diverticula

KW - Orthostatic headaches

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