Successful outcomes with flaps for recurrent cerebrospinal fluid leaks: A systematic review of the literature.

Complex back wounds with cerebrospinal fluid (CSF) leak constitute a challenge for surgeons in clinical practice. While repair of complex back wounds with various flaps is well described in the literature, there is a paucity of reviews and articles regarding optimal treatment for refractory CSF leaks. The aim of this systematic review was to present the different flap techniques proposed in the literature for CSF leaks fistulas and pseudo-meningoceles. A systematic review of the literature was conducted using the PubMed, Medline, Embase, and Cochrane databases. Studies tackling different flap techniques used for spinal or skull base CSF leak were included in the studies. The main outcomes were complications and recurrences after previous failed treatments. Fifteen studies were included in the study, constituting a cohort of 42 patients (mean age 45 years; F/M ratio 1.15:1). A previous unsuccessful non-flap procedure was proposed in 88.1% of patients for their CSF leak. Only 16.7% had a recurrence of their CSF leak after the flap procedure. Free radial forearm flap and regional muscle flaps were more frequently used in the skull base region. Pedicled omental flaps and reverse turnover latissimus dorsi were the most commonly used flaps in the thoracolumbar region. No statistically significant differences were found between these flaps regarding rates of complications and recurrence. Flaps should be considered as a safe and effective treatment option for complex back wounds with CSF leaks. All proposed flaps in the literature seem to provide an equivalent cure rate for recurrent and refractory leaks.