Beck Jürgen, Hubbe Ulrich, Klingler Jan-Helge, Roelz Roland, Kraus Luisa Mona, Volz Florian, Lützen Niklas, Urbach Horst, Kieselbach Kristin, Fung Christian
Departments of1Neurosurgery and.
2Neuroradiology, Medical Center, University of Freiburg, Freiburg; and.
J Neurosurg Spine. 2022 Sep 9;38(1):147-152. doi: 10.3171/2022.7.SPINE2252. Print 2023 Jan 1.
Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors.
Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications.
Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36-55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension.
Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.
脊柱脑脊液漏可导致自发性颅内低压（SIH）。手术封闭脊柱脑脊液漏是持续性漏液的首选治疗方法。手术入路各不相同，且尚无使用微创技术的研究。在本研究中，作者旨在详细阐述使用不可扩张管状牵开器对脊柱脑脊液漏进行微创显微手术封闭的安全性和可行性。
纳入2019年4月至2020年12月在单一机构接受治疗的连续SIH患者且已确诊为脊柱脑脊液漏者。手术通过2.5厘米的背部皮肤切口进行，使用不可扩张管状牵开器并进行定制的椎间开窗术，如有必要，采用经硬膜入路。主要结局是硬膜成功封闭，次要结局是并发症的发生。
共纳入58例患者，其中65.5%为女性（中位年龄46岁[四分位间距36 - 55岁]），有38例腹侧漏、17例侧方漏和2例脑脊液静脉瘘。56例（96.6%）患者的漏口得以封闭，2例（3.4%）患者因影像学检查解读错误而漏诊。其中1例患者再次手术成功，另1例患者决定在另一机构接受手术。另外2例患者因封闭不充分和漏液持续存在而不得不再次手术。永久性神经功能缺损率为1.7%，持续性或复发性漏液的翻修率为3.4%，总体翻修率为10.3%。初次封闭尝试时成功封闭率为96.6%，3.4%的患者需要二次尝试。出院时14例患者临床短期结局无变化，25例患者有所改善，19例患者有颅内高压反弹迹象。
使用管状牵开器并进行定制的椎间开窗术，如有必要采用经硬膜入路的微创手术治疗脊柱脑脊液漏安全有效。作者建议在专业中心对脊柱脑脊液漏进行微创封闭。
