Epstein Nancy E, Agulnick Marc A
Professor of Clinical Neurosurgery, School of Medicine, State University of NY at Stony Brook and Editor-in-Chief Surgical Neurology International NY, USA, and c/o Dr. Marc Agulnick, 1122 Franklin Avenue Suite 106, Garden City, NY, USA.
Assistant Clinical Professor of Orthopedics, NYU Langone Hospital, Long Island, NY, USA, 1122 Franklin Avenue Suite 106, Garden City, NY, USA.
Surg Neurol Int. 2024 Nov 1;15:401. doi: 10.25259/SNI_815_2024. eCollection 2024.
The incidence of cerebrospinal fluid (CSF) leaks/dural tears (DT) occurring during anterior cervical diskectomy and fusion (ACDF) are typically relatively low. However, this frequency markedly increases when anterior corpectomy and fusion (ACF) are performed to address ossification of the posterior longitudinal ligament (OPLL).
The reported frequencies of CSF leaks/DT occurring during elective ACDF (i.e. exclusive of trauma), ranges from 0.24% to 1.7%. Notably, this incidence substantially rises for multilevel ACF addressing anterior OPLL, markedly varying from 3.4 - 44.7%.
The classical risks of anterior cervical CSF leaks/DT with anterior cervical surgery may be minimized utilizing an operating microscope. For OPLL, careful evaluation of preoperative non-contrast CT studies is critical, especially to document whether any of the 3 signs of dural penetrance is present. Here, posterior operative choices should be strongly considered in the presence of sufficient lordosis and/or a Positive K Line (+ K Line) as this will avoid an anterior cervical CSF leak/dural fistula. Alternatively, for patients with kyphosis and a Negative K Line (- K Line), preoperative anticipation and planning to treat an intraoperative anterior CSF leak/DT (i.e. direct anterior primary dural graft repair with 7-0 Gore-Tex sutures, microdural staples, microfibrillar collagen, wound-peritoneal shunt, and lumbar drain or lumboperitneal shunt) are essential in the course of performing direct anterior OPLL resection.
The incidence of anterior cervical CSF leaks/DT is relatively low (i.e. range 0.24 - 1.7%) where ACDF is performed for disc disease/spur/spondylosis exclusive of OPLL. However, where ACF is performed for multilevel OPLL, the risk of CSF Leaks/DT is substantially higher (i.e. range 4.3-44.7%).
颈椎前路椎间盘切除融合术（ACDF）期间发生脑脊液（CSF）漏/硬脊膜撕裂（DT）的发生率通常相对较低。然而，当进行前路椎体次全切除融合术（ACF）以处理后纵韧带骨化（OPLL）时，这种发生率会显著增加。
择期ACDF（即不包括创伤）期间发生CSF漏/DT的报告频率为0.24%至1.7%。值得注意的是，对于处理前路OPLL的多节段ACF，这一发生率大幅上升，明显在3.4% - 44.7%之间变化。
使用手术显微镜可将颈椎前路手术导致颈椎前路CSF漏/DT的典型风险降至最低。对于OPLL，术前非增强CT研究的仔细评估至关重要，特别是要记录是否存在任何硬脊膜穿透的3种征象。在此，如果存在足够的前凸和/或阳性K线（+K线），应强烈考虑后路手术选择，因为这将避免颈椎前路CSF漏/硬脊膜瘘。或者，对于后凸和阴性K线（-K线）的患者，在进行直接前路OPLL切除过程中，术前预期并计划处理术中颈椎前路CSF漏/DT（即使用7-0 Gore-Tex缝线进行直接前路原发性硬脊膜移植修复、微型硬脊膜钉、微纤维胶原蛋白、伤口-腹膜分流术以及腰椎引流或腰腹膜分流术）至关重要。
对于不包括OPLL的椎间盘疾病/骨刺/脊椎关节强硬进行ACDF时，颈椎前路CSF漏/DT的发生率相对较低（即范围为0.24 - 1.7%）。然而，对于多节段OPLL进行ACF时，CSF漏/DT的风险则显著更高（即范围为4.3 - 44.7%）。
