Keywords
autograft - blood patch - CSF leak - postoperative - sealing agents
Introduction
Cerebrospinal fluid (CSF) leak after a neurosurgical procedure is a known complication
that may result in bad outcomes.[1] The incidence of CSF leak varies based on the site involved; it ranges from 4 to
32% for transsphenoidal to posterior fossa procedures.[2] With this complication, the possibility of developing meningitis and that resulting
in morbidity always remains.[2]
[3]
[4] The costs involved in treating postoperative CSF leak increases exponentially that
becomes a barrier in continuing optimum treatment.[2] Since most of these CSF leaks postoperatively are low pressure leaks, the treatment
options are to first manage with agents that reduce CSF production like acetazolamide
(carbonic anhydrase inhibitor), furosemide.[5] The next option is being invasive and putting a catheter into the subarachnoid space
in the form of a lumbar drain.[6] This can be done in combination of continuing with the conservative measures mentioned
earlier.[7] If conservative measures and lumbar subarachnoid catheter fail and the CSF leak
is persistent, then surgical repair in the form of resuturing or closure of the defect
is planned.[8] There are many studies that compare treatment modalities and even use of sealing
agents but none give an algorithm of management.
Our study aims at known technique that can help to treat these types of low-pressure
CSF leaks.
Materials and Methods
This was a prospective study which was done over period of 5 years from January 2014
to January 2019. Ethical clearance was obtained from the institutional ethics committee
as per the institutional policy. Ours is a tertiary care center catering to neurosurgical
patients with ailments in both cranial and spinal diseases. Detailed workup was done
including assessment of nutritional status, liver function tests, renal function tests,
and coagulation profile. All patients who underwent procedures in which durotomy was
done were included in the study. The procedures included cranial and spinal neurosurgery.
Age and sex were not taken as a parameter. Adult and pediatric as well as male and
female patients were included.
Patients who had high-pressure CSF leaks, infections, CSF leaks due to trauma, patients
operated at other centers, and who have active allergies were not included in the
study. We did not encounter CSF leak in pregnant ladies as we did not come across
them during the period of study.
All the patients who had a CSF leak after surgery were enrolled into the study after
taking their informed consent and informing them of the complications of the proposed
intervention and further procedures that may occur or may be required. Informed consent
was taken. In our study, there were two surgeons involved having the same protocol
on preoperative and postoperative care.
Procedure
In all the patients in whom durotomy was done, it was closed either primarily or using
autologous graft (pericranium or fascia lata). This was mentioned in the informed
consent that was taken from the patient and patient bystanders prior to procedure.
The closure was done with 3–0 sized braided absorbable suture made of a copolymer
of lactide and glycoside (polyglactin 910). The technique of suturing was continuous
sutures all along the dural defect. The end result was a lax dural closure that was
watertight. No sealant agents were used. This was used for both cranial and spinal
procedures. When needed the bone flap was replaced, a subgaleal drain to prevent hematoma
collection was placed and the skin was closed in two layers: the galea with 2–0 polyglactin
910 and skin with nylon 2–0 sutures. After procedure patients were kept in postoperative
ward till recovery of conscious and then shifted to ward.
Follow-Up
The patients were on daily follow-up; the collection of CSF that did not cause any
tension in the healing wound was managed with conservative methods. The patients who
had a leak from the wound site were started with conservative treatment and if the
leak persisted were offered a blood patch procedure. A local ultrasound was done to
detect the defect if not proved, then a magnetic resonance imaging was done to ascertain
the defect. Only those whose defect was diagnosed underwent the blood patch procedure.
Blood Patch Procedure
Once the defect is detected, it can be approached with a percutaneous route that causes
least damage. Under aseptic precaution a 10cc syringe with the patient's blood drawn
from the femoral vein was used to percutaneously inject the blood at the defect site.
Once injected, the site was held under compression for 4 to 5 minutes. Then a compression
bandage was done at that site. The patient is then followed up. This is a bedside
procedure that has to be done under aseptic precaution.
Results
A total of six patients were enrolled for the study. The duration of the study spanned
5 years from January 2014 to January 2019. One patient was a post-temporal craniotomy
who had CSF otorrhea, one was post-suboccipital craniectomy with CSF otorrhea, one
was a postfrontal craniotomy with CSF rhinorrhea, one was a post-microdiscectomy,
and two were postoperative lumbosacral neural tube defects closure ([Table 1]).
Table 1
Causes of postoperative CSF leak
|
Type of procedure
|
Number of patients
|
|
Post-temporal craniotomy
|
1
|
|
Post-suboccipital craniectomy with CSF otorrhea
|
1
|
|
Post-frontal craniotomy
|
1
|
|
Post-microdiscectomy
|
1
|
|
Postoperative lumbosacral neural tube defects closure
|
2
|
Abbreviation: CSF, cerebrospinal fluid.
All the patients after takin informed consent underwent the necessary investigations
and a blood patch was done. In five patients the CSF was stopped, but in one patient
it persisted. This patient again underwent investigation and under image guidance
another blood patch was put after which the CSF leak stopped.
All these patients were on agents that reduce CSF production for 3 days after the
CSF leak started but had persisted to have leak of the same quantity as detected on
the first occasion. Post the blood patch application, CSF leak had stopped in all
the patients. There were no further complications.
Discussion
The results of our prospective study gave us favorable outcomes. But the number of
cases taken for the study was small as most of the patients yield to conservative
managements. We propose a relatively lesser invasive procedure to manage low-pressure
postoperative CSF leaks as the approximate defect can be ascertained.
This method can be used just before an invasive catheter insertion or surgical intervention.
Literature proves that the cost of managing postoperative CSF leaks is 141% more than
patients not having a CSF leak.[1] The risk further increases if meningitis sets in thereby also increasing the morbidity.[2]
[3] The presence of CSF leaks mandates a long intensive care unit stay, antibiotics
to prevent infections, lumbar drain, revision surgeries, resuturing, and shunt placement.[9]
[10]
[11]
Blood patch has been used to treat spontaneous dural rupture that results in intracranial
hypotension.[12]
Bayazit et al analyzed 32 patients who had CSF leak postoperatively; they observed
10 patients were treated successfully by conservative management. The rest of them
had to go to the next level of management that was lumbar drain insertion, in which
12 patients responded and the leak stopped. The remaining 10 had to undergo surgical
correction and closure of CSF leak. They concluded that this algorithm is the safest
and best option in the management of CSF leaks. This was confirmed in their study
by nonrecurrence of the leak.[5] Magnus et al in their study too shared the same conclusion as that of Bayazit et
al.[6] There is a dearth of literature on the technique of blood patch for iatrogenic CSF
leak. Gottschalk in his paper concluded that blood patch therapy is a safe and technically
relatively simple method with a high success rate.[13] He also went on to state that even though the success rates are good, some cases
need repeating the blood patch that was the same we too observed. Since CSF leak can
predispose the patient to grave sequelae, the proposed procedure can be done with
the least available infrastructure yielding good results.
Conclusion
In our study, we conclude that blood patch under imaging guidance is a safe and simple
technique. The success rates of cessation of CSF leaks are good. Also, it is a cost-effective
method using an autograft (patient's blood). The chances of the hematoma getting infected
are present but we did not encounter it. Since our study number is small, we will
need more studies on this technique.
