P1. A review on the management strategies for cerebrospinal fluid leak after spinal surgery

Abstract

BACKGROUND CONTEXT

Cerebrospinal fluid leak (CSF) is a common and serious complication of spinal surgery with an incidence rate of up to 15%. Consequences can be serious, including meningitis or even life-threatening conditions such as status epilepticus, acute subdural hematomas or cerebellar hemorrhage. Yet, at present there are no unified guidelines regarding optimal management and measures to mitigate risk of CSF leak.

PURPOSE

This review aims to consolidate current strategies available in literature to provide an evidence-based guide for incorporation in day-to-day practice.

STUDY DESIGN/SETTING

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PATIENT SAMPLE

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OUTCOME MEASURES

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METHODS

A review of available literature was performed to summarize papers from 2005 to 2025 published on the topic of CSF leaks following spinal surgery. Forty-two papers were identified and summarized to identify key suggestions, points of contention and areas for future research.

RESULTS

Key suggestions identified can be classified into three categories: strategies to mitigate risk of dural breach, intraoperative management of intention durotomy and iatrogenic dural tears and management of post-operative suspected/confirmed CSF leak. Mitigating risk of dural breach can be achieved through early identification of at-risk patients and optimizing the choice of operative equipment for adequate visualization. In the case of intention durotomy and iatrogenic dural tear, there is consensus recommendation for attempting primary dural defect closure with sutures where possible. However, measures that remain contentious include choice and use of adjunctive sealants and grafts and prophylactic use of subfascial drains. Post-operative management measures include the use of lumbar drains as supported by three studies. Prolonged bed rest, use of acetazolamide and broad spectrum prolonged use of prophylactic antibiotics do not demonstrate proven benefit.

CONCLUSIONS

To conclude, strategies for CSF leak prevention and management following spinal surgery have differing levels of evidence to support their use. While measures such as primary closure of dural defect with sutures remain the gold standard, options such as the use of prophylactic subfascial drains show evidence of benefit but require further refinement and nuance before incorporation. Future research should thus pay particular attention to identifying the indications and optimizing the protocols for use of subfascial and lumbar drains as well as identifying the ideal choice of sealants and grafts for use in dural defect closure.

FDA Device/Drug Status

This abstract does not discuss or include any applicable devices or drugs.