Minimally Invasive, Tubular Approach for Ligation of Spinal Cerebrospinal Fluid-Venous Fistulas: A Single Surgeon, Consecutive Case Series.

Background and objectives: Spontaneous intracranial hypotension results from spinal cerebrospinal fluid (CSF) leaks, with Type III leaks, CSF-venous fistulas, being particularly challenging to diagnose and treat. Over approximately 2 years, 138 patients were diagnosed with spontaneous CSF leaks at our institution, with 57 requiring surgery with 31 of those surgical patients having Type III leaks. This study evaluates the safety, efficacy, and durability of a minimally invasive (MIS), tubular, nerve-sparing surgical technique for repairing Type III CSF leaks.

Methods: We retrospectively reviewed 31 consecutive patients (mean age: 57.0 ± 15.0 years; 51.6% female; mean body mass index: 27.4 ± 6.3) diagnosed with Type III CSF leaks who underwent MIS surgical ligation from September 2022 to October 2024. Most leaks involved the thoracic spine (96.8%), with 35.5% of patients exhibiting multilevel leaks. Preoperative evaluation included MRI and myelography for precise leak localization. The surgical approach used a paramedian incision, tubular retractor placement, lateral facetectomy, and venous ligation without nerve sacrifice. Clinical outcomes included symptom resolution, headache severity (Visual Analog Scale scores), radiographic improvement measured by Bern scores, and postoperative complications.

Results: Presenting symptoms included headaches (100%), dizziness (51.6%), nausea (38.7%), neck pain (32.3%), tinnitus (29.0%), and cognitive disturbances (29.0%). Postoperatively, 90.3% experienced complete headache resolution. Headache severity significantly decreased from a median preoperative Visual Analog Scale of 4.0 (IQR: 2.5) to 1.0 (IQR: 3.0) postoperatively (P < .01). Bern scores improved significantly from 6.3 ± 2.8 preoperatively to 3.0 ± 2.9 postoperatively (P < .001). The median follow-up was 5.87 months (IQR: 6.62). Complications were limited to 2 patients (6.4%): 1 transient high-pressure headache managed conservatively.

Conclusion: MIS, tubular ligation of CSF-venous fistulas is a safe and effect management strategy with high efficacy rates and low incidence of complications.