Spinal Fluid Leak After Back Surgery

by lmatthews on August 29, 2012

cerebrospinal fluid leak after back surgery

Some dural tears are spotted and repaired during back surgery but others that are missed can lead to spinal fluid leaks.

Accidents happen, even during back surgery, and a misplaced scalpel or needle that nicks the dura can cause symptoms of a spinal fluid leak after back surgery. Oftentimes, an accidental tear in the dura is spotted during spine surgery and promptly repaired but on some occasions the slip may be missed and the patient’s incisions closed without the tear being detected or addressed. Symptoms of a spinal fluid leak from a dural tear may appear straight away after surgery but some develop slowly and so patients recovering from back surgery may not know immediately that something is wrong.

Risks of Back Surgery

Back surgery is usually undertaken once all conservative methods of treatment have been employed but pain and other symptoms persist. There are numerous risks to back surgery, including spinal fluid leaks, nerve damage, and infection, and patients need to be aware that surgery for pain relief carries a risk of actually increasing their pain and disability. Common surgeries for spinal stenosis, degenerative disc disease and arthritis may all be performed using endoscopic techniques which can complicate visibility during surgery and may result in the surgeon failing to spot a durotomy.

Long-Term Effects of Durotomy

The dura mater that covers the spinal cord is a protective, watertight sheath that can heal if accidentally torn during surgery, sometimes even if the tear is not immediately noticed and repaired. In most cases this incident has no lasting effects but where the dura fails to heal it may leak CSF into surrounding tissues and cause swelling as well as increasing the risk of spinal meningitis.

Lumbar Spine Surgery and CSF Leaks

According to Brookfield, et al (2008), dural tears are not uncommon complications of lumbar spine surgery and are usually repaired as and when they arise with subarachnoid drains fitted to clear any leaking fluid as the dura heals. Tissue grafting and the use of fibrin-adhesive sealant are also employed along with bed-rest to aid healing and reduce a build-up of fluid and the formation of a cavity in the spine. Long-term symptoms of spinal fluid leak after back surgery are usually prevented in cases where the tear is spotted and treated.


Delayed Symptoms of CSF Leak After Back Surgery

Where a dural tear (durotomy) is not recognized early and properly addressed, however, symptoms such as a headache and/or photophobia may arise. These symptoms of a cerebrospinal fluid (CSF) leak may be brought on by sitting upright after back surgery and it appears that most cases occur within seventy-two hours of incidental durotomy. Some patients do not develop symptoms until a week or more after surgery, however, especially where initial inflammation in the spine means that CSF leakage is slow at first. In such cases, patients may require additional back surgery to repair the dura and drain the fluid.

Treating Dural Tears

Treating spinal fluid leaks after back surgery will often involve compression to prevent further leakage while surgery is scheduled to repair the dural tear or while the tear heals itself. Compression bandages are often advised by a physician to minimize the risks of permanent cavities in the spine being created as the fluid leaks.

Persistent Symptoms of Spinal Fluid Leaks

Such cavities can continue to cause problems even after the spinal fluid leak has ceased. This is because they can instead fill with lymph, which itself puts pressure on the spinal cord and nerves and creates the same symptoms. Patients with large spinal cavities resulting from spinal fluid leak may have to have an accessible cover and drain placed into the wound to allow for fluid to be cleared frequently and for gauze and other packing material to be regularly changed in an attempt to get the body to fill in the cavity itself.

Using Glue for Spinal Fluid Leaks

A less invasive procedure for repairing dural tears and spinal fluid leak after back surgery involves percutaneous, CT-guided injections of fibrin glue to try to seal the wound. This is usually successful in repairing the spinal fluid leak but where it is unsuccessful it may be that an unsuspected secondary dural tear is responsible for continued symptoms. Patients may have further diagnostic imaging to ensure that all dural tears have been successfully plugged by the injected material. This can avoid the need for additional invasive procedures but where symptoms of spinal fluid leak after back surgery persist further surgery may become unavoidable.

References

Patel, M.R., Louie, W., Rachlin, J., (1996), Postoperative Cerebrospinal Fluid Leaks of the Lumbosacral Spine: Management with Percutaneous Fibrin Glue, AJNR: 17, March 1996.

Brookfield, K., Randolph, J., Eismont, F., Brown, M., (2008), Case Reports: Delayed Symptoms of Cerebrospinal Fluid Leak Following Lumbar Decompression, Orthopedics, August 2008 – Volume 31 · Issue 8:

{ 1 comment… read it below or add one }

Dennis Klein February 10, 2014 at 11:31 am

I had a L 4 / L 5 laminectomy. 10 days after surgery I had a CSF leak accompanied by headaches. The leak was repaired by a second surgery. I was informed the rupture was due to the dura going from a compressed state in the area of the tear to a decompressed state after the surgery.
Then 12 days later another leak occurred. A third surgery was performed. A flap using the right latissmiss (sp?) muscle was used to help supply a blood flow in the tissue which was not prevalent. (Patient is 76 years old with the start of diabetes). A leak again occurred and a 4th surgery was required. During surgery no leak was seen. The gluteous maximus muscle was used to provide an additional flap. No further leaks occurred. However it took 18 days at a rehab center, 2 weeks of home therapy and 10 weeks of outpatient therapy to eliminate post surgery pain.
Please provide any comments.

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