Introduction: Persistent cerebrospinal fluid (CSF) leak is a known complication following spine surgery with a higher incidence occurring after revision surgery because of adhesions and scarring involving the dura mater. Patients often present with postural headache and subcutaneous fluid collections. If left untreated, the symptoms may progress to persistent pain, meningitis, and progressive neurological deficits. The surgical resection of laminae allows high-resolution ultrasound imaging to be a useful tool for the diagnosis and treatment of persistent CSF leak because of the acoustic window formed.
Methods: Eighteen patients following spine surgery with symptomatic dural tears and CSF leaks were studied. In fourteen of the eighteen patients, the durotomy was identified during surgery and attempted repair by various combinations of suture, tissue sealant and local muscle graft. Ultrasound was used to identify and aspirate the fluid collection and guide placement of an 18-gauge Tuohy needle above the dural defect using a low frequency curvilinear probe. Following aspiration of CSF, a total of 15- 35 cc (25 average) of autologous blood was injected over the dural defect.
Results: Fifteen of eighteen patients (83%) had symptomatic relief of their headache and resolution of the pseudomeningocele over 12-month follow-up. Three patients returned to surgery within 24 hours of the blood patch, (broken dural suture, large dural leak, meningitis).
Conclusions: Real-time ultrasound guidance allows accurate positioning of a Tuohy needle and deposition of autologous epidural blood patch in the setting of a surgically removed ligamentum flavum. Further investigation is needed to confirm our finding that ultrasound guided epidural blood patch may offer symptomatic relief of post-surgical persistent cerebrospinal fluid leak and serves as an intermediate step along a spectrum between conservative initial management and surgical re-exploration.
Patient Care: Alternative technique to treat postoperative dural leak following spine surgery.
Learning Objectives: By the conclusion of this session, participants should be able to identify a possible effective treatment in managing postoperative pseudomeningocele.
References: Fridley JS, Jea A, Glover CD, Nguyen KP: Symptomatic postsurgical cerebrospinal fluid leak treated by aspiration and epidural blood patch under ultrasound guidance in 2 adolescents. J Neurosurg: Pediatrics 2013; 11: 87-90
Clendenen SR, Pirris S, Robards CB, Leone B, Nottmeir EW: Symptomatic Postlaminectomy Cerebrospinal Fluid Leak Treated With 4-Dimensional Ultrasound-guided Epidural Blood Patch. J Neurosurg Anesthesiol 2012; 24: 222-5
Elbiaadi-Aziz N, Benzon HT, Russell EJ, et al. Cerebrospinal fluid leak treated by aspiration and epidural blood patch under computed tomography guidance. Reg Anesth Pain Med. 2001;26:363–367