Introduction: Postoperative cerebrospinal fluid (CSF) leak is a known complication of intraoperative durotomy. Intraoperative placement of subfascial epidural drains following primary dural repair has been proposed as a potential management strategy to prevent formation of CSF-cutaneous fistula and symptomatic pseudomeningocele. Here we describe our experience with subfascial epidural drain placement in cases with intentional intraoperative durotomy to prevent postoperative wound complications and pseudomeningocele formation.
Methods: Medical records of patients who underwent placement of subfascial epidural drains during spinal procedures with intentional intraoperative durotomies over a 4 year period at 2 institutions were retrospectively reviewed for demographic and clinical data. Primary outcomes of interest were postoperative CSF-cutaneous fistula or symptomatic pseudomeningocele formation.
Results: Twenty five patients (13 male and 12 female) were included in the study. Mean length of follow up was 9.5 months (0.5 – 28 months). Twelve patients (48%) also underwent simultaneous arthrodesis. The average duration of the drain was 5.3 ± 3.4 days with average daily output of 126.5 ± 103.2 cc. Average drain duration for the arthrodesis group was 6.33 ± 4.0 days, which is significantly greater than that of the non-fused group at 3.7 ± 1.1 days (p = 0.016). Similarly, the average daily drain output for the arthrodesis subgroup at 153.1 ± 117.4 cc was significantly higher than that of the non-fused subgroup (86.8 ± 63.5 cc, p = 0.04). No patient developed postoperative CSF-cutaneous fistula, symptomatic pseudomeningocele, or suffered negative sequelae associated with over-drainage of CSF, such as intracranial subdural hematoma or severe positional headache.
Conclusions: The intraoperative placement of subfascial epidural drains was not associated with postoperative development of CSF-cutaneous fistula, symptomatic pseudomeningocele, over-drainage, or subdural hematoma in the cases reviewed. We also did not observe any wound breakdown. Therefore, based on our observation, subfascial closed wound drain placement is a safe and efficacious management method after intentional spinal durotomies. It is particularly helpful in those who undergo simultaneous arthrodesis, as those patients have statistically higher daily drain output and longer drain durations. In our experience, placing an epidural subfascial drain after durotomy prevented postoperative CSF leakage.
Patient Care: Here we share our experience in using epidural subfascial drains after intentional durotomy in spine surgeries. CSF leak is a possible complication associated with any spinal procedures. Our experience is that epidural subfascial drain is a safe and effective management after intentional durotomy in spine surgeries
Learning Objectives: By the conclusion of the session, participants should be able to: 1) appreciate epidural subfascial drain placement after intentional durotomy is safe and effective in preventing CSF leak
2) appreciate epidural subfascial drain is particularly useful in those undergoing simultaneous arthrodesis