CSF Leaks After Anterior Decompression for OPLL
CSF Leaks After Anterior Decompression for OPLL
Object. Anterior decompression is an effective way to treat cervical myelopathy associated with ossification of the posterior longitudinal ligament (OPLL); however, this approach is associated with an increased risk of a dural tear and resultant CSF leak because fusion of the dura with the ossified PLL is common in these cases. The authors review the literature and present an algorithm for treatment of CSF leaks in these patients.
Methods. A MEDLINE review was performed to identify papers related to CSF leak after anterior decompression for OPLL, and data were summarized to identify treatment options for various situations. A treatment algorithm was identified based on these findings and the experience of the authors.
Results. Eleven studies were identified that presented data on intra- and postoperative management of a CSF leak during ventral surgery for OPLL. The incidence of cervical dural tears and CSF leaks after anterior decompression procedures for OPLL ranged from 4.3% to 32%. Techniques including preventative measures, intraoperative dural repair with various materials, and postoperative drainage or shunt placement have all been used.
Conclusions. Although direct dural repair is the preferred treatment for CSF leak, this technique is not always technically possible. In these cases, intraoperative adjuncts in combination with postoperative measures can be used to decrease the pressure gradient across the dural tear.
Ossification of the posterior longitudinal ligament (OPLL) is a known cause of cervical stenosis resulting in myelopathy and/or radiculopathy. Various operative procedures, including anterior, posterior, and combined approaches, have been used for treating this disease. Although posterior approaches such as multilevel laminoplasty or laminectomy with or without fusion provide a straightforward albeit indirect approach to treat OPLL, anterior decompression with direct resection of the OPLL is often necessary because the anchoring effect of the dentate ligaments, nerve roots, and anteriorly attached root sleeves may preclude sufficient decompression of the spinal cord with a posterior approach. In cases of OPLL, however, the dura mater often becomes ossified or calcified and fuses with the PLL, thereby increasing the chance for CSF leak and spinal cord or nerve root injury during surgical manipulation for removal of the ossified mass. The possibility for traumatic manipulation increases the risk of a CSF leak during an anterior decompression in comparison with a posterior approach, because laminoplasty or laminectomy obviates direct manipulation of OPLL. Hence, although anterior decompression of the spinal cord by resection of the ossified ligament combined with anterior fusion can achieve more satisfactory results than a posterior approach, the surgeon must take into account the risk of a CSF leak. Additionally, when choosing an anterior approach, the surgeon must be aware of intra- and postoperative management strategies to treat a CSF leak and minimize manipulation of the thecal sac to avoid any spinal cord damage. In this article, we review the literature on intra- and postoperative management of cervical dural tears during surgery for OPLL and suggest a treatment algorithm.
Abstract and Introduction
Abstract
Object. Anterior decompression is an effective way to treat cervical myelopathy associated with ossification of the posterior longitudinal ligament (OPLL); however, this approach is associated with an increased risk of a dural tear and resultant CSF leak because fusion of the dura with the ossified PLL is common in these cases. The authors review the literature and present an algorithm for treatment of CSF leaks in these patients.
Methods. A MEDLINE review was performed to identify papers related to CSF leak after anterior decompression for OPLL, and data were summarized to identify treatment options for various situations. A treatment algorithm was identified based on these findings and the experience of the authors.
Results. Eleven studies were identified that presented data on intra- and postoperative management of a CSF leak during ventral surgery for OPLL. The incidence of cervical dural tears and CSF leaks after anterior decompression procedures for OPLL ranged from 4.3% to 32%. Techniques including preventative measures, intraoperative dural repair with various materials, and postoperative drainage or shunt placement have all been used.
Conclusions. Although direct dural repair is the preferred treatment for CSF leak, this technique is not always technically possible. In these cases, intraoperative adjuncts in combination with postoperative measures can be used to decrease the pressure gradient across the dural tear.
Introduction
Ossification of the posterior longitudinal ligament (OPLL) is a known cause of cervical stenosis resulting in myelopathy and/or radiculopathy. Various operative procedures, including anterior, posterior, and combined approaches, have been used for treating this disease. Although posterior approaches such as multilevel laminoplasty or laminectomy with or without fusion provide a straightforward albeit indirect approach to treat OPLL, anterior decompression with direct resection of the OPLL is often necessary because the anchoring effect of the dentate ligaments, nerve roots, and anteriorly attached root sleeves may preclude sufficient decompression of the spinal cord with a posterior approach. In cases of OPLL, however, the dura mater often becomes ossified or calcified and fuses with the PLL, thereby increasing the chance for CSF leak and spinal cord or nerve root injury during surgical manipulation for removal of the ossified mass. The possibility for traumatic manipulation increases the risk of a CSF leak during an anterior decompression in comparison with a posterior approach, because laminoplasty or laminectomy obviates direct manipulation of OPLL. Hence, although anterior decompression of the spinal cord by resection of the ossified ligament combined with anterior fusion can achieve more satisfactory results than a posterior approach, the surgeon must take into account the risk of a CSF leak. Additionally, when choosing an anterior approach, the surgeon must be aware of intra- and postoperative management strategies to treat a CSF leak and minimize manipulation of the thecal sac to avoid any spinal cord damage. In this article, we review the literature on intra- and postoperative management of cervical dural tears during surgery for OPLL and suggest a treatment algorithm.
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