Management of CSF Leakage Occurring during Minimally Invasive Decompressive Spine Surgery in an Ambulatory Surgery Center.
Presented at SMISS Annual Forum 2018
By Thomas Francavilla MD
With Jeffrey Fischgrund MD, Rick Sasso MD, Alfred Rhyne MD,
Disclosures: Thomas Francavilla MD None Jeffrey Fischgrund MD A; Relievant. B; Relievant., Rick Sasso MD A; Relievant., Alfred Rhyne MD A; Relievant. B; Relievant.,
Incidental durotomy is a well know complication of spinal surgery which may occasionally occur. Increasingly, minimally invasive techniques are being used for spinal decompressions in an ambulatory care setting.
The management of this complication in an Ambulatory Surgery Center (ASC) setting has not been previously reported.
In the year 2016, 832 consecutive minimally invasive decompressive spinal surgeries were performed by a single surgeon in an ASC. Incidental durotomies with CSF leakage were repaired and patients were discharged to home. A technique for suture repair of a dural lacerations is presented. Patients with a watertight suture dural repair did not receive any modifications to the usual discharge activities allowed. All other patients were treated with bedrest overnight and head of bed (HOB) elevation restrictions. A protocol for close patient follow-up after discharge was followed. The complications were collected prospectively and analyzed retrospectively.
There were 30 (3.6%) incidental durotomies, with all occurring in the lumbar spine. Suture repair was accomplished in 28 (93%) patients. Patch repair of anterior dural lacerations was performed in 2 (7%) patients. All patients were discharged to home from the ASC. There were 2 short-term complications noted after discharge. One patient had a transient headache. A second patient developed urinary dysfunction requiring 2 further surgical interventions. The patient safety protocols in place identified the complications and allowed timely interventions.
Incidental durotomy occurring during minimally invasive spinal decompressive surgery is an occasional event. Suture repair of the laceration is feasible in most instances. Patients can be stratified into those with, or those without, a watertight suture dural closure. Those with such a closure, who are without symptoms of decreased ICP, do not require modification of their activities. The remainder can be successfully treated with an overnight period of bedrest and HOB modification. Routine prolonged bedrest is not necessary. Lumbar spine patients who have had a dural repair may be safely discharged to home from the ASC. However, protocols for patient safety must be in place to identify and timely manage potentially more serious complications evident after ASC discharge.