Neurosurgery 93:473–479, 2023
Postoperative spinal cerebrospinal ﬂuid (CSF) leaks are common but rarely cause extensive CSF collections that require specialized imaging to detect the site of the dural breach.
OBJECTIVE: To investigate the use of digital subtraction myelography (DSM) for patients with extensive extradural CSF collections after spine surgery.
METHODS: A retrospective review was performed to identify a consecutive group of patients with extensive postoperative spinal CSF leaks who underwent DSM.
RESULTS: Twenty-one patients (9 men and 12 women) were identiﬁed. The mean age was 46.7 years (range, 17-75 years). The mean duration of the postoperative CSF leak was 3.3 years (range, 3 months to 21 years). MRI showed superﬁcial siderosis in 6 patients. DSM showed the exact location of the CSF leak in 19 (90%) of the 21 patients. These 19 patients all underwent surgery to repair the CSF leak, and the location of the CSF leak could be conﬁrmed intraoperatively in all 19 patients. In 4 (19%) of the 21 patients, DSM also showed a CSF-venous ﬁstula at the same location as the postoperative dural tear.
CONCLUSION: In this study, DSM had a 90% detection rate of visualizing the exact site of the dural breach in patients with extensive postoperative spinal CSF leaks. The coexistence of a CSF-venous ﬁstula in addition to the primary dural tear was present in about one-ﬁfth of patients. The presence of a CSF-venous ﬁstula should be considered if CSF leak symptoms persist in spite of successful repair of a durotomy.