Original ArticleTailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome
Introduction
Tethered cord syndrome (TCS) is a neurologic condition that requires surgical detethering. Complications are associated with detethering in approximately 11%–36% of cases and include superficial wound infection, wound dehiscence, cerebrospinal fluid (CSF) subcutaneous pseudomeningocele, and CSF leaks.1, 2, 3 CSF leaks are associated with significant patient morbidity, including pseudomeningocele, meningitis, epidural abscesses, wound dehiscence, radiculopathy, cranial nerve palsy, postural headache, sensory and motor deficits, and even death.
CSF leaks can occur after detethering surgery for many reasons. Anomalous closure of midline structures during fetal development can contribute to poor wound healing,3 and a failure to close properly at the time of surgery can undermine surgical repair from within the wound, subsequently causing a progressive wound dissection and a fistulous tract. Tract formation further undermines the wound healing process, promoting the development of a persistent fistula.3 Wound dehiscence and fistulas developed after detethering in 6% of previously repaired myelomeningocele and 9% of lipomyelomeningocele.3 Chern et al.4 reported CSF leaks in 13 patients (5.9%) of patients with tight filum terminale syndrome, 11 of whom were taken to the operating room for wound revision. In these 11 patients, 2 leaks were oversewn at the bedside, and pseudomeningocele was noted in 9 patients (4.1%). Thus, abnormalities in fetal development and surgical complications can both contribute to CSF leak development.
Leaks can occur at various times after surgery, ranging from immediately postoperatively to the first 3 weeks after surgery. They may present either as an apparent leak or as a tense pseudomeningocele with signs of an impending leak. Persistent leakage may lead to wound dehiscence, which can subsequently cause local wound infection and meningitis. Thus, for patients with TCS, techniques used to avoid CSF leaks are particularly important. However, such methods are imperfect, because complications still occur after TCS surgery.
In this study, we analyzed a cohort of patients with TCS, a subset of whom experienced postoperative CSF leaks or significant pseudomeningocele. For this subset, we compared management strategies for efficacy, patient outcomes, and morbidity. Using this analysis, we created an algorithm to optimize the selection of CSF leak management techniques for different groups of patients with TCS.
Section snippets
Methods
Our study cohort comprised children who underwent surgery for TCS from January 2011 to March 2017 (n = 260; Table 1). Subject ages ranged from 1 day to 6 years. Included in this analysis were patients who underwent surgery for TCS and a CSF leak or significant pseudomeningocele within the first 30 days after surgery (n = 25). All tense pseudomeningocele with/without impending leak was considered significant. We analyzed patient age, sex, presentation, details of leak appearance, management, and
Results
Of the 260 children included in this cohort, 25 patients (13 female and 12 male) showed overt CSF leak or pseudomeningocele. Among these patients, all tethering was lumbosacral, and 3 had hydrocephalus. Anomalies associated with CSF leak formation were myelomeningocele (n = 5), myelocystocele (n = 4), and lipomyelomeningocele (n = 16) (Table 3). Thus, the most common disease associated with CSF leaks was lipomyelomeningocele. Management techniques included CPS (n = 15), primary resuturing with
Discussion
CSF leaks are a devastating complication of surgery for TCS. Meticulous closure remains the best technique to avoid leak after surgery for TCS.5 Despite effective strategies to prevent leaks after TCS surgery, complications still arise. Thus, improved techniques and understanding of existing strategies are needed to avoid and treat this surgical complication properly (Table 4). In this study, we compared different approaches used to manage postoperative CSF leaks to create an algorithm that
Conclusions
CSF leaks occur in patients undergoing surgery for TCS, particularly in those at the lumbosacral area and with lipomyelomeningocele. We created a leak management algorithm that recommended CPS early after CSF leak development, which yielded a high success rate in carefully selected cases with low morbidity. In low-pressure leaks without pseudomeningocele, primary closure may be attempted. Hydrocephalus must be ruled out whenever the possibility is present, especially in open spina bifida. All
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.