Treatment

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>> Spinal CSF Leak Treatment

 
Treatments for spinal CSF leaking vary from conservative to surgical procedures. The specific situation will dictate the course of action. Some serious complications such as stupor/coma or large subdural hematomas dictate emergent and more aggressive intervention. Some patients have symptoms that resolve spontaneously in a matter of hours, days or weeks without ever seeking or requiring medical care. A substantial percentage of patients respond favorably to one or more epidural blood patching procedures. When epidural blood patching is unsuccessful or if symptoms recur, spinal imaging findings help to guide further treatment. Epidural patching with fibrin sealant may be directed at a known or suspected leak location or a surgical repair may be the best option. Surgical repairs of spinal CSF leaks have good success rates in the hands of experienced neurosurgeons but a subset of patients have persistent symptoms and associated disability.

Conservative + Symptom Management
General:
• bedrest / horizontal positioning
• oral and IV hydration (temporary symptomatic benefit)
• oral and IV caffeine (temporary symptomatic benefit)
• oral theophylline (questionable benefit)
• steroids (questionable benefit + risks significant = rarely recommended)
• use of abdominal binder
Nausea:
• ginger products and/or drugs such as ondansetron (Zofran)
Pain:
• non-opiate analgesics (limited effectiveness)
• opiate analgesics (regular use not supported by pain management guidelines)
• complementary approaches: nutrition, supplements, mind-body techniques, acupuncture

Epidural Blood Patch (EBP)
The patient’s own blood is injected into the epidural space, the space just outside the dura within the spinal canal, forming a “patch” over the dura. This is most often done with fluoroscopic guidance and intravenous sedation by an anesthesiologist or a radiologist. This can be directed (placed at location(s) of leaking), such as a post LP leak, OR non-directed (placed at lumbar or thoracolumbar locations) usually when leak site(s) has/have not yet been localized, or for diagnostic purposes. Volumes range from small (10 mL) to large (100 mL).
The precise manner in which an epidural blood patch (EBP) is helpful is not entirely clear, since patching remote from actual leak location is often helpful. A favorable response to an epidural blood patch supports the diagnosis of a leak but often lacks durability.
After blood patching, while restrictions are individualized, it is typical for physicians to recommend avoidance of bending, lifting and twisting, as well as straining (valsalva) for about 4-6 weeks.

Typical radiology suite where an EBP might be performed.

Reproduced with permission from Wouter I. Schievink, MD

and Cedars-Sinai, Los Angeles, CA.

 
Epidural patch with fibrin sealant
Fibrin sealant is a pooled blood product which has been treated with a two-step process to reduce the risk of viral transmission. Fibrin sealant can occasionally result in allergic / anaphylactic reactions but pre-treatment with medication reduces that risk. Injection of fibrin sealant into the epidural space is an “off-label” use, but accumulated experience has demonstrated this to be safe in experienced hands. This procedure is most often performed by neuroradiologists with imaging guidance and intravenous sedation to target specific known or suspected leak locations. Anesthesiologists and other clinicians also perform this procedure. It may be used in isolation or in combination with whole blood.

Surgical repairs
The findings and interpretation of spinal imaging is of critical importance in surgical planning and outcomes. Surgical repairs are often less technically straightforward than might be anticipated, due to frequently noted abnormal dura and the variety of anatomic leak types and locations. See our summary document on the Classification of Spontaneous Spinal CSF Leaks. The specific approach is tailored to the type and location of the leak and to the individual patient.

These OR photos show a ventral (anterior = front) dural defect before and after suturing to repair.
This repair was done with a posterior approach, gently moving the spinal cord slightly to access the defect.
Reproduced with permission from Wouter I. Schievink, MD and Cedars-Sinai, Los Angeles, CA.


 
Surgical procedures for a subset of patients
When other measures have failed, some procedures have been used in carefully selected patients to reduce the severity of symptoms, such as epidural saline infusions via indwelling epidural catheter, or lumbar dural reduction surgery.

Key points
• an unknown percentage of patients will have their symptoms resolve spontaneously without treatment
• rarely, serious complications such as coma or a large subdural hematoma will dictate emergent intervention
• epidural patching is effective for many patients but may lack durability
• correct interpretation of spinal imaging findings is critical to targeted treatment approaches; false localizing signs on imaging can lead to misdirected treatment
• epidural patching procedures and surgical procedures may have better outcomes with clinicians that treat a larger volume of patients
• surgical repairs are often less technically straightforward than they may appear, due to the variety of anatomic leak types and locations as well as the frequently encountered attenuated dura associated with Heritable Disorders of Connective Tissue
• outcomes are generally favorable but a small subset of patients has persistent symptoms and associated disability