Endoscopic repair of spontaneous ventral spinal cerebrospinal fluid leaks after failed open intradural surgery, and vice versa.

OBJECTIVE: Ventral spinal CSF leaks are a common cause of spontaneous intracranial hypotension (SIH) and may require surgical repair. Open intradural and endoscopic transforaminal extradural approaches may be considered for treatment of these ventral spinal lesions. The authors report their experience using complementary surgical techniques for patients with persistent ventral spinal CSF leaks after prior unsuccessful surgery with the other approach.

METHODS: The authors present a series of patients from their prospectively maintained registry of patients with SIH evaluated at their institution. Inclusion criteria were 1) diagnosis of SIH based on modified International Classification of Headache Disorders, 3rd edition criteria, 2) thoracic ventral spinal CSF leak, 3) at least 1 prior failed surgical repair with either an open transdural or endoscopic transforaminal approach. Disability was assessed pre- and posttreatment using the SIH Disability Assessment Score (SIHDAS). Surgical outcome was determined by symptom improvement and resolution of extradural CSF collection on postoperative imaging.

RESULTS: Ten patients (7 males, 3 females; mean age 49.8 years) met inclusion criteria. Six patients underwent endoscopic extradural repair following failed open intradural repair, and 4 underwent open intradural repair after failed endoscopic extradural repair (1 after 2 prior endoscopic attempts). The mean interval between surgeries was 13.5 months. No operative complications occurred with either approach. Persistent ventral dural defects were identified intraoperatively in all cases. Postoperative imaging demonstrated complete resolution of the extradural CSF collection in 8 of 10 patients (4 of 6 after salvage endoscopic repair; 4 of 4 after salvage open intradural repair). All patients had acceptable clinical SIHDAS scores of I or II (no or mild disability) at the final follow-up.

CONCLUSIONS: This study suggests that using complementary surgical techniques provides an effective strategy for managing persistent postoperative ventral spinal CSF leaks. Employing the alternative approach avoids prior surgical corridors and associated scar tissue and may reduce risk while improving effectiveness. Both endoscopic extradural and open intradural techniques can be performed safely in revision settings, and selective use of the alternative approach may optimize outcomes in treating this challenging pathology.