Surgical Exploration of Radiographically Resolved Spontaneous Ventral Spinal CSF Leaks

BACKGROUND AND PURPOSE: Some patients with spontaneous intracranial hypotension (SIH) continue to have symptoms despite radiographic resolution of their spinal CSF leak. The purpose of the present study is to report the indications, intraoperative findings, and outcomes of exploratory surgery of radiographically resolved spontaneous ventral spinal CSF leaks. MATERIALS AND METHODS: A single-center review was performed of a prospectively maintained database to identify a consecutive group of patients who underwent surgical exploration of radiographically resolved spontaneous ventral spinal CSF leaks. Patients completed a spontaneous intracranial hypotension disability assessment score (SIHDAS) pre- and postoperatively. RESULTS: Eight patients (4 men and 4 women) were identified. The mean age was 45.9 years (range, 31-61 years). Radiographic resolution of the extradural CSF collection occurred spontaneously in 2 patients and followed epidural blood or fibrin glue patching in 6 patients. The mean duration of SIH symptoms at the time of surgical exploration was 24 months (range 5 months to 6 years). The most common site for exploration was at T1-T2. At surgery, we were able to identify the healed dural defect in 7 patients and these were repaired with sutures or a muscle plug. Postoperatively, 6 patients reported complete or near-complete symptom resolution with SIHDAS scores improving from moderate or severe disability to little or no or mild disability. CONCLUSIONS: In highly selected patients, surgical exploration of radiographically resolved spontaneous ventral spinal CSF leaks may be considered in patients with persistent symptoms of SIH. The target of surgical exploration is the most suspicious causative calcific lesion or is based on prior imaging showing the exact site of the CSF leak.