Can the efficacy of bone wax sealing method in dealing with cerebrospinal fluid leakage during ACDF be alternative to that of dural patch repair method?

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is an important treatment for cervical degenerative diseases and trauma. Cerebrospinal fluid (CSF) leakage caused by intraoperative dural injury is a rare but clinically significant complication. The current mainstay approach involves dural repair using patches and fibrin glue. The bone wax sealing method is a novel technique for managing intraoperative CSF leakage during ACDF. This study aims to analyse the effectiveness of bone wax sealing in treating intraoperative CSF leakage. METHODS: A retrospective analysis was conducted on consecutive patients who underwent ACDF and were identified as having intraoperative CSF leakage between January 2020 and October 2025. Patients were divided into two groups according to the primary method used to manage the leak: the patch repair group and the bone wax sealing group. In the patch repair group, a dural patch was applied over the dural tear and secured with fibrin glue. In the bone wax sealing group, bone wax was used to completely occlude the anterior interbody space around the interbody cage, thereby physically isolating the prevertebral space from the intervertebral space. Clinical outcomes were assess between the two groups. RESULTS: Among 1,311 ACDF patients, 23 cases (1.75%) experienced intraoperative cerebrospinal fluid (CSF) leakage resulting from iatrogenic dural tear. The maximum diameter of all tears was ≤ 5 mm. Twelve cases were managed with dural patch repair (using dural substitute and fibrin glue), and 11 with bone wax sealing. In the dural patch group, 10 cases achieved successful repair, while 2 required additional lumbar drainage due to persistent leakage. No failures were observed in the bone wax group, and no case developed other postoperative complications. In two groups, no safety-related comorbidities were identified. The cost of the patch and adhesive was ¥3,953, whereas the bone wax costed only ¥18, indicating a significant difference. CONCLUSION: The bone wax sealing method is easy to operate, simple, and highly cost-effective. In appropriately selected cases (small dural tears and complete hemostasis), it may be considered a viable alternative to dural patch repair.