Undergoing any kind of surgery requires acceptance of risks, such as risk of things not going exactly as planned.  Cerebrospinal fluid leaks (aka, CSF leak or spinal fluis leak) are one complication of spinal surgery.

Anatomy:

When operating in and around the nervous system (such as while performing spinal surgery), one of the structures that is present, and particularly delicate, is the dura.  This is a fibrous coating that surrounds the major nerves within the spinal canal and neural foramina (the holes in the spine where the nerve roots exit the spine), and therefore one of the more frequent complications of spinal surgery is damage to this dura, resulting in a leak of the spinal fluid that the dura holds back.

The spinal covering (the meninges) actually consists of two distinct protective barrier layers between the rest of the body and the spinal fluid; the outer thicker layer which is the dura mater, and then an inner thinner layer known as the arachnoid, which is the final barrier to cerebral spinal fluid (CSF) leaking.  The outer layer is frequently scarred down when there is prior surgery such as a laminectomy, laminotomy, diskectomy, or other spinal procedure that involves taking pressure off of the nerves or spinal cord.  If you see it, you can injure it, therefore if it is scarred down from prior surgery, it could have been either thinned or damaged from the prior surgery, making injuring the dura or even the nerves under the dura slightly more common in patients who already had one surgery.

Injuries to the dura, if not adequately repaired, can lead to a persistent communication of CSF out from where it belongs, since the spinal fluid itself is under greater pressure than the surrounding tissue.  This can create a fluid cavity that can be in communication with the rest of the inside of nervous system (pseudomeningocele)

Photo (unretouched) showing a pocket of spinal fluid under the skin around the prior low back surgery site. This fluid was leaking from a hole that developed after the spinal surgery in the dura.

or worse, lead to a progressive leakage out of the body (active CSF leak) that can lead to wound breakdown problems as well as infection of the nervous system known as meningitis (this is different than the infectious meningitis that sometimes involves students in epidemics, neisseria meningitides infection).

CSF Leaks: How do they happen?

Different techniques can be used to close a problem found at the time of surgery and some of these even heal upon their own.  However other spinal fluid leak problems are not even noticed at the time of surgery and sometimes even develop sometime after the operation. This is likely due to either a thinning or damage to the dura at the time of the operation that was not appreciated by the surgeon, or from a small spike of bone that was left unappreciated against the dura that when the patient bore down in some way or other, and increased the pressure in the spinal sac, it inflated like a balloon over the spike and popped through.

How do you know you have a CSF Leak?

One of the most common symptoms of a spinal fluid leak or pseudomeningocele is having a headache that starts after the operation, which either occurs or is made worse by sitting or standing up.  Standing up increases the pressure in the lumbar region of the spine, by gravity, promoting more fluid to come out into the soft tissue.

However, there are other symptoms, including a new severe radiating pain down the leg or arm that maybe due to a portion of a nerve root herniating through the defect and getting trapped like an elbow in a sling, pinching the nerve.  Sometimes this nerve hernaition, in addition to causing severe pain, may actually plug the hole like a proverbial finger in a dike, and so sometimes the only symptom of the spinal fluid leak maybe this new pain.  However if it heals with a nerve root trapped in the dura, only an additional surgery to release the nerve will make the pain go away.

Complications of untreated CSF leaks:

This can result in an infection of the nervous system by any one of number of bacteria that can be found on the skin or in the environment and can lead to if not treated properly, permanent disability or death.  Even if the spinal fluid does not leak all the way out through the skin, the presence of a pseudomeningocele can lead to reflux of spinal fluid from the nervous system back and forth into the cavity and in so doing bringing into the nervous system with it blood and tissue breakdown products that when deposited on the surface of the spinal cord or brain, can lead to disabling neurologic symptoms.  These can range from headaches to severe nerve dysfunction in a condition known as superficial siderosis.

How do you fix a CSF Leak?

Different techniques used to repair these problems have various success rate and it is critical that the CSF leak, once identified, be treated appropriately.  Some CSF leaks require second or even third operations to fix, while others may take the first time; each leak is different and unique, just like our patients. While all spine surgeons (orthopedic and neurosurgery) are taught basic skills and how to repair dural defects and injuries, neurosurgeons have particular training in these particular types of surgical procedures including the microsurgery often utilized to repair these defects, and as in most aspects of life and medicine, some surgeons have even greater experience and skills.  One should consider an escalation of both treatment strategies and even treating surgeon if initial attempts to fix a problem are unsuccessful; after all, isn’t one definition of insanity “doing the same thing over and over and expecting different a different outcome”?

Conclusion:

Anything we (as surgeons) operate around we put at hypothetic risk of being injured in one way or another.  This is true regardless of what type of surgery is being performed and whether it is minimally invasive or maximally invasive.  If there is a structure nearby where surgeons are going to be working and putting instruments, those structures are theoretically “at risk”.  In general, one should always make sure that one’s surgeon, if operating around the nervous system, has the skills necessary not only to do the procedure that they are describing, but to manage any potential complications that might arise.  If they do not, make sure that they have such as surgeon in backup.  This is why it is usually best to make sure that surgery is being done at a facility that can manage such complications.

While CSF leaks rarely have dire consequences at the time of the operation, people do die from CSF leak-induced meningitis even in the setting of active treatment.  Spinal surgery is clearly not to be undertaken by or on the weak of heart; having said that, the vast majority of patients have no complications that require such intricate skills to manage and repair.  As usual, skill of the surgeon, complexity of the procedure, the overall health of the patient, and the resources of the facility where the procedure is being done all play into the process of making surgery safest for our patients.   Caveat Emptor!

Arthur L Jenkins III, MD, FACS

 

This blog does not constitute medical advice.   For you to receive medical advice, you would need to have a two-way relationship with a physician who can examine you, not just exchange emails or comments with.  Originally Posted to arthurjenkinsmd.Blogspot.com on Monday, February 27, 2017.
17 Comments
  1. I came across your blog post researching a case that I am currently treating. The picture is an almost exact replication of what I am seeing with this patient in the clinic. Revision laminectomy L3L4 with pseudomenigocele 12/11/17 and 12/18/17 second repair necessitated due to CSF leakage not contained leading orthostatic intracranial hypotension HA, nausea, tinnitus, dizziness, cervical myelopathy (C6 dermatomal and myotomal involvement). 64 y/o male with cervical C5-C7 fusion history and discectomy from C3 down to C7. Referred this week for PT and treatment has been directed at upper cervical spine mobilization with full day relief of cervicogenic HA and increased mytomal C6 strength. Added light aerobic conditioning and lumbar stability exercises with care taken not to increase pressure too much as to avoid onset of symptoms. The fluid filled sack actually deflated like a balloon in session. My question is what is the typical prognosis/length of time for this to seal naturally or will it? Should this patient be worked up for additional surgery due to the risk of infection/meningitis? He has had a tough run with bilateral THA past 2 years with revision so I understand his trepidation of more surgery. I look forward to your response.

    Best regards,

    Damon PT, DPT, OCS, COMT

    • This type of pseudomeningocele often does not usually repair on its own if the collection is that large. It can lead to other complications down the road if not treated. Please reach out to my office, if my office does not get in touch with you.

  2. I had a new pain develop about a month after the surgery. MRI showed what was described as a small cyst that my body should reabsorb.Thanjs for the truth of the matter.

    • There are different types of cysts. Some are benign, like synovial cysts. Others may represent a fluid leak, or a pseudomeningocele. The truth would depend on an evaluation of your symptoms, your films, your surgical history (including the operative note), and potentially other studies that we might want to order. Please reach out to my office if you wish a more detailed evaluation.

  3. Thank you for the information that you have provided. You covered much of my questions but still I want more.
    I think I have had a leak at one time… And now since 2009 and the later 1990s.

    Just how does one test to see if there is a leakage of the fluid?
    Can this spinal fluid fester to become like a boil beneath the skin? Working its way out as the body gathers it then try to push it out in that fashion?

    Looking at this as being my problems for awhile. All symptoms I have seem to lean towards this possiable spinal fluid leakage.

    Again Thank You.

    Sincerely, Nora Mae

    • We hope that there is no active leak from under the skin to outside, although it can happen and does over time often work its way through the old incision if the communication does not heal. The two best tests are a CT myelogram (for a leak that is obvious but not outside the skin) and a nuclear scintogram (if the location of the leak is not obvious).

      Please reach out to my office directly if you wish more evaluations.

  4. Thank you for the information you have provided. I had a laminectomy in 2000 and was always in terrible pain with migraines. Just 1 migraine lasted 8 days with constant vomiting. Nothing the Dr tried worked. I could barely walk and needed someone to turn me over in bed. I was so sick all the time that I lost a lot of weight and was diagnosed with anorexia. I was hospitalised a number of times due to unbearable pain but they just put me on lots of medications, including methadone. After months of pain,migraines,crutches,drugs, and being sectioned for anorexia and they thought I’d gone a bit crazy, I went to another specialist who ordered an MRI. This confirmed I had a Dural tear at the operation site causing a cyst the size of a large grapefruit. I was referred to a neurosurgeon for surgery. This was 8 months after the initial surgery. It was unsuccessful as there was too much spinal leakage so 2 days later I had my 3rd surgery. I walked with crutches for a long time and then 1 crutch for 7 years. I was on lots of medications,was very slow,and had weakness down my right side going all the way to my foot. I had also developed fibromyalgia and was told I had a lot of nerve damage. I am nowhere near as bad as I used to be and have learnt to manage my pain but it has been getting harder and doesn’t take much for the pain to get worse. I can’t sit or stand for too long and finally decided to go back and see the specialist again. I have been told there is nothing that can be done as it is from nerve damage. After all this time and suffering, I have never been offered any help with anything. Do you agree that there is nothing that can be done to help?
    Kind Regards…….. Karen

    • Sounds quite complicated. Please contact my office to discuss how we could give you a consultation to discuss your options. I have yet to find a pseudomenigocele I cannot fix, but with large ones, complicated ones, or ones that have been around for a long time, it can be a multi-step process. In addition, there may be other conditions that mimic pseudomeningocele, as well as medical conditions that cannot be improved. I don’t want to give blind advice with incomplete information. Let us know how we can help.

  5. Hi I would love to find out what you find about this as I have a sack of spinal fluid in the same spot now for 3 months, 4 months since the initial operation and had 3 x to fix it but it didn’t help. My headaches are unbelievable and sore neck. Thank you Regards Janine

    • This generally needs to be definitively repaired. I have several techniques I have developed, as well as having learned from some of the other experts in the field, that may help you. Please reach out to my office to see how we can be of service.

      • Can a csf leak occur 12 years after a spine surgery??

        • I would say very unlikely, but it would also depend on what your symptoms are, and what happened with your last surgery. Feel free to reach out if you want a remote consultation. The details are what make the story.

  6. Dr. Jenkins

    Sir maybe you can help me. I’m a 34 y/o male who is going through a type of brain cancer, they can not definitely tell me a type, I’ve had 3 different biopsies. And now I have a huge csf leak on the back of my head my neuro surgeon (34) said may never be able to go away (I’m not bashing him, he absolutely saved my life!) But my oncologist says it needs to go and that it can be done. My thoughts are that it hurts and does cause headaches and I just want it gone. Please Help-Chad

    • Sounds like you need to go to a teaching hospital where they have both a busy brain oncology service and plastic surgeons experienced with complicated cranial spinal leak repairs. If you want to reach out to our office, we may be able to reccomend a facility close to you.

  7. Wow, I have the same thing going on. Headache started a week after surgery to remove a prolapse. Now 2 weeks after surgery, headache and neck stiffness has mostly gone, but have a new swelling, just like the picture. I will contact the hospital that performed my surgery and see what they say. I am grateful for this post as its the only explanation i found. Thank you.

    • Glad to have helped. Let us know if there’s any other way we can help.

  8. Hello!
    I have a large lumbar pseudomeningocele with herniated nerves. After 2 yrs. of neurological symptoms I was
    finally able to go to UCSF. They found the pseudomeningocele but said the surgery was too risky. My 2 feet and 2 legs
    and butt are numby with poor gait/weakness. I’m very healthy and trim besides this. I’m going to Stanford for a 2nd opinion. I do not want to be in a wheel chair. I had a large spinal fusion in 2011due to lifelong scoliosis. I came through the surgery fine. I was also hit by a car in crosswalk in 2013. According to my mri and ct no damage after accident.
    What would you do in my situation? I’m 64 but in great shape.
    I can’t work and drive. My life has been difficult over the past 2 yrs.
    Helen
    209-495-9100

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