Sample Report Cerebrospinal Fluid Leak Repair
Preoperative Diagnosis: Cerebrospinal fluid leak with headache secondary to dural tears.
Postoperative Diagnosis: Cerebrospinal fluid leak with headache secondary to dural tears.
Procedure Performed: Left L4-5 laminotomy and primary repair of tiny dural tears times two with 7-0 Prolene suture and fibrin glue.
Anesthesia: General endotracheal.
Operative Indications and Consent: The patient is a 35-year-old female who is status post left L4-5 and right L5-S1 percutaneous microdiscectomy. She went home and was doing well, but then after being home she developed a headache, nausea, and vomiting. She was returned to the hospital with an intractable headache. She was put on bedrest with intravenous hydration and intravenous narcotics plus antiemetics. She started feeling better and I got her back up the following day and the headaches returned immediately.
At the time of the surgery, there was some CSF leakage. It was repaired with a fat graft and fibrin glue at the time. I discussed this problem with the patient and her daughter. I told her that we would have to go back and do a primary repair with suture since it is obvious clinically that the fat graft did not work. Understanding the above and the risks involved, the patient and her daughter requested the following procedure be performed.
Details of Procedure: The patient was taken to the operating room after induction of general endotracheal anesthesia. The patient was placed in the prone position on the Wilson frame. The back was prepped and draped in the usual aseptic fashion and the upper portion of the old incision was reopened sharply and taken down.
The investing fascia was opened with Bovie electrocautery and a finger dissection was carried out to expose the lamina of L4 and L5, and the Aesculap retractor system was placed in the usual fashion. The microscopes were brought into place.
At this point in time, I removed the fat graft and then took down more of the ligamentum flavum dorsally and did a laminotomy of L4 and L5 with a Black Max drill using a blue 8 tip and also a 3-mm punch, being careful to keep the dura down with a Woodson. CSF was coming out through two small holes measuring a couple of millimeters each; they were adjacent to one another. These were closed with two individual interrupted 7-0 Prolene sutures. Once the second one was in place, there was no longer any CSF, and a Valsalva maneuver confirmed the same. I then placed fibrin glue over this and activated it. I then also inspected the disk space again. I found a little bit more disk material medially that I took down with a downbiting Scoville curette and then removed with pituitary rongeurs. The dura was again free, soft, and supple.
The wound was irrigated with antibiotic solution and closed in multiple layers using interrupted 0 Vicryl in the investing fascia, the second layer in the deep layer of superficial fascia, and then interrupted subcuticular closure was accomplished with 3-0 Vicryl. Benzoin and Steri-Strips were applied to the skin edges and a sterile dressing was placed over the same. Needle and sponge counts were correct. Estimated blood loss was approximately 25-50 cc. Replacement was that of crystalloid only. There were no complications. The patient was extubated and taken to the recovery room in stable condition.
Postoperative Diagnosis: Cerebrospinal fluid leak with headache secondary to dural tears.
Procedure Performed: Left L4-5 laminotomy and primary repair of tiny dural tears times two with 7-0 Prolene suture and fibrin glue.
Anesthesia: General endotracheal.
Operative Indications and Consent: The patient is a 35-year-old female who is status post left L4-5 and right L5-S1 percutaneous microdiscectomy. She went home and was doing well, but then after being home she developed a headache, nausea, and vomiting. She was returned to the hospital with an intractable headache. She was put on bedrest with intravenous hydration and intravenous narcotics plus antiemetics. She started feeling better and I got her back up the following day and the headaches returned immediately.
At the time of the surgery, there was some CSF leakage. It was repaired with a fat graft and fibrin glue at the time. I discussed this problem with the patient and her daughter. I told her that we would have to go back and do a primary repair with suture since it is obvious clinically that the fat graft did not work. Understanding the above and the risks involved, the patient and her daughter requested the following procedure be performed.
Details of Procedure: The patient was taken to the operating room after induction of general endotracheal anesthesia. The patient was placed in the prone position on the Wilson frame. The back was prepped and draped in the usual aseptic fashion and the upper portion of the old incision was reopened sharply and taken down.
The investing fascia was opened with Bovie electrocautery and a finger dissection was carried out to expose the lamina of L4 and L5, and the Aesculap retractor system was placed in the usual fashion. The microscopes were brought into place.
At this point in time, I removed the fat graft and then took down more of the ligamentum flavum dorsally and did a laminotomy of L4 and L5 with a Black Max drill using a blue 8 tip and also a 3-mm punch, being careful to keep the dura down with a Woodson. CSF was coming out through two small holes measuring a couple of millimeters each; they were adjacent to one another. These were closed with two individual interrupted 7-0 Prolene sutures. Once the second one was in place, there was no longer any CSF, and a Valsalva maneuver confirmed the same. I then placed fibrin glue over this and activated it. I then also inspected the disk space again. I found a little bit more disk material medially that I took down with a downbiting Scoville curette and then removed with pituitary rongeurs. The dura was again free, soft, and supple.
The wound was irrigated with antibiotic solution and closed in multiple layers using interrupted 0 Vicryl in the investing fascia, the second layer in the deep layer of superficial fascia, and then interrupted subcuticular closure was accomplished with 3-0 Vicryl. Benzoin and Steri-Strips were applied to the skin edges and a sterile dressing was placed over the same. Needle and sponge counts were correct. Estimated blood loss was approximately 25-50 cc. Replacement was that of crystalloid only. There were no complications. The patient was extubated and taken to the recovery room in stable condition.