Autologous Platelet Rich Fibrin: A Novel Multilayer Sealing Approach for Persistent Cerebrospinal Fluid Leak After Spinal Surgery

Introduction: Persistent cerebrospinal fluid (CSF) leak is a common complication after spinal surgery. When conservative strategies fail, an operative revision aims to locate the dura matter defect and augment its closure with sutures and autologous or commercial sealants.
Platelet-rich fibrin (PRF) is an autologous biomaterial that is easily prepared in the operating theater from patients' blood, composed of a fibrin matrix with high concentrations of growth factors. It can be prepared after a single cycle of angulated centrifugation in two forms, solid membranous (s-PRF) and injectable (i-PRF). Its regenerative and adhesive properties have been previously demonstrated in other disciplines such us maxillo-facial, plastic, and orthopedic surgery.
This work is a technical note and a case series on its novel application for the treatment of persistent cerebrospinal fluid leaks after spinal surgery.

Methods: 14 patients with persistent CSF-leak after lumbar spinal surgery have been referred to our medical center for treatment. MRI scans revealed the level of the leak. All patients presented persistent symptoms of intracranial hypotension. Revision surgery was indicated in all cases.
During surgery, dural defects responsible for the CSF leak were identified and in a first step sutured with Premicron 5-0 running simple closure suture. In a second step, the sutured defect was initially covered with a flattened s-PRF membrane. Another layer of sealing was accomplished by covering it with i-PRF, which was gradually polymerized further and created a gelatinous on lay. The watertight closure was evaluated intraoperatively with two cycles of short Valsalva manoeuvres.

Results: In all patients, CSF-leak was successfully treated with the PRF approach. The postoperative course was uneventful and during a 12-month follow-up period, no CSF leak recurrence or adverse effects were recorded.

Conclusion : The novel autologous PRF multilayer augmentation of dural lacerations is a safe and effective strategy for treating persistent CSF-leaks after spinal surgery.