Resident Physician UPMC Dept. of Neurological Surgery Pittsburgh, Pennsylvania, United States
Introduction: Cerebrospinal fluid (CSF) leak secondary to anterior osteophyte at the cervico-thoracic junction is a rare cause of intracranial hypotension. We report our technique of Type 1 thoracic CSF leak repair through an anterior approach and present illustrative cases that highlight the operative technique, diagnostic workup, surgical planning, and rare pathologic etiology.
Methods: A series of three total patient cases were reviewed from our institutional experience of anterior approaches for ventral osteophyte associated Type I CSF Leaks. We utilize a variety of pre-operative CT/MRI image, intra-operative video, and post-operative CT/MRI images to illustrate our technical surgical approach for repair of Type I ventral osteophyte-associated CSF leak.
Results: Three total patients from our institutional experience presented with clinical symptoms of high-flow CSF leak. Pre-operative workup yielded a diagnosis of ventral osteophyte-associated Type I CSF leak in all patients, with the illustrative video detailing a 23 year-old patient with a central osteophyte located at T1-T2. The patients were 23, 39 and 55 years old, and all had near-complete resolution of their preoperative symptoms prior to discharge. One leak was not amenable to direct primary repair and was repaired with only dural inlay and fibrin sealant while the other two cases were primarily repaired, including the case presented in the illustrative video. A lumbar drain was placed at surgery in one patient and removed on postoperative day two after a clamp trial. In all three cases, patient anatomy allowed an anterior approach to access the offending bony pathology and surgically repair this potentially life-threatening condition.
Conclusion : We describe an anterior upper thoracic approach to repair a Type 1 CSF leak secondary to anterior osteophyte at the cervico-thoracic junction and report three cases. If conservative management and targeted blood patch treatment fail, an anterior thoracic approach may be considered for primary repair after careful radiographic evaluation.
