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Introduction

A cerebrospinal fluid (CSF) leak is an often-overlooked medical condition that can cause life-altering symptoms like severe headaches, neck pain, and dizziness. These leaks occur when the fluid surrounding the brain and spinal cord escapes through a tear in the dura, the protective membrane. While CSF leaks can result from trauma, medical procedures, or spontaneous causes, they are frequently misdiagnosed, leaving patients without proper treatment.

This page explores the causes, symptoms, and treatments for CSF leaks, offering vital information to help patients and carers understand this condition and seek the care they need. Whether you’re experiencing symptoms or supporting a loved one, this guide is here to provide clarity and support.

A short video about CSF leaks

This video explains the main types of CSF leaks and how they can be caused, from iatrogenic leaks due to medical procedures to spontaneous leaks such as dural tears.

Thank you for watching! Now that you’ve learned about the main types of CSF leaks, read on to explore more in-depth information about this condition, including symptoms, causes, and treatment options.

Overview:
Cerebrospinal fluid (CSF) leaks are a condition that can cause challenging symptoms like severe headaches, nausea, and cognitive difficulties. Often misunderstood or misdiagnosed, these leaks occur when protective fluid surrounding the brain and spinal cord escapes due to a tear in the dura.

CSF is an essential fluid which plays several critical roles in maintaining brain and central nervous system health:

• Cushioning and Protection: CSF acts as a cushion, allowing the brain to float within the skull, reducing the impact of sudden movements and protecting delicate neural tissues from injury.
• Waste Removal: CSF helps clear away metabolic waste products from the brain. This “cleaning” function is especially active during sleep, when the brain flushes out toxins that can accumulate during the day.
• Nutrient Transport: CSF provides important nutrients to the brain and spinal cord and helps maintain a stable chemical environment, which is vital for normal brain function.

This fluid constantly circulates through the brain’s ventricles and the spinal cord, refreshing itself several times each day. When there’s a leak, however, this balance is disrupted, leading to symptoms that can be challenging to diagnose and manage.

When cerebrospinal fluid (CSF) leaks, it drains away from around the brain, causing a drop in intracranial pressure – this condition is known as spontaneous intracranial hypotension. The primary symptom of a CSF leak is severe head pain that typically improves when lying down.

Why Does Lying Down Help?
Lying down allows the remaining CSF to flow back around the brain, temporarily restoring some pressure and easing the pain. The relief can take anywhere from a few minutes to several hours, depending on the severity of the leak and individual factors.

Cranial CSF Leaks: Causes, Symptoms, and Treatment

A cranial cerebrospinal fluid (CSF) leak occurs when CSF escapes through a defect in the skull, often resulting in fluid draining from the nose (CSF rhinorrhoea) or ear (CSF otorrhoea). These leaks can lead to various symptoms, including hearing loss, a metallic or salty taste in the mouth, or a reduced sense of smell.

Causes of Cranial CSF Leaks
Cranial leaks are typically caused by:

• Head trauma or accidents that fracture the skull.
• Surgical procedures involving the sinuses or ear that inadvertently create openings in the skull.
• Increased intracranial pressure from conditions like hydrocephalus, which can force CSF through small defects.
• Congenital abnormalities or malformations in the skull or inner ear, which can predispose individuals to leaks.

Diagnosing Cranial CSF Leaks
Cranial leaks differ from spinal CSF leaks, as they generally do not cause the low-pressure symptoms associated with spinal leaks. Diagnosis often involves imaging, such as thin-sliced CT, head MRI, and CT cisternography, where a contrast dye is injected to visualise CSF flow and pinpoint the leak. Additionally, collecting and testing the draining fluid can confirm it is CSF.

Treatment Options for Cranial CSF Leaks
Cranial CSF leaks require prompt attention due to the risk of meningitis, as the open connection between the brain and the nasal or ear cavities can allow bacteria to enter.

• Conservative Management: Some cranial leaks, especially small, spontaneous leaks, may resolve with rest and hydration. In certain cases, doctors may recommend bed rest, elevating the head, and avoiding activities that increase intracranial pressure, such as straining or heavy lifting.
• Surgical Repair: For persistent leaks or those caused by trauma or structural defects, surgery may be necessary. Endoscopic surgery through the nasal passages is a minimally invasive option for repairing leaks in the sinus region. Surgeons may use tissue grafts, fat, or synthetic materials to seal the defect and prevent further leaking.
• Managing Underlying Causes: If raised intracranial pressure is contributing to the leak, addressing this pressure is essential. Treatment may involve medications to reduce CSF production, weight management, or procedures like ventriculoperitoneal (VP) shunting to divert excess fluid.
• Long-Term Monitoring: Following surgery or conservative treatment, follow-up care is essential to monitor for signs of recurrence or infection. In some cases, patients may require additional imaging to confirm that the repair is holding and that CSF flow has stabilised.

Early treatment and regular monitoring are key to preventing complications from cranial CSF leaks, such as meningitis, and ensuring better long-term outcomes.

Visit our Cranial Leak Resource Hub for more…

Iatrogenic CSF Leak

Some CSF leaks are caused unintentionally by medical interventions, known as iatrogenic leaks. These can occur as a result of procedures that puncture or compromise the protective layers around the brain and spinal cord, allowing cerebrospinal fluid to escape. Common causes of iatrogenic CSF leaks include:

Surgical Procedures: Surgeries involving the brain, spine, or surrounding structures – such as spinal surgery, neurosurgery, or sinus surgery – carry a risk of damaging the dura, which may result in a CSF leak. Spinal surgeries can be particularly complex, and even with the utmost care, a CSF leak may occur.

Lumbar Punctures (Spinal Taps): Often performed to measure intracranial pressure or to collect CSF for diagnostic testing, lumbar punctures can sometimes create a small hole in the dura, leading to a CSF leak. In most cases, these leaks heal on their own, but some may persist and require further treatment.

Epidural Injections: Administered for pain relief, particularly during childbirth, epidural injections involve placing a needle close to the dura. Accidental puncture of the dura during this procedure can lead to an iatrogenic CSF leak.

Learn More About Iatrogenic CSF Leaks
If you’ve experienced a CSF leak following a medical procedure, our dedicated Resource Hub for Iatrogenic CSF leaks offers practical tools, advocacy support, and detailed guidance to help you navigate your care.

Explore the Iatrogenic Needle Puncture Resource Hub here.

Spontaneous Spinal CSF Leak

There are different causes of spontaneous spinal CSF leak and these are categorised into “types”.
Type 1 – Dural tear
1a – ventral CSF leaks
1b – posterolateral CSF leaks
Type 2 – Meningeal Diverticula 
Type 3 – CSF-Venous Fistulas
Type 4 – Indeterminate

Spontaneous CSF leaks occur without direct medical intervention and can be triggered by a range of factors, often related to structural vulnerabilities or pressure changes within the body. These types of leaks may arise from:

Abnormal Connections Between the Dura and Veins: In certain cases, abnormal tissue connections between the dura and nearby veins can create weak points in the dura, making it more likely to rupture and leak CSF.

Head Injury or Trauma: Even minor head injuries or falls can create small tears in the dura, leading to a CSF leak.

Lifting Heavy Objects: Strenuous activities, such as lifting heavy items, can temporarily increase intracranial pressure, potentially causing or worsening a leak in individuals with pre-existing weaknesses in the dura.

Increased Intracranial Pressure (Idiopathic Intracranial Hypertension or IIH): In some individuals, raised intracranial pressure can place stress on the dura, resulting in a spontaneous CSF leak.

Bone Spurs (Osteophytes): Bony growths, particularly in the spine, can press against or puncture the dura, leading to a leak. Osteophytes are more common in people with degenerative spine conditions, which can increase the likelihood of spontaneous CSF leaks.

Dural Abnormalities Around Nerve Roots: Structural abnormalities in the dura mater near the nerve roots in the spine, sometimes congenital or due to connective tissue disorders, can make these areas more susceptible to tears and leaks.

One of the first symptoms a patient will complain of with a spinal CSF leak is a headache. Over 90% of patients name this as their main symptom. The headache, or head pain, is orthostatic. This means it is worse when upright: whether it be sitting up, or standing, and it will improve or go away when lying down.
The pain is usually sited at the back of the head (but can present anywhere) and can be described as a “pulling down” sensation.

Other symptoms associated with spontaneous intracranial hypotension:

• neck pain and stiffness
• nausea or vomiting
• dizziness
• tinnitus
• photophobia (sensitivity to light)
• phonophobia (sensitivity to sound)
• cognitive difficulties such as brain fog and memory loss

TOP TIP: Patients can describe many other symptoms, but there is no need to give complex long lists to your doctor as this might confuse them. List the main symptoms only, with the important one being the orthostatic nature of the headache improving when lying down. This should be the only thing you need to convince your GP for getting further investigations done for SIH.

Brain MRI

An MRI scan of the brain is used to detect signs of spontaneous intracranial hypotension (SIH). Ideally, this scan is performed with contrast to enhance visibility, though it can also be effective without it, as most indicators of SIH are visible on non-contrast images. A skilled neuroradiologist will be able to identify these characteristic signs, which include:

• Diffuse Dural Thickening (although please note, this has a time dependence associated with it, as the longer the patient has been leaking, the more likely this appearance will diminish over time)
• Subdural fluid collections, which are usually bilateral and over time can get progressively worse.
• Dural Enhancement (only seen with contrast)
• Brainstem displacement
• Brain sag
• Venous Distension

Bern Score:

A Bern score, derived from the brain MRI, ranges up to a maximum of 9 and helps to assess the likelihood of locating a CSF leak during myelography. A lower score indicates that the leak may be more challenging to identify, though even higher scores can sometimes present similar difficulties in pinpointing the exact site of the leak.

Category	Finding	Points
Major	Venous Distension	2
	Dural Enhancement	2
	Suprasellar cistern ≤ 4mm	2
Minor	Subdural Collections	1
	Prepontine cistern ≤ 5mm	1
	Mammillopotine distance ≤ 6.5mm	1

Full Spine MRI

Understanding the purpose of a spine MRI is crucial. Its primary aim is not to localise the CSF leak but to help categorise the type of leak. While it is rare to visually identify the exact source of the leak on a spine MRI, this occurrence is considered an added benefit rather than the main objective. The preferred method for confirming the leak’s location remains myelography.

Similar to a brain MRI, a spine MRI may reveal signs of spontaneous intracranial hypotension (SIH), such as dural enhancement or thickening. However, the primary focus of a spine MRI is to assess fluid collections and to determine whether these collections are:

• Ventral (front) – more commonly associated with type 1 – bone osteophyte caused leaks
• Dorsal (rear) – more commonly associated with nerve root sleeve tears

The presence of a fluid collection indicates a dural defect, and this fluid can extend over considerable distances.

If no external fluid collection is observed, it suggests that the leak may be due to a venous fistula. In such cases, the radiologist should specifically look for meningeal diverticula, although it is important to note that MRI alone cannot determine the exact source of the leak.

Negative MRI

Approximately 1 in 5 patients may have negative MRI results, and this likelihood increases the longer a patient has been symptomatic, as certain findings can diminish over time. When a brain MRI appears completely normal, the importance of a spine MRI escalates; if diverticula are present alongside a clear clinical syndrome, this raises the suspicion of a venous fistula. Conversely, if both the brain and spine MRIs are entirely normal, the chances of locating a leak during myelography are significantly reduced.

It is also important to note that patients with iatrogenic leaks – those caused by procedures such as lumbar punctures or accidental dural punctures during epidural injections – often present with negative imaging and show no fluid collections. This may be due to the leak being so slow that the body is able to absorb the fluid almost immediately.

We often hear, “My doctor wants me to have a lumbar puncture to check my intracranial pressure (ICP) for signs of a CSF leak.”

Please think carefully before proceeding.

While a lumbar puncture can measure ICP, it is not a reliable diagnostic tool for detecting CSF leaks. Here’s why:

• Normal Pressure in Leaking Patients: Many patients with CSF leaks present with normal ICP, which can lead to a misleading result. Relying on ICP measurements alone may overlook the presence of a leak.
• Risk of Worsening the Leak: For someone already experiencing a CSF leak, a lumbar puncture can create additional risk. The procedure may inadvertently cause or exacerbate a leak, leading to increased symptoms and complications.

If a CSF leak is suspected, consult with a specialist knowledgeable about alternative diagnostic methods and imaging techniques specifically suited for CSF leak detection.

To effectively target treatment for a CSF leak, it is crucial to localise and identify the precise leak site. Failure to do so may result in ineffective treatment.

The findings from the spine MRI will guide the next steps for localisation, which may involve either a CT Myelogram (CTM) or a Digital Subtraction Myelogram (DSM). The choice between these procedures will depend on the type of leak being investigated as well as the resources available at the hospital.

CT Myelography (Computed Tomography)

This is a type of CT scan which requires contrast dye to be injected into the spinal canal. The patient is then moved into the scanner.

There are different approaches that can be taken with performing myelograms and this will depend on the type of leak being investigated.

For ventral dural tears, a high temporal resolution is required, using dynamic ultra fast myelography. Imaging should be taken immediately after injection of contrast and again with a slight delay. If the imaging is done too late, the likelihood of seeing the leak is reduced significantly.

The position the patient is placed on the table is crucial depending on the type of leak being investigated.
Ventral tears: prone position – and often with the addition of a foam wedge and pillows to tilt the patient down.
Lateral / nerve root sleeve tears: decubitus position with the side where the most collection of fluid was noted on the MRI.

CSF-Venous Fistula: Decubitus position, and both sides need to be investigated as there’s no prior indication from the MRI which side the venous fistula is. It is suggested most venous fistulas are found on the right side, so this should be scanned first.

Digital Subtraction Myelography (DSM)

Similar to a CTM, with the positioning of the patient needing to be suitable for the type of leak being investigated, but this type of scan is used to find rapid CSF leaks and is conducted under fluoroscopy.
The procedure is usually done under general anaesthesia to enable a long breath hold to be done, although this isn’t always possible or necessary. As above, when looking for a venous fistula, both sides need to be scanned, and because of the amount of contrast dye required, the scan is done over two consecutive days. Again, it is suggested the right side be scanned first.

Once the leak has been located, a plan can be put in place for suitable treatment, and this treatment will depend on the type of leak, location, and also considering how long you have been leaking for as well.

Treatment Options

Conservative Approach:

Before your neurology referral has gone through, if you are suspect of having a CSF leak, you should be told to (or just do this yourself):

• Go on strict bedrest for two weeks, only getting up to use the loo
• increase your fluids to at least 3 litres (5 pints) a day
• increase caffeine intake
• increase salts (to help absorb the fluid)

Epidural Blood Patch:

It is worth noting patients could be offered blood patches before the location of the leak is considered, thus this would come under the “non-targeted” procedure, which as you will read below is only worth considering within the first few weeks of symptoms presenting themselves. As much as this might help with alleviating symptoms further down the line, it does not necessarily mean the defect has been sealed. Further MRIs should be offered after several months and a review of the patients symptoms to ensure the leak site has been sealed. It is possible for symptoms to go and be quite functional but still have a leak.

An epidural blood patch is a procedure that involves drawing your own blood – typically from a vein in your arm – and injecting it into the epidural space in attempt to promote healing a hole or defect in the dura mater. For optimal results, the procedure should be performed as “targeted” as possible, ideally close to the defect and within the first 12 weeks of the leak. The longer a leak persists, the less effective blood patches tend to be. While the precise mechanism by which blood patches work is not fully understood, it is believed to stimulate the body’s natural healing response.

Some patients may be offered non-targeted blood patches, sometimes referred to as a “blind” blood patch. However, this term can be misleading, as it suggests the procedure is performed without imaging guidance, which is generally not recommended. Non-targeted patches should only be considered if the procedure is done very early in the course of symptoms. If the patient has had SIH confirmed via Brain MRI, don’t wait for the spine to be scanned; if you are within three months of onset of symptoms, a non-targeted epidural blood patch should be considered.

These patches are typically administered in the lumbar region, as this site is considered safer and more accessible, being further away from the spinal cord. The procedure can serve two purposes: it may help alleviate symptoms in approximately 50% of cases or act as a diagnostic tool to assess whether symptoms improve. A high-volume patch – defined as greater than 20ml of blood – can create pressure against the spinal cord, thereby increasing the pressure above that point.

Note: Blood patches are not effective for sealing venous fistulas.

Risks of Having a Blood Patch

Like any medical procedure, an epidural blood patch carries certain risks and potential after-effects. It’s important to be informed about these before undergoing the procedure. The following are some of the associated risks:

• Headache: Post-procedure headaches are a common side effect and may occur due to the introduction of blood into the epidural space or as a result of changes in cerebrospinal fluid pressure.
• Bruising: Bruising at the injection site can occur due to the needle puncturing blood vessels, leading to localised swelling and discoloration.
• Infection: As with any invasive procedure, there is a risk of infection, which can occur at the injection site or within the epidural space.
• Nerve Damage: While rare, there is a possibility of nerve damage during the injection process. This can result in symptoms such as persistent pain, weakness, or altered sensation.
• Back Pain: Some patients may experience temporary back pain following the procedure, which may be due to the injection itself or irritation of surrounding tissues.
• Numbness: Numbness or tingling sensations may arise following the procedure, which can be temporary or, in rare cases, more persistent.
• Fever: A mild fever may develop post-procedure, often as a response to the body’s reaction to the injected blood.
• Arachnoiditis: One of the more serious risks associated with blood patches is the potential development of arachnoiditis, an inflammatory condition affecting the arachnoid mater, one of the membranes surrounding the spinal cord. This condition can lead to chronic pain, neurological issues, and other complications.

Given these risks, it’s essential to discuss them thoroughly with your healthcare provider before proceeding with an epidural blood patch. Understanding the potential outcomes can help you make an informed decision about your treatment options and ensure that you are adequately monitored during and after the procedure.

Fibrin Glue

Similar procedure as a blood patch, but this is a targeted treatment using fibrin glue at the defect site. In some institutes, this can be done as a day case on the same day following a myelogram. You might also be offered a combination of blood and fibrin depending on the experience of the hospital.

Tisseel is the most commonly used glue.

It is crucial to be informed about the risks associated with the injection of fibrin glue. This substance contains a protein that has the potential to trigger anaphylactic shock in some individuals. Additionally, because fibrin glue is derived from human blood, there is a risk of transmitting active viruses or infections. Due to these considerations, hospitals are required to obtain a special local license for the use of fibrin glue in this manner, as it is not approved by the manufacturer for injection purposes. Understanding these risks can help you make an informed decision regarding your treatment options..

The exact mechanism by which fibrin glue works remains somewhat unclear. While we understand the chemical properties of the glue, it is still uncertain whether it adheres directly to the dura mater, triggers an inflammatory healing response in the body, effectively stops the flow of cerebrospinal fluid at the site of the defect, or, in the case of venous fistulas, blocks the flow from the affected vein. It is likely that the effectiveness of fibrin glue arises from a combination of these factors.

The injection of fibrin glue is performed under CT or fluoroscopy guidance while the patient is awake and made comfortable with local anaesthetic. A needle is inserted through the skin, and its position is confirmed using air or a small amount of contrast. A local anaesthetic is administered at the nerve root, and typically, between 2 to 6 ml of glue is injected. The fibrin glue remains in the body for a maximum of 4 to 6 weeks before being absorbed.

Regarding the effectiveness of fibrin glue, high-quality data is limited; however, anecdotal evidence suggests that it can be reasonably successful, particularly in acute cases rather than chronic ones. Chronic cases refer to patients who have been experiencing leaks for more than a year. Nevertheless, even in long-standing cases, fibrin glue can be a suitable initial procedure, especially for addressing venous fistulas. The procedure itself is generally considered straightforward and well-tolerated by patients, though repeat treatments may be necessary.

After-care advice following epidural blood patch or fibrin glue injection.

There is little attention given in the medical literature about after-care advice following epidural blood patching or fibrin glue injections, and the advice given can vary between centres, however, these are our top tips:

We understand that many individuals enjoy exercising and frequently ask when they can resume physical activity. While there are currently no specific evidence-based guidelines or case studies available on this topic, it is generally recommended to avoid all intentional exercise for the first month following your procedure.

During months 2 to 3, you may gradually start to incorporate some low-impact exercises into your routine. However, it is crucial to avoid strenuous activities involving bending, lifting, and twisting for several months.

It’s important to remember that the dura can take up to a year to fully heal and recover. Therefore, even if you start to feel well, it’s essential to take care of yourself and avoid overexertion too soon. Listening to your body and proceeding with caution will help support your healing process.

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Surgery

In cases where blood patches or fibrin glue injections fail or are unlikely to work, surgery should be offered.

There are different techniques surgeons use to repair the dura. You’ll usually have plenty of opportunity to talk the procedure through with your surgeon. Some surgeons use laminectomy’s, whilst others prefer to use a laminoplasty technique.

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For the repair of a ventral spinal cerebrospinal fluid (CSF) leak in the thoracic or lumbar spine, the surgical approach is typically from the posterior aspect of the spine. A 10 to 15-centimetre incision is made, followed by either a full or hemilaminectomy. A full laminectomy involves the removal of both laminae, which constitute the roof of the spinal canal at the targeted vertebrae. In contrast, a hemilaminectomy entails the removal of only one lamina from each vertebra, allowing for the preservation of most of the bone. Depending on the location of the leak and the access required, the patient may require a double laminectomy or a more extensive one-and-a-half laminectomy.

Once the dura mater is exposed, it is carefully opened to locate and repair the defect. Throughout the procedure, the nerve pathways are meticulously monitored, providing the surgeon with continuous feedback regarding the integrity of the spinal cord and surrounding nerves.

The specific methods and materials used to repair the defect are determined during the surgery, as they depend on the size of the dural tear and whether any bony fragments are protruding through the dura. While most bony spicules will have been absorbed by this stage, bone removal will only occur if absolutely necessary. Small tears can often be repaired with a single stitch, whereas larger tears may require the use of a dural substitute (such as DuraGuard) or a muscle graft. The surgeon should discuss their planned technique with you beforehand, ensuring that you are comfortable with the approach being taken.

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For the repair of a ventral spinal cerebrospinal fluid (CSF) leak in the cervical spine, the surgical approach typically involves an anterior approach. An incision is made in the front of the neck, allowing the surgeon to access the cervical spine directly. The specific length of the incision may vary depending on the location of the leak and the necessary access.

During the procedure, the surgeon may need to retract the trachea and oesophagus to reach the affected vertebrae. Once access is obtained, the appropriate vertebrae are identified, and the anterior aspect of the spine is exposed. If necessary, the surgeon may remove any bony structures, such as osteophytes, that could be contributing to the leak.

The dura mater is then carefully opened to locate the site of the CSF leak. Continuous monitoring of the nerve pathways occurs throughout the operation, providing the surgeon with real-time feedback on the condition of the spinal cord and surrounding nerves.

The method of repair will depend on the size and nature of the dural tear. Small tears can often be closed with sutures, while larger defects may require the use of a dural substitute or graft to ensure an effective seal. If there are any bony fragments involved, they will be addressed as necessary. The surgeon will discuss the planned technique with you prior to the procedure, ensuring you are informed and comfortable with the approach to be taken.

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For the repair of a lateral spinal cerebrospinal fluid (CSF) leak due to a nerve root sleeve tear, the surgical approach is posterior. The procedure begins with a careful incision over the affected area of the spine, usually around 10cm in length, allowing access to the targeted vertebrae.

Once the incision is made, the surgeon performs a laminectomy to expose the relevant nerve roots and surrounding structures. This may involve removing a portion of the lamina to gain adequate visibility and access to the nerve root sleeve where the tear has occurred.

During the operation, the surgeon carefully isolates the affected nerve root and identifies the site of the CSF leak. Continuous monitoring of the nerve pathways is conducted throughout the procedure, providing real-time feedback on the integrity of the spinal cord and nearby nerves.

The repair technique employed will depend on the size and location of the tear. Smaller tears may be sutured directly, while larger tears may require the use of a dural patch or graft to effectively seal the defect. Additionally, any contributing factors, such as bone spurs or other abnormalities that could be causing irritation or pressure on the nerve root, will be addressed as needed.

The surgeon will discuss the specific repair technique to be used during the operation, ensuring that you understand the approach and feel comfortable with the planned procedure.

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The surgical management of venous fistulas typically involves two primary approaches, tailored to the specific characteristics of the fistula and the patient’s anatomy.

1. Direct Clipping of the Fistulous Connection:
In cases where the fistulous connection is accessible, the surgeon may opt to clip the abnormal vessel directly. This procedure aims to occlude the communication between the veins, effectively stopping the flow of blood that contributes to the fistula. The decision to use this method will depend on the fistula’s location, size, and the surrounding anatomical structures. During the operation, careful dissection is performed to identify the exact point of the fistula, ensuring minimal disruption to adjacent tissues.

2. Clipping or Ligation of the Non-Eloquent Nerve Root:
If direct clipping of the fistulous connection is not feasible due to its position or other factors, the surgeon may consider clipping or ligating a non-eloquent nerve root associated with the fistula. Non-eloquent nerve roots are those that do not control critical functions, allowing the surgeon to prioritise the resolution of the fistula without compromising essential nerve pathways. This approach can effectively reduce or eliminate the venous flow contributing to the fistula while maintaining the integrity of surrounding neural structures.

Throughout the procedure, the surgical team employs careful monitoring and imaging techniques to ensure precision in addressing the fistula and to minimise potential complications. The choice between these two techniques will be influenced by the specific clinical scenario, and the surgeon will discuss the rationale for the chosen approach with the patient prior to surgery.

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Risks of having spinal surgery:

The surgical procedure carries inherent risks, including a 5% chance of total paralysis affecting the legs, bladder, and bowel. Additionally, there is an overall 10% risk of permanent neurological impairment, which may manifest as weakness or diminished sensation in the legs, potentially leading to long-term issues with bladder or bowel function. Many patients report a temporary exacerbation of arm and/or leg function post-surgery, although this is typically not severely debilitating.

As with any surgical intervention, there are also general risks to consider, such as infection, bleeding, and worsening pain. Anaesthesia-related complications may include blood clots in the legs or lungs, heart attacks, strokes, pneumonia, bladder infections, skin damage, and ulcers. Furthermore, there is a risk of nerve injury affecting other areas of the body, as well as potential threats to vision.

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What any treatment a patient receives is considered by the team looking after them.

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Prognosis

Overall, the prognosis for the majority of patients who receive appropriate treatment for CSF leaks is positive. Many individuals experience significant relief from their symptoms and can return to their daily activities. With advancements in medical techniques and therapies, the likelihood of successful intervention has increased.

However, it is important to note that a small percentage of patients may continue to face challenges, experiencing ongoing pressure issues and persistent symptoms despite receiving affective interventions. Factors such as the complexity of the leak, the duration of symptoms before treatment, and individual patient health can influence outcomes. Continuous follow-up care and a tailored approach to each patient’s needs are essential to optimise recovery and address any lingering issues effectively.

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Rebound High Pressure

After successfully sealing the defect, some patients may experience headaches due to the body continuing to over-produce CSF even though the leak has resolved. It can take time for the body to recalibrate, and during this period, changes in intracranial pressure can lead to headaches that mimic those associated with high pressure. Patients often report that the pain is exacerbated when lying down and improves when sitting or standing. Additionally, some individuals may notice visual disturbances.

To manage these symptoms, medication may be prescribed to reduce CSF production. This treatment is typically temporary, lasting from a few days to a few weeks. However, in approximately 25-30% of cases, patients may continue to experience persistent pressure issues, indicating the need for ongoing management and monitoring.

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