Cerebrospinal fluid leaks secondary to dural tears: a review of etiology, clinical evaluation, and management

Abstract

Objective

Damage to the dura mater often occurs in trauma cases of the head and spine, surgical procedures, lumbar punctures, and meningeal diseases. The resulting damage from dural tears, or durotomy, causes cerebrospinal fluid (CSF) to leak out into the surrounding space. The CSF leak induces intracranial hypotension, which can clinically present with a range of symptoms not limited to positional headaches which can confound accurate diagnosis. Current methods of evaluation and management of dural tears are discussed herewith, as well as the present understanding of its etiology, which may be classified as related to surgery, procedure, trauma, or connective tissue disorder.

Methods

We piloted a MEDLINE® database search of literature, with emphasis on the previous five years, combining keywords such as "cerebrospinal fluid leak," "surgery," "procedure," and "trauma" to yield original research articles and case reports for building a clinical profile.

Results

Patients with suspected dural tears should be evaluated based on criteria set by the International Headache Society, radiological findings, and a differential diagnosis to accurately identify the tear and its potential secondary complications. Afflicted patients may be treated promptly with epidural blood patches, epidural infusions, epidural fibrin glue, or surgical repair. At this time, epidural blood patches are the first line of treatment. Dural tears can be prevented to an extent by utilizing minimally invasive techniques and certain positions for lumbar puncture. Surgical, trauma, lumbar puncture, and epidural injection patients should be observed very carefully for dural tears and CSF leaks as the presenting clinical manifestations can be highly individualized and misguiding.

Conclusion

Because studies have demonstrated a high frequency of dural tears, particularly in spinal surgery patients, there is a need for prospective studies so that clinicians can develop an elaborate prevention strategy and response to avoid serious, unseen complications.

Keywords:

• Cerebrospinal fluid leak
• intracranial hypotension
• incidental durotomy
• spinal surgery
• cerebrospinal fluid fistula
• epidural blood patch

Acknowledgements

The authors are thankful to Drs. Kelly Warren, Inefta Reid, Todd Miller, and Peter Brink (Department of Physiology and Biophysics at the Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA) for departmental support, as well as Mrs. Wendy Isser and Ms. Grace Garey (Northport VA Medical Center Library, Northport, NY, USA) for literature retrieval.

Disclosure statement

The authors have no conflicts of interest to declare.