Journal of Orthopedic Research and Therapy

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Seven Cases of Blood Injection Therapy for the Treatment of Cerebrospinal Fluid Leakage Following Lumbar Surgery

Yuyu Ishimoto1,2*, Mamoru Kawakami1, Elizabeth Curtis2,3, Cyrus Cooper2,3,4, Nami Moriguchi1, Shin-ichi Nakao5, Yukihiro Nakagawa1 

1Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, Japan

2MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, Hampshire, United Kingdom

3Arthritis Research UK/MRC Centre for Musculoskeletal Work and Health, Southampton General Hospital, Southampton, Hampshire, United Kingdom

4National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, UK

5Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Japan 

*Corresponding author: Yuyu Ishimoto, Spine Care Center, Wakayama Medical University Kihoku Hospital, Wakayama, 219 Myoji, Katsuragicho, Itogun, Wakayama Prefecture, 6497113, Japan. Tel: +81736220066; Fax: +81736222579; Email: yuyu.ishimoto@hotmail.co.jp; yuyu.ishimoto@gmail.com 

Received Date: 02 August, 2018; Accepted Date: 13 August, 2018; Published Date: 17 August, 2018

Citation: Ishimoto Y, Kawakami M, Curtis E, Cooper C, Moriguchi N, et al. (2018) Seven Cases of Blood Injection Therapy for the Treatment of Cerebrospinal Fluid Leakage Following Lumbar Surgery. J Orthop Res Ther 2018: 1106. DOI: 10.29011/2575-8241.001106

1.       Abstract 

1.1.  Introduction: Cerebrospinal Fluid (CSF) leak is a common complication of surgery involving the lumbar spine. However, although there are various therapeutic options for CSF leak, there is currently no optimal technique, and the choice of therapy often depends on the surgeon’s cumulative experience. The aim of this study was to describe the successful treatment of CSF leakage using blood injection therapy along the drain removal tract. 

1.2.  Technical Note: We enrolled 7 consecutive patients who underwent lumbar surgery at our institute. The surgeries performed included decompression in two patients (one microendoscopic surgery), fusion in four, and an epidural cyst resection in one. After finding a CSF leak, we injected about 10 ml of blood from the patient into the drain tract. CSF leak did not recur after the blood injection in any of the seven patients. Following just one day of bed rest, the symptoms of intracranial hypotension disappeared with no instances of worsened symptoms of back pain, lower limb pain or fever. 

1.3.  Conclusion: We propose this route of blood injection therapy as a novel method for the treatment of CSF leak after lumbar surgery. 

2.       Keywords: Blood Injection; Complication; Cerebrospinal Fluid Leak; Lumbar Spine; Lumbar Surgery 



Figures 1(a,b):  a) An indwelling plastic needle is inserted into the drain tract, and blood from the patient is injected into the needle. b) Blood is injected slowly, whilst checking the patient’s clinical state. 


Figure 2: Approaches to blood injection to seal a CSF leak. Left: The procedure used in this case series. Entering via the drain tract may be the most accurate way of reaching a dural tear, enabling us to seal both the leakage point itself and the route from dura to skin by using less than 10ml blood. Right: Using the standard epidural blood patch technique, about 20-30ml blood is required. In addition, the drain tract is not sealed up with blood. 

No.

Gender

Age, Year

Disease

Operation

Suturing of Dura

Size of Tube

1

F

67

LSS

Decompression

No

19Fr

2

F

65

epidural cyst

cyst resection

Yes

19Fr

3

F

76

LSS

Fusion+ decompression

Yes

19Fr

4

F

82

LSS

Fusion+ decompression

No

19Fr

5

F

66

LSS

Fusion+ decompression

Yes

19Fr

6

F

49

LSS

Fusion+ decompression

Yes

19Fr

7

M

67

LSS

MEL

No

10Fr

LSS means lumbar spinal stenosis. Fr means French, MED means microendoscopic laminectomy

 

Table 1: Summary of the patients. 

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3.       Guerin P, El Fegoun AB, Obeid I, Gille O, Lelong L, et al. (2012) Incidental durotomy during spine surgery: incidence, management and complications. A retrospective review. Injury 43: 397-401.

4.       Shibayama M, Mizutani J, Takahashi I, Nagao S, Ohta H, et al. (2008) Patch technique for repair of a dural tear in microendoscopic spinal surgery. JBJS 90: 1066-1067.

5.       Niinami H, Tabata M, Takeuchi Y, Umezu M (2006) Experimental assessment of the drainage capacity of small silastic chest drains. Asian Cardiovasc Thorac An 14: 223-226.

6.       Eismont FJ, Wiesel SW, Rothman RH (1981) Treatment of dural tears associated with spinal surgery. JBJS 63: 1132-1136.

7.       Mihlon F, Kranz PG, Gafton AR, Gray L (2014) Computed tomography-guided epidural patching of postoperative cerebrospinal fluid leaks. J Neurosurg Spine 21: 805-810.

8.       Patel MR, Caruso PA, Yousuf N, Rachlin J (2000) CT-guided percutaneous fibrin glue therapy of cerebrospinal fluid leaks in the spine after surgery. AJR 175: 443-446.

9.       McCormack BM, Taylor SL, Heath S, Scanlon J (1996) Pseudomeningocele/CSF fistula in a patient with lumbar spinal implants treated with epidural blood patch and a brief course of closed subarachnoid drainage. A case report. Spine 21: 2273-2276.

10.    Hughes SA, Ozgur BM, German M, Taylor WR (2006) Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks. Surg Neurol 65: 410-414.

11.    Shapiro SA, Scully T (1992) Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery 30: 241-245.

12.    Lauer KK, Haddox JD (1992) Epidural blood patch as treatment for a surgical durocutaneous fistula. J Clin Anesth 4: 45-47.

13.    Maycock NF, van Essen J, Pfitzner J (1994) Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch. Spine 19: 2223-2225.

14.    Tanweer O, Kalhorn SP, Snell JT, Wilson TA, Lieber BA, et al. (2015) Epidural Blood Patch Performed for Severe Intracranial Hypotension Following Lumbar Cerebrospinal Fluid Drainage for Intracranial Aneurysm Surgery. Retrospective Series and Literature Review. J Cerebrovasc Endovasc Neurosurg 17: 318-323.

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