CHAPTER
152
Cerebrospinal Fluid Fistula
and Pseudomeningocele
Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fis-
tulas are caused by similar mechanisms. A pseudomeningocele
is defined as a postoperative extravasated collection of extra-
dural CSF that communicates with the subarachnoid space
through a breach in the dura mater and arachnoid. A pseudo-
meningocele may, however, develop into a CSF fistula, which
occurs when the extradural CSF communicates with another
cavity or if a direct communication to the outside exists. Dural
breaches that lead to CSF fistulas and pseudomeningoceles
may also be expected to lead to increased perioperative mor-
bidity, prolonged hospitalization, and possible reoperation to
repair the leak. In patients who present with symptomatic
pseudomeningoceles and CSF fistulas, a trial of nonoperative
management may be warranted. It is, however, important to
note that treatment strategies should be tailored to each indi-
vidual patient and operative repair should occasionally be
undertaken without delay. Factors that affect treatment choice
include size, location, timing, and symptoms. Small leaks may
heal spontaneously without sequelae or with nonoperative
measures such as CSF diversion via a lumbar drain or place-
ment of an epidural blood patch.
INCIDENCE
Spinal CSF fistulas and pseudomeningoceles are a common
complication of spine surgery and the majority of them are iat-
rogenic as a result of spine surgery. In the lumbar spine, there
is a reported incidence of CSF fistula of between 0.3% and
13%.10,14 Oppel et al18 reported the incidence of dural tears to
be 5.9% in a study of 3038 operations in which the dural tears
occurred during bone removal or dural sac and nerve root
retraction. Schumacher et al21 reported the incidence of
pseudomeningoceles to be less than 0.1% in 3000 patients who
had undergone a lumbar discectomy. It is difficult to determine
the true incidence of pseudomeningoceles following incidental
durotomies because many cases are asymptomatic. In certain
patient populations, the incidence of CSF wound complica-
tions is higher. These populations include patients with lamine-
ctomy for spinal dysraphism and patients with a history of prior
spinal irradiation. Zide et al25,26 reported a 43% incidence of
CSF fistula or pseudomeningocele after surgery in patients with
intramedullary spinal cord neoplasia previously treated with
LWBK836_Ch152_p1617-1621.indd 1617
Kene Ugokwe
Edward C. Benzel
radiation. The same authors also reported a 43% incidence of
pseudomeningocele and a 13% incidence of CSF fistula in
patients who underwent surgical release of a tethered spinal
cord.
PATHOPHYSIOLOGY
The primary cause of a pseudomeningocele or a postoperative
cutaneous CSF fistula is a persistent iatrogenic dural violation.
This may be incidentally discovered. It may be inadvertently
created during surgery. In intradural tumor surgery, a duro-
tomy is intentionally created to access the tumor. As discussed
earlier, majority of the dural tears that lead to pseudomeningo-
celes and CSF fistulas are iatrogenic but traumatic and con-
genital causes are occasionally identified.1,2,4 Other causes of
CSF leak include lumbar punctures, dural puncture during
myelography, and dural puncture during placement of an epi-
dural catheter. When a dural breach is recognized, CSF leakage
may persist as a result of inadequate repair of the initial dural
violation, especially in difficult to reach areas such as in the
lateral gutters and in the ventral dura mater.
Cutaneous CSF fistulas occur in the immediate postopera-
tive period when CSF tracks from the site of dural breach,
through the wound, to the skin surface. The CSF is usually
under low pressure and travels slowly. A pseudomeningocele
forms when the CSF travels slowly into the soft tissue, without
evidence of external drainage. In some situations, the dura may
be violated while the arachnoid remains intact, leading to the
arachnoid herniating through the dura and the arachnoid
lined sac becoming the pseudomeningocele. Teplick et al23
have suggested that when the intact arachnoid herniates
through the dura, it is more likely for the communication to
remain open, whereas when the arachnoid is breached along
with the dura, the communication will often close. Although
feasible, this is not proven.
Entrapment of nerve roots in the pseudomeningocele may
lead to radiculopathy and may become a barrier to dural heal-
ing.8 The majority of dural tears heal spontaneously, but large
defects are unlikely to follow this course. Some factors that con-
tribute to poor healing of dural tears include radiation, infec-
tion, nutritional deficits, steroids, scar tissue, poor overlying
soft tissue coverage, and elevated CSF pressure.
1617
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 1618 Section XIV Complications
CLINICAL FEATURES
Majority of pseudomeningoceles are asymptomatic but some
may present with back pain, radicular pain, posture-related
headache, nausea and vomiting, photophobia, meningismus,
or other signs of meningitis. Cervical and thoracic pseudo-
meningoceles are more easily palpable than lumbar ones, but
occasionally, lumbar collections may be identifiable in the sub-
cutaneous tissue. Cutaneous CSF fistulas are often diagnosed
by simple inspection of the wound. Light yellow to clear drain-
age from the wound, which is augmented by the Valsalva
maneuver, or associated with a postural headache, is usually
indicative of a CSF fistula. The drainage may be tested for B2
transferrin, which is not present in sweat or serous fluid, and
detection of B2 transferrin, which is indicative of a CSF.20 B2
transferrin is a protein isoform arising by the action of cerebral
neuraminidase. It is found only in the central nervous system.
The disadvantage to this test is related to the fact that it may
take up to 5 days for results to be obtained.
Postural headaches are worse when the patient is in the
upright position and improve or resolve when the patient is in
the recumbent position. The headaches occur as a result of
altered CSF dynamics (e.g., low CSF pressure) with CSF loss
through the fistula exceeding CSF production.
IMAGING STUDIES
Magnetic resonance imaging (MRI) and computed tomo-
graphic scans are routinely used to elucidate CSF fistula tracts
or pseudomeningoceles.14 MRI, however, is the diagnostic study
of choice because of its ability to visualize soft tissue. With MRI,
a pseudomeningocele typically reveals low-signal intensity on
T1-weighted images and high-signal intensity on T2-weighted
images, as illustrated in Figure 152.1. Since the pseudomenin-
gocele contains CSF, it is not surprising that its signal character-
istics on MRI are consistent with CSF. It is also important to
note that both contrast and noncontrast images should be
obtained to rule out an infectious process. MRI may demon-
A
Figure 152.1. (A) T2-weighted sagittal magnetic resonance imaging (MRI) scan showing a lumbar
pseudomeningocele. (B) T1-weighted axial MRI scan showing a lumbar pseudomeningocele.
LWBK836_Ch152_p1617-1621.indd 1618
strate the level of communication with the thecal sac, as well as
any spinal cord compression or nerve root entrapment that
may exist.9 Myelographic studies are useful in elucidating trau-
ma-induced nerve root pseudomeningoceles. These appear as
unilateral lesions that vary in size with irregular contours.2
Delayed computed tomographic myelography is useful in
detecting a slow-filling pseudomeningocele13 (Fig. 152.2). Ret-
rograde radionuclide myelography has been used to detect
slow, intermittent leaks after lumbar puncture,7 traumatic
injury,15 and pleural CSF fistulas.12
TREATMENT
As with any surgical procedure, preparation and meticulous
planning is imperative. The occurrence of iatrogenic pseudo-
meningoceles and CSF fistulas cannot be eliminated com-
pletely, but their incidence can be reduced with attention paid
to detail and careful bone and scar removal. Careful review of
preoperative imaging studies may also help detect any bone
anomalies or defects that may be congenital or a result of prior
surgery. The dura mater should be carefully freed laterally, via
meticulous dissection, prior to bone removal with a Kerrison
punch. High-speed drills should be used in a lateral, to and fro,
sweeping manner so that a slip will not necessarily result in a
dural laceration. It is also important to ensure that exposed
dura is covered with a cottonoid during drilling in order to
decrease the chance of the drill-induced dural laceration. If a
breach in the dura does occur, it should be closed in a water-
tight primary fashion. It may be necessary to remove more
bone than initially planned in order to expedite efficient and
effective repair of the dural laceration.
CONSERVATIVE THERAPY
The initial treatment of postoperative CSF fistulas has ranged
from conservative measures to immediate surgical repair.
The treatment choice depends on various factors, including
size, symptoms, and the presence or absence of infection
B
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 Chapter 152 Cerebrospinal Fluid Fistula and Pseudomeningocele 1619

Figure 152.2. (A) Sagittal postmyelogram computed tomo-

A graphic (CT) scan showing a lumbar pseudomeningocele. (B) Axial
postmyelogram CT scan showing a lumbar pseudomeningocele.

(Fig. 152.3). For a small CSF fistula in a mildly symptomatic Asymptomatic pseudomeningoceles can be followed clini-
patient without evidence of infection, a trial of bed rest, over- cally. If they become symptomatic, surgery should be consid-
sewing of the wound,24 percutaneous injection of an epidural ered but if the symptoms constitute just mild pain without neu-
blood patch,16 or closed subarachnoid drainage3,6 may be suc- rologic deficit, compressive garments and abdominal binders
cessful. A trial of lumbar drainage for approximately 3 to may be trialed. If they develop into CSF cutaneous fistulas, they
5 days, during which 10 to 15 mL/day of CSF is drained, is a may be treated in the way previously described for CSF fistulas.
reasonable first choice as a conservative strategy. It is important
to note that lumbar drainage is not necessarily a benign proce-
dure. As an invasive procedure, it carries with it the risk of sev- SURGICAL TREATMENT
eral complications, including spinal headaches (60%), infection
including meningitis (2.5%), discitis (5%), wound infection Surgical repair of dural lacerations and breaches is the defini-
(2.5%), and transient nerve root irritation and recurrence.22 tive treatment for CSF fistulas and pseudomeningoceles. Such
Closed CSF drainage is often effective. It is reported to elimi- should be instituted when conservative measures have failed or
nate cutaneous fistulas in 90% to 100% of cases.11,17,22 A percu- in situations in which conservative measures are expected to
taneous epidural blood patch has also been used to treat fail. Surgical treatment should be considered first-line therapy
postoperative CSF fistulas. Such strategies, however, are associ- for patients with profuse leakage of CSF. In patients with
ated with a paucity of literature that substantiates their utility.16 impaired CSF absorption, CSF shunting should be undertaken
With such a procedure, approximately 10 to 25 mL of fresh first, since any primary repair strategy for a dural defect under
autologous blood is injected into the epidural space near the such circumstances will usually fail. Once it is determined that
dural breach. The blood, theoretically, forms an occlusive clot surgical repair will be undertaken, adequate preoperative imag-
over the breach site.16 ing should be obtained to determine the level of the dural
breach unless the site of leakage is obvious from the history.
Also, in patients with wound breakdown, spinal dysraphism,
CSF Fistula/Pseudomeningocele and poor nutritional status, a preoperative plastic surgery con-
sult may be warranted. Intraoperatively, a generous skin inci-
sion should be employed. Oftentimes, this involves lengthening
Asymptomatic Symptomatic with Symptomatic the prior skin incision. Once the pseudomeningocele is identi-
without infection infection without infection fied and entered, it is explored and followed to the durotomy
site (Fig. 152.4). The durotomy site should be protected with a
cottonoid and must be completely exposed. This may require
Conservative Immediate If symptoms are
therapy including primary mild, consider extensive bone removal but this must be done before attempt-
bed rest, blood surgical conservative ing to repair the durotomy. Any visible nerve roots should be
patch, oversewing repair with therapy but with freed and reduced into the dura and the durotomy should be
the wound, and wound neurologic deficits, carefully inspected to ensure that there is no evidence of spinal
lumbar drainage washout consider surgery cord strangulation. The durotomy should be repaired under
microscopic magnification and illumination and a No. 4-0 to
Figure 152.3. Cerebrospinal fluid fistula/pseudomeningocele 7-0 nonabsorbable suture on a taper or reverse cutting, half
treatment algorithm. circle needle is usually used. Whenever possible, the dura

LWBK836_Ch152_p1617-1621.indd 1619 8/26/11 2:15:44 PM

 1620 Section XIV Complications
Figure 152.4. Intraoperative view of a pseudomeningocele cavity.
should be repaired primarily. With larger defects, however, a
fascial graft, artificial dura, or muscle plug may be used in a
manner that does not cause compression of any neural ele-
ments. After the completion of the dural closure, the closure
may be tested by asking the anesthesiologist to elicit a Valsalva
maneuver. Any sites of persistent leakage may then be sutured.
CASE 152.1
A 54-year-old man presented with progressive upper extrem-
ity weakness, myelopathy, and a cervicothoracic syrinx. His
preoperative images are attached. (A) He underwent a
C5-C7 laminectomy with duraplasty and no fusion or instru-
mentation. He did well initially with improvement in his
muscle strength and his myelopathy but 2 months later, he
deteriorated neurologically with his upper extremity
strength diminishing from 4/5 to 3/5. What is the next
A B
LWBK836_Ch152_p1617-1621.indd 1620
Another way to test the dural closure involves the injection of
saline into the thecal sac via a small gauge needle, thereby
revealing any site of leakage. Any of several commercially avail-
able dural sealants may be used to augment the dural repair.
These include Tissel, fibrin glue, DuraGen, and BioGlue.
Fibrin sealant alone remains in situ for only 5 to 7 days and, as
such, is not effective in the long term. They should, therefore,
be supplemented with dural, muscle, or fat grafts.5,19 The
paraspinal muscles and fascia should be closed in at least two
layers with No. 0 or 2-0 gauge monofilament sutures in an
interrupted or figure-of-eight fashion to create a watertight
closure.
Some surgeons avoid placing postoperative drains alto-
gether because they feel like the drain may serve as a nidus for
infection and may also lead to the persistence of the communi-
cation between the intradural and extradural space. Other sur-
geons choose to place drains routinely. Drains should be
inserted subcutaneously through a distant (from the surgical
incision) stab incision. The drain should not be placed below
the fascia as this may lead to the formation of a persistent com-
munication between the intra and extradural space. The drain
is usually removed within 48 hours but the farther away the stab
incision is from the primary incision, the longer the drain may
be left in place. The drain should be anchored to the skin with
a purse-string suture. The skin should be closed in three layers,
with the first set of sutures placed in the subcutaneous fat, the
second in the deep dermis, and the third set of sutures used to
bring the superficial skin surface together.
step in the management of this patient? (B) Repeat MRI
showed a pseudomeningocele, which later became a CSF
cutaneous fistula. The skin incision is shown below. (C) He
underwent surgical repair of his CSF cutaneous fistula with
supplementation of the repair with DuraSeal. The ery-
thematous areas along the suture line that extend from the
posterior cervical area to the upper back are a result of
edema and pressure from a pseudomeningocele.
C
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 Chapter 152 Cerebrospinal Fluid Fistula and Pseudomeningocele 1621

13. Lau KK, Stebnyckyj M, McKenzie A. Post-laminectomy pseudomeningocele: an unusual

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