Continuous Spinal Drainage in the Treatment of Postoperative Cerebrospinal-Fluid Fistulae

Abstract

T HE development of a cerebrospinal-fluid fistula within the dural envelope of the nervous system after an operation creates a dangerous situation. Surface pathogens or established infection of the wound may gain quick entrance to the leptomeningeal spaces, and patient and surgeon are faced with the grave consequences of an established leptomeningitis or cerebritis. Postoperative cerebrospinal-fiuid fistulae are fortunately unusual since very early in the development of operations on the nervous system surgeons realized there was no substitute for primary healing of the wound. This became routine with the use of stringent asepsis, gentle and meticulous surgical technique, debridement and the closure in layers of a clean dry wound. Special attention was devoted to careful dural closure whenever possible. However, the occasional development of a cerebrospinal-fluid leak in a disrupted surgical wound demands urgent treatment. General surgical principles again dictate the drainage of established infection of the wound and removal of dead tissue and foreign bodies to encourage delayed secondary healing. Clean disrupted wounds should be closed immediately but this rarely was possible with infected wounds. Great difficulty often attends the closure of a clean, but disrupted, laminectomy wound for the tissues are edematous and friable, making closure of layers impossible. Large throughand-through sutures may be the only means of approximation, tearing and strangulating large portions of muscle and fascia. A persevering cerebrospinal-fluid fistula flooding the wound retards the natural events of healing of the wound. Diversion of the stream is the basic principle promoting closure of fistulae when direct