Prevention and treatment of liquorrhea after cervical spondylodesis

Objective: to determine the risk factors, frequency and causes for damage of dura mater (DM), optimize algorithm for prevention and  treatment of postoperative liquorrhea at patients with trauma and  degenerative diseases of subaxial cervical spine.

Material and methods. We analyzed surgical treatment outcomes of 552 patients with trauma and degenerative diseases of cervical  spine which were operated on in neurosurgical department of  Sklifosovsky Research Institute of Emergency Care from 01.01.2001  till 31.12.2013. Among them 438 operations were performed  because of cervical spine trauma, 116 operations — because of  degenerative spinal diseases (79,0 and 21,0% of operations correspondingly). Anterior approach was used at 505  (91,0%) operations, posterior cervical fusion — 28 patients (5,0%  operation), combined interventions on anterior and posterior structures of cervical spine — 21 patients (4,0% operations).  Operation on one spinal motion segment (SMS) was performed at  225 (40,5%) patients, 2 SMS — 269 (48,4%) patients, 3 SMS — 49  (8,8%), 4 SMS — 9 (1,6%) and on 5 SMS — at 2 (0,4%) patients.  Emergency surgical intervention was done at 403 patients (73,0%  operations), scheduled surgery — 151 patients (27,0% operations).

Results: damage of DM after or during surgery occurred at 27 patients (5,0% operations, n=554). Among all patients with cervical  spine trauma liquorrhea was detected at 17 (3,9%, n=438) patients  comparing with 10 (9,0%, n=116) among patients with degenerative spinal disease. The following mechanisms of DM damage were  revealed: 1) DM damage by sharp fragments of fractured vertebra—  9 (33,3%, n=27) patients with spinal trauma; 2) multiple tearings of DM during preganglionic detachment of spinal roots— 2 (7,4%, n=27) patients; 3) damage of DM by Kerrison rongeurs during  decompression of neurovascular structures — 16 (59,2%, n=27) patients. The leakage of cerebrospinal fluid during operation was seen at 24 (88,9%, n=27) patients. This group of patients  demonstrated the high efficacy of wound liquorrhea prevention  during operation and in early postoperative period, DM damage had  not influenced on hospital stay days and treatment outcome. Iquorrhea in eraly postoperative period was revealed at 3  (11,1%, n=27) patients, all of them underwent repeated surgery.

Conclusion: the high risk of DM damage with liquorrhea is seen at patients with ossified оposterior longitudinal ligament (18,0%, p  <0,000001). The most DM damages could be detected  intraoperatively (88,9%) and dangerous complications could be prevented in case of on-time prophylaxis of wound liquorrhea.

1. Губин А.В., Бурцев А.В. Классификации субаксиальных повреждений шейного отдела позвоночника. Хирургия позвоночника 2012; 2: 8-15. Russian (Gubin A.V., Burcev A.V. Hirurgija pozvonochnika 2012; 2: 8-15).

2. Крылов В.В., Гринь А.А., Луцик А.А. и соавт. Рекомендательный протокол лечений острой осложненной и неосложненной травмы позвоночника у взрослых (Ассоциация нейрохирургов РФ). Часть 1. Журнал Вопросы нейрохирургии им. Н.Н. Бурденко 2014;6: 60-67. Russian (Voprosy nejrohirurgii 2014;6: 60-67).

3. Vaccaro A.R., Hulbert R.J., Patel A.A., et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex // Spine. — 2007. Vol. 32. P 2365—2374.

4. Zehnder S.W., Lenarz C.J., Place H.M. Teachability and reliability of a new classification system for lower cervical spinal injuries // Spine. — 2009. Vol. 34. P 2039— 2043.