Commentary: Unnecessary preoperative epidural steroid injections lead to cerebrospinal fluid leaks confirmed during spinal stenosis surgery

The Impact of Preoperative Spinal Injection Timing on the Postoperative Complications of Lumbar Fusion

OBJECTIVE

To determine the impact of epidural spinal injections (ESIs) on postoperative surgical complications.

METHODS

This retrospective all-payer database analysis identified 202,181 adult patients undergoing one- to three-level transforaminal lumbar interbody fusion (TLIF) from 2010 to 2020. A 1:1 exact matching on comorbidities and demographics was performed, creating 2 cohorts: 1) patients who received an ESI within 90 days of surgery and 2) patients who did not receive an ESI. The primary outcome was surgical complication rates between groups at 30 days postoperatively. For the secondary outcome, patients were stratified based on injection time before surgery: 1-30, 31-45, 46-60, 61-75, and 76-90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. The P value was set to 0.05 for the primary analysis, and the Bonferroni correction was utilized for the secondary outcome.

RESULTS

Exact matching produced 12,491 pairs for analysis. Groups were well-matched on demographics, comorbidities, and fusion levels. The 30-day postoperative rates of surgical complications, hematomas, wound disruptions, or surgical site infections did not differ between groups (P > 0.05). The rate of cerebrospinal fluid (CSF) leak was increased in the ESI group (0.19% vs. 0.09%, P = 0.042). When temporally stratified, patients receiving an ESI within 30 days had significantly higher odds of CSF leak (odds ratio: 4.24, 95% confidence interval: 1.97-9.14).

CONCLUSIONS

Patients who receive an ESI within 30 days of transforaminal lumbar interbody fusion are at an increased risk for CSF leak. While the incidence of CSF leak remains small, it may be advisable to avoid ESIs at least 30 days before surgery for certain patients.

Incidence and management of cerebrospinal fluid fistulas in 336 multilevel laminectomies with noninstrumented fusions

Background:

The incidence (e.g., 3–27%) and the types of cerebrospinal fluid (CSF) fistulas occurring during multilevel lumbar laminectomy with noninstrumented spinal fusions varies.

Methods:

From 2000 to 2015, we retrospectively evaluated the incidence/etiologies of CSF fistulas occurring for 336 patients undergoing average 4.7 laminectomies with average 1.4 level noninstrumented fusions over a 15 year period. The varied etiologies of CSF leaks included; ossification of the yellow ligament (OYL) extending through the dura, postoperative surgical scar, iatrogenic traumatic leak, epidural steroid injections (ESI), resection of synovial cysts, and the removal of intradural tumors. Techniques for primary repairs included combinations of; 7-0 Gore-Tex (Newark, Delaware, USA) sutures, micro-dural staples, muscle patch/other (e.g., bovine pericardial) grafts, fibrin sealants/glues (e.g., Tisseel; Baxter International Inc., Westlake Village, CA, USA), and Duragen (Integra LifeSciences, Hawthorne, NY, USA) including both the thin and suturable types.

Results:

The etiologies of CSF fistulas in descending order included: Epidural spinal injections (ESI) (7 patients), synovial cysts (6 patients), OYL (5 patients), and equally for postoperative scar and intradural tumors (3 patients). CSF fistulas occurred in 24 (7.14%) of 336 patients; this frequency was reduced to 4.2% when ESI and intradural tumors were excluded.

Conclusion:

CSF fistulas occurred in 7.14% of 336 patients undergoing average 4.7 multilevel laminectomies with average 1.4 level noninstrumented fusions attributed to a lumbar stenosis with mild/moderate instability. The dural repair addressed seven prior ESI, six synovial cysts, five OYL, and operative scarring and intradural tumors (three apiece). Knowing the pathologies contributing to CSF fistulas should help the surgeon to better anticipate and treat these fistulas.

Tisseel does not reduce postoperative drainage, length of stay, and transfusion requirements for lumbar laminectomy with noninstrumented fusion versus laminectomy alone

BACKGROUND

Typically, fibrin sealants (FSs) and fibrin glues (FGs) are used to strengthen dural repairs during spinal surgery. In 2014, Epstein demonstrated that one FS/FG, Tisseel (Baxter International Inc., Westlake Village, CA, USA) equalized the average times to drain removal and length of stay (LOS) for patients with versus without excess bleeding (e.g. who did not receive Tisseel) undergoing multilevel laminectomies with 1-2 level noninstrumented fusions (LamF).[6].

METHODS

Here Tisseel was utilized to promote hemostasis for two populations; 39 patients undergoing average 4.4 level lumbar laminectomies with average 1.3 level noninstrumented fusions (LamF), and 48 patients undergoing average 4.0 level laminectomies alone (Lam). We compared the average operative time, estimated blood loss (EBL), postoperative drainage, LOS, and transfusion requirements for the LamF versus Lam groups.

RESULTS

The average operative times, EBL, postoperative drainage, LOS, and transfusion requirements were all greater for LamF versus Lam patients; operative times (4.1 vs. 3.0 h), average EBL (192.3 vs. 147.9 cc), drainage (e.g. day 1; 199.6 vs. 167.4 cc; day 2; 172.9 vs. 63.9 cc), average LOS (4.6 vs. 2.5 days), and transfusion requirements (11 LamF patients; 18 Units [U] RBC versus 2 Lam patients; 3 U RBC).

CONCLUSIONS

Utilizing Tisseel to facilitate hemostasis in LamF versus Lam still resulted in greater operative times, EBL, postoperative average drainage, LOS, and transfusion requirements for patients undergoing the noninstrumented fusions. Although Tisseel decreases back bleeding within the spinal canal, it does not reduce blood loss from LamF decorticated transverse processes.