Early Epidural Cerebrospinal Fluid Leak After Anterior Cervical Discectomy and Fusion: A Case Report of Postoperative Intracranial Hypotension

Introduction

Anterior cervical discectomy and fusion (ACDF) is a well-established surgical procedure for the treatment of cervical spondylosis and other degenerative disorders of the cervical spine. It involves decompression of the spinal cord and nerve roots through anterior discectomy, followed by interbody fusion using bone grafts or cages. This procedure is one of the most frequently performed spinal operations, demonstrating high effectiveness and predictable outcomes in treating cervical spine pathologies [1].

Despite its success, ACDF carries a small but significant risk of complications, including neurological deficits, dysphagia, hematoma, worsening myelopathy, recurrent laryngeal nerve palsy, wound infection, radiculopathy, and instrument failure [1,2]. One of the rarest complications is incidental durotomy leading to cerebrospinal fluid (CSF) leakage, with an incidence of 0.2% to 1.7% [3]. If not treated effectively intraoperatively, it can manifest as CSF accumulation at the surgical site or leakage outside the wound, which are therefore typically external to the spinal canal [3].

Cerebrospinal fluid leaks are uncommon but clinically important complications that can arise after spinal or cranial surgery. They occur due to a breach in the dura mater, resulting in CSF egress and potential intracranial hypotension. Diagnosis is based on clinical symptoms such as postural headache, nausea, or photophobia, supported by magnetic resonance imaging (MRI) or computed tomography (CT) imaging. Management strategies include conservative measures (eg, bed rest, hydration, caffeine), lumbar drainage, or surgical repair, depending on the severity and persistence of the leak [4–6].

Several case reports have documented delayed CSF leaks after ACDF [7,8], but only 1 case of epidural (intraspinal) CSF collection has been previously reported [7]. This underscores the rarity of this complication following anterior approaches to the cervical spine.

This report describes the case of a 51-year-old woman with postoperative headache due to an early epidural CSF leak after ACDF for cervical spondylosis.

Case Report

A 51-year-old woman was admitted to the Department of Neurosurgery and Pediatric Neurosurgery, Pomeranian Medical University in Szczecin for elective surgery due to cervical spondylosis. She had a history of chronic neck pain, cervicogenic headaches, and paresthesia of the upper limbs, which persisted despite conservative management, including rehabilitation. On neurological examination, she presented with mild left biceps brachii weakness (4/5), limited neck mobility, and increased tension of the paraspinal muscles. Preoperative magnetic resonance imaging (MRI) demonstrated C4/C5 and C6/C7 discopathy, as well as a transitional C5/C6 segment showing a mild “wasp-waist” deformity suggestive of a variant of Klippel-Feil syndrome.

After routine preparation, ACDF at levels C4–C7 was performed using the standard Smith-Robinson approach. Discectomy at C4/C5 and C6/C7 was uneventful. During the preparation of the C5/C6 interbody space, CSF leakage was observed at the moment of distraction with the Caspar device, even though the posterior longitudinal ligament (PLL) was not exposed. The dura mater appeared tightly adherent to the PLL, and the exact site of dural tear could not be identified. The defect was repaired using TachoSil (Takeda), a muscle graft, and Tisseel fibrin glue (Baxter). Zero-P (DePuy Synthes) stand-alone cages were implanted. The Valsalva maneuver confirmed adequate sealing without CSF egress.

On the first postoperative day, she developed severe headache, dizziness, and nausea with vomiting, which hindered mobilization. Conservative symptomatic management was initiated, including analgesics, antiemetics, hydration, and bed rest. The wound healed without signs of CSF leakage or collection. Cervical X-ray confirmed the correct position of the implants. Over the next few days, symptoms persisted, accompanied by neck stiffness, tinnitus, and photophobia. On the fourth postoperative day, MRI revealed an expanding epidural CSF collection in the ventral cervical spinal canal and a smaller dorsal collection in the thoracic canal (Figure 1). A diagnosis of intraspinal (epidural) CSF leak was made, and lumbar drainage (LD) was inserted.

Adequate CSF drainage (350–400 mL/day) was achieved, resulting in gradual symptom improvement. On day 8, a repeat MRI (Figure 2) demonstrated near-complete resolution of the epidural collection and relaxation of the dural sac. The LD was clamped and removed 3 days later. The patient was successfully mobilized, with full regression of symptoms. She was discharged in good general condition and able to independently perform in daily activities. Follow-up MRI at 6 weeks (Figure 3) confirmed complete resolution of the epidural CSF leak and stable fusion construct.

Discussion

This case provides important clinical insight into the rare occurrence and management of early epidural CSF leakage following ACDF. It emphasizes that prompt recognition and targeted intervention can prevent the need for revision surgery and lead to full recovery. The case highlights the importance of intraoperative vigilance and early postoperative imaging in patients who develop symptoms consistent with intracranial hypotension after ACDF.

CSF leaks following ACDF are rare complications, with incidence rates of 0.2% to 1.7% [3,10]. The etiology most often involves incidental dural tears due to adhesions between the PLL and the dura mater, particularly in patients with degenerative changes, ossification of the PLL, or prior trauma [3,11]. When such tears occur, the CSF usually accumulates externally to the spinal canal, forming a pseudomeningocele or draining through the wound [3]. In this case, however, the leakage was internal and epidural, making it an exceptional and diagnostically challenging presentation that has not been previously reported.

Intraoperative dural repair techniques include the use of fibrin sealants, muscle grafts, and collagen or synthetic patches, with adjuncts such as TachoSil or Tisseel shown to improve watertight closure [12,13]. The management of persistent or symptomatic leaks often requires lumbar CSF drainage, which helps reduce pressure at the repair site and facilitates healing [5,6,13]. In the present case, the intraoperative dural repair was effective in preventing external leakage, but a tight seal likely contributed to epidural accumulation of CSF. The early onset of symptoms, including severe headache, nausea, and dizziness, was consistent with intracranial hypotension, as described in previous reports [14].

Comparison with previously reported cases underscores the uniqueness of this presentation. Halayqeh et al (2023) described the only other reported epidural CSF leak after ACDF, occurring 1 year postoperatively in a patient with Ehlers-Danlos syndrome [7]. That delayed case required revision surgery due to mechanical screw penetration of the dura and subsequent kyphotic deformity. In contrast, our case involved an acute epidural CSF leak detected within days after the primary operation, successfully treated conservatively using LD without the need for reoperation. This shows that early recognition and imaging can obviate surgical intervention and improve outcomes [3,6,9].

Risk factors for CSF leaks during ACDF include advanced age, obesity, hypertension, and ossification of the PLL [11,15]. Although our patient lacked these typical predisposing factors, the anatomical adhesion between the dura and PLL at the C5–C6 level likely contributed to the tear. Clinicians should maintain a high index of suspicion for CSF leaks when patients present with orthostatic headaches, photophobia, or nausea postoperatively, as early imaging and conservative management can ensure full neurological recovery.

This case illustrates that even with meticulous intraoperative technique, rare complications such as epidural CSF leakage can occur. However, with early detection, imaging confirmation, and the use of lumbar drainage, conservative management can be sufficient. The key learning point from this case is that epidural CSF leaks after ACDF, although rare, should be considered in the differential diagnosis of early postoperative headaches and dizziness, and prompt MRI evaluation is crucial to guide management.

Conclusions

Epidural CSF leakage after ACDF is an extremely rare complication. This case demonstrates that early diagnosis, close clinical monitoring, and timely lumbar drainage can achieve full recovery without the need for reoperation. Early postoperative imaging is essential in patients presenting with symptoms of intracranial hypotension after ACDF, allowing for effective and minimally invasive management.