Posterior Transdural Repair of a Spontaneous Ventral Thoracic Cerebrospinal Fluid Leak: 2-Dimensional Operative Video

Spontaneous intracranial hypotension is a rare but serious condition characterized by orthostatic headaches and a variety of neurological symptoms. 1,2 Spontaneous intracranial hypotension should be considered in all patients with new onset, daily, persistent headaches, and orthostatic symptoms. It is typically caused by spontaneous spinal cerebrospinal fluid (CSF) leaks. 1,2 Traditional first-line treatments include hydration, bedrest, epidural blood patches, and fibrin glue injections. However, refractory cases often require surgical intervention, especially those caused by a small ventral osteophyte, which is classified as a type 1 leak. 3-5 The small osteophyte causes a tear in the dura of the ventral canal, usually near the cervicothoracic junction. Diagnosis of these leaks is challenging because these small osteophytes can also occur asymptomatically, or patients may have several of them at multiple levels. Typically, dynamic myelography is needed for accurate localization due to the inadequacy of standard imaging. 6 This video details a young patient with refractory spontaneous intracranial hypotension from a type 1 spontaneous CSF leak, treated successfully using a posterior transdural surgical approach with spinal cord mobilization. Our video presentation outlines the surgical technique and provides an overview of this underdiagnosed condition. Our described approach offers direct visualization, suturing of the leak site, and a multilayer repair without the need for spinal fusion. It also avoids the morbidity to the neck, chest, and mediastinal structures that is at risk with lateral or anterior approaches. A combined intradural and extradural repair may enhance the durability of repair for ventral CSF leaks. The patient consented to the procedure. This operative video did not require Institutional Review Board approval as all patient information has been anonymized, ensuring no identifiable information is disclosed. The video is a single case that does not involve interventions or pose risks beyond standard care, adhering to ethical guidelines and institutional policies.