Postoperative cerebrospinal fluid leaks: a narrative review of diagnosis and management

Background Postoperative cerebrospinal fluid (CSF) leaks are important complications in neurosurgical practice and may occur after cranial, skull base, or spinal procedures. These complications are associated with increased morbidity, risk of infection, prolonged hospitalization, and need for reintervention. Objective To review current evidence regarding the epidemiology, classification, diagnosis, management, and outcomes of postoperative cranial, skull base, and spinal CSF leaks. Methods A narrative review was conducted following the SANRA criteria. PubMed/MEDLINE, Scopus and Web of Science were searched for articles published between January 2000 and March 2026. Eligible studies addressed CSF leaks after cranial, skull base or spinal surgery and reported incidence, risk factors, diagnosis, management or outcomes. Systematic reviews, meta-analyses, randomized trials and prospective studies were given priority; case reports were cited only to illustrate techniques or uncommon presentations. Results The incidence, presentation, and management of postoperative CSF leaks vary according to surgical location and defect characteristics. In cranial and skull base surgery, major risk factors include posterior fossa approaches, high-flow intraoperative leaks, obesity, revision procedures, and inadequate dural closure. These leaks commonly present with wound drainage, rhinorrhea, or otorrhea. In spinal surgery, incidental durotomy, revision procedures, multilevel surgery, and dural adhesions are important predictors of postoperative leak, typically presenting with orthostatic headache, pseudomeningocele, or persistent wound drainage. Diagnosis relies on clinical suspicion, biochemical confirmation, and imaging studies. Management ranges from conservative treatment and lumbar drainage to surgical multilayer repair using autologous grafts, synthetic substitutes, and vascularized flaps. Conclusions Management of postoperative CSF leaks should be adapted to the anatomical site, leak flow, intracranial pressure, infection and integrity of the repair. Comparative evidence is limited mostly to endoscopic skull base surgery, and part of the current recommendations is extrapolated from spontaneous or traumatic leaks.