Postoperative Cerebrospinal Fluid Leakage after Surgical Repair of Myelomeningocele and Tethered Cord Syndrome in Pediatric Patients.

Myelomeningocele and tethered cord syndrome represent two of the most prevalent congenital abnormalities that affect the spinal cord in paediatric patients. In such cases, early surgical intervention is often necessary to prevent progressive neurological decline, preserve motor function, and reduce long-term morbidity [1]. Although surgical repair remains the standard of care, postoperative complications continue to present significant clinical challenges. One of the most concerning complications that may arise is cerebrospinal fluid (CSF) leakage, which can occur despite meticulous surgical closure techniques [2]. CSF leakage has been demonstrated to both delays wound healing and increase the risk of infection, pseudomeningocele formation, and, in severe cases, meningitis [3]. These factors can adversely affect neurological outcomes. Post-operative complications resulting from cerebrospinal fluid leakage, following repair of myelomeningocele or tethered cord surgery, pose several risks that can significantly affect patient recovery [4]. The failure to achieve a watertight seal during dural closure, or the disruption of the dural closure itself, can result in the escape of cerebrospinal fluid (CSF) into the subcutaneous tissues or through the incision site. This leakage can lead to wound dehiscence, pseudomeningocele formation, and potential bacterial contamination [5]. The risk of meningitis is of particular concern in neonates and infants, who possess an underdeveloped immune system and are thus more susceptible to severe infections [6]. Furthermore, persistent cerebrospinal fluid (CSF) leakage may necessitate prolonged hospitalisation, further interventions, or repeat surgery, all of which increase the physical, emotional, and financial burden for families and healthcare systems. The incidence of postoperative cerebrospinal fluid (CSF) leakage varies across studies, reflecting differences in patient populations, surgical experience, closure techniques, and institutional practices [7].

In the context of myelomeningocele repair, it is frequently observed that leakage rates are elevated in comparison to other surgical interventions [8]. This phenomenon can be attributed to the inherent anatomical challenges associated with the procedure, including the presence of substantial defect size, thin or underdeveloped dura, and the complexity of achieving multi-layered closure in newborns [9]. Some infants present with large lumbosacral defects for which primary closure may be insufficient, requiring plastic surgical techniques to reinforce soft tissue coverage [10]. In the context of tethered cord release, the potential risk factors for leakage encompass a range of surgical interventions, including revision surgery, extensive adhesiolysis, dural scarring, and the necessity for expansion duraplasty [11]. Despite meticulous technique, postoperative cerebrospinal fluid leakage may still occur due to increased lumbar cisternal pressure, positioning, or subtle gaps in the dural suture line. Recent advancements in surgical materials, including dural sealants, grafts, and reinforced sutures, have contributed to a reduction in leakage rates [12]. Nevertheless, the optimal technique remains a matter of ongoing debate. The utilisation of dural substitutes or sealants is a practice advocated by certain surgeons, while others emphasise that careful multilayer closure alone is sufficient when performed correctly [13]. It is challenging to ascertain the most efficacious methods due to variability in surgeon preference and institutional resources. Furthermore, postoperative care protocols, encompassing patient positioning, wound care, and early detection strategies, exhibit significant variation across medical centres, potentially exerting considerable influence on leak rates [14].

Objective

To evaluate the incidence, risk factors, and clinical consequences of postoperative CSF leakage in children undergoing surgical repair of myelomeningocele and tethered cord syndrome.

Data were collected from 75 patients, mean age differed between groups, with myelomeningocele patients being younger (3.2 ± 3.1 years) compared with tethered cord patients (5.5 ± 4.2 years), giving an overall mean age of 4.1 ± 3.8 years. Male sex distribution was similar across groups: 26 males (57.8%) in the myelomeningocele group and 15 males (50.0%) in the tethered cord group, totaling 41 males (54.7%). Most myelomeningocele defects were located at the lumbosacral level (34 patients, 75.6%), whereas only 11 tethered cord patients (36.7%) had lumbosacral involvement. Thoracolumbar lesions were more common in tethered cord patients (13 patients, 43.3%) than in myelomeningocele cases (9 patients, 20.0%). Cervical or upper thoracic defects were observed in 2 myelomeningocele patients (4.4%) and 6 tethered cord patients (20.0%), totaling 8 patients (10.7%). Revision surgery rates were identical in both groups at 13.3% (6 in myelomeningocele and 4 in tethered cord).

Table 1. Baseline Characteristics of Pediatric Patients (N = 75)

A total of 12 out of 75 patients (16.0%) developed CSF leakage. The incidence was notably higher among patients with myelomeningocele, where 10 out of 45 patients (22.2%) experienced leakage, compared to only 2 out of 30 tethered cord patients (6.7%). The average time to detection was slightly longer in the myelomeningocele group (4.1 ± 1.8 days) compared with the tethered cord group (3.5 ± 1.2 days), resulting in an overall mean detection time of 3.9 ± 1.6 days. Two patients (2.7%) developed pseudomeningocele, both from the myelomeningocele group (2 patients, 4.4%).

Table 2. Frequency of Postoperative CSF Leakage

 Large defects (>4 cm) were present in 9 of 12 leakage cases (75.0%), but only in 22 of 63 non-leakage cases (34.9%). Revision surgery was strongly associated with leakage: 5 of 12 leakage patients (41.7%) had undergone revision compared with only 5 of 63 (7.9%) in the non-leakage group. Duraplasty was performed in 7 leakage patients (58.3%) versus 18 non-leakage patients (28.6%). The use of dural sealant was similar between groups: 6 leakage patients (50.0%) and 31 non-leakage patients (49.2%). Soft-tissue flap closure was used in 8 leakage cases (66.7%) compared with 21 non-leakage cases (33.3%). Mean operative time was longer in patients who developed leakage (142 ± 28 minutes) compared with those who did not (118 ± 24 minutes).

 Table 3. Surgical Factors Associated with CSF Leakage

Wound infection occurred in 4 of the 12 patients with leakage (33.3%), compared with 3 of the 63 patients without leakage (4.8%). Meningitis developed in 1 leakage patient (8.3%) and in none of the non-leakage patients. Wound dehiscence was observed in 3 leakage patients (25.0%) and 2 non-leakage patients (3.2%). Reoperation was required in 3 leakage patients (25.0%) compared with only 1 non-leakage patient (1.6%). The mean hospital stay was longer for leakage cases, averaging 11.2 ± 3.4 days, compared with 6.7 ± 2.8 days in patients without leakage.

Table 4. Postoperative Complications

The mean age was slightly lower in the leakage group (2.8 ± 2.4 years) than in the non-leakage group (4.5 ± 4.0 years), though this difference was not statistically significant (p = 0.11). Large defects (>4 cm) were significantly associated with leakage (9 of 12 patients, 75.0%) compared with the non-leakage group (22 of 63 patients, 34.9%), with p = 0.01. Revision surgery showed a powerful association (41.7% in leakage vs. 7.9% in non-leakage, p = 0.001). Duraplasty was also more common in leakage patients (58.3% vs. 28.6%, p = 0.04). Wound infection was significantly higher among leakage patients (33.3% vs. 4.8%, p = 0.006). Length of hospital stay differed significantly, with leakage patients staying 11.2 ± 3.4 days compared with 6.7 ± 2.8 days in the non-leakage group (p = 0.001).

Table 5. Comparison of Patients with and Without CSF Leakage

This study evaluated postoperative cerebrospinal fluid (CSF) leakage following surgical repair of myelomeningocele and tethered cord syndrome in a cohort of 75 pediatric patients. The overall leakage rate of 16% is consistent with previously reported ranges for paediatric spinal dysraphism surgery, reflecting the inherent challenges of achieving durable dural closure in this population. As anticipated, the incidence of cerebrospinal fluid leakage was found to be considerably higher in cases of myelomeningocele repair compared to tethered cord release. This observation underscores the intricate anatomical and technical intricacies associated with addressing open spinal defects in neonatal and infant populations. It was demonstrated that an increase in the magnitude of the defect was a significant predictor of postoperative leakage. Among patients who exhibited leakage, 75% had defects measuring more than 4 cm, compared to 34.9% in the non-leakage group. This finding is consistent with the understanding that larger defects require more extensive tissue handling and often lack adequate native dura for closure, increasing the reliance on duraplasty, graft augmentation, or soft-tissue flaps. The elevated leakage rate observed in this particular subgroup underscores the necessity for meticulous planning, the implementation of multiple layers of closure, and a high degree of surgical expertise in the management of extensive spinal dysraphism defects [15].

 Furthermore, it was observed that revision surgery was another factor significantly associated with CSF leakage, with 41.7% of leakage cases occurring in patients undergoing reoperation. This figure stands in stark contrast to the 7.9% rate observed in primary surgeries. Revision cases generally involve scarring of the dura, adhesions, and altered anatomy, all of which serve to increase the difficulty of achieving a watertight seal. These findings underscore the necessity for refined intraoperative strategies in revision cases, such as meticulous dural mobilisation, graft reinforcement, or the judicious use of adjunctive sealants when indicated [16]. Furthermore, Duraplasty was observed to be more prevalent among patients who exhibited leakage, suggesting a tendency among surgeons to utilise grafts in more intricate cases. Although duraplasty does not inherently result in leakage, it frequently serves as an indicator of the severity of the underlying defect. Postoperative complications were found to be significantly higher in the leakage group, with increased rates of wound infection, meningitis, and wound dehiscence [17]. The presence of cerebrospinal fluid (CSF) at the wound site has been demonstrated to compromise tissue healing, facilitate bacterial entry, and increase the risk of infectious complications. These findings emphasise the clinical significance of early detection and management of leakage to prevent progression to more severe morbidity. Furthermore, the observation that leakage patients exhibited a significantly longer hospital stay is indicative of the augmented burden on healthcare resources and families [18]. Despite the complications associated with cerebrospinal fluid (CSF) leakage, neurological outcomes remained stable, and most cases resolved with conservative or surgical management. This suggests that with prompt identification and appropriate intervention, long-term neurological harm can often be avoided [19]. Nevertheless, the elevated incidence of infection and the necessity for subsequent surgical procedures underscore the significance of implementing preventative measures [20]. It is imperative to acknowledge the limitations of this study when interpreting the findings. Firstly, the retrospective design of the study is contingent on the accuracy and completeness of existing medical records, which may introduce bias due to documentation. It is important to note that important intraoperative details such as subtle dural defects, suture tension, or surgeon-specific techniques may not have been consistently recorded. Secondly, the study was conducted at a single tertiary care centre, which may limit the generalisability of the results to other institutions with differing surgical expertise, patient populations, or postoperative care protocols. A further limitation is the heterogeneity of the age range of the included patients, which spans from neonates to adolescents. This is due to the fact that tissue characteristics, healing capacity, and anatomical challenges vary significantly with age.

It is concluded that postoperative cerebrospinal fluid (CSF) leakage remains a significant complication following surgical repair of myelomeningocele and tethered cord syndrome in pediatric patients. The overall leakage rate of 16% observed in this study highlights the ongoing challenges of achieving durable and watertight dural closure, particularly in cases involving large defects, revision surgeries, or complex anatomical variations. Factors such as extensive defect size, duraplasty, and reoperation were found to be strongly associated with higher leakage rates, emphasizing the need for heightened surgical attention and preventive strategies in these high-risk situations.

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