The patient was operated by me 9 days ago for huge recurrent extrusion L4-5 with upward migration and was discharged to progress CSF leak 5 days after surgery. The first evaluation was done 31-December-2012 and about 70 ml xanthochromic CSF was evacuated and today another 40 cc.

On examination: the patient improved clinically and he forgot to receive his antibiotic prescribed after discharge.

The wound was opened and a gush of CSF came out. Inspection of the dura reveal a pinpoint CSF leak coming from the old scar in the lower field, where there was no surgical activity. This point was leaking during the first surgery and considering that it was a massive scar, Vicryl traumatic polyfilament 2 zero was used and it was snuggly closed and the surgical steps continued on. This same point gave the emergence of the new CSF leak. Nylon atraumatic 4 zero was used and several stitches were applied, after what the patient was put in maximum position to have the head up and Valsalva maneuver was used to check for any possible CSF leak. The field was dry. Despite this fact , DuraGen was used to cover this area to ensure that no more possible CSF leak will emerge after such closure. It was noticed that lamina of L4 was fractured partially, which was removed. This could be due to some trauma, that the patient suffered after surgery.

Routine closure of the wound. Smooth postoperative recovery.

The patient had very huge extrusion that could made pinpoint perforations of the thinned dura. We usually perform putting the patient in head up position and performing Valsalva maneuver to detect any CSF leak. In this case it was negative. The CSF leak took place 5 days after surgery, which could be related to arachnoidal rupture at the microscopic defective dura.

Using polyfilament traumatic Vicryl to close dural defects in scar seems to be an bad idea. By time it will become loose and the scareous defect will trigger the leak. Nylon will not change its nature and it will stand better for such situation. Adding DuraGen is for more security.

Usually the CSF leak take place immediately after tear or removal of the huge extrusion. But this case demonstrate the possibility of CSF even several days after surgery.

I had similar cases, but they were treated conservatively, but the patient came from Qatar, for what there is no time window to follow him conservatively.