Jeffrey R. Carlson, MD
Recently, Golden State Warriors head coach Steve Kerr underwent surgery for a “spinal leak” as described by the owner of the Warriors. Since this happened, patients have asked me about this complication when discussing spine surgery.
“Spinal leak” is medically termed a dural tear or spinal fluid leak. The dura is the covering of the nerves and spinal cord in the canal of the spinal bones. During surgery for disc herniations or spinal stenosis, the nerves and their dural covering are visualized and manipulated to allow the disc to be exposed. The typical lower back surgery requires an incision on the patient’s back. Through this incision, the muscles are moved and the bones are exposed. Small portions of the bones may be removed to allow the surgeon to see into the spinal canal and view the spinal nerves. The nerves lie on the disc and must be moved to allow access to the disc. Moving the nerves is similar to holding a half-filled water balloon, the dural covering can slide and move into awkward and sometimes unseen positions. This close proximity to the delicate nerve covering requires the surgeon to be very cautious around these structures, but sometimes even with the best of care, the dura may develop a small tear.
Sometimes these tears are seen immediately, as the clear spinal fluid will leak out and can be seen in the wound. Special attention must be taken for these tears to close, allowing the dura covering to grow back into position. Closures can be done with sutures, glue or numerous other products that are used to close the hole and allow the dura heal. Even with the best closure techniques, the dura must heal. If the dura does not close and seal the hole, spinal fluid can leak out and cause headaches, dizziness and sometimes a leak of the fluid from the spinal incision.
These same symptoms can be seen if the patient has a spinal leak that was not seen at the time of the surgery. If there is a hole in the dura at the time of the surgery that does not leak fluid or develops when the nerve settles into its new position after surgery, the patient may have difficulty standing, due to being light-headed or nauseated. The patient will not have these symptoms while lying down, because the fluid pressure in the brain decreases as the fluid leaks out of the lumbar spine upon standing. These symptoms, which change based on the standing or recumbent position of the patient, are important indicators of a spinal fluid leak.
Late dural fluid leaks can be treated with bed rest, to allow the dura to heal without the pressure of the fluid on the hole. However, this method may lead to a long recovery period and may be frustrating for the patient. Surgery to close the dural leak usually leads to a quicker recovery and better functional outcomes.