Effectiveness of Sealants in Prevention of Cerebrospinal Fluid Leakage after Spine Surgery: A Systematic Review

Background: Sealants are often used in spine surgery to prevent postoperative cerebrospinal fluid (CSF) leakage. Objective: To investigate the efficacy of sealants in preventing postoperative CSF leakage in spine surgery. Methods: The PubMed, Embase, and Cochrane databases were searched for articles reporting the outcome of patients treated with a sealant for spinal dural repair. The number of patients, indication of surgery, surgical site, applied technique, type of sealant used, and outcome in terms of postoperative CSF leakage were noted for each study. The primary outcome was CSF leakage in general and secondary outcome infection. Results: Forty-one articles were selected with a total of 2542 cases; there were 4 comparative studies with 540 sealed cases and 343 cases with primary suture closure only. The quantity of CSF leakage did not differ between the sealant group (50 of 540, 9.1%) and the group treated with sutures only (48 of 343, 13.8%) (risk ratio [RR], 0.58 [confidence interval [CI], 0.18–1.82]). The infection rate did also not differ between the sealant and primary suture groups (RR, 0.94 [CI, 0.55–1.61]). This result was found in both the intended and the unintended durotomy subgroups. Secondary analysis of all cases showed that endoscopic or minimally invasive surgery had lower CSF leakage rates compared with open surgery regardless of sealant use (RR, 0.18 [CI, 0.05–0.75]). Conclusions: Currently available sealants seem not to reduce the rate of CSF leakage in spine surgery. In endoscopic and minimally invasive surgery, the CSF leakage rate is less frequent compared with open, conventional surgery regardless of sealant use.