There is currently no most ideal technique among the available options. The choice of which technique to be applied in each case is dependent on each surgeon's cumulative experience as well as a clear understanding of the contributory underlying factors in each patient, the nature and site of the leak, the available facilities and equipment 1).
Primary and meticulous dural closure is sine qua non in preventing postoperative Cerebrospinal fluid leakage.
To avoid cerebrospinal fluid leaks and related possible complications, the dura mater should be meticulously closed after craniotomy procedures. Several techniques for duraplasty and different material for watertight closure have been described.
A plastic dummy with a balloon was developed to test the efficacy of the watertight closure of the dura. The technical notes to reproduce the method have been described.
The described model represents a new, simple, effective and affordable device to be used for neurosurgical training in the procedures of duraplasty and to test the efficacy of watertight closures 2).
Fat is an ideal sealant because it is impermeable to water. Black reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventral dural leak. Leaks in the posterior fossa are managed similarly to those in the spine. Dural suture lines, following suboccipital or spinal intradural exploration, are prophylactically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 150 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following posterior fossa and spinal surgery 3).