Incidental durotomy (ID) is a relatively common complication of spinal surgery, with a reported incidence ranging from 1% to 17% [1]. Known risk factors include older age, revision procedures, prior local radiation, elevated surgical complexity, and surgeon experience [2]. Ossification of the posterior longitudinal ligament (OPLL) is a degenerative condition characterized by pathological calcification of the ligament within the spinal canal. Although more prevalent in Asian populations, it occurs globally. Surgical intervention is typically indicated when neurological symptoms arise due to spinal cord compression. However, surgery for OPLL—particularly through an anterior approach—carries a substantially higher risk of intraoperative complications.

Direct repair is the preferred treatment for ID. If direct repair is not feasible, alternative approaches such as indirect repair using fat or muscle grafts, or patching with sealants, can be considered. Nonetheless, direct repair has a reported failure rate of 5% to 9% [3,4]. Additionally, surgical re-exploration of symptomatic CSF leaks after primary repair carries risks and morbidities associated with surgery on a recently postoperative spine [5]. Epidural blood patch (EBP) provides a less invasive treatment option for persistent CSF leakage that avoids the need for general anesthesia or the morbidity linked to surgical re-exploration. EBP promotes clot formation at the dural tear and increases extradural pressure compared with subarachnoid pressure, thereby reducing the pressure gradient and limiting CSF efflux to facilitate dural healing [6]. EBP has been successfully used to treat post-epidural puncture headache and spontaneous intracranial hypotension (SIH). Several studies have reported the efficacy and safety of EBP for the treatment of symptomatic incidental durotomies following spinal surgery [7,8]. However, the majority of published studies on the efficacy of EBP after spinal surgery focus on lumbar spine procedures, and even in cases of cervical spine surgery, most describe posterior surgical approaches [8-12].

Although EBP is traditionally used for post-dural puncture headaches, SIH, and symptomatic CSF leaks resulting from ID, only a few cases have described targeted anterior cervical EBP for symptomatic CSF leakage following anterior cervical spine surgery. Here, we report a case in which the targeted anterior cervical EBP was successfully performed under fluoroscopic guidance to treat persistent CSF leaking following anterior cervical discectomy and fusion (ACDF). The needle was accurately and safely positioned at the targeted site to ensure the effective administration of EBP.

A 68-year-old male with a medical history of hypertension and diabetes mellitus presented with motor weakness in the right upper and lower extremities (grade 3/5 in both the upper and lower limbs) accompanied by paresthesia and dysesthesia involving both shoulders and upper limbs. He previously underwent unilateral laminotomy for bilateral decompression 7 years earlier but had no prior history of cervical surgery. He additionally reported neck and bilateral radiating pain extending from the shoulder girdle to the arms, along with severe paresthesia and sensory disturbances. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed C3–4–5 anterolisthesis, OPLL at C4–5, and bilateral foraminal stenosis at the C3–4 and C4–5 levels. Consequently, the patient underwent ACDF through an anterior approach, which included removal of the intervertebral disc and OPLL, followed by placement of an interbody cage (Figure 1). During removal of the OPLL at C4–5, a dense adhesion between the ossified mass and the dura was encountered. Although the OPLL was thinned using a high-speed burr to minimize the risk of dural injury, a round ID approximately 0.5 × 0.4 cm occurred on the anterior dural surface. Because direct suturing was not feasible within the limited anterior operative space, an indirect repair was performed using 3 layers of TachoSil (fibrin-coated collagen patch) followed by the application of Greenplast fibrin sealant. No visible CSF leakage was observed after reinforcement, and the interbody cage was inserted. A small amount of fibrin sealant was placed along both sides of the cage for additional protection.

Postoperatively, the patient maintained absolute bed rest (ABR) for approximately 7 days. He developed no symptoms suggestive of CSF leakage or other complications and was discharged on postoperative day 10. However, he was readmitted 20 days after surgery with complaints of positional headache, nausea, and a recurrent subcutaneous fluid collection. Aspiration of the anterior cervical subcutaneous collection yielded approximately 16 mL of serosanguinous fluid. A compression dressing was applied, and continued ABR was recommended. Laboratory tests revealed a white blood cell count of 7,370/μL (46.1% neutrophils) and a C-reactive protein level of 0.34 mg/L, both within normal limits. No bacterial growth was detected in cultures of the aspirated fluid. On postoperative day 21, the fluid collection in the anterior cervical region recurred. Follow-up MRI demonstrated a fluid collection extending from the C4–5 interbody space to the prevertebral deep neck muscle layer at C4–5–6, with further extension into the subcutaneous layer. The patient continued to experience positional headaches and nausea, which were attributed to CSF leakage at the surgical site (Figure 2).

Instead of surgical re-exploration, a less invasive method (fluoroscopy-guided targeted anterior cervical EBP) was attempted. The procedure followed the same percutaneous trajectory used in cervical nucleoplasty, as described in previous studies [13,14]. With the neck slightly extended, the needle was advanced medially to the sternocleidomastoid muscle and laterally to the tracheoesophageal complex under strict anteroposterior and lateral fluoroscopic guidance. The needle was first positioned in the C4–5 prevertebral space, where 21 mL of serosanguineous fluid was aspirated. It was then advanced into the C4–5 interbody space, yielding an additional 4 mL of aspirated fluid. Subsequently, 5 mL of autologous blood was injected into the interbody space and 10 mL into the prevertebral space, consistent with the injection volumes considered safe in percutaneous cervical procedures [15] (Figures 3 and 4). The patient tolerated the procedure without neurological deficits or bleeding complications. He experienced immediate and sustained relief from headache and nausea, and further, no anterior cervical fluid collection was detected. At 6-month follow-up, he remained free of recurrent headaches, nausea, and subcutaneous fluid accumulation, indicating durable success of the procedure.

This study was approved by the Institutional Review Board of Chosun University Hospital (CHOSUN 2024-09-008), which waived the requirement for written informed consent due to the retrospective nature of the study.

ID is a common complication of spinal surgery, with an overall prevalence of approximately 5% [16]. Reported rates vary across spinal regions, with cervical spine surgeries demonstrating a lower incidence (1.0%–1.4%) compared with lumbar surgery (up to 6.7%) [8]. In surgeries addressing degenerative conditions, the reported incidence ranges from 0.2% to 20% [3,17]. Multiple factors contribute to the occurrence of ID, including the technical difficulty and patient-specific risks [1]. Established risk factors include advanced age, rheumatoid arthritis, OPLL, longer operative duration, multilevel procedures, poor preoperative neurological status, and procedures such as corpectomy or revision laminectomy [8,18,19]. Although ID is typically associated with posterior spinal surgery, anterior cervical spine surgeries also carry a substantial risk, particularly in patients with extensive ossification, such as OPLL [20,21]. Direct dural repair remains the standard approach; however, when direct repair is not feasible, indirect repair using fat, muscle grafts, or synthetic agents may be performed. Despite appropriate direct or indirect repair, symptomatic CSF leakage, such as pseudomeningocele, may occur in approximately 5%–9% of cases [3,4]. In anterior ID, limited visibility and confined operative space make direct suturing challenging, thereby posing significant challenges to intraoperative and postoperative management.

In the present case, the patient underwent ACDF for OPLL with concurrent stenosis and spondylolisthesis at the C3–4 and C4–5 levels. An interbody cage was inserted to partially restore disc height and ensure adequate nerve root decompression. A disc-space distractor with the largest possible cage was used to minimize vertebral body damage during discectomy and endplate decortication. ID occurred during OPLL resection. Because of limited visibility and the confined space, direct repair was not feasible; therefore, an indirect repair was performed using a synthetic agent. After confirming the absence of visible CSF leakage, interbody cage insertion and plate fixation were completed, and surgery was performed. Although intraoperative CSF leakage was not grossly visible after repair, the patient developed delayed symptoms, including positional headache, nausea, and subcutaneous fluid collection—approximately 2 weeks postoperatively. Management options for symptomatic CSF leakage include ABR, subarachnoid lumbar drainage catheter placement, epidural autologous blood patching, and surgical re-exploration for direct repair of the durotomy site. Although reoperation offers the opportunity for direct repair, it is associated with high morbidity, particularly in the early postoperative period [5]. As a result, minimally invasive approaches such as EBP have gained increasing acceptance and have been actively investigated as safer, effective options.

The therapeutic principle of EBP is based on the formation of an autologous blood clot that seals dural defects within the epidural space. Previous studies have demonstrated that blood patches can prevent pseudomeningocele formation and reduce the risk of persistent CSF leakage. Although concerns exist regarding the potential for mass effect from blood clots, leading to severe spinal cord compression, multiple studies have demonstrated no significant neurological complications when EBPs are performed cautiously and at appropriate volumes [22]. Because the anterior cervical trajectory used in our targeted EBP was identical to the percutaneous approach used in cervical nucleoplasty, it is important to consider the complications reported in the nucleoplasty literature. Previous studies have described transient dysphagia, prevertebral soft-tissue irritation, and minor retropharyngeal swelling as the most common approach-related events [13]. Rare but potentially serious complications, including esophageal irritation or perforation, carotid sheath-related vascular injury, and prevertebral hematoma, have also been reported when the needle is misdirected or advanced without strict fluoroscopic guidance [15,23]. These complications remain uncommon and are largely preventable when anatomical landmarks are meticulously observed and biplanar fluoroscopic monitoring is used. In the present case, the procedure was performed with these precautions, and no mass-effect- or approach-related complications occurred.

Phan et al. reported symptomatic improvement in approximately 90% of patients with ID in a cohort of 1,392 spinal surgery cases, including 436 cervical spine cases [8]. Although this represents one of the largest studies examining the efficacy of EBP after spinal surgery, no data were provided regarding the effectiveness of an anterior approach for treating DT in anterior cervical procedures. EBP has been widely employed not only for symptomatic CSF leakage resulting from ID but also for treating postdural puncture headaches and SIH [7,9-12,24,25]. Although our case is unique, existing literature demonstrates the effectiveness of anterior cervical EBP in treating postdural puncture headaches and SIH. Park and Villablanca [26] described a technical report on the placement of an anterior cervical EBP for SIH following a cervical ventral dural tear. Kapoor and Ahmed [22] reviewed 15 studies and reported the safety and efficacy of cervical EBP in patients with positional headaches associated with CSF leaks. Similarly, Shekhawat et al. [14] demonstrated favorable outcomes using targeted anterior cervical EBP in refractory SIH. Given the risk associated with surgical re-exploration, the established efficacy and safety of EBP following spinal surgery, and previous reports supporting the efficacy of CT-guided anterior cervical EBP in patients with refractory SIH, we selected to perform a fluoroscopy-guided anterior cervical EBP. A total of 25 mL of serosanguinous fluid was aspirated, including 21 mL from the C4–5 prevertebral region and 4 mL from the C4–5 interbody space. Subsequently, a total of 15 mL of autologous blood was aseptically collected and administered, with 5 mL injected into the C4–5 interbody space and 10 mL into the C4–5 prevertebral region (Figures 3 and 4). The procedure was successful, and the patient experienced immediate resolution of symptoms without complications.

This case report demonstrates a novel application of fluoroscopy-guided anterior cervical EBP for managing CSF leaks following ACDF-associated ID. This technique highlights its potential value as an adjunct treatment when direct anterior dural repair is challenging. Further studies involving larger patient cohorts are required to validate the efficacy and safety of this approach. A limitation of this report is the lack of post-anterior cervical EBP cross-sectional imaging, as the patient declined follow-up MRI or CT due to financial constraints. Nevertheless, the durable clinical improvement strongly suggests successful sealing of the dural defect.

This case demonstrates the successful use of fluoroscopy-guided anterior cervical EBP to manage symptomatic CSF leakage following ID during ACDF. This minimally invasive approach may serve as a useful alternative when direct anterior dural repair is not feasible.