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Occurrence of CSF-Venous Fistulas by Spinal Level and Laterality
Zaid Saadeh1, Sherief A Ghozy2, Esref A Bayraktar3
1From the Department of Radiology (Z.S., E.A.B., W.B., A.A.M., J.C.B., J.T.V., P.H., I.T.M.), Mayo Clinic, Rochester, Minnesota Saadeh.Zaid@mayo.edu.
Background:
CSF-venous fistulas (CVFs) are an important and underrecognized cause of spontaneous intracranial hypotension. Accurate localization is essential for effective treatment. However, data regarding which areas of the spine are at higher risk are limited.
Purpose:
To evaluate the prevalence of affected laterality and spinal levels in patients with CVFs.
Data Sources:
Scopus, Web of Science, Embase, and PubMed databases.
Study Selection:
Studies involving 3 or more patients with confirmed CVFs that specified the level and side of involvement were included. When multiple studies originated from the same institution or research group, they were further reviewed and narrowed to avoid data overlap, prioritizing inclusion of the largest studies.
Data Analysis:
Meta-analysis of demographic characteristics, side of involvement, and spinal levels of CVFs. Pooled prevalence rates were computed, and age and gender distribution across studies were analyzed. Pair-wise meta-regression was used, and laterality was further assessed at each spinal level to determine the distribution of right-versus left-sided leaks. Heterogeneity was assessed using Q statistics and the I2 test, with significance defined as an I2 value >50% or a P value <.05.
Data Synthesis:
Thirty-six observational studies consisting of 1145 patients (63% women) were analyzed. Most CVFs involved the lower portion of the thoracic spine, including T7 (28/180; 19%; 95% CI: 0.13-0.28), T9 (33/238; 19%; 95% CI: 0.13-0.30), and T10 (31/190; 17%; 95% CI: 0.13-0.24). More CVFs occurred on the right side of the spine (394/709; 67%; 95% CI: 0.62-0.73; P <.001) when compared to the left (214/786; 31%; 95% CI: 0.24-0.39) and bilaterally (18/313; 8%; 95% CI: 0.04-0.18).
Limitations:
Study limited by retrospective approach, reporting bias, and paucity of large published series of patients with CVFs. Furthermore, reporting was not standardized, making statistical comparison difficult.
Conclusions:
In patients with CVFs, the thoracic spine appears to be the most heavily involved region, especially on the right side.
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