Minimally Invasive Versus Traditional Repair of Spinal Cerebral Spinal Fluid Leaks: A Systematic Review and...

Spontaneous spinal cerebrospinal fluid leaks are a major cause of spontaneous intracranial hypotension. Minimally invasive surgical (MIS) approaches have been developed to reduce perioperative morbidity while preserving repair durability, yet their comparative effectiveness remains incompletely defined. We performed a systematic review and meta-analysis of contemporary surgical series following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Twenty studies met criteria for qualitative synthesis; 9 contributed to the quantitative synthesis. Primary closure success was 95% (95% confidence interval 88.8-97.8; I² = 0%), and recurrence or reoperation occurred in 10% (95% confidence interval 5.9-15.8; I² = 0%). Subgroup analysis showed numerically similar rates between MIS and open repair in both closure (97% vs. 92%; P > 0.05) and recurrence (10% vs. 9%; P = 0.86), though formal noninferiority testing was not appropriate because the available evidence consisted predominantly of nonrandomized retrospective cohorts without a prespecified noninferiority margin or direct adjusted between-group comparisons. Complete symptom resolution was 71% in open cohorts (I² = 87%); MIS cohorts lacked consistent denominators for quantitative pooling. Some cohorts reported shorter length of stay and reduced postoperative pain in MIS groups, but these between-study comparisons were descriptive and confounded by case selection. However, the observational nature of the data, absence of randomization, and unmeasured selection bias-whereby more complex leaks may have been preferentially treated with open surgery-preclude definitive comparative conclusions. In selected cases, MIS dural repair may approach the success rates of open procedures with comparable complication profiles, but prospective studies controlling for selection bias are needed.