Surgical management of ventral epidural cerebrospinal fluid leak: a scoping review and illustrative case

INTRODUCTION: Spontaneous intracranial hypotension (SIH) is a neurological disorder caused by cerebrospinal fluid (CSF) leaks, most often spinal in origin, and is characterized by orthostatic headache, nausea, and cognitive impairment that can markedly reduce quality of life. Epidural blood patching (EBP) is first-line therapy, but spinal leaks due to ventral dural tears are less likely to respond and often require surgical repair. This scoping review synthesizes current evidence on surgical management of ventral spinal CSF leaks from dural tears and presents an illustrative case of osteophyte-related SIH. METHODS: A comprehensive database search in PubMed, Web of Science, SCOPUS, and EMBASE was conducted. Studies reporting operative strategies for SIH due to ventral dural tears were included. Data were extracted on diagnostic methods, surgical techniques, and outcomes. RESULTS: Seventeen studies reporting operative strategies for ventral dural tear-associated spinal CSF leak leading to SIH were included. Posterior transdural techniques were most frequently described, with recent literature increasingly reporting minimally invasive approaches from a select number of specialized centers. Minimally invasive approaches have been reported with favorable outcomes and acceptable complication rates in recent series. The illustrative case demonstrates successful surgical repair without prior EBP trials in a patient with a severe, high-flow ventral leak, resulting in complete symptom resolution. CONCLUSION: Surgical management of ventral dural tear-related CSF leaks has evolved, with minimally invasive techniques demonstrating favorable outcomes in selected series. However, interpretation of comparative outcomes to open approaches is limited by heterogeneity of outcomes, era effects in surgeon experience and techniques, and potential overlap among reporting centers. Accurate leak localization using advanced imaging and a tailored, algorithmic management strategy remain essential. Prospective comparative studies evaluating long-term outcomes and cost-effectiveness are needed to inform best practice.