Abstract
BACKGROUNDDural tears must be quickly addressed to avoid the development of positional headaches and pseudomeningoceles, among other complications. However, sizeable areas of friable or absent dura create unique challenges when attempting to achieve a watertight seal. We have developed a two-layer subdural and epidural fibrous patch technique to treat expansive or challenging dural tears as a result of our experience treating spinal fluid leaks.OBSERVATIONSThe authors present the treatment of a large necrotic (5 × 1.5 cm) dural defect refractory to initial attempts at standard primary repair with dural patch grafting and requiring a revision with a dual-layer patch to manage persistent cerebrospinal fluid leakage.LESSONSThe use of a two-layer (subdural and epidural) patch is both a safe and effective dural repair technique for creating a watertight seal in challenging large areas in which the dura may be damaged, scarred, or absent. We also propose that this technique may be able to be used for smaller challenging tears, as well as potentially for repairs of large blood vessels or other fluid-filled structures in the body.
Highlights
Dural tears must be quickly addressed to avoid the development of positional headaches and pseudomeningoceles, among other complications
We fashioned an AlloDerm dual-layer patch that was approximately 2.5 cm wide by 7 cm long on the inner layer and 1.5 cm wide by 5 cm long on the outer layer with the outer layer mimicking the teardrop shape of the dural defect (Fig. 2)
The patient did not require any additional dural intervention nor did she suffer from Cerebrospinal fluid (CSF) leak symptoms
Summary
Dural tears must be quickly addressed to avoid the development of positional headaches and pseudomeningoceles, among other complications. We have developed a two-layer subdural and epidural fibrous patch technique to treat expansive or challenging dural tears as a result of our experience treating spinal fluid leaks. LESSONS The use of a two-layer (subdural and epidural) patch is both a safe and effective dural repair technique for creating a watertight seal in challenging large areas in which the dura may be damaged, scarred, or absent. CSF leaks, recognized intraoperatively or through imaging, can be managed conservatively or surgically.[4] Conservative management includes bed rest, an epidural blood patch, and/or fibrin glue.[1,5] Those patients for whom conservative management fails may require a neurosurgeon to either suture the tear closed, use a dural sealant such as fibrin glue, place a fat or muscle graft, insert a patch, or use a combination of techniques to achieve a watertight closure.[6] The specific repair depends on the length, location, and cause of the leak. In some cases, the edges of the native dura may be so friable that suturing or clipping to the dura results in incomplete seals, tears, or leaks through the suture holes.[4,8] those with a history of radiotherapy to or near the spine may have compromised dural blood supply, extensive scarring or adhesions, and/or tissue hypoxia, thereby weakening the dura mater, increasing the likelihood of CSF leaks, and requiring a more intensive dural closure.[4,8] this study presents a novel approach to treating a radiation-induced dural injury and CSF leak as well as expansive dural tears by the use of a two-layer intradural and extradural patch graft
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