Abstract
Differently from the posterior, the anterior dural tears associated with spinal fractures are rarely reported and debated. We document our experience with a coating technique for repairing ventral dural lacerations, providing an associated literature review on the available strategies to seal off such dural defects. A PubMed search on watertight repair techniques of anterior dural lacerations focused on their association with spinal fractures was performed. Studies on animal or cadaveric models, on cervical spine, or based on seal/gelfoam or “not suturing” strategies were excluded. 10 studies were finally selected and our experience of three patients with thoracic/lumbar spinal fractures with associated ventral dural tear was integrated into the analysis of the surgical techniques. Among the described repair techniques for ventral dural lacerations a preference for primary suturing, mostly trans-dural, was noted (n = 6/10 papers). Other documented strategies were the plugging of the dural opening with a fat graft sutured to its margins, or stitched to the dura adjacent to the defect, and the closure of the dural tear with two patches, both trans-dural and epidural. Our coating techniques of the whole dural sac with the heterologous patch were revealed as safe and effective alternatives strategies, even when patch flaps wrapping nerve roots have to be cut and a fat graft has to be stitched in the patch respectively for sealing off antero-lateral and wide anterior dural tears. Compared to all the documented strategies for obtaining a watertight closure of an anterior dural laceration, the coating techniques revealed advantages of preserving neural structures, being adaptable to anterior and antero-lateral dural tears of any size.
Highlights
Introduction published maps and institutional affilDural lacerations are relatively common findings in thoracic and lumbar spinal fractures
Regarding management and treatment strategies of anterior dural lacerations resulting from fractured vertebral body fragments encroaching the spinal canal, only few reports are available adding little to the topic, especially in terms of techniques for nerve roots preservation and dural sac reconstruction [1,3,4,5,6,7,8,9,11,20]
The described surgical steps, exclusively epidural, together with the use of a large autologous fat graft, covering all the exposed dura and stitched to the intact peripheral dura instead of the dural tear margins, represent indisputable advantages over the other techniques reported in the literature. Inspired by such a concept of restoring a closed dural compartment, maximizing both preservation of neural structures and watertightness, we developed our strategies based on a circumferential epidural coating, creating a single layer enveloping the entire dural tube and the anterior dural laceration
Summary
Dural lacerations are relatively common findings in thoracic and lumbar spinal fractures. Posterior and sustained by fractured laminae, dural tears are typically associated with burst fractures and identified through a standard posterior approach. Few reports discuss anterior dural lacerations, registered in up to 10% of patients with thoracic and lumbar burst fractures, and resulting from vertebral body fragments encroaching the spinal canal [1]. Due to their location being difficult to detect through the conventional posterior approach, the repair of such ventral dural tears is a challenge. We present our experience with a coating technique and an overview of the literature on different surgical strategies for sealing off anterior dural lacerations in a watertight fashion. We present our experience with a coating technique and an overview of the literature on different surgical strategies for sealing off anterior dural lacerations in a watertight fashion. iations.
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