Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations

Abstract

Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage. After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked byperforming the Valsalva maneuver at the end of the surgery. No CSF leakages were observed after surgery. Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might beeffective in cases with untraumatized arachnoid membrane.