Closure Of Durotomy Research Articles

Minimally invasive surgery for intradural extramedullary spinal cord pathologies: A case series and technical note

BackgroundIntradural spinal cord pathologies have traditionally been managed with open surgical procedures and require the completion of a durotomy. Minimally invasive techniques are emerging as alternative procedures with the goal of reducing complications, but often require specialized equipment with additional training. MethodsWe conduct a single institution retrospective review from 2016 to 2019 of patients undergoing minimally invasive durotomy closure for intradural extramedullary pathologies using a novel technique that utilizes standard operating room equipment. This cohort is compared to a cohort of patients treated with a traditional open approach. ResultsPatients treated with minimally invasive surgery (MIS) had no statistically significant differences in baseline characteristics compared to patients treated with open procedures. Patients treated with MIS had decreases in complication rates, estimated blood loss, and length of stay in the hospital compared to the patients treated with open procedures, but these differences did not reach levels of statistical significance. ConclusionsOur novel MIS technique for intradural extramedullary pathologies appears to be safe and effective in creating a watertight dural closure using standard operating room equipment, while avoiding the costs and training associated with specialized equipment and possibly improving surgical outcome measures when compared to open approaches.

P15. Can cervical and lumbar epidural blood patches help avoid revision surgery for symptomatic postoperative dural tears?

<h3>BACKGROUND CONTEXT</h3> Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks are a known sequela of spine surgeries. Treatments include bedrest, subarachnoid lumbar drain, epidural blood patch, and most commonly, surgical reexploration for durotomy closure. Surgical reexploration carries the inherent consequences of an additional surgical procedure. The theory behind epidural blood patches is to form a clot over the tear in a minimally invasive manner and to allow the dura to heal without the need for additional surgery. Within the literature, there is a paucity of data available evaluating the efficacy of epidural blood patches for CSF leaks secondary to incidental durotomies. <h3>PURPOSE</h3> The purpose of this study is to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series. <h3>PATIENT SAMPLE</h3> All patients undergoing cervical, thoracolumbar, or posterior lumbar spine surgeries at an academic institution between 10/2012 and 12/2020 were included. <h3>OUTCOME MEASURES</h3> Rate of dural tears, type of dural repair, use of blood patches for dural tears, intraoperative/perioperative complications, length of hospital stay, discharge status. <h3>METHODS</h3> Patients undergoing cervical, thoracolumbar, and posterior lumbar surgeries performed by a single surgeon at an academic institution between 10/2012 and 12/2020 were included. Their charts were reviewed retrospectively for demographic information, type of surgery, rate of dural tear, type of repair, and use of blood patches postoperatively. <h3>RESULTS</h3> A total of 1,392 patients (726 males, 666 females, average age: 56.3 ±15.4 years old) were included who received cervical, thoracolumbar, or posterior lumbar surgeries. Of the 436 cervical spine surgeries, there were 236 anterior cervical fusions, 183 posterior cervical surgeries, and 17 anterior and posterior cervical surgeries. Of the 956 thoracolumbar and posterior lumbar spine surgeries, there were 207 laminectomies, 458 fusions and 291 microdiscectomies. There were 6 (1.4%) cervical, 65 (6.8%) lumbar, a total of 71 (5.1%) patients identified with incidental dural tears/blebs. Durotomies were fixed primarily, or if they were inaccessible, then treated with duraseal and/or fat graft. Persistent CSF leaks were indicated by positive beta-2 transferrin or clinical symptoms of positional headaches; these patients were referred to interventional radiology for a blood patch. We identified 2 (2 males) cervical spine and 8 (4 females and 4 males) lumbar spine patients who received blood patches in this study. Nine of 10 patients had resolution of symptoms without reaccumulation of fluid (90%). One lumbar spine surgery patient had a persistent pseudomeningocele after a blood patch and subsequently underwent primary repair with no relief. A second blood patch was then performed, which alleviated his symptomatic pseudomeningocele. Of the10 total patients who received blood patches, the mean length of hospital stay was 10.4 days, and three were discharged to rehabilitation. <h3>CONCLUSIONS</h3> The rate of dural tears/blebs within this series was 1.4% in cervical spine, 6.8% in lumbar spine, and 5.1% in total spine surgeries. Of the 10 patients with symptomatic postoperative CSF leaks, 9 out of 10 were successfully treated with a blood patch. Targeted epidural blood patch is an effective option to treat symptomatic CSF leaks that minimizes the morbidity of surgical reexploration. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?: 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes.

Retrospective case-control study. To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks. Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty. It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups-study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests. The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups. Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries. 4.

Retrospective evaluation of surgical outcomes after closure of durotomy in eight dogs affected by spinal subarachnoid diverticulum

Background:Canine spinal subarachnoid diverticulum has been studied since 1968 and a few advancements have been made with regard to the treatment of this disease. Several surgical techniques have been proposed which include durectomy, fenestration, and/or marsupilization with the latter two regarded as the more favorable surgical treatments.Aim:In this retrospective study, we evaluated the closure of the durotomy incision in the treatment of canine spinal subarachnoid diverticulum.Methods:We retrospectively evaluated eight dogs with clinical signs and magnetic resonance imaging findings consistent with spinal subarachnoid diverticulum located in the cervical and thoracolumbar area. This was to determine whether the fenestration with closure of durotomy was superior to the marsupialization technique. In all dogs, fenestration and removal of subarachnoid adherences alongside closure of the durotomy were carried out.Results:Mild post-operative deterioration was observed in all dogs. Follow-up from 7 to 36 months indicated a satisfactory outcome.Conclusion:We conclude that the closure of durotomy has similar short-term and long-term outcomes compared to the previous reported studies. These results suggest that the closure of durotomy is a viable technique for spinal subarachnoid diverticulum.

Pseudomeningocele Aspiration and Blood Patch Effectively Treats Positional Headache Associated With Postoperative Lumbosacral Pseudomeningocele.

Retrospective chart review with limited prospective follow-up survey. To evaluate the efficacy and safety of blood patch injection for the treatment of positional headaches caused by postoperative lumbosacral pseudomeningoceles. Pseudomeningocele is one of the most common complications after posterior lumbosacral spinal surgery. Common treatments include bedrest, abdominal binder use, subarachnoid lumbar drainage, and surgical re-exploration for durotomy closure. To date, only small case reports support the use of epidural blood patch injection for symptomatic pseudomeningocele treatment. A retrospective chart review analyzed the outcomes and complications of 19 consecutive patients who underwent blood patch injection, with and without pseudomeningocele aspiration, for symptomatic postoperative lumbosacral pseudomeningoceles between 2009 and 2015. An attempt was made to survey patients by phone regarding satisfaction. As of last follow-up (average time = 22.3 months), 16 patients (84%) experienced headache resolution after blood patch injection and did not require further treatment of their pseudomeningocele. In addition to symptomatic improvement, 12 of the 16 successful patients had imaging, which demonstrated pseudomeningocele resolution. Persistent pseudomeningoceles were demonstrated on imaging among all three unsuccessful patients. Pseudomeningocele aspiration followed by blood patch is an effective treatment for symptomatic postoperative lumbosacral pseudomenigocele. This is a minimally invasive alternative to surgical re-exploration with durotomy closure. Injections are most effective when performed early after pseudomeningocele development. 4.

Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model.

Open-label laboratory investigational study; non-animal surgical simulation. The authors perform a comparison of dural closure strength in a durotomy simulator across 2 different suture materials. Incidental durotomy leading to persistent cerebrospinal fluid leak adds considerable morbidity to spinal procedures, often complicating routine elective lumbar spinal procedures. Using an experimental durotomy simulation, the authors compare the strength of closure using Gore-Tex with other suture types and sizes, using various closure techniques. A comparison of dural closures was performed through an analysis of the peak pressure at which leakage occurred from a standardized durotomy closure in an established cerebrospinal fluid repair model with a premade L3 laminectomy. Nurolon was compared with Gore-Tex sutures sizes (for Gore-Tex, CV-6/5-0 and CV-5/4-0 was compared with Nurolon 4-0, 5-0, and 6-0). Thirty-six trials were performed with Nurolon 4-0, 5-0, and 6-0, whereas 21 trials were performed for 4-0 and 5-0 Gore-Tex. The mean peak pressure at which fluid leakage was observed was 21 cm H2O for Nurolon and 34 cm H2O for Gore-Tex. Irrespective of suture choice, all trials were grouped by closure technique: running suture, locked continuous, and interrupted suture. No significant difference was noted between the groups. For each of the 3 trials groups by closure technique, running, locked continuous, and interrupted, Gore-Tex closures had a significantly higher peak pressure to failure. Interrupted Gore-Tex was significantly higher than Interrupted Nurolon (P=0.007), running Gore-Tex was significantly higher than running Nurolon (P=0.034), and locked Gore-Tex was significantly higher than locked Nurolon (P=0.014). Durotomy closure in the lumbar spine with Gore-Tex suture may be a reasonable option for providing a watertight closure. In this laboratory study, Gore-Tex suture provided watertight dural closures that withstood higher peak pressures.

Surgical Technique and Clinical Outcomes for Primary Intradural Extramedullary Spinal Tumors

Background: Primary intradural extramedullary spinal tumors are rare and comprise nerve sheath tumors, meningiomas, and other rare pathologies. Clinical symptoms of these tumors are often nonspecific and are usually not obvious until neurological deterioration occurs. A delay in surgical treatment can lead to permanent neurological deficits. The aim of this study is to assess the clinical manifestations and surgical results of patients diagnosed with primary intradural extramedullary spinal tumors. Methods: From September 1999 to June 2014, patients who underwent surgery for primary intradural extramedullary spinal tumors at the orthopedic departments of authors' institutes were included in this study. Surgical procedures included laminectomy and midline durotomy for adequate exposure, total excision of tumors, and primary closure of durotomy by non-absorbable sutures. Spinal instrumentation and fusion was performed to prevent postlaminectomy kyphosis in only one patient whose tumor located in upper thoracic spine. The data were gathered retrospectively from medical records and included clinical presentation, tumor location, histopathology, postoperative complications and outcomes. Results: There were 11 patients, 5 males and 6 females, included in this study. The mean age of the patients was 52.8 (between 25 and 75) years. Preoperative symptoms included back pain in all cases, Brown-Sequard syndrome in the 3 cases of thoracic lesions, and sciatica-type of symptoms in 8 cases of lumbar lesions. The histopathologic results were meningiomas for 2 cases, schwannomas for 6 cases, paraganglioma for 1 case, ependymoma for 1 case, and mesenchymal chondrosarcoma for 1 case. Meningiomas and mesenchymal chondrosarcoma were located in the thoracic spine. Three schwannomas located at the level of conus medullaris. Paraganglioma, ependymoma, and the other three schwannomas located at the level of cauda equina. The case of mesenchymal chondrosarcoma received radiotherapy after surgery for the malignant nature of the tumor. All patients recovered well from preoperative symptoms after surgery. Persistent CSF leakage needed revision of dural repair was noted in one case. Iatrogenic spondylolisthesis at the operated levels was noted in one case but the patient declined the suggestion of additional spinal fusion because the clinical symptoms were minimal. No recurrence of tumor was found in the follow-up period. Conclusion: Although malignant lesions have been reported sporadically in the literature, intradural extramedullary tumors are usually benign. There is no typical presentation of clinical symptoms, therefore early-stage intradural extramedullary tumors are difficult to detect. Complete excision of these tumors is usually achievable and the neurologic prognosis after surgical excision is often better than the other spinal neoplasia.

Simulated Spinal Cerebrospinal Fluid Leak Repair

In the era of surgical resident work hour restrictions, the traditional apprenticeship model may provide fewer hours for neurosurgical residents to hone technical skills. Spinal dura mater closure or repair is 1 skill that is infrequently encountered, and persistent cerebrospinal fluid leaks are a potential morbidity. To establish an educational curriculum to train residents in spinal dura mater closure with a novel durotomy repair model. The Congress of Neurological Surgeons has developed a simulation-based model for durotomy closure with the ongoing efforts of their simulation educational committee. The core curriculum consists of didactic training materials and a technical simulation model of dural repair for the lumbar spine. Didactic pretest scores ranged from 4/11 (36%) to 10/11 (91%). Posttest scores ranged from 8/11 (73%) to 11/11 (100%). Overall, didactic improvements were demonstrated by all participants, with a mean improvement between pre- and posttest scores of 1.17 (18.5%; P = .02). The technical component consisted of 11 durotomy closures by 6 participants, where 4 participants performed multiple durotomies. Mean time to closure of the durotomy ranged from 490 to 546 seconds in the first and second closures, respectively (P = .66), whereby the median leak rate improved from 14 to 7 (P = .34). There were also demonstrative technical improvements by all. Simulated spinal dura mater repair appears to be a potentially valuable tool in the education of neurosurgery residents. The combination of a didactic and technical assessment appears to be synergistic in terms of educational development.

Hydrostatic Comparison of Nonpenetrating Titanium Clips Versus Conventional Suture for Repair of Spinal Durotomies

Biomechanics. To compare the hydrostatic strength of suture and nonpenetrating titanium clip repairs of standard spinal durotomies. Dural tears are a frequent complication of spine surgery and can be associated with significant morbidity. Primary repair of durotomies with suture typically is attempted, but a true watertight closure can be difficult to obtain because of leakage through suture tracts. Nonpenetrating titanium clips have been developed for vascular anastomoses and provide a close apposition of the tissues without the creation of a suture tract. Twenty-four calf spines were prepared with laminectomies and the spinal cord was evacuated leaving an intact dura. After Foley catheters were inserted from each end and inflated adjacent to a planned dural defect, the basal flow rate was measured and a 1-cm longitudinal durotomy was made with a scalpel. Eight repairs were performed for each material, which included monofilament suture, braided suture, and nonpenetrating titanium clips. The flow rate at 30, 60, and 90 cm of water and the time needed for each closure were measured. There was no statistically significant difference in the baseline leak rate for all 3 groups. There was no difference in the leakage rate of durotomies repaired with clips and intact specimens at any pressure. Monofilament and braided suture repairs allowed significantly more leakage than both intact and clip-repaired specimens at all pressures. The difference in leak rate increased as the pressure increased. Closing the durotomy with clips took less than half the time of closure with suture. Nonpenetrating titanium clips provide a durotomy closure with immediate hydrostatic strength similar to intact dura whereas suture repair with either suture was significantly less robust. The use of titanium clips was more rapid than that of suture repair.