Dural Closure Technique Research Articles

Decompressive Craniectomy with or Without Dural Closure: Systematic Review and Meta-analysis.

Decompressive craniectomy is used to alleviate intracranial pressure in cases of traumatic brain injury and stroke by removing part of the skull to allow brain expansion. Traditionally, this procedure is followed by a watertight dural suture, although evidence supporting this method is not strong. This meta-analysis examines the feasibility of the open-dura (OD) approach versus the traditional closed-dura (CD) technique with watertight suturing. A systematic review and comparative meta-analysis were conducted on OD and CD dural closure techniques. Medline, Embase, and Cochrane were searched for relevant trials. The primary end point was the rate of complications, with specific analyses for infection and cerebrospinal fluid (CSF) leaks. Mortality, poor neurological outcomes, and operation duration were also assessed. Odds ratios with 95% confidence intervals (CIs) were calculated using a random-effects model. Following a comprehensive search, 930 studies were screened, from which four studies and a total of 368 patients were ultimately selected. The primary outcome analysis showed a reduced likelihood of complications in the OD group when compared with the CD group (368 patients, odds ratio 0.54 [95% CI 0.32-0.90]; I2 = 17%; p < 0.05). Specific analysis of infections and CSF leaks did not show statistically significant results, as well as the evaluation of the mortality rates and poor neurological outcome differences between groups. Assessment of operation duration, however, demonstrated a significant difference between techniques, with a mean reduction of 52.50min favoring the OD approach (mean difference - 52.50 [95% CI - 92.13 to - 12.87]; I2 = 96%). This study supports the viability of decompressive craniectomy without the conventional time-spending watertight duraplasty closure, exhibiting no differences in the rate of infections or CSF leaks. Furthermore, this approach has been associated with improved rates of complications and faster surgery, which are important aspects of this technique, particularly in its potential to reduce both costs and procedure length.

Enhanced technique of dural closure using autologous fat graft and Gelfoam for effective management of dural tear following interlaminar endoscopic lumbar spine surgery.

Incidental dural tears are common complications in lumbar spine surgery, particularly in endoscopic procedures where primary closure via suturing is challenging. The absence of a standardized approach for dural closure in endoscopic spine surgery necessitates exploring alternative techniques. This study introduces a surgical technique for dural closure utilizing fat graft and Gelfoam, offering an effective alternative to standard approaches in endoscopic spine surgery. Surgical data from patients who underwent interlaminar endoscopic discectomy or stenosis decompression at Lerdsin Hospital from October 2014 to October 2021 were analyzed. Among 393 cases, dural tears occurred in 2% (8 patients). Our technique achieved successful closure in all these cases, with no incidents of cerebrospinal fluid leakage or wound complications. The majority of patients showed favorable clinical outcomes, except for one case involving concomitant nerve root injury. This study demonstrates that using fat graft and Gelfoam for dural closure is a simple, reliable, and safe technique, particularly effective for challenging-to-repair areas in interlaminar endoscopic lumbar spine surgery.

Predictors of Cerebrospinal Fluid Leak Following Dural Repair in Spinal Intradural Surgery.

We aim to compare the effectiveness of dural closure techniques in preventing cerebrospinal fluid (CSF) leaks following surgery for intradural lesions and seek to identify additional factors associated with CSF leaks. Surgical management of spinal intradural lesions involves durotomy which requires a robust repair to prevent postoperative CSF leakage. The ideal method of dural closure and the efficacy of sealants has not been established in literature. We performed a retrospective analysis of all intradural spinal cases performed at a tertiary spine centre from 1 April 2015 to 29 January 2020 and collected data on patient bio-profile, dural repair technique, and CSF leak rates. Multivariate analysis was performed to identify predictors for postoperative CSF leak. A total of 169 cases were reported during the study period. There were 15 cases in which postoperative CSF leak was reported (8.87%). Multivariate analysis demonstrated that patient age (odds ratio [OR], 0.942; 95% confidence interval [CI], 0.891-0.996), surgical indication listed in the "others" category (OR, 44.608; 95% CI, 1.706-166.290) and dural closure with suture, sealant and patch (OR, 22.235; 95% CI, 2.578-191.798) were factors associated with CSF leak. Postoperative CSF leak was associated with the risk of surgical site infection with a likelihood ratio of 8.704 (χ² (1) = 14.633, p < 0.001). Identifying predictors for CSF leaks can assist in the counselling of patients with regard to surgical risk and expected postoperative recovery.

Comparison of supratentorial meningioma resection outcomes by dural reconstruction technique.

Excision of intracranial meningiomas often requires resection or coagulation of the dura mater. The choice of dural closure technique is individualized and based on surgeon preference. The objective of this study was to determine outcomes following various dural closure techniques for supratentorial meningiomas. A retrospective, single-center cohort study was performed for patients who underwent excision of supratentorial meningiomas from 2000 to 2019. Outcomes including operative time, postoperative in-hospital complications, readmission, causes of readmission including surgical site infection, pseudomeningocele, need for shunt surgery, and imaging appearance of pseudomeningocele on long-term follow-up imaging were compared. Univariate and multivariable analyses were conducted. A total of 353 patients who had complete clinical and operative data available for review were included. Of these patients, 227 (64.3%) had nonsutured dural graft reconstruction and 126 (35.7%) had sutured dural repair, including primary closure, artificial dura, or pericranial graft. There was significant variability in using nonsutured dural reconstruction compared with sutured dural repair technique among surgeons (p < 0.001). Tumors with sagittal sinus involvement were more likely to undergo nonsutured closure (n = 79, 34.8%) than dural repair (n = 26, 20.6%) (p = 0.003). There were no other differences in preoperative imaging findings or WHO grade. Frequency of surgical site infection and pseudomeningocele, need for shunt surgery, and recurrence were similar between those undergoing nonsutured and those undergoing sutured dural repair. The mean operative time for the study cohort was 234.9 (SD 106.6) minutes. The nonsutured dural reconstruction group had a significantly shorter mean operative time (223.9 [SD 99.7] minutes) than the sutured dural repair group (254.5 [SD 115.8] minutes) (p = 0.015). In a multivariable linear regression analysis, after controlling for tumor size and sinus involvement, nonsutured dural graft reconstruction was associated with a 36.8-minute reduction (95% CI -60.3 to -13.2 minutes; p = 0.002) in operative time. Dural reconstruction using a nonsutured graft and sutured dural repair exhibit similar postoperative outcomes for patients undergoing resection for supratentorial meningiomas. Although sutured grafts may sometimes be necessary, nonsutured graft reconstruction for most supratentorial meningioma resections may suffice. The decreased operative time associated with nonsutured grafts may ultimately result in cost savings. These findings should be taken into consideration when selecting a dural reconstruction technique for supratentorial meningioma.

Collagen-bound fibrin sealant (TachoSil®) for dural closure in cranial surgery: single-centre comparative cohort study and systematic review of the literature

Cerebrospinal fluid (CSF) leakage is a well-known complication of craniotomies and there are several dural closure techniques. One commonly used commercial product as adjunct for dural closure is the collagen-bound fibrin sealant TachoSil®. We analysed whether the addition of TachoSil has beneficial effects on postoperative complications and outcomes. Our prospective, institutional database was retrospectively queried, and 662 patients undergoing craniotomy were included. Three hundred fifty-two were treated with dural suture alone, and in 310, TachoSil was added after primary suture. Our primary endpoint was the rate of postoperative complications associated with CSF leakage. Secondary endpoints included functional, disability and neurological outcome. Systematic review according to PRISMA guidelines was performed to identify studies comparing primary dural closure with and without additional sealants. Postoperative complications associated with CSF leakage occurred in 24 (7.74%) and 28 (7.95%) procedures with or without TachoSil, respectively (p = 0.960). Multivariate analysis confirmed no significant differences in complication rate between the two groups (aOR 0.97, 95% CI 0.53–1.80, p = 0.930). There were no significant disparities in postoperative functional, disability or neurological scores. The systematic review identified 661 and included 8 studies in the qualitative synthesis. None showed a significant superiority of additional sealants over standard technique regarding complications, rates of revision surgery or outcome. According to our findings, we summarize that routinary use of TachoSil and similar products as adjuncts to primary dural sutures after intracranial surgical procedures is safe but without clear advantage in complication avoidance or outcome. Future studies should investigate whether their use is beneficial in high-risk settings.

Cerebrospinal fluid leaks following intradural spinal surgery-Risk factors and clinical management.

BackgroundCerebrospinal fluid leakage (CSFL) following spinal durotomy can lead to severe sequelae. However, while several studies have investigated accidental spinal durotomies, the risk factors and influence of clinical management in planned durotomies remain unclear.MethodsWe performed a retrospective analysis of all patients who underwent planned intradural spinal surgery at our institution between 2010 and 2020. Depending on the occurrence of a CSFL, patients were dichotomized and compared with respect to patient and case-related variables as well as dural closure technique, epidural drainage placement, and timing of mobilization.ResultsA total of 351 patients were included. CSFL occurred in 4.8% of all cases. Surgical indication, tumor histology, location within the spine, previous intradural surgery, and medical comorbidities were not associated with an increased risk of CSFL development (all p > 0.1). Age [odds ratio (OR), 0.335; 95% confidence interval (CI), 0.105–1.066] and gender (OR, 0.350; 95% CI, 0.110–1.115) were not independently associated with CSFL development. There was no significant association between CSFL development and the dural closure technique (p = 0.251), timing of mobilization (p = 0.332), or placement of an epidural drainage (p = 0.321).ConclusionCSFL following planned durotomy pose a relevant and quantifiable complication risk of surgery that should be factored in during preoperative patient counseling. Our data could not demonstrate superiority of any particular dural closure technique but support the safety of both early mobilization within 24 h postoperatively and epidural drainage with reduced or no force of suction.

Modified Shoelace Dural Closure with Collagen Matrix in Extended Transsphenoidal Surgery.

Extended endonasal transsphenoidal surgery (eTSS) offers a wide surgical field for various parasellar lesions; however, intraoperative high-flow cerebrospinal fluid (CSF) leakage is inevitable. Therefore, secure sellar reconstruction methods are essential to prevent postoperative CSF leakage. Although collagen matrix has been applied for dural reconstruction in neurosurgery, its suitability for application in extended eTSS remains unclear. Eighteen patients underwent modified shoelace dural closure using collagen matrix after lesionectomy via extended eTSS. In this technique, a collagen matrix, which was placed subdurally (inlay graft), was continuously sutured with both open dural edges like a shoelace. Then, another collagen matrix was placed epidurally (onlay graft), and rigid reconstruction was performed using the septal bone and a resorbable fixation mesh. Postoperative CSF leakage did not occur in 17 patients but did occur in 1 patient with tuberculum sellae meningioma. In this case, the CSF leakage point was detected just around the area between the coagulated dura and the adjacent collagen matrix. The collagen matrix harvested from this area was pathologically examined; neovascularization and fibroblastic infiltration into the collagen matrix were not detected. On the other hand, neovascularization and fibroblast infiltration into the collagen matrix were apparent on the surface of the collagen matrix harvested from the non-CSF leakage area. Our novel dural closure technique using collagen matrix could be an effective option for sellar reconstruction in extended eTSS; however, it should be applied in patients in whom normal dural edges are preserved.

High efficacy of tetra-PEG hydrogel sealants for sutureless dural closure

Advances in meticulous dural closure technique remain a great challenge for watertight dural closure in the aged society, because the cerebrospinal fluid (CSF) leakage after spinal surgery is often accompanied with the disgusting wound infection, meningitis and pseudomeningocele. Here, a tetra-poly (ethylene glycol) (PEG)-based hydrogel sealant is developed with collective advantages of facile operation, high safety, quick set time, easy injectability, favorable mechanical strength and powerful tissue adhesion for effective sutureless dural closure during the surgery procedure. Impressively, this tetra-PEG sealant can instantaneously adhere to the irregular tissue surfaces even in a liquid environment, and effectively prevent or block off the intraoperative CSF leakage for sutureless dural closure and dura regeneration. Together, this sutureless tetra-PEG adhesive can be utilized as a very promising alternative for high-efficient watertight dural closure of the clinical patients who incidentally or deliberately undergo the durotomy during the spinal surgery.

Comparison of Transthecal Approach With Traditional Conservative Approach for Primary Closure After Incidental Durotomy in Anterior Lumbar Tear.

Incidental durotomies (IDs) are frequent complications of spinal surgeries which are mostly posterior or lateral. Anterior IDs are rare; however, they may lead to severe complications. We compared the transthecal approach with the conservative approach for primary closure after durotomy in anterior lumbar dural tear to assess the efficacy of these approaches to decrease postsurgical complications and clinical outcomes. A total of 21 patients undergoing L2-S1 laminectomy with anterior ID were randomly divided into a transthecal group (n = 9) and a conservative group (n = 12) based on the surgical dural closure technique. Postoperative pseudomeningocele, wound infection, rootlet herniation, pneumocephalus, cerebrospinal fluid (CSF) leakage, headache, meningitis, in addition to surgery duration and length of hospitalization were examined and compared in both groups. The frequency of pseudomeningocele and CSF leakage in patients undergoing the transthecal approach was significantly lower than those undergoing the conservative approach (P = .045 and .008, respectively). Furthermore, although the differences in the frequency of meningitis, pneumocephalus, headache, and wound infection were not statistically significant between the 2 groups, the effect sizes of the comparison were obtained as 49.4, 19.8, 7.1, and 2.6, respectively. This indicated that the differences were clinically significant between the 2 groups. We found that the transthecal approach was significantly more successful in managing CSF leakage as well as its complications and clinical outcomes. However, further clinical trials with bigger sample sizes are needed to substantiate this claim.

A Questionnaire-based Survey of Clinical Neuro-oncological Practice in India.

Neuro-oncology is a relatively young subspecialty of neurosurgery. 2018 was the 10th year since the founding of the Indian Society of Neuro-oncology. To assess patterns in neuro-oncology practice in India. This was an online survey covering various domains of neuro-oncology such as demographics and practice setting, protocols for the medical management of patients with brain tumors, protocols for surgery and the perioperative period (including antibiotic prophylaxis, dural closure techniques, etc.), technological adjuncts used for brain/spine tumors (including intraoperative neurologic monitoring-IONM), and management protocols for certain specific clinical scenarios. The response rate was 13%. Although 37% of the respondents' institutions could be considered as having reasonable surgical volumes (>1 procedure/day), only about half of these had high volumes of malignant brain tumor surgery. A wide variation was seen in medical management, perioperative protocols, use of adjuncts and intraoperative technologies, and paradigms for specific clinical scenarios. There is a need to standardize the protocols in neuro-oncology. This could be achieved by strengthening the formal training process in surgical neuro-oncology.

Surgical nuances and placement of subgaleal drains for supratentorial procedures\u2014a prospective analysis of efficacy and outcome in 150 craniotomies

BackgroundFor supratentorial craniotomy, surgical access, and closure technique, including placement of subgaleal drains, may vary considerably. The influence of surgical nuances on postoperative complications such as cerebrospinal fluid leakage or impaired wound healing overall remains largely unclear. With this study, we are reporting our experiences and the impact of our clinical routines on outcome in a prospectively collected data set.MethodWe prospectively observed 150 consecutive patients undergoing supratentorial craniotomy and recorded technical variables (type/length of incision, size of craniotomy, technique of dural and skin closure, type of dressing, and placement of subgaleal drains). Outcome variables (subgaleal hematoma/CSF collection, periorbital edema, impairment of wound healing, infection, and need for operative revision) were recorded at time of discharge and at late follow-up.ResultsEarly subgaleal fluid collection was observed in 36.7% (2.8% at the late follow-up), and impaired wound healing was recorded in 3.3% of all cases, with an overall need for operative revision of 6.7%. Neither usage of dural sealants, lack of watertight dural closure, and presence of subgaleal drains, nor type of skin closure or dressing influenced outcome. Curved incisions, larger craniotomy, and tumor size, however, were associated with an increase in early CSF or hematoma collection (p < 0.0001, p = 0.001, p < 0.01 resp.), and larger craniotomy size was associated with longer persistence of subgaleal fluid collections (p < 0.05).ConclusionsBased on our setting, individual surgical nuances such as the type of dural closure and the use of subgaleal drains resulted in a comparable complication rate and outcome. Subgaleal fluid collections were frequently observed after supratentorial procedures, irrespective of the closing technique employed, and resolve spontaneously in the majority of cases without significant sequelae. Our results are limited due to the observational nature in our single-center study and need to be validated by supportive prospective randomized design.

Postoperative Thecal Sac Compression Induced by Hydrogel Dural Sealant after Spinal Schwannoma Removal

Cerebrospinal fluid (CSF) leak is a common complication of spinal and cranial surgery, and patients undergoing spinal tumor surgery are probably particularly predisposed due to the presence of an intradural tumor and many other factors. Furthermore, a meticulous dural closure technique does not always result in watertight closure. A number of adjunctive methods have been used to assist with dural closure. Synthetic, absorbable polyethylene glycol hydrogel dural sealants are widely used and have been approved for use as adjuncts for cranial applications requiring sutured dural closure. We report a case of thecal sac compression by DuraSeal® Dural Sealant used to repair the CSF leak after intentional durotomy during lumbar schwannoma extirpation.

Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip

BackgroundThe classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought. ObjectiveThe purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI). MethodsWe performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018. ResultsThe mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks. ConclusionsWe describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging.

Common Practice in the Management of Dural Closure: An Italian Questionnaire

The optimal management of dural closure is unclear; therefore, we aimed to survey current common practices among Italian practitioners. The Delphi method was used to achieve a consensus on dura mater closing techniques in Italy. A steering committee decided 3 major topics to be investigated: pre- and postoperative conditions associated with cerebrospinal fluid (CSF) leak, indications to perform watertight dural closure, and dural closure technique. A questionnaire containing 12 statements was then submitted to Italian neurosurgeons. The response rate was 60%. Among 60 items, 36 reached a positive consensus, 5 reached a negative consensus, and 19 did not reach consensus. Intrathecal hypertension, arachnoid opening, previous treatments, spinal incidental durotomy, wide size of osteo-dural defect, and lack of nasoseptal flap were considered major risk factors for CSF leak. Early mobilization, avoidance of stress maneuvers, and use of CSF external drainage were considered to reduce CSF leak rate. Italian neurosurgeons always attempt watertight dural closure, ideally with monofilament nonabsorbable sutures. Both autologous and heterologous dural grafts are used. Among dural sealants, fibrin glues are preferred, which are used most commonly in transsphenoidal surgery. This study elucidates the areas of consensus and uncertainty on dural closure management among a group of Italian neurosurgeons. It provides reliable and comparable data for the investigation of the departments' daily practice in dural closure. Given the lack of solid evidence, there is a need for further comparative studies of dural repair strategies.

Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip.

The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought. The purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI). We performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018. The mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks. We describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging.

Dural Closure in Chiari I Malformation. Technique Description and Analysis of Results

Introduction. Surgical posterior fossa decompression of Chiari malformation type 1 (CM-I) is recommended in symptomatic patients. The classic surgery is a suboccipital craniectomy and C-1 laminectomy, with duroplasty. However, a range of complications associated with surgical management of CM-I includes pseudomeningocele, CSF leakage, aseptic meningitis, and wound infections, making dural closure and reconstruction one important step to determine morbidity. Our objective is to present a technique of pericranium harvest and dural closure and describe our experience. Methods. A retrospective study was conducted based on records of patients treated in Hospital das Clínicas of the University of São Paulo, diagnosed with CM-I and submitted to posterior fossa decompression from January 2008 until May 2015. We evaluated the occurrence of post-operative complications of symptomatic pseudomeningocele or incisional CSF leak. The occurrence of meningitis, surgical site infection or other complications were also available. Results. A total of 22 patients were evaluated in this study. Sixteen (72.7%) were female patients. Overall, the mean age at the time of surgery was 49 ± 13.6 years-old. Four patients (18%) presented complications: 3 CSF leakages (13.5%) and 1 pseudomeningocele (4.5%). Discussion. Postoperative complications of CM-I are still frequent and determinants of surgical success. We propose a new surgical technique with autologous pericranium graft and duraplasty. Additionally to dural closure, we propose another modality of muscular fascia closure, allowing increased tight closure. Our data corroborate with current literature. Conclusion. Our technique of dural closure using pericranium autologous graft in CM-I is safe and feasible.

Management of Dural Tears in Endoscopic Lumbar Spinal Surgery: A Review of the Literature

The incidental dural tear is a common complication in lumbar spine surgery. It has been reported that the incidence of dural tears is much greater in endoscopic procedures. Primary closure via suturing remains challenging in endoscopic procedures. The objective of this study was to conduct a literature review on the surgical technique for dural closure and repair in endoscopic spine surgery. A systematic literature search was performed using the database PubMed. In total, 12 studies reported specifically about the surgical treatment for dural tear in percutaneous and tubular assisted endoscopic technique. The dural tear rate, the technique of dural closure, postoperative time of bed rest, postoperative symptoms related to cerebrospinal fluid fistula, and revision surgery were assessed. The overall rate of dural tears in endoscopic spinal surgery was 2.7%, with a range from 0% to 8.6%. The incidence of a dural tear was much greater in cases with lumbar stenosis (3.7%) than in lumbar disc herniation (2.1%). The greatest rate was accompanied by resecting synovial cysts. In addition, the risk of dural tear is greater in bilateral decompression procedures via a unilateral approach. There is no consensus about the ideal technique for dural closure in endoscopic procedures. Furthermore, there is a debate whether dural tear requires surgical treatment or not. An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in lumbar endoscopic spine surgery.

Watertight Dural Closure in Pediatric Craniotomies-Is It Really Necessary?

Dural closure after intracranial procedures is considered crucial to reduce postoperative complications such as pseudomeningocele (PM), cerebrospinal fluid (CSF) leaks, hydrocephalus, and infections. However, watertight dural closure (WTDC) is often difficult to achieve, and dural substitutes often are used. We describe our experience with non-WTDC in children. Data were collected retrospectively. Redo and craniectomy cases were excluded. Collected data included demographics, surgical etiology, various radiologic parameters, ventricular opening, usage of drains and shunts, dural closure technique, and complications. In total, 163 cases aged 3 months to 18.5 years (90 ± 56 months) were included. Main surgical indications were tumors (120, 74%) and epilepsy (29, 18%). In total, 122 (74%) cases were supratentorial. The ventricular system was opened in 69 (42%) cases. In 145 (89%) cases, a non-WTDC was performed. Fibrin glue was used in 22 (13%) cases. In 156 cases (96%), a dural substitute was used. One patient (0.6%) had a CSF leak. At 3 months, 20% had a radiologic PM but only 8.4% were noticed clinically. At 1 year, 7.7% had a radiologic PM but only 3% were noticed clinically. Overall, 3% needed a PM tap, and 15 patients (9%) underwent CSF diversion procedures. There were no infections. The only factor significantly associated with PM or a need for CSF surgery was an infratentorial location. Non-WTDC after cranial surgery in children was associated with a low rate of clinically significant PM, infections, leaks, and hydrocephalus. Non-WTDC is fast and reduces the need to harvest additional tissue, thus minimizing the surgical incision.

Full endoscopic treatment of dural tears in lumbar spine surgery.

An incidental durotomy is a common complication of spinal surgery. Its treatment remains challenging, especially in endoscopic procedures. The objective of this study is to describe a technique for endoscopic dural closure which is safe and effective. From a prospective database all endoscopic spinal procedures with incidental durotomy were identified. Retrospectively, video recordings were analysed with a special reference to the applied technique of dural closure. Additionally 1, 6 and 12week follow-up examinations were evaluated for clinical outcome and associated complications. Out of 212 consecutive patients, an intraoperative dural tear was observed in nine patients (4.2%). A dural tear occurred in 1.1% of cases of lumbar disc herniation, in 7.9% of cases with lumbar spinal stenosis, in 37.5% of cases with a synovial cyst. An autologous muscle sample was harvested within the operative field and grafted at the dural defect in several layers. Fixation of the transplantation and watertight closure were achieved by the application of fibrin sealant with gelfoam. The mean time for dural closure was 209s (range 47-420s). Postoperatively no CSF fistula, no new deficits nor worsening of a pre-existing neurological deficit occurred. None of the patients had problems with wound healing, or discomfort which could be related to the CSF leak. Dural closure with an autologous muscle graft in combination with fibrin sealant patch is a fast, safe and alternative technique for the management of dural tear in microendoscopic surgery.

The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study

Background ContextWatertight dural repair is crucial for both incidental durotomy and closure after intradural surgery. PurposeThe study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques. Study Design/SettingThe study is set in a fresh tissue dissection laboratory. Sample SizeThe sample includes eight fresh human cadavers. Outcome MeasuresA watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines. MethodsFresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7–T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage. ResultsSpinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p>.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p<.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p<.01) when compared with mean pressures without the hydrogel sealant. ConclusionsWe described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.