Dural Reconstruction Research Articles

SURG-13. PATHOLOGICAL EXAMINATION OF MENINGIOMA RECURRENCE AFTER ABSORBABLE ARTIFICIAL DURA MATER RECONSTRUCTION

Abstract INTRODUCTION In meningioma surgery, the removal of the tumor and tumor-attached dura mater is essential. Due to its high affinity, absorbable artificial dura mater is used for the reconstruction of dural defects. In this study, we report a pathological examination of dural-like tissue in a case of meningioma that recurred at the same site after the use of absorbable artificial dura mater during initial surgery. METHOD We investigated two cases in which absorbable artificial dura mater was used for dural reconstruction during meningioma resection, and subsequently, a recurrent lesion was identified at the site of the dural reconstruction. We examined MRI images and surgical and pathological findings at the time of recurrence in these cases. RESULT All patients underwent total resection, and the pathological diagnosis was atypical meningioma. MRI images at the time of recurrence revealed multiple meningiomas along the artificial dura site. Gross findings during recurrent surgery indicated that the absorbable dura had been replaced by dura-like tissue, with the tumor also attached to the same site. Pathological findings showed bundles of fibrous tissue within the dura-like tissue, albeit with a sparser density compared to autologous dura mater. Meningioma cell invasion and angiogenesis were also observed in the dural-like tissue. DISCUSSION In all cases, multiple meningiomas were found along the dural-like tissue. This suggests that meningioma cells invading the dural-like tissue may have used it as a scaffold for meningioma recurrence. Future studies are necessary to determine the appropriateness of absorbable artificial dura mater for dural defect sites during malignant meningioma surgery.

Proposing Novel Biological Scaffolds for the Regeneration of the Dura Mater

ABSTRACTThe dura mater protects underlying tissues and cerebrospinal fluid, but dural abnormalities can cause leaking and meningitis and wound infections. This review emphasizes the relevance of dural repair and the progress of dural reconstruction materials, focusing on biological scaffolds. A comprehensive assessment of dural substitution literature focused on composite, acellular, natural, synthetic, and homologous materials. Decellularized dura scaffolds as viable natural biomaterials for tissue engineering are explored in this overview of these materials' properties, effectiveness, and therapeutic uses. The evaluation also compares materials and assesses host tissue response in preclinical and clinical studies. The review highlights various dural substitution findings. There is no gold standard for dural repair, despite the variety of materials used. Replicating natural dura mater's mechanical and structural qualities is difficult. Recent research suggests that decellularized dura scaffolds can regenerate tissue while reducing inflammation and transplant rejection. Furthermore, the movement toward personalized medicine in this sector suggests that bespoke alternatives might be chosen depending on patient characteristics, improving treatment effects. Synthesizing dural replacement research and clinical uses in this review adds to knowledge. It tackles standard materials' shortcomings and shows how biological scaffolds might improve dural repair. The analysis opens the door to personalized dural repair research that might enhance patient outcomes and advance neurosurgery. The insights presented herein highlight the intriguing prospects for appropriate dural restorative materials, seeking to improve dural defect treatment.

Fibrin glue-coated collagen matrix is superior to fibrin glue-coated polyglycolic acid for preventing cerebral spinal fluid leakage after spinal durotomy

After surgery for intradural lesions, dural reconstruction is essential for preventing cerebrospinal fluid (CSF) leakage, which can cause serious complications. However, there is currently no established intraoperative procedure. While hydrophobic polyglycolic acid (PGA) sheets and fibrin glue are effective for dural reconstruction, the usefulness of hydrophilic artificial dura mater made of a porous collagen matrix has also been reported. This study aimed to compare the ability of a fibrin-coated porous collagen matrix and a fibrin-coated PGA sheet to prevent CSF leakage during spinal surgery. This study included 319 patients who underwent surgery for intradural lesions requiring dural reconstruction. Patients in the PGA sheet group (group P) and the porous collagen matrix group (group C) were compared. The median age was 60 years. A total of 319 patients were included, with 219 in Group P and 100 in Group C. CSF leakage occurred in 11 patients (5.0%) in Group P and 0 patients in Group C (P < 0.05). This is the first report showing the superiority of a porous collagen matrix sheet over a PGA sheet in preventing CSF leakage during spinal surgery. The porous collagen matrix is hydrophilic and may be more effective against CSF leakage than hydrophobic PGA sheets.

Clinicoradiological, pathological, and surgical outcome in patients with tethered cord syndrome: A prospective study

Background: Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord in which the caudal part is anchored by an inelastic structure. It is believed that, if the viscoelasticity of the filum is lost or compromised by either fatty infiltration or abnormal thickening, caudal tension and traction may cause undue stress upon the conus, resulting in TCS. It typically occurs in children, and it is rare in adults. Aims and Objectives: The study was conducted to know the clinicoradiological, pathological, and surgical outcomes in patients with TCS. Materials and Methods: This is a prospective observational study done in the premier institute of central India from May 2022 to April 2024. This study included patients who exhibited clinical and/or radiological features of congenital tethered cords. This encompassed both patients with tethered cord and those with TCS. Patients who failed to give consent and refused to participate in the study were excluded from the study. Results: A total of 30 patients were recruited for the study. The median age of the patients was 6–12 months (range). The gender distribution M:F was 63.3:36.6. Based on 30 cases studied, most of the patients (75%) had improvement in urinary symptoms, 57.1% of patients had improvement in bowel symptoms, 80% of patients had improvement in pain symptoms, 75% had improvement in motor deficit, and 83.3% had improvement in sensory deficit. Conclusion: Our prospective, cross-sectional study aimed at complete detethering of the spinal cord and the nerve roots along with excision of filum terminale and dural reconstruction to maintain adequate cerebrospinal fluid space around the spinal cord to prevent retethering.

Surgical resection and reconstruction techniques for jugular foramen schwannoma

IntroductionJugular foramen schwannomas present formidable challenges due to their deep-seated location and complex anatomical constraints, leading to significant difficulties in tumor excision, postoperative complications further hinder surgical interventions in this area. We aim to explore and summarize surgical and reconstruction techniques for jugular foramen schwannomas to enhance patient outcomes. Materials and methodsIn a retrospective analysis, we reviewed the surgical approaches and reconstruction techniques utilized in 31 patients undergoing surgical resection for jugular foramen schwannomas from January 2018 to the present. Our goal was to summarize the materials and methods used for skull base reconstruction in this region and propose a clinically applicable procedural framework for surgical intervention. ResultsResults revealed that 28 patients underwent treatment via the far lateral paracondylar approach, while 3 patients opted for the suboccipital retrosigmoid approach. Among them, 15 patients underwent surgical cavity tamponade. Additionally, we summarized three methods of dural reconstruction in the surgical area. Postoperative temporary complications showed varying degrees of improvement during follow-up, leading to an overall favorable prognosis. ConclusionOur study presents clinical insights into the surgical resection and skull base reconstruction of jugular foramen schwannomas. We discuss the selection of surgical approaches, intraoperative landmarks, and reconstruction techniques aimed at improving patient outcomes effectively.

Meningiomas in the Central Skull Base:From the Perspective of Endoscopic Transnasal Surgery

Recent advancements in endoscopic transnasal surgery(ETS)have expanded the application of this technique to meningiomas in the central skull base area, offering a less invasive alternative with a potentially lower physical burden on patients than conventional microscopic skull base surgery. Notably, while ETS allows surgeons to reach tumors without traversing the brain and nerves, thus theoretically reducing the risk of cranial nerve damage, it requires a high level of proficiency to avoid inadequate resection and tumor recurrence. In this article, we discuss the various surgical considerations, including preoperative imaging, surgical setting, nasal cavity expansion, skull base opening, tumor removal, and skull base reconstruction, as general procedures for specific meningiomas. We further describe the concept and details of our multi-layer fascial closure technique for dural repair in ETS, underlining the importance of skilled dural reconstruction in preventing postoperative complications. In conclusion, while ETS for skull base meningiomas presents a promising and less invasive treatment option, its success relies heavily on the surgeon's experience and understanding of the skull base anatomy, stressing the need for careful approach selection.

Evaluating the Need for Durotomy and Duraplasty in Adults Undergoing Suboccipital Craniectomy for Chiari Decompression: A Case Series Analysis of Radiographic and Clinical Outcomes.

Background Suboccipital craniectomy (SOC)in conjunction withdura opening and duraplasty for posterior fossa decompression is an effective treatment for symptomatic Chiari 1 malformations (CM1), primarily carried out in the pediatric population. However, dural opening and reconstruction are associated with an increased risk of complications, and their necessity in the adult population has not yet been robustly demonstrated. Givendifferences in clinical presentation and disease severity between the pediatric and adult patients, we aimed to identify if SOC alone with intraoperative ultrasound confirmation of adequate restoration of pulsatile motion of cerebellar tonsil is sufficient to treat symptomatic CM1 while mitigating surgical risks. Methods We identified a retrospective, institutional cohort of adult patients who underwent SOC for Chiari decompression between 2014 and 2023. Demographic, clinical, and radiographic features were extracted for each patient. Clinical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) and Motor-Sensory-Sphincter signs score (Clinical Sign Score (CSS)). Radiographic outcomes assessed cerebellar ectopia and associated syrinx characteristics. Results A total of 15 patients were identified, with an average follow-up period of three years. Eight patients underwent SOC with duraplasty, whereas seven patients underwent SOC only without duraplasty. Both groups of patients were of similar age at surgery and had similar nature and duration of symptoms prior to surgery. On pre-operative radiographic evaluation, both groups of patients had similar lengths of cerebellar ectopia (9.9±11.0 mm to 11.1±5.7 mm, p=0.591), and associated syrinxes (75% vs. 42.9%, p=0.205). Intraoperatively, both groups had similar estimated blood losses, though the length of surgery was significantly shorter when durotomy was spared (202±58.3 minutes to 116.3±47.8 minutes, p=0.011). The length of ICU stay was also significantly longer in the durotomy group (1.1±0.6 days to 0.0 days, p<0.001). Neither group reported any post-operative complications. On follow-up, both groups demonstrated similar reductions in cerebellar ectopia and syrinx characteristics. Clinically, the CCOS and CSS scores were similar between the two cohorts at follow-up, with no repeat surgery required in either group. Conclusion Our cohort suggests that for adult CM1 patients, SOC decompression alone without dural reconstruction might lead to comparable clinical and radiographic outcomes to SOC decompression with durotomy/duraplasty, especially if intraoperative ultrasound confirms good cerebrospinal fluid (CSF) flow after SOC. Notably, sparing durotomy and duraplasty is also associated with decreased operative time and decreased ICU stay.

Orbital reconstruction and volume in the correction of proptosis after resection of spheno-orbital meningiomas.

The objective of this study was to evaluate the effect of reconstruction and orbital volume on the reduction of proptosis in patients undergoing resection for spheno-orbital meningiomas. Additionally, potential predictors of optimal proptosis reduction after surgery were evaluated. Patients with spheno-orbital meningiomas who underwent resection at the authors' institution between 2005 and 2020 were evaluated retrospectively. The exophthalmos index (EI) was measured on pre- and postoperative imaging to quantify proptosis and calculate the primary outcome measure of proptosis reduction. Patients were excluded if they had no preoperative proptosis (i.e., EI < 1.1), prior resection, or insufficient imaging available for analysis. Clinical and surgical characteristics were collected, including sex, extent of resection, WHO grade, and rigid orbital reconstruction, and assessed as predictors of greater proptosis reduction. Additionally, orbital volumes of the affected and contralateral orbits were measured to correlate postoperative orbital volumes with proptosis reduction. Thirty-three patients, with a mean age of 53 years, met inclusion criteria. The majority of the patients were female (23, 69.7%), and most tumors were classified as WHO grade 1 (29, 87.9%). Six patients (18.2%) underwent rigid orbital reconstruction. The mean EI across all patients decreased from 1.36 ± 0.18 to 1.19 ± 0.15 (p < 0.001). Patients who underwent reconstruction had on average a 76.4% greater reduction in the EI (p = 0.036) and a 9.1 times higher odds of achieving a normal EI (< 1.1) compared with those who did not receive reconstruction (OR 9.1, p = 0.025). Additionally, patients without residual hyperostotic bone compressing the orbit had a 2.16 times greater reduction in EI (p = 0.039). A linear relationship between orbital volume ratios (affected/unaffected orbit) and proptosis reduction was observed (p = 0.029, r = 0.529), including at ratios > 1.0. This suggests that greater orbital volumes postoperatively correlated with greater reductions in proptosis. Three factors were identified that optimize proptosis correction. First, all abnormal bone compressing the orbital contents must be removed completely. Second, rigid orbital reconstruction leads to improved proptosis correction, possibly by preventing frontal lobe and dural reconstruction from descending onto the compressed orbit. Third, aiming for an orbital volume slightly larger than the contralateral normal side leads to improved proptosis correction.

Free temporalis muscle fascia graft in dural reconstruction following surgical resection of intermediate and malignant skull base tumors: A 10-year experience from a single center.

Data from patients with post-ablative dural defects reconstructed using a free temporalis muscle fascia graft (FTFG) after resection of anterior or central skull base tumors were retrospectively analyzed. The primary predictor and outcome variables were the reconstructive methods for dural repair and postoperative cerebrospinal fluid (CSF) leakage rate, respectively. Eighty patients were included, and 94 postoperative dural reconstructions were performed using FTFG. The postoperative CSF leakage rate was 3.19%. The postoperative CSF leakage rates did not significantly differ between open and endonasal endoscopic surgeries (1.92% vs. 4.88%; p > 0.05). In cases completed using the endonasal endoscopic approach, the postoperative CSF leakage rate was significantly associated with the intraoperative CSF leak flow (p < 0.05). Post-ablative dural defect reconstruction using FTFG resulted in low postoperative CSF leakage and complication rates comparable to those of free fascia lata graft from available literature.

Neurofibroma of C2 root

Background: Intra and extradural neurofibromas of C2 root is a challenging pathology, usually with indolent evolution, that is why the onset symptoms are neurologic deficit just like upper cervical myelopathy symptoms and explains the late diagnosis of giant tumours with severe spinal cord compression with involvement and distortion of great vessels anatomy. These facts make surgeries more difficult. The follow-up of this type of surgery must be very close because CSF fistula can often occur. Case description: The present article reports a series of three cases of neurofibromas, two of them are giant dumbbell-shaped C2 neurofibromas and the third one is a case of neurofibromatosis type 1 of C2 roots bilaterally, C3 root unilateral with unusual postoperative course. Dural reconstruction was necessary in all cases. Conclusions: The patients in this series were very symptomatic with good recovery. The surgical procedures were challenging, total tumour removal was possible, and the reconstruction of dural defects was needed in all cases. In the case of NF1, the postoperative period was practically just the follow-up of complications and addressing them. This fact stresses the importance of meticulous preoperative planning and close follow-up. Postoperative quality of life was better than preoperative in all the cases. The purpose of the surgical treatment is the decompression of the spinal cord, tumour removal and prophylaxis of CSF fistula by closing the dural defects. Overall, the surgical C2 root neurofibromas resection is a safe procedure and is associated with good clinical outcomes.

Evaluation of Biocompatibility and Healing Properties of Dural Substitutes Produced by Electrospinning Technology.

Dural reconstruction is a critical process after neurosurgical procedures. Improper dural repair leads to serious side-effects, such as cerebrospinal fluid leakage or infection. This is why it is important to properly repair the dura using a dural substitute, and research into dural substitutes is ongoing. The ideal dural substitute should be non-toxic, biocompatible, and capable of maintaining adequate tension and preventing cerebrospinal fluid leakage for extended periods in vivo. This study evaluated the biocompatibility and healing properties of Safe-Seal, poly-L-lactic acid synthetic bioabsorbable dural substitute produced by electrospinning technology. Safe-Seal, was created by electrospinning, which is a technique for nanofiberizing polymers into three-dimensional structures, and its cytotoxicity was evaluated. The animal study used 30 rats, divided into three groups assessed at two time points (4 and 12 weeks). The study groups were a negative control group with no treatment, an experimental group with Safe-Seal (TDM Co. Ltd., Gwangju, Republic of Korea) implantation, and a positive control group with a commercial product, Redura® (Medprin Biotech, Frankfurt, Germany) implantation. Safe-Seal exhibited no cytotoxic or adverse effects in the in vivo animal study. Histologically, Safe-Seal displayed less inflammatory cell infiltration, less adhesion to brain tissue, and connectivity with the surrounding dura mater as compared to the negative control group and without any significant differences from Redura® in all evaluation criteria. Safe-Seal presented adequate biocompatibility in vivo and contributed to the healing of the dura mater at a similar level to that of Redura® when applied to dural defects.

Dural reconstruction with or without a bone graft of paranasal and anterior skullbase malignancies: Retrospective single-center analysis of 11 cases and review of literature

IntroductionThe reconstruction of frontobasal defects following oncologic resections of paranasal and anterior skull base (ASB) malignancies remains challenging. Ineffective reconstruction could lead to cerebrospinal fluid leak, meningitis, and tension pneumocephalus. Research questionAim of this investigation was to analyse postoperative complication rates with or without bone graft for anterior skull base reconstruction. Material and methodsIn this retrospective study, we included patients following resection of paranasal and/or anterior skull base malignancies between October 2013 and December 2022. Complications were analysed with regards to the type of skull base reconstruction. ResultsEleven patients were identified (2 female, 9 male, age (median, SD) 64 ± 14.1 years (range 38–81). There were nine cases of paranasal sinus and nasal cavity carcinomas and two cases of olfactory neuroblastomas. Overall survival was 22.5 ± 28 months (range: 5–78), progression free survival was 17.0 ± 20.3 months (range: 11–78). Bone skull base reconstruction using a split graft was performed in three cases. Postoperative complications requiring surgical intervention were seen in 33% (one tension pneumocephalus) of cases in the bone reconstruction group and 50% (three patients with cerebrospinal fluid leak, one infection) in the non-bone reconstruction group. Discussion and conclusionThe structural reinforcement of structural bone chip grafting might provide additional support of the ASB and prevent CSF leakage or encephalocele. Especially in large (>10 cm2) bone defects of advanced sinonasal malignancies extending into the middle cranial fossa, the full armamentarium of reconstruction possibilities should be considered.

A Case of Sellar Arachnoid Cyst Operated Using the Endoscopic Supraorbital Keyhole Approach

BACKGROUND AND IMPORTANCE: In recent years, sellar arachnoid cysts (ACs) have been increasingly treated using an endoscopic transnasal approach. It is important to connect the subarachnoid space with the AC to prevent recurrence; however, a high frequency of postoperative cerebrospinal fluid (CSF) leakage has been reported with the endoscopic transnasal approach, and the suitability of the endoscopic transnasal approach for treating sellar ACs is questionable to begin with. CLINICAL PRESENTATION: A man in his 40s underwent surgery for a sellar AC compressing the optic chiasm. The normal pituitary gland was compressed dorsally by the cyst, and an endoscopic supraorbital keyhole approach was adopted to reduce the risk of postoperative CSF leakage. A small incision was made in the right eyebrow, and a small craniotomy was performed. A rigid scope was used to approach the cyst and incise the arachnoid membrane of the prechiasmatic cistern and the anterior wall of the cyst. Postoperatively, the cyst shrank, and the preoperative visual field defects improved. The duration of the endoscopic manipulation was approximately 40 minutes. DISCUSSION: The endoscopic supraorbital keyhole approach eliminates the need to incise the dura mater of the anterior skull base and reduces the risk of CSF leakage compared with the transnasal approach. In addition, cumbersome dural reconstruction using fat and fascia is not required during the supraorbital keyhole approach, which reduces operation time. CONCLUSION: The endoscopic supraorbital keyhole approach may be more suitable than the transnasal approach for surgery of sellar ACs.

Dural Reconstruction Materials for the Repairing of Spinal Neoplastic Cerebrospinal Fluid Leaks.

Spinal tumors often lead to more complex complications than other bone tumors. Nerve injuries, dura mater defect, and subsequent cerebrospinal fluid (CSF) leakage generally appear in spinal tumor surgeries and are followed by serious adverse outcomes such as infections and even death. The use of suitable dura mater replacements to achieve multifunctionality in fluid leakage plugging, preventing adhesions, and dural reconstruction is a promising therapeutic approach. Although there have been innovative endeavors to manage dura mater defects, only a handful of materials have realized the targeted multifunctionality. Here, we review recent advances in dura repair materials and techniques and discuss the relative merits in both preclinical and clinical trials as well as future therapeutic options. With these advances, spinal tumor patients with dura mater defects may be able to benefit from novel treatments.

Acellular Fish Skin for Tissue Replacement.

In modern practice, xenografts play a crucial role in wound management due to their regenerative properties. Of the various xenografts currently available on the market, acellular fish skin (AFS) grafts have emerged as a more effective alternative to existing xenografts and other standard of care (SOC) treatments for wound healing. Since AFS grafts require minimal processing, they maintain their structural integrity and natural properties, including an abundance of Omega-3 fatty acids, which is a distinctive, pro-regenerative feature. AFS grafts are also unique in that they are not derived from mammalian tissue, so there is no risk of viral transmission and no cultural or religious barriers to use. AFS grafts have been shown to be more cost-effective in the treatment of diabetic foot ulcers (DFUs) and result in a higher percentage of healed wounds, fewer amputations, and better patient quality of life. Several studies and case reports have highlighted the versatility of AFS in not only acute and chronic wound healing, but also for burn wound skin regeneration. Additionally, AFS may have promise as an implantable biologic matrix for suture line reinforcement in hernia repairs or breast and dura reconstruction.

Dural reconstruction following resection of ventral and lateral spinal cord meningiomas: Fenestrated Durotomy with Oversized Graft technique

BackgroundMeningiomas, although benign, often require complete resection due to their tendency for recurrence. However, dural reconstruction poses significant challenges, especially in the case of ventral meningiomas. While some reports have highlighted the usefulness of dural reconstruction using an artificial dura mater, no studies have yet confirmed dural canal enlargement through MRI post-surgically. This study aimed to assess the effectiveness of the Fenestrated Durotomy with Oversized Graft (FDOG) technique in cases of meningiomas and other intradural extramedullary tumors and evaluated dural canal dilation through MRI after using an artificial dura mater. MethodsThis retrospective case series included 8 patients who underwent combined resection of intradural extramedullary tumors and dural repair using the FDOG technique. An artificial dura mater larger than that resected was inserted into the dural defect resulting from complete tumor resection on the ventral or lateral side of the spinal cord. The new dura mater was secured with a single dorsal suture. The dural incision was closed using watertight sutures following standard procedure. Measurement of the extent of dural canal enlargement was achieved via pre- and postoperative MRI scans. ResultsNone of the patients required additional treatments or lumbar drainage. All achieved independent ambulation without complications, and imaging tests indicated satisfactory dural expansion without signs of cerebrospinal fluid leakage. ConclusionsThe proposed method for dural repair in cases involving large dural defects on the ventral or lateral side of the spinal cord was shown to be a straightforward and effective approach with minimal postoperative complications.

Perioperative complications and secondary retethering after pediatric tethered cord release surgery.

Tethered cord syndrome refers to a constellation of symptoms characterized by neurological, musculoskeletal, and urinary symptoms, caused by traction on the spinal cord, which can be secondary to various etiologies. Surgical management of simple tethered cord etiologies (e.g., fatty filum) typically consists of a single-level lumbar laminectomy, intradural exploration, and coagulation and sectioning of the filum. More complex etiologies such as lipomyelomeningoceles or scar formation after myelomeningocele repair involve complex dissection and dural reconstruction. The purpose of this study was to evaluate operative complications and long-term outcomes of secondary retethering related to pediatric tethered cord release (TCR) at a tertiary children's hospital. Medical records of children who underwent surgery for TCR from July 2014 to March 2023 were retrospectively reviewed. Data collected included demographics, perioperative characteristics, surgical technique, and follow-up duration. Primary outcomes were 60-day postoperative complications and secondary retethering requiring repeat TCR surgery. Univariate and multivariate analyses were performed to identify risk factors associated with complications and secondary retethering. A total of 363 TCR surgeries (146 simple, 217 complex) in 340 patients were identified. The mean follow-up was 442.8 ± 662.2 days for simple TCRs and 733.9 ± 750.3 days for complex TCRs. The adjusted 60-day complication-free survival rate was 96.3% (95% CI 91.3%-98.4%) for simple TCRs and 88.7% (95% CI 82.3%-91.4%) for complex TCRs. Lower weight, shorter surgical times, and intensive care unit admission were associated with complications for simple TCRs. Soft-tissue drains increased complications for complex TCRs. The secondary retethering rates were 1.4% for simple TCRs and 11.9% for complex TCRs. The 1-, 3-, and 5-year progression-free survival rates in complex cases were 94.7% (95% CI 89.1%-97.4%), 77.7% (95% CI 67.3%-85.3%), and 62.6% (95% CI 46.5%-75.1%), respectively. Multivariate analysis revealed that prior detethering (OR 8.15, 95% CI 2.33-28.50; p = 0.001) and use of the operative laser (OR 10.43, 95% CI 1.36-80.26; p = 0.024) were independently associated with secondary retethering in complex cases. This is the largest series to date examining postoperative complications and long-term secondary retethering in TCR surgery. Simple TCR surgeries demonstrated safety, rare complications, and low secondary retethering rates. Complex TCR surgeries presented higher risks of complications and secondary retethering. Modifiable risk factors such as operative laser use influenced secondary retethering in complex cases.

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.

Dual Dural Patch Graft With AlloDerm and DuraGen Underlay for Duraplasty in Chiari Malformation Results in Significantly Decreased Cerebrospinal Fluid Leak Complications.

Grafts available for posterior fossa dural reconstruction after Chiari decompression surgery include synthetic, xenograft, allograft, and autograft materials. The reported rates of postoperative pseudomeningocele and cerebrospinal fluid leak vary, but so far, no dural patch material or technique has sufficiently eliminated these problems. To compare the incidence of graft-related complications after posterior fossa surgery using AlloDerm alone vs AlloDerm with a DuraGen underlay. We performed a retrospective single-center study of a cohort of 106 patients who underwent Chiari decompression surgery by a single surgeon from 2014 through 2021. Age, sex, body mass index, tonsillar descent, syrinx formation, type of dural graft, and follow-up data were analyzed using univariate and χ2 statistical tests. The AlloDerm-only group had a percutaneous cerebrospinal fluid (CSF) leak rate of 8.6% vs a 0% rate in the dual graft group (P = .037). At initial follow-up, there was a 15.5% combined rate of pseudomeningocele formation plus CSF leak in the AlloDerm-only group vs 18.8% in the AlloDerm + DuraGen group (P = .659). However, the pseudomeningoceles were larger in the AlloDerm-only cohort (45.5 vs 22.4 mm anteroposterior plane, P = .004), and 5 patients in this group required operative repair (56%). All pseudomeningoceles resolved without reoperation in the AlloDerm + DuraGen group (P = .003). The use of a DuraGen underlay with a sutured AlloDerm dural patch resulted in significantly fewer CSF-related complications and eliminated the need for reoperation compared with AlloDerm alone. This single-center study provides evidence that buttressing posterior fossa dural grafts with a DuraGen underlay may decrease the risk of postoperative complications.

A dural substitute based on oxidized quaternized guar gum/porcine peritoneal acellular matrix with improved stability, antibacterial and anti-adhesive properties

Trauma and neurosurgery often result in dural defects and are followed by serious complications or even death, finding suitable dural replacement materials to repair the defective dura has important clinical significance. Porcine peritoneal acellular matrix (PPAM) is a promising alternative material, but its poor stability makes it difficult to meet the various needs of dural reconstruction. In this work, we developed a novel antibacterial cross-linking agent oxidized quaternized guar gum (OQGG) and used it for the first time to stabilize PPAM to construct a dural mater substitute (OQGG-PPAM). The results showed that 1.5% OQGG-PPAM presented suitable mechanical property as well as good thermal stability and resistance to enzymatic degradation. It also exhibited good antibacterial activity and good anti-leakage ability. Furthermore, 1.5% OQGG-PPAM not only exhibited excellent cell compatibility but also significantly stimulated the secretion of bFGF and VEGF from seeded cells which was convenient for dural remodeling. In vivo experiment, it also exhibited the excellent histocompatibility and good anti-adhesion property. This study showed that OQGG can be used as a novel antibacterial cross-linking reagent for crosslinking natural tissues and 1.5% OQGG-PPAM was a potential candidate material for dura mater substitute.