Dissection Of Paraspinal Muscles Research Articles

Biomechanical effects of posterior lumbar interbody fusion with vertical placement of pedicle screws compared to traditional placement.

The pedicle screw technique is widely employed for vertebral body fixation in the treatment of spinal disorders. However, traditional screw placement methods require the dissection of paraspinal muscles and the insertion of pedicle screws at specific transverse section angles (TSA). Larger TSA angles require more force to pull the muscle tissue, which can increase the risk of surgical trauma and ischemic injury to the lumbar muscles. To study the feasibility of zero-degree TSA vertical pedicle screw technique in the lumbosacral segment. Finite element models of vertebral bodies and pedicle screw-rod systems were established for the L4-S1 spinal segments. A standard axial load of 500 N and a rotational torque of 10 N/m were applied. Simulated screw pull-out experiment was conducted to observe pedicle screw resistance to pull-out, maximum stress, load-displacement ratio, maximum stress in vertebral bodies, load-displacement ratio in vertebral bodies, and the stress distribution in pedicle screws and vertebral bodies. Differences between the 0-degree and 17-degree TSA were compared. At 0-degree TSA, the screw pull-out force decreased by 11.35% compared to that at 17-degree TSA (P < 0.05). At 0-degree and 17-degree TSA, the stress range in the screw-rod system was 335.1-657.5 MPa and 242.8-648.5 MPa, separately, which were below the fracture threshold for the screw-rod system (924 MPa). At 0-degree and 17-degree TSA, the stress range in the vertebral bodies was 68.45-78.91 MPa and 39.08-72.73 MPa, separately, which were below the typical bone yield stress range for vertebral bodies (110-125 MPa). At 0-degree TSA, the load-displacement ratio for the vertebral bodies and pedicle screws was slightly lower compared to that at 17-degree TSA, indicating slightly lower stability (P < 0.05). The safety and stability of 0-degree TSA are slightly lower, but the risks of screw-rod system fracture, vertebral body fracture, and rupture are within acceptable limits.

Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

Comparison of clinical effect and muscle injury imaging between oblique lateral lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of single-segment degenerative lumbar spinal stenosis

To compare the efficacy and muscle injury imaging between oblique lateral lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis. The clinical data of 60 patients with single-segment degenerative lumbar spinal stenosis who underwent surgical treatment from January 2018 to October 2019 was retrospectively analyzed. The patients were divided into OLIF groups and TLIF group according to different surgical methods. The 30 patients in the OLIF group were treated with OLIF plus posterior intermuscular screw rod internal fixation. There were 13 males and 17 females, aged from 52 to 74 years old with an average of (62.6±8.3) years old. And 30 patients in the TLIF group were treated with TLIF via the left approach. There were 14 males and 16 females, aged from 50 to 81 years old with an average of (61.7±10.4) years old. General data including operative time, intraoperative blood loss, postoperative drainage volume, and complications were recorded for both groups. Radiologic data including disc height (DH), the left psoas major muscle, multifidus muscle, longissimus muscle area, T2-weighted image hyperintensity changes and interbody fusion or nonfusion were observed. Laboratory parameters including creatine kinase (CK) values on postoperative 1st and 5th days were analyzed. Visual analogue scale(VAS) and Oswestry disability index(ODI) were used to assess clinical efficacy. There was no significant difference in the operative time between two groups(P>0.05). The OLIF group had significantly less intraoperative blood loss and postoperative drainage volume compared to the TLIF group(P<0.01). The OLIF group also had DH better recovery compared to the TLIF group (P<0.05). There were no significant differences in left psoas major muscle area and the hyperintensity degree before and after the operation in the OLIF group (P>0.05). Postoperativly, the area of the left multifidus muscle and longissimus muscle, as well as the mean of the left multifidus muscle and longissimus muscle in the OLIF group, were lower than those in the TLIF group (P<0.05) .On the 1st day and the 5th day after operation, CK level in the OLIF group was lower than that in the TLIF group(P<0.05). On the 3rd day after operation, the VAS of low back pain and leg pain in the OLIF group were lower than those in the TLIF group (P<0.05). There were no significant differences in the ODI of postoperative 12 months, low back and leg pain VAS at 3, 6, 12 months between the two groups(P>0.05). In the OLIF group, 1 case of left lower extremity skin temperature increased after the operation, and the sympathetic chain was considered to be injured during the operation, and 2 cases of left thigh anterior numbness occurred, which was considered to be related to psoas major muscle stretch, resulting in a complication rate of 10% (3/30). In the TLIF group, one patient had limited ankle dorsiflexion, which was related to nerve root traction, two patients had cerebrospinal fluid leakage, and the dural sac was torn during the operation, and one patient had incision fat liquefaction, which was related to paraspinal muscle dissection injury, resulting in a complication rate of 13% (4/30). All patients achieved interbody fusion without cage collapse during the 6- month follow-up. Both OLIF and TLIF are effective in the treatment of single-segment degenerative lumbar spinal stenosis. However, OLIF surgery has obviously advantages, including less intraoperative blood loss, less postoperative pain, and good recovery of intervertebral space height. From the changes in laboratory indexes of CK and the comparison of the left psoas major muscle, multifidus muscle, longissimus muscle area, and high signal intensity of T2 image on imaging, it can be seen that the degree of muscle damage and interference of OLIF surgery is lower than that of TLIF.

Full endoscopic lumbar decompression of spinal stenosis through uniportal approach

Introduction: To investigate the certain advantages of full endoscopic lumbar decompression (FELD) surgery over conservative techniques in lumbar spinal stenosis (LSS). Minimal invasive techniques have been introduced recently to treat lumbar spinal stenosis and gained popularity over conservative techniques because of the minimal tissue damage along with the satisfactory postoperative outcome. In our study, the FELD technique using a uniportal approach is described and investigated in accordance with the preliminary clinical results of patients who had degenerative spinal stenosis.&#x0D; Methods: 55 patients who underwent FELD were retrospectively reviewed. General demographics and parameters including operation time, length of hospital stay, mean time to return to work, complications were recorded. Clinical outcomes were evaluated using the visual analogue scale (VAS) for low back and leg pain, Oswestry Disability Index (ODI) for functional assessment.&#x0D; Results: The mean follow-up time was 36 months. There was no measurable intraoperative blood loss. The mean operating time was 97,4 minutes. The length of hospital stay after the operation was 27 hours on average. The difference between preoperative and postoperative VAS scores was statistically significant (p&lt;0.001). No surgery-related complication was noted.&#x0D; Conclusions: Amongst other standard techniques, FELD has the technical advantages of less paraspinal muscle dissection, less tissue trauma, less risk of spinal instability, minimal blood loss, quicker postoperative recovery and shorter length of hospital stay.

Minimally Invasive Subaxial Cervical Pedicle Screw Placement with Routine Fluoroscopy: Cadaveric Feasibility Study and Report of 6 Clinical Cases

Objective: Conventional cervical pedicle screw insertion necessitates extensive paraspinal muscle dissection and retraction in order to achieve the lateral to medial angulation needed to achieve the optimal screw trajectory. Minimally invasive transmuscular approach can comfortably achieve this angulation without significant injury to the midline structures and its musculo-ligamentous attachments.Methods: Minimally invasive cervical pedicle screws were inserted in 4 fresh frozen cadaveric specimens. Pre-procedure and post-procedure CT scans were done to assess the pedicle dimensions, suitability for screw insertion and integrity of the screws. The same technique was applied in a clinical cohort of six cases – 3 cases of traumatic subluxation; one case of traumatic vertebral fracture and 2 cases of infective facet destruction (Koch’s); with successful outcomes.Results: Among the 38 screws in the cadaver specimens, a total of 11 screws (28.9%) had breached the pedicle wall (Lateral wall breach–9; Medial wall breach–2). Of the 9 screws (23.6%) that had a lateral breach into the vertebral canal, 4 (10.5%) each had Grade IIa breach and one (2.6%) had Grade III breach. The mean transverse screw angle in the subset of pedicle screws with no breach was 34.1 whereas it was 22.1 in screws that had lateral breach and 43.6 in those with medial breach. Among the 22 screws inserted in the clinical cohort of 6 cases, 4 screws (18.1%) had breached the pedicle wall. All the identified breaches were in the lateral wall (Grade IIa – 3; Grade IIb–1; Grade III–nil). Conclusion: Minimally invasive subaxial pedicle screw insertion can be utilized in cases where a robust posterior fixation is required, either in isolation or as an adjunct to anterior surgery, in cases where a direct posterior decompression is not warranted. It is a safe and effective approach which minimizes injury to the paraspinal structures and midline attachments.

Standard Techniques of Spinal Fusion for Lumbar Degenerative Diseases

Recently, many neurospinal surgeons are utilizing spinal fusion techniques for lumbar degenerative diseases. This paper aims to summarize the standard techniques of lumbar spinal fusion. Lumbar spinal fusion is categorized into posterolateral fusion(PLF)and interbody fusion(IF)based on the location of bone grafting. PLF needs wide dissection of paraspinal muscles beyond the synovial joints. It is often utilized for long fusion at the thoraco-lumbar junction with open posterior instrumentation. Techniques for IF include posterior lumbar interbody fusion(PLIF)or transforaminal lumbar interbody fusion(TLIF)via the posterior approach, and anterior lumbar interbody fusion(ALIF), lateral lumbar interbody fusion(LLIF), and oblique lumbar interbody fusion(OLIFTM)performed via the anterior approach. PLIF/TLIF procedures include laminectomy and/or facetectomy for direct neural decompression, and local bone grafting into the interbody space through the interlaminar space or the vertebral foramen. ALIF/LLIF/OLIFTM are usually performed via the retroperitoneal approach. ALIF has an advantage of obtaining lordosis with insertion of a large angled cage from the anterior aspect of the intervertebral space. LLIF/OLIFTM are less invasive methods, in which bone grafting is performed through or beside the psoas muscle. As a larger cage can be plated between the bilateral edge of the intervertebral space, LLIF/OLIFTM has an advantage in the correction of scoliosis.

Alternatives to Traditional Pedicle Screws for Posterior Fixation of the Degenerative Lumbar Spine.

Traditional pedicle screws are currently the gold standard to achieve stable 3-column fixation of the degenerative lumbar spine. However, there are cases in which pedicle screw fixation may not be ideal. Due to their starting point lateral to the pars interarticularis, pedicle screws require a relatively wide dissection along with a medialized trajectory directed toward the centrally located neural elements and prevertebral vasculature. In addition, low bone mineral density remains a major risk factor for pedicle screw loosening, pullout, and pseudarthrosis. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with posterior fixation techniques of the degenerative lumbar spine beyond the traditional pedicle screws. Comprehensive literature searches of the PubMed, Scopus, and Web of Science databases were performed for 5 methods of posterior spinal fixation, including (1) cortical bone trajectory (CBT) screws, (2) transfacet screws, (3) translaminar screws, (4) spinous process plates, and (5) fusion mass screws and hooks. Articles that had been published between January 1, 1990, and January 1, 2020, were considered. Non-English-language articles and studies involving fixation of the cervical or thoracic spine were excluded from our review. After reviewing over 1,700 articles pertaining to CBT and non-pedicular fixation techniques, a total of 284 articles met our inclusion criteria. CBT and transfacet screws require less-extensive exposure and paraspinal muscle dissection compared with traditional pedicle screws and may therefore reduce blood loss, postoperative pain, and length of hospital stay. In addition, several methods of non-pedicular fixation such as translaminar and fusion mass screws have trajectories that are directed away from or posterior to the spinal canal, potentially decreasing the risk of neurologic injury. CBT, transfacet, and fusion mass screws can also be used as salvage techniques when traditional pedicle screw constructs fail. CBT and non-pedicular fixation may be preferred in certain lumbar degenerative cases, particularly among patients with osteoporosis. Limitations of non-pedicular techniques include their reliance on intact posterior elements and the lack of 3-column fixation of the spine. As a result, transfacet and translaminar screws are infrequently used as the primary method of fixation. CBT, transfacet, and translaminar screws are effective in augmenting interbody fixation and have been shown to significantly improve fusion rates and clinical outcomes compared with stand-alone anterior lumbar interbody fusion. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive spinal fusion technique in patients with lumbar segmental instability.

Background: Lumbar fusion is a common surgical procedure for treatment of back pain caused by degeneration of lumbar disc. The aim of fusion is to prevent motion in the destabilized segments to decrease the back pain . All types of interbody fusion approaches work with posterior pedicle screw fixation to increase stabilization and fusion rates. It has some disadvantages including paraspinal muscle dissection, screw malposition, neurologic risk , increased the time of operation with blood loss and risk of infection. A modified interspinous device can provide stabilization similar to pedicular screw fixation avoiding its complication when used for interbody fusion as a minimally invasive procedur. Patient and Methods: The study involved 20 patients with moderate segmental instability in lumbar spine . Transforaminal interbody fusion using the polyethere- therketone( PEEK )cage and rigid interspinous device fixation was performed. Patients were followed up and treatment outcomes were assessed within approximately 24 months after surgery. Results: according to pain intensity level on the visual analogue scale, the need for painkillers and the quality of life according to the Oswestry Disability Index scale during the early postoperative period demonstrated significantly better outcomes due to a less severe operative trauma to the paravertebral soft tissues. The formation of interbody bone formation was observed after 20—36 months in 94% of patients . Postoperative complications occurred in 2.2% of patient. Conclusion: The use of transforaminal interbody fusion and rigid interspinous stabilization provides better clinical outcomes and fewer postoperative complications in patients with moderate lumbar segmental instability.

Fully endoscopic interlaminar and transforaminal lumbar discectomy: clinical results of 857 surgically treated patients.

Minimally invasive surgical techniques are becoming increasingly common in spinal surgery in an attempt to decrease tissue trauma during surgery, which in turn decreases post-operative pain and opioid use. The aim of this study was to investigate the clinical outcomes of a large group of patients with lumbar disc disease who underwent full endoscopic surgery. 857 patients who underwent fully endoscopic lumbar discectomy were investigated retrospectively. General demographics were evaluated in terms of mean operating time, mean length of hospital stay, mean time to return to work, complications and recurrences. Clinical outcomes were evaluated using visual analogue scale (VAS) for low back and leg pain, and Oswestry Disability Index (ODI) for functional assessment. The mean follow-up time was 36 months. The operation time ranged from 20 to 65 minutes (39 min on average), and there was no measurable intraoperative blood loss. Patients were mobilised on average 3.5 hours after the surgery. The length of hospital stay after the operation was 12-24 hours (18 hours on average). During postoperative follow-up, 19 patients required revision surgery due to recurrence (2.2%). There was one case of nerve root injury in which the patient recovered well following physical therapy, and 11 cases of paresthesia that gradually improved following 2-6 weeks of rehabilitation and treatment with pregabalin. All types of lumbar disc herniations are accessible via the full-endoscopic technique. Full-endoscopic discectomy, as a minimally invasive procedure, has the technical advantages of less paraspinal muscle dissection, less tissue trauma, less risk of spinal instability, and minimal blood loss.

Development of a New Coupled Cobb-Suction Instrument for Posterior Spinal Approaches: Technical Note

During dissection of paraspinal muscles in posterior surgical approaches, the spine surgeon usually holds a subperiosteal (Cobb) elevator in 1 hand and a monopolar cautery in the other hand. In such a scenario, both the surgical smoke generated by the monopolar and eventual bleeding constitute a significant hindrance to simultaneous bilateral dissection of the paraspinal muscles by 2 surgeons. To address the identified shortcomings in the currently available instrumentation, we initially analyzed the most common surgical techniques employed by residents and fellows at our institution for paraspinal muscle dissection during posterior spinal approaches. Additionally, we collected trainees' feedback regarding the efficacy of available strategies for dealing with surgical smoke. A new coupled Cobb elevator-suction instrument was designed, manufactured, and tested by residents, fellows, and experienced spine surgeons, and small additional design modifications were performed. We present what we believe is the first description of a new coupled Cobb-suction instrument that has been developed to enable simultaneous retraction and suction with 1 hand, while allowing the spine surgeon to use the monopolar cautery with the other hand. In our preliminary institutional experience, this new tool has been proven to be especially useful in long posterior spinal approaches in the thoracolumbar region.

The Feasibility of cortical bone trajectory screw fixation for lower thoracic spine

The traditional pedicle screw fixation technique is described widely used in cervical, thoracic, lumbar, and sacral regions (1,2), which can provide strength biomechanical properties for most spinal surgery. However, there are some drawbacks of traditional pedicle screw fixation. The trajectory is from lateral to medial, and the screw entry point is located on the cross of middle horizon line of transverse process and the middle vertical line or lateral wall of the upper facet (3,4). Therefore, surgeons need considerable paraspinal muscle dissection for traditional pedicle screw fixation.

S2 alar-iliac screws versus iliac screws for pelvic fixation

Achieving a sacropelvic fusion continues to be a challenge due to complex anatomy biomechanics and morbidity associated with invasive procedures. Initially, the Galveston technique was utilized until the introduction of iliac screws (IS) in the early 2000s, which showed improved fusion rates and decreased complications (1-3). However, drawbacks to the IS technique include extensive dissection of paraspinal muscles, screw prominence given its high profile, and the requirement of offset connector use (4,5).

Irrigation endoscopic decompressive laminotomy. A new endoscopic approach for spinal stenosis decompression

Background contextThe classic surgical treatment of spinal stenosis involves bilateral dissection of paraspinal muscles to expose all the involved levels, wide laminectomy, and medial facetectomy and foraminotomy. The surgical morbidity of the procedure is further magnified by being more common in elderly with associated medical comorbidities and being usually global involving multiple levels. To address this problem, several less invasive techniques have been introduced over the past decade including the microendoscopic decompression. PurposeThe aim was to describe and evaluate a new endoscopic technique for lumbar spinal canal decompression named irrigation endoscopic decompressive laminotomy. Study designThis was a technical report. Patient sampleOne hundred four consecutive patients suffering from neurogenic claudication and resistant to 3 months of conservative management were included in the study. Grade I degenerative spondylolisthesis and degenerative scoliosis were not considered a contraindication. Patients with segmental instability and predominant low back pain were excluded. Outcome measuresPrimary outcome measures included the final functional outcome using modified Macnab criteria and the Oswestry Disability Index (ODI). In addition, the operative time and complication rate have been evaluated. Secondary outcome measures included the evaluation of the early postoperative course using visual analog scale for postoperative incisional pain, time for ambulation, and length of hospital stay. MethodsTwo 0.5-cm portals were used, one for the endoscope and the other for instruments. For every additional level, one portal is added. The endoscope and instruments are directly placed over the surface of lamina without any dissection, and saline under pump pressure is used to open a potential working space. Unilateral laminotomy/laminectomy is performed according to the severity of stenosis, followed by bilateral decompression beneath the midline structures. ResultsMean follow-up period was 28 months. The final outcome was excellent in 63%, good in 24%, fair in 9%, and poor in 4%. The preoperative ODI dropped from a mean of 64.2±10.0 to 23.1±20.8 postoperatively. Complications were limited to six cases of dural tear, which required no open conversion. ConclusionsIrrigation endoscopic decompressive laminotomy allows the surgeon to safely perform effective central and foraminal decompression resulting in satisfactory midterm clinical results. Substituting long surgical incisions with 0.5-cm stabs and direct placement of instruments without dissection or dilatation could result in an improved postoperative course, shortened time for hospitalization, and reduced infection rate. However, still multicenter studies and randomized trials are needed before making final conclusions.

Asymmetric Posterior Thoracolumbar Fixation following a Posterolateral Transpedicular Approach for Unilateral Vertebral Disease.

The present study aimed to evaluate the clinical outcomes of patients who underwent asymmetrical posterior screw fixation for the treatment of unilateral posterior vertebral pathological entities. The study included 21 patients with a spinal tumor who underwent asymmetrical posterior spinal fusion surgery between April 2009 and March 2012. The American Spinal Injury Association (ASIA) motor score visual analog scale (VAS) score were used as the outcome measure at admission and follow-up. Among the 21 patients, 12 were male and 9 were female, and mean age was 50.71 (range, 24–78) years. Mean follow-up was 16.04 (range, 4–47) months. Postoperatively, neurological findings did not deteriorate in any of the patients. Among the ASIA grade C and D patients, eight (38%) of them exhibited clinical stability or recovery to ASIA E, whereas none of the ASIA B patients scores changed postoperatively. Perioperative complications were noted in six patients (28%). Spinal stability and fusion were achieved in 18 (85%) patients. The surgical asymmetrical fixation technique described reduced the duration of surgery, and the patients required less dissection of paraspinal muscles than bilateral symmetrical fixation. Asymmetrical fixation provides good stabilization for unilateral thoracolumbar vertebral pathological entities, and facilitates rapid rehabilitation of such patients, who are often elderly with comorbidities.

Minimally Invasive Tubular Microdiscectomy

Minimally invasive spinal techniques have been developed with the goal of achieving the same outcomes of open surgery through smaller incisions and minimal muscle dissection. Paraspinal muscle dissection and devascularization are a cause of postoperative pain, wound infection, and prolonged hospitalization. It has been well documented that with minimally invasive tubular access surgery, muscle stripping is obviated, resulting in faster patient recovery and decreased complication rates (cerebrospinal fluid leaks and wound infections) while maintaining similar long-term outcomes compared with open techniques. In this video, we describe a common application of tubular surgery: minimally invasive discectomy, demonstrated in a 3-dimensional video. A 47-year-old woman whose body mass index was 45.7 presented with right lower extremity radiculopathy with radiating pain along the L5 dermatome. She also had weakness with dorsiflexion. She was evaluated with magnetic resonance imaging that showed a large right-sided paracentral disc herniation at the L4-5 level. Her symptoms progressed...

Effect of Cerebrospinal Fluid Leakage on Wound Healing in Flap Surgery: Histological Evaluation

The aim of this study was to find out the effect of CSF leakage on wound healing after flap surgery. Sixteen male Wistar rats were used. The superiorly based rectangular dorsal skin flap 3 × 3 cm was elevated at the interscapular region. Through this opening, paraspinal muscle dissection and three-level bilateral laminectomy were done. Finally, a dura defect with a diameter of 3–4 mm was created. In the control group, laminectomy was performed as in the study group but the dura was left intact. Persistent CSF leakage was confirmed using isotope cisternography. At the end of 2-week study period, there was no necrosis, infection, or dehiscence of the flap in either group. On necroscopy, cyst formation over the dura defect was detected in 4 animals of the study group. Another gross finding in this group was intensive vascularization of the undersurface of the flap and wound bed. With HE staining, the tissue sections from the study group revealed new vessel formation with small diameter, increase in the reactional mesenchymal tissue, granulation tissue, degeneration of the striated muscle fibers, dystrophic calcifications, fat necrosis, and coagulation necrosis (ischemic necrosis). In the control group, there was only minimal lymphocytic invasion of the subdermal plane. In this study, we have shown that CSF leakage itself has effects on wound healing in the absence of known causative factors.