Primary Dural Repair Research Articles

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

Objective Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks. Methods This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure. Results Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection. Conclusions Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Quantitative lateral flow immunoassay for rapid detection and monitoring of cerebrospinal fluid leakage following incidental durotomy

Cerebrospinal fluid (CSF) leakage due to incidental durotomy is an inherent complication of spine surgery. With appropriate treatment, complications of CSF leakage, such as headache and even meningitis, can be reduced. CSF leakage could be detected on the basis of correlated clinical symptoms; diagnosis should be based on these symptoms and appropriate imaging studies. However, the diagnosis of CSF leakage remains a challenge, especially if incidental durotomy is unrecognized during surgery; even if incidental durotomy is detected and repaired intraoperatively, the severity of the leakage and quality of the primary dural repair are difficult to evaluate postoperatively. Rapid, inexpensive, and safe methods of detecting CSF-containing samples are currently lacking; hence, the development of a point-of-care test (POCT) method to improve diagnostic efficiency is necessary. We developed a high-sensitivity lateral flow immunoassay with a stacking pad (sLFIA) for quantitative detection of β-trace protein (BTP), a specific CSF marker. The BTP concentration in 39 clinical samples was calculated using a calibration equation for test-line intensity and evaluated by a standard laboratory method. To avoid the hook effect, we diluted each sample prior to testing. The correlation coefficient between the enzyme-linked immunosorbent assay and our BTP sLFIA method was 0.991 A 75-fold sample dilution was applied owing to the hook effect point, identified as 175 ng mL−1. We established an optimal sample-specific cutoff point at a value of 4.0 μg mL−1 for CSF leakage in subfascial drainage samples following spinal posterior decompression. The sensitivity and specificity of the BTP sLFIA method were 90% and 97%, respectively, according to a receiver operating characteristic curve analysis. In addition, clinical samples from patients who underwent primary dural repair intraoperatively were tested, and CSF leakage was successfully diagnosed using our method. Finally, the quantitation of BTP in samples collected daily provided an accurate assessment of the severity of the residual leakage. Our results demonstrate that the BTP sLFIA method possesses the potential to serve as a POCT method for screening and monitoring postoperative CSF leakage.

Anterior Skull Base Tumors and Surgery

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery

Primary Dural Repair Using Titanium Microclips Following Lateral Skull Base Surgery

Objective Standard techniques for primary dural repair following lateral skull base surgery are both technically challenging and time consuming without the potential for primary dural repair. Inadequate closure may result in postoperative cerebrospinal fluid (CSF) leak infectious sequalae. Traditional methods of dural repair rely on secondary obliteration of the CSF fistula. We hypothesized that the use of nonpenetrating titanium microclips may serve as a useful adjunct in primary dural repair or the establishment of an immobile repair layer following lateral skull base surgery. Methods Here, we report a novel technique for primary dural repair using nonpenetrating titanium microclips as an adjunct to standard techniques in a series of six patients with lateral skull base pathologies. Results A total of six consecutive lateral skull base tumor patients with titanium microclip dural reconstruction were included in our case series. Lateral skull base pathologies represented in this group included two jugular foramen schwannomas, one vestibular schwannoma, one petroclival meningioma, one glomus jugulare paraganglioma, and one jugular foramen chordoid meningioma. Conclusion To our knowledge, this is the first report on the use of microclips in repairing dural defects following lateral skull base surgery. Surgical outcomes for this small case series suggest that dural repair of the later skull base with nonpenetrating titanium microclips is a useful adjunct in dural repair following lateral skull base surgery.

Primary Dural Repair via an Endoscopic Endonasal Corridor: Preliminary Development of a 3D-Printed Model for Training.

Objectives Endonasal suturing is an investigational method for dural repair that has been reported to decrease the incidence of cerebrospinal fluid fistula. This method requires handling of single-shaft instrumentation in the narrow endonasal corridor. In this study, we designed a low-cost, surgical model using three-dimensional (3D) printing technology to simulate dural repair through the endonasal corridor and subsequently assess the utility of the model for surgical training. Methods Using an Ultimaker 2+ printer, a 3D-printed replica of the cranial base and nasal cavity was fitted with tissue allograft to recapitulate the dural layer. Residents, fellows, and attending surgeons were asked to place two sutures using a 0-degree endoscope and single-shaft needle driver. Task completion time was recorded. Participants were asked to fill out a Likert scale questionnaire after the experiment. Results Twenty-six participants were separated into groups based on their prior endoscope experience: novice, intermediate, and expert. Twenty-one (95.5%) residents and fellows rated the model as "excellent" or "good" in enhancing their technical skills with endoscopic instrumentation. Three of four (75%) of attendings felt that the model was "excellent" or "good" in usefulness for training in dural suturing. Novice participants required an average of 11 minutes for task completion, as compared with 8.7 minutes for intermediates and 5.7 minutes for experts. Conclusion The proposed model appears to be highly effective in enhancing the endoscopic skills and recapitulating the task of dural repair. Such a low-cost model may be especially important in enhancing endoscopic facility in countries/regions with limited access to cadaveric specimens.

Repair of Incidental Durotomy Using Sutureless Nonpenetrating Clips via Biportal Endoscopic Surgery.

Study Design:Technical report.Objectives:Dural tear is one of the most common complications of endoscopic spine surgery. Although endoscopic dural repair of the durotomy area may be difficult, we successfully repaired the dural tear area using nonpenetrating clips during biportal endoscopic surgery. We introduce the surgical technique of dural repair using nonpenetrating titanium clips in biportal endoscopic spine surgery and report its clinical outcome.Methods:We retrospectively reviewed and analyzed 5 patients who were treated via primary dural repair using nonpenetrating titanium clips during biportal endoscopic lumbar surgery. The 2 methods of dural clipping and repair include 2 or 3 portals. We analyzed radiological parameters such as cerebrospinal fluid collection as well as clinical parameters, including postoperative clinical outcomes.Results:Five patients underwent biportal endoscopic dural repair using nonpenetrating clips. Incidental durotomy was successfully repaired using nonpenetrating titanium clips in all 5 patients. No cerebrospinal fluid collection was detected in the postoperative magnetic resonance images. Clinically, preoperative symptoms improved significantly after surgery (P < .05).Conclusions:We repaired the dural tear area completely using nonpenetrating titanium vascular anastomosis clips in biportal endoscopic lumbar surgery. Dural repair via clipping method may be an effective alternative for incidental durotomy.

Primary Dural Repair after Endoscopic Endonasal Approaches to the Cribriform Using Nonpenetrating Titanium Clips: Initial Experience and Surgical Technique

Primary Dural Repair after Endoscopic Endonasal Approaches to the Cribriform Using Nonpenetrating Titanium Clips: Initial Experience and Surgical Technique

How to address cerebrospinal fluid leakage following ossification of the posterior longitudinal ligament surgery

BackgroundPrimary dural repair in ossification of posterior longitudinal ligament (OPLL) surgery via anterior is challenging because of limited space. Based on several years of our experiences, we present our concept for addressing cerebrospinal fluid (CSF) leakage following dural tear during anterior OPLL surgery. MethodsWe reviewed the medical records of 65 patients who underwent anterior OPLL surgery from 2003 to 2014. We included 7 patients whose operation records described dural tear followed by CSF leakage. Primary dural repair could not be performed in 6 patients because of ragged tear and limited space. We managed them with our own strategy: simple cover with an artificial dura, collagen sponge and/or fibrin glue on defect site; anatomical layer-by-layer repair without either subfascial or CSF drain, and early ambulation. ResultsOf 7 patients, wound problems developed in 2 patients. Wound aspiration and antibiotic treatment was done without wound compression in one patient, and simple irrigation followed by anatomical layer-by-layer re-closure was done in the other patient without either bed rest or lumbar drainage.Pseudomeningoceles were detected in 4 patients, including 2 patients who had wound problems. However, all pseudomeningoceles were absorbed spontaneously or stabilized on follow-up images without interventions such as bed rest, lumbar drain or wound compression. ConclusionsWithout interference of pressure equilibrium between intradural and extradural space, the defect site would heal and close. After that, the isolated pseudomeningocele would be spontaneously absorbed after certain period of time.

Postoperative Cerebrospinal Fluid Leak Rates with Subfascial Epidural Drain Placement after Intentional Durotomy in Spine Surgery.

Study Design Retrospective chart review. Objective Postoperative cerebrospinal fluid (CSF) leak is a known complication of intraoperative durotomy. Intraoperative placement of subfascial epidural drains following primary dural repair has been proposed as a potential management strategy to prevent formation of CSF cutaneous fistula and symptomatic pseudomeningocele. Here we describe our experience with subfascial drain after intentional durotomy. Methods Medical records of patients who underwent placement of subfascial epidural drains during spinal procedures with intentional intraoperative durotomies over a 4-year period at two institutions were retrospectively reviewed. Primary outcomes of interest were postoperative CSF cutaneous fistula or symptomatic pseudomeningocele formation. Results Twenty-five patients were included. Mean length of follow-up was 9.5 months. Twelve patients (48%) underwent simultaneous arthrodesis. The average duration of the drain was 5.3 days with average daily output of 126.5 mL. Subgroup analyses revealed that average drain duration for the arthrodesis group was 6.33 days, which is significantly greater than that of the nonfused group, which was 3.7 days (p = 0.016). Similarly, the average daily drain output for the arthrodesis subgroup at 153.1 mL was significantly higher than that of the nonfused subgroup (86.8 mL, p = 0.04). No patient developed postoperative CSF cutaneous fistula or symptomatic pseudomeningocele or had negative sequelae associated with overdrainage of CSF. One patient had a delayed wound infection. Conclusions The intraoperative placement of subfascial epidural drains was not associated with postoperative development of CSF cutaneous fistula, symptomatic pseudomeningocele, overdrainage, or subdural hematoma in the cases reviewed. Subfascial closed wound drain placement is a safe and efficacious management method after intentional spinal durotomies. It is particularly helpful in those who undergo simultaneous arthrodesis, as those patients have statistically higher daily drain output and longer drain durations.

A multicentre, prospective, randomized, controlled study to evaluate the use of a fibrin sealant as an adjunct to sutured dural repair

Background. Obtaining intra-operative watertight closure of the dura is considered important in reducing post-operative cerebrospinal fluid (CSF) leak. The purpose of this study was to evaluate a fibrin sealant as an adjunct to sutured dural repair to obtain intra-operative watertight closure in cranial neurosurgery. Methods. This randomized, controlled multicenter study compared a fibrin sealant (EVICEL® Fibrin Sealant [Human]) to sutured dural closure (Control). Subjects underwent supratentorial or posterior fossa procedures. Following primary dural repair by sutures, the closure was evaluated for intra-operative CSF leak by moderately increasing the intracranial pressure. If present, subjects were randomized to EVICEL® or additional sutures (2:1 ratio), stratified by surgical approach. Following treatment, subjects were successful if no CSF leaks were present during provocative challenge. Safety was assessed to 30 days post-surgery, including incidence of CSF leakage. Results. One hundred and thirty-nine subjects were randomized: 89 to EVICEL® and 50 to Control. Intra-operative watertight closure was achieved in 92.1% EVICEL®-treated subjects versus 38.0% controls; a treatment difference of 54.1% (p < 0.001). The treatment differences in the supratentorial and posterior fossa strata were 49.1% and 75.7%, respectively (p < 0.001). The incidence of adverse events was similar between treatment groups. No deaths or unexpected serious adverse drug reactions were reported. CSF leakage within 30 days post-operatively was 2.2% and 2.0% in EVICEL® and control groups, respectively. In addition, 2 cases of CSF rhinorrhoea were observed in the EVICEL® group. Although not associated with the suture line where EVICEL® was applied, when combined with the other CSF leaks, the observed leak rate in the EVICEL® group was 4.5%. Conclusions. These results indicate that EVICEL® is effective as an adjunct to dural sutures to provide watertight closure of the dura mater in cranial surgery. The study confirmed the safety profile of EVICEL®.

Thoracolumbosacral Spinal Subdural Abscess

Case report and review of relevant literature. To report a rare case of a thoracolumbosacral spinal subdural abscess (SSA) and highlight the magnetic resonance imaging (MRI) appearance and surgical management. SSA is rare, as most intraspinal abscesses are epidural in location. Extensive thoracolumbosacral SSA has only rarely been reported. The MRI features and options for limited surgical management are not well described. A case report of SSA is presented and relevant literature is reviewed. An elderly female presented with worsening back pain and sepsis. MRI demonstrated an extensive intraspinal abscess, extending from the upper thoracic spine to the sacrum. Both axial and sagittal images demonstrated a subdural location of the collection, with preservation of the dorsal epidural fat and mass effect on the spinal cord. Cord compression was most marked at the T8 level. Limited midthoracic laminectomies were performed. The epidural space seemed normal intraoperatively. A limited longitudinal durotomy yielded purulent fluid. After intraoperative irrigation, primary dural repair was performed. At 2-year follow-up, the patient had no clinical, radiographical, or laboratory evidence of residual or recurrent spinal infection. Careful review of MRI can localize an intraspinal abscess to the subdural space. Even for extensive subdural collections, limited operative management can achieve excellent clinical outcome. N/A.

Incarcerated spinal cord: A preventable surgical debacle

Incarcerated spinal cord: A preventable surgical debacle

Primary Dural Repair in Minimally Invasive Spine Surgery

We describe an effective surgical technique in primary repair of the spinal dura during minimally invasive spine surgery (MISS). Objective. Minimally invasive spine surgery includes the treatment of intradural lesions, and proper closure of the dura is necessary. However, primary dural closure can be difficult due to the restricted space of MIS retractors and the availability of appropriate surgical instrumentation. Methods. We describe the use of a needle already used in the pediatric neurosurgical arena that can facilitate easier and safer closure of spinal dura through MISS retractors in two illustrative intradural cases. Results and Discussion. The primary dural closure technique is described and patient demographics are included. The instruments specifically used for the intradural closure through MIS retractor systems include (1) 4-0 Surgilon braided nylon (Covidien, Dublin, Ireland) with a CV-20 taper 1/2 circle, 10 mm diameter needle; (2) Scanlan (Saint Paul, MN, USA) dura closure set. Conclusion. Successful primary dural repair can be performed on primary and incidental durotomies during minimally invasive spinal surgery. We describe the novel use of a 10 mm diameter needle to help surgeons safely and efficiently close the dura with more ease than previously described.

Isolated abducens nerve palsy due to cerebrospinal fluid leakage following lumbar discectomy: a rare clinical entity

Cerebrospinal fluid (CSF) leakage can cause abducens nerve palsy which is such a rare complication after spine surgery. A 48-year-old man was diagnosed with isolated abducens nerve palsy due to CSF leakage by inadvertent dural tearing after lumbar discectomy. We performed primary dural repair of CSF leakage and 1 week after, the diplopia and headache disappeared with complete resolution of CSF leakage. We will also review the clinical features and outcomes of three cases that have been reported in the literature. This rare complication of spinal surgery helped us to discuss appropriate therapeutic strategies for the early surgical management of cranial nerve palsy following CSF leakage.

Limited vertical dural opening for lesions of the vermis, 4thventricle, and distal PICA segments

Background:Lesions of the vermis and 4th ventricle are commonly addressed through a midline suboccipital approach. Most neurosurgeons use either a Y-shaped or a curvilinear dural opening in this setting. Although these approaches offer a wide intraoperative surgical exposure, in occasion, the dural opening is difficult to repair primarily, often necessitating the use of a patch, which may increase the risk for development of CSF fistula. We are describing our experience with a limited, vertical, midline, dural opening for approaches to the vermis, tentorium, 4th ventricle, and distal posterior-inferior cerebellar artery (PICA) segments as an alternative to the classic Y-shaped or curvilinear incision.Methods:We report our experience with a limited vertical midline durotomy in five patients with posterior fossa lesions. The lesions treated included a PICA dissecting aneurysm, three metastatic lesions (located in the vermian, floor of the 4th ventricle, and undersurface of the tentorium cerebelli), and one intra-axial tumor (ependymoma). All patients were positioned prone, and the lesions were accessed without difficulty through a limited, vertical, midline durotomy.Results:Mass lesions and vascular abnormalities located from the midline as far lateral as the outlet foramina of the 4th ventricle can be accessed comfortably via a limited midline dural opening when combined with microsurgical techniques, and the use of a frameless Stealth Station Neuronavigation System (SSNS) [Medtronic Sofamor Danek, Inc., Memphis, TN]. By doing this, simple primary dural closure was achieved with a single running absorbable suture without tension in each case.Conclusion:In our experience, a suboccipital linear dural opening appears to be as effective as the more traditional Y-shaped incision, yet allows for quicker and easier primary dural repair.

A Prospective, Multi-center, Randomized Controlled Study to Compare a Low Swell Formulation of a PEG Hydrogel Spinal Sealant as an Adjunct to Sutured Dural Repair with Common Dural Sealing Methods

After durotomy, primary dural repair is often effective, but failures resulting in postoperative spinal fluid leak can occur. Adjunctive spinal sealants have been used, but prospective, multi-center, randomized trials are needed in order to validate superiority over primary dural repair alone.

PRIMARY DURAL REPAIR DURING MINIMALLY INVASIVE MICRODISCECTOMY USING STANDARD OPERATING ROOM INSTRUMENTS

Minimally invasive microdiscectomies are commonly being performed for disc herniations. Although inadvertent dural tears are not common, they do occur. Present management of many dural tears includes fibrin glue or other adhesive substances over the dura, tight closure of the fascia and skin, and possibly bedrest. Because these surgeries are usually performed through a small tube, a primary dural repair can be prohibitively difficult. One reason for the difficulty in a primary closure is that the small tube limits the use of proper opening and closing of standard dural repair instruments as well as the proper angulation of the instruments. To circumvent this difficulty, we have improvised using commonly available instruments in the operating room for primary dural closure. We describe our technique and present a video demonstrating the method of primary dural closure without custom-made instruments. Primary dual repair during minimally invasive microdiscectomy can be performed using standard operation room instruments, including a standard micropituitary ronguer, 5-0 Prolene suture (Ethicon, Inc., Somerville, NJ), and a laparoscopic knot pusher.

Spontaneous intracranial hypotension associated with transdural thoracic osteophyte reversed by primary dural repair

Spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome associated with a specific set of clinical and imaging findings; however, determining the site of spinal cerebrospinal fluid (CSF) leakage in these patients is often difficult, and indications for surgical intervention need to be better defined. The authors report on a 55-year-old woman who presented with posture-related headache, disorientation, and memory impairment. Imaging features were consistent with SIH. Computerized tomography myelography demonstrated a large T2-3 anterior transdural osteophyte associated with a CSF fistula. After an unsuccessful trial of conservative therapy, the patient underwent median sternotomy, T2-3 discectomy and removal of osteophyte, which allowed adequate exposure for primary dural repair. Postoperatively, there was immediate and prolonged resolution of all of her symptoms. This case of SIH was caused by transdural penetration by an anterior osteophyte and CSF leakage in the upper thoracic spine, which was treated effectively by anterior exposure and primary dural repair. Aggressive surgical intervention may be required to treat upper thoracic CSF leaks refractory to other measures.

P63. Collagen matrix (Duragen) in spinal durotomy: technique appraisal and clinical results

HYPOTHESIS: Incidental durotomy occurs in 0.3–13% of spinal surgery & up to 18% in re-operation, often aggravated by epidural scarring, with a prevalence rate of 5% despite meticulous attention to surgical technique, Grafts may also be required to reconstitute the dura after resection of tumors e.g. meningiomas, following penetration by bony fragments of fractures, penetrating trauma or even to augment primary dural repair. Repair of torn dura is time consuming and often difficult to repair especially lateral and anterior tears. Traditional methods of spinal dural repair involve tedious attempts at primary watertight suturing augmented by synthetic or biological grafts.

Cerebral spinal fluid pressure: effects of body position and lumbar subarachnoid drainage in a canine model.

This study used in vivo an model of subarachnoid cerebrospinal fluid pressure measurement. To examine the relation between subarachnoid cerebrospinal fluid pressure in the cervical and lumbar spine and varying body positions, and to test the hypothesis that increasing body inclination and lumbar subarachnoid drainage decreases cervical cerebrospinal fluid pressures. Cerebrospinal fluid leaks are a recognized complication of anterior or posterior cervical surgery. Conflicting opinion exists regarding the benefits of postoperative patient positioning and lumbar subarachnoid drainage. Subarachnoid cerebrospinal fluid pressure of 7 beagles was monitored via two angiocatheters attached to pressure transducers inserted into the subarachnoid space through laminectomies at C3 and L4. Pressure measurements were taken when body position was inclined to 30 degrees, 60 degrees, and 90 degrees. A lumbar durotomy was performed to simulate the effects of lumbar subarachnoid drainage. The body was repositioned to 90 degrees, and pressure was measured. As inclination increased from 0 degrees to 90 degrees, the mean cervical cerebrospinal fluid pressure significantly decreased. The mean lumbar subarachnoid pressure significantly increased as inclination increased from 0 degrees to 90 degrees. Lumbar durotomy plus repositioning to 90 degrees resulted in a significant reduction in cervical cerebrospinal fluid subarachnoid pressure, with pressures dropping by 46%. Lumbar cerebrospinal fluid subarachnoid pressure dropped to zero after lumbar durotomy plus repositioning to 90 degrees. Cerebrospinal fluid pressures in the subarachnoid space of both the cervical and lumbar spines are affected by changes in body position. Both patient positioning and lumbar drainage may be important in reducing cervical cerebrospinal fluid pressure, and may reduce the occurrence of cerebrospinal fluid leaks after primary dural repair in the neck.