Repair Of Dural Defect Research Articles

Postoperative Cervical Cord Compression Induced by Hydrogel Dural Sealant (DuraSeal®)

Cerebrospinal fluid (CSF) leakage is a potential complication of cranial and spinal surgery. Postoperative CSF leakage can induce delayed healing, wound infection and meningitis. DuraSeal® (Covidien, Waltham, MA, USA) is a synthetic product which has been increasingly used to facilitate watertight repair of dural defects after cranial and spinal surgery. Despite some advantages of Duraseal®, the authors report a patient who developed cord compression following the use of DuraSeal® in cervical spine surgery in which the expansion of the DuraSeal® was believed to be the causative factor.

Spinal Extradural Arachnoid Cyst

Spinal extradural arachnoid cyst (SEAC) is a rare disease and uncommon cause of compressive myelopathy. The etiology remains still unclear. We experienced 2 cases of SEACs and reviewed the cases and previous literatures. A 59-year-old man complained of both leg radiating pain and paresthesia for 4 years. His MRI showed an extradural cyst from T12 to L3 and we performed cyst fenestration and repaired the dural defect with tailored laminectomy. Another 51-year-old female patient visited our clinical with left buttock pain and paresthesia for 3 years. A large extradural cyst was found at T1-L2 level on MRI and a communication between the cyst and subarachnoid space was illustrated by CT-myelography. We performed cyst fenestration with primary repair of dural defect. Both patients' symptoms gradually subsided and follow up images taken 1-2 months postoperatively showed nearly disappeared cysts. There has been no documented recurrence in these two cases so far. Tailored laminotomy with cyst fenestration can be a safe and effective alternative choice in treating SEACs compared to traditional complete resection of cyst wall with multi-level laminectomy.

Use of Endoscopic Vascularized Nasoseptal Flap in Children

Objective: 1) Determine ability to achieve 100% coverage of sellar skull base defects with the vascularized nasal septal flap in pediatric patients. 2) Identify the rate of residual CSF leaks following this repair technique in these pediatric patients. 3) Review the demographics and perioperative course in these children. Method: Study design: Retrospective case series. Study conducted: January 1, 2006, to January 1, 2012. Condition studied: Repair of skull base defects after resection of sellar lesions. Subjects: Children. Setting: Children’s hospital. Intervention: Endonasal repair of skull base defects with a vascularized nasoseptal flap. Outcome measurement(s): 1) Complete coverage of defect. 2) Postoperative CSF leak. Results: Demographics: Ten children were identified, and 11 flaps were performed. The average patient age was 12.6 years old (range of 5.1-17.4 years). Total coverage was achieved in all cases. The technique was particularly challenging in the younger patients. A brisk CSF leak was observed during closure in 3 cases, but no CSF leaks were observed after balloon packing removal (day 5). No lumbar drains were used. Only minor complications were observed. A second look with debridement of packing material due to poor cooperation with office endoscopy was done in 7 children (70%). Conclusion: The endonasal vascularized nasal septal flap is a feasible and reliable method of repair of dural defects after resection of sellar lesions in children. Despite active CSF leak in 3 children, there were no residual CSF leaks. Unlike adult patients, children may require operative nasal debridement after repair has healed.

Dural Defect Repair in Translabyrinthine Acoustic Neuroma Surgery and Its Implications in Cerebrospinal Fluid Leak Occurrence

Cerebrospinal fluid (CSF) leak is a complication that may occur after translabyrinthine (translab) acoustic neuroma (AN) removal. The aim of this study is to verify the incidence of CSF leak using two techniques for dural defect closure in translab AN surgery and present a new technique for dural repair. A retrospective study was held, reviewing charts of 34 patients in a tertiary neurotologic referral center. Out of these 34 patients that underwent translab AN excision in a 1-year period, 18 had their dural defect repaired using only abdominal fat graft and 16 using synthetic dura substitute (SDS) plus abdominal fat tissue. One patient (5.5%) in the first group had CSF leak and 1 (6.2%) in the second group had CSF leak postoperatively. Our data suggest that there are no significant differences in CSF leak rates using both techniques, although studies in a larger series must be undertaken to conclude it. We believe that the development of some points in the new technique for dural repair can achieve better results and reduce the CSF leak incidence in the translabyrinthine acoustic neuroma surgery in the near future.

Hemostatic effect of human fibrin glue on bleeding surface of the brain: An experiment on albino Wistar rats

BackgroundAchieving and maintaining hemostasis in neurosurgical procedures is critical to the outcome and challenging especially in cases of coagulopathy with diffuse oozing. After trauma to the brain, a cascade of events initiated by tissue factor (TF) or thromboplastin results in a defective coagulation process that even may lead to disseminated intravascular coagulation (DIC). Fibrin glue is sealant made up of fibrinogen and thrombin used for dural defect repair at the base, convexity, anastomosis of the nerve and nerve graft, reinforcing microvascular anastomosis. This study was carried out to determine the hemostatic effect of human fibrin glue on bleeding surface of brain and compare the effect with conventional methods of hemostasis. MethodThirty (30) white rats (Rattus novergicus) were divided equally into study and control group. After craniotomy and dural opening a stab incision was made on right frontal region of brain. In case group the bleeding was controlled with fibrin glue (average 0.5ml) and in control group conventional method of hemostasis (cautery, cottonoid patty, and saline wash, surgicel) was used. Both the groups were studied for bleeding time, seizure, neurological deficit, wound complications and mortality. ResultsOutcome was assessed as 1) Bleeding in both the groups 2) Complications in both the groups. It was observed that in study group the time taken in hemostasis was significantly less in comparison to the control, No significant difference in the post procedure clinical outcome and inflammatory reaction/gliosis reaction was found in both the groups. ConclusionHuman fibrin glue is simple, easy and safe alternative to conventional methods of hemostasis.

What is a reasonable surgical procedure for spinal extradural arachnoid cysts: is cyst removal mandatory? Eight consecutive cases and a review of the literature

Spinal epidural arachnoid cysts (EAC) are rare and may present with myelopathy, which can be completely curable with surgery. The majority of investigators believe that the repairment of dural defect is important to treat EAC. However, the necessity of excising EACs remains controversial. The purpose of this study was to find a reasonable surgical technique for treatment of EACs after considering the clinical outcome, recurrence, and complications. The data from 44 operations in the literature and eight cases from our own experience were analyzed. This data included the surgical method, patient characteristics, level and size of the EAC, global assessment of the clinical outcomes, and the incidence of recurrence. The recurrence rate was 2.0 % and 66.7 % in the patients who underwent repair of the dural defect and in those failed to repair of the dural defect, respectively (p = 0.007). The recurrence rate was 8.3 % and 3.6 % in patients who underwent complete EAC excision totally, and those who underwent EAC fenestration only, respectively (p = 0.590). The clinical outcome in patients with repaired dural defects was significantly better than that in patients with unrepaired dural defects (2.61 vs.1.67) (p = 0.027). The clinical outcome score was 2.42 and 2.68 in patients who underwent complete EAC excision and those who underwent EAC fenestration only, respectively (p = 0.158). The mean EAC length was 5.04 vertebral body levels (range, 2-13). Six of the 51 patients (11.7 %) had multiple EACs. Total excision of EACs may have little benefit in terms of cyst recurrence and clinical outcome. The procedure for EAC resection carries a risk of complications such as kyphosis. If EAC resection is performed, we suggest that a tailored short-level laminotomy be used to allow for the repair of dural defects. Particularly in patients with small EAC, a partial hemilaminectomy with dural defect repair may be a possible method to reduce complications.

Extra dural spinal arachnoid cyst occuring in a child: case report

Extradural archnoid spinal cysts are rare lesions. Their localization is usually the thoracic spine. Clinically, they are a cause of spinal cord and/ or nerve roots compression. The diagnosis is made by magnetic resonance imaging (MRI). The pathophysiology is not well known and seems to be different from intradural lesions. The best treatment is surgery. We report the case of a 5-year-old girl with spinal cord compression symptoms who was treated by open surgery. We performed dural defect repair. The outcome was good in the immediate post operative period without complication and total recovery.

Results of the Prospective, Randomized, Multicenter Clinical Trial Evaluating a Biosynthesized Cellulose Graft for Repair of Dural Defects

After intradural cranial surgery, a dural substitute is often required for dural closure. Although preferred, limitations of autograft include local availability and additional surgical site morbidity. Thus, allografts, xenografts, and synthetics are frequently used. To report 6-month results of a randomized, controlled trial of a biosynthesized cellulose (BSC) composed duraplasty device compared with commercially available dural replacements. A total of 99 patients (62 BSC; 37 control) were treated on protocol, using a 2:1 (BSC:control) blocked randomization schedule. Physical examinations were performed pre- and postoperatively within 10 days and at 1, 3, and 6 months. Magnetic resonance imaging was performed preoperatively and at 6 months. The primary study endpoint was the absence of pseudomeningocele and extracerebral fluid collection confirmed radiographically and the absence of cerebrospinal fluid fistula at 6 months. At 6 months, the primary hypothesis, noninferiority of the BSC implant compared with the control group, was confirmed (P = .0206). Overall success was achieved by 96.6% of BSC and 97.1% of control patients. No significant difference was revealed between treatment groups for surgical site infection (P = 1.0000) or wound healing assessment (P ≥ .3685) outcomes, or radiologic endpoints (P ≥ .4061). Device strength and seal quality favored BSC. This randomized, controlled trial establishes BSC as noninferior to commercially available dural replacement devices. BSC offers a hypothetical advantage concerning prion and other infectious agent exposure; superior handling qualities are evident. Longer term data are necessary to identify limitations of BSC and its potential equivalence to the gold standard of pericranium.

Ventral intraspinal fluid-filled collection secondary to CSF leak presenting as bibrachial amyotrophy

MRI has identified a broader clinical spectrum of CSF leaks than what was initially recognized. Although headache, particularly orthostatic, is the most common manifestation, most patients display additional symptoms, and some have no headaches.1,2 Other manifestations include cochleovestibular and oculomotor disturbances, cognitive impairment, interscapular pain, and imbalance.1,2 This report draws attention to yet another manifestation of CSF leaks: segmental amyotrophy related to cervical cord compromise from an intraspinal ventral epidural fluid-filled collection in communication with the subarachnoid space. The 3 reported patients showed clinical improvement after dural defect repair; imaging resolution of the intraspinal fluid-filled collection was demonstrated in all. ### Case reports. #### Case 1. A 48-year-old man presented with a 5-year history of progressive, bilateral, asymmetric, proximal greater than distal, upper limb atrophy and weakness. EMG demonstrated chronic neurogenic changes in the C4–C8 myotomes. MRI showed a ventral extradural intraspinal fluid-filled collection from C2 to L4 with posterior displacement and flattening of the cord from C3–C7 (figure, A1 and A2). A dural defect was identified on a dynamic CT myelogram at T12–L1 (figure, A3); this was surgically closed. At 6-month follow-up, significant clinical improvement was noted; this was accompanied by complete resolution of the imaging abnormality (figure, A4 and A5). Figure Preoperative (A1, A2, B1, B2, C1, C2) and postoperative (A4, A5, B4, B5, C4) MRI and preoperative CT myelogram (A3, B3, C3) in case 1 (A1–A5), case 2 (B1–B5), and case 3 (C1–C4) (A1–A5) (Case 1) Sagittal (A1, A2) and axial (inset in A1, A2) MRI of the cervical …

Use of Antibiotic - Impregnated DuraGen®to Reduce the Risk of Infection in Dura Repair: An In Vitro Study

To investigate the efficacy of antibiotic-impregnated DuraGen® in preventing infection when used for repair of dural defects. 2 groups of 7 samples were formed. In the first group, normal DuraGen® samples without antibiotic impregnation and in the second group, DuraGen® samples with antibiotic impregnation (30 mg vancomycin) were used. Staphylococcus aureus (ATCC 25923), and Staphylococcus epidermidis (ATCC 12228) were selected for this study. Antimicrobial efficacy was evaluated by counting the number of colonies on and by measuring the diameter of the inhibition zone around the samples. There was no zone diameter around the normal DuraGen® for the 2 types of bacteria. There was significant bacterial growth (10 (5)) according to the colony count. For antibiotic-impregnated DuraGen®, there was a zone with a mean diameter of 32 mm in the agar with S. aureus and a zone with a mean diameter of 35 mm in the agar with S. epidermidis. Antibiotic-impregnated DuraGen® was quite effective against both microorganisms and there was no bacterial growth according to the bacterial colony count. In our in vitro study, antibiotic-impregnated DuraGen® material significantly inhibited microorganism growth. Our results show that antibiotic-impregnated DuraGen® has the potential to prevent infection.

The collagenic architecture of human dura mater

Human dura mater is the most external meningeal sheet surrounding the CNS. It provides an efficient protection to intracranial structures and represents the most important site for CSF turnover. Its intrinsic architecture is made up of fibrous tissue including collagenic and elastic fibers that guarantee the maintenance of its biophysical features. The recent technical advances in the repair of dural defects have allowed for the creation of many synthetic and biological grafts. However, no detailed studies on the 3D microscopic disposition of collagenic fibers in dura mater are available. The authors report on the collagenic 3D architecture of normal dura mater highlighting the orientation, disposition in 3 dimensions, and shape of the collagen fibers with respect to the observed layer. Thirty-two dura mater specimens were collected during cranial decompressive surgical procedures, fixed in 2.5% Karnovsky solution, and digested in 1 N NaOH solution. After a routine procedure, the specimens were observed using a scanning electron microscope. The authors distinguished the following 5 layers in the fibrous dura mater of varying thicknesses, orientation, and structures: bone surface, external median, vascular, internal median, and arachnoid layers. The description of the ultrastructural 3D organization of the different layers of dura mater will give us more information for the creation of synthetic grafts that are as similar as possible to normal dura mater. This description will be also related to the study of the neoplastic invasion.

Reconstruction of skull base defects in sphenoid wing dysplasia associated with neurofibromatosis I with titanium mesh

Sphenoid wing dysplasia occurs in 3–7% of patients with neurofibromatosis type 1 (NF1). The typical radiological features are partial or complete absence of the greater wing of the sphenoid. This condition is slowly progressive and may result in temporal lobe herniation into the orbital cavity, producing pulsating exophthalmos and gross facial deformity. Thus, reconstruction of the orbit is important for both cosmetic and functional reasons. Traditional surgical treatment of sphenoid dysplasia involves split bone grafting and repair of the anterior skull base defect. However, several reports have demonstrated complications of graft resorption and recurrence of proptosis and pulsating exopthalmos. In this case series, we present two patients suffering from pulsating exophthalmos due to sphenoid dysplasia. Radiological and MRI studies demonstrated orbital enlargement and complete absence of the greater wing of the sphenoid. Surgical management of these patients involved dural defect repair, and the use of titanium mesh in conjunction with bone graft to act as a barrier between the orbit and the middle cranial fossa. The mesh was fixed by fine screws. Proptosis improved markedly post-operatively and resolved within a few weeks. Ocular pulsation subsided and remained quiescent with at least 1-year follow-up.

Feasibility of a Robotic Surgical Approach to Reconstruct the Skull Base

The role of robotic surgery in the skull base is evolving and represents the natural progression toward maximizing surgical resections in confined spaces without compromising oncological principles. In this study, we describe the novel application of robotic surgery to the repair of dural defects in the skull base. A transmaxillary-transantral approach to the nasal cavity was performed bilaterally in a cadaveric model. Repair of the skull base defect was undertaken robotically. In this technical report, we demonstrate the feasibility of a suture-based technique for surgical reconstruction of the skull base with robotic assistance in a cadaveric model. In all cases, suture repair of dural defects was successfully performed with robotic-assisted technique. Although preliminary in nature, this study suggests that traditional suture techniques can be implemented in a confined surgical site with the use of robotic technology.

A simple and versatile tissue adhesive applicator for endonasal endoscopic skull base surgery

Repair of dural defects following endonasal endoscopic cranial base surgery remains a challenge. A variety of reconstructive techniques have been described, many of which utilize tissue adhesives or glues. One of the main difficulties with the endonasal use of these sealants is the available applicators, which often result in the imprecise and excessive application of the material. In this report, we describe the modified use of straight and curved suction tips as simple and versatile rigid tissue adhesive/glue applicators for use during endonasal skull base surgery.

Neurological recovery after surgical treatment of giant cervical pseudomeningoceles extending to lumbar spine associated with previous brachial plexus injury

The authors describe a case of 28-year-old man who presented with cervical myelopathy and lumbar radiculopathy due to the giant cervical pseudomeningocele extending to the lumbar spine at 10 years after previous brachial plexus injury. To evaluate the communicating tract between pseudomeningocele and subarachnoidal space, the multidetector-row helical CT with simultaneous myelography was performed preoperatively. The surgical treatment in the cervical spine included the resection of pseudomeningocele and the repair of dural defects communicating into the cyst following multi-level laminoplasty and foraminotomies. At 6 years after surgery, the significant neurologic recovery and complete obliteration of cysts in the whole spine area were maintained. This serves as the first report describing the significant neurologic recovery after the surgical treatment of giant cervical pseudomeningocele extending to the lumbar spine after previous brachial plexus injury.

Transpalpebral Orbitofrontal Craniotomy: A Minimally Invasive Approach to Anterior Cranial Vault Lesions

To describe a minimally invasive approach to anterior cranial vault pathology using a transpalpebral exposure with a miniorbitofrontal craniotomy. Case series. Tertiary referral hospital with multidisciplinary skull base program. Participants include patients with intra-axial and extra-axial anterior skull base lesions who underwent the transpalpebral minicraniotomy approach. Feasibility of the approach to permit adequate exposure of targeted lesion. We applied this approach in seven patients for the repair of persistent cerebrospinal fluid leaks, pneumocephalus, and the biopsy or resection of midline brain tumors along the anterior cranial base. The approach allowed bimanual instrumentation working with either endoscopic or microscopic visualization for tumor resection and repair of dural and cranial base defects. We measured an average working distance of 4 cm to the sella. The transpalpebral miniorbitofrontal craniotomy approach to the anterior cranial base is quick, adequate, and safe and should be considered as an alternative to extended bifrontal approaches and/or pterional craniotomies for select anterior cranial vault pathology.

Endoscopic treatment of cerebrospinal fluid leaks with the use of lower turbinate grafts: a retrospective review of 125 cases

Endoscopic transnasal approaches to the skull base have revolutionized the treatment of cerebrospinal fluid (CSF) fistulae, making repair less invasive and more effective compared with craniotomy or extracranial techniques. This study evaluated, retrospectively, the results of endoscopic repair of dural defects with the use of mucoperiostal grafts taken from the lower turbinate. Between January 1997 and January 2007, 125 cases of anterior skull base CSF fistulae were treated endoscopically at the Instituto Felippu de Otorrinolaringologia, Sao Paolo, Brazil, and at the Department of Otolaryngology of the University Hospital "Ospedali Riuniti", Foggia, Italy. Fistula closure was achieved by overlay apposition of a lower turbinate mucoperiostal graft fixated with fibrin glue and Surgicell. The etiology of the fistula was accidental trauma in 41 cases, iatrogenic trauma in 29, skull base tumour in 12, and spontaneous in 43. The site of the defect was the sphenoid sinus in 43 patients, the cribriform plate in 42, the anterior ethmoid roof in 21, the posterior ethmoid roof in 17, and the posterior wall of the frontal sinus in 2. The success rate at first attempt was 94.4%; the 7 cases of postoperative recurrent CSF leakage involved patients presenting with spontaneous fistula and elevated intracranial pressure; 5 of these had a body-mass index > 30 and 3 suffered from diabetes mellitus. In our hands, the success rate of endoscopic fistula repair was high, even in defects larger than 2 cm. Success rates may be further improved with accurate diagnosis of elevated intracranial pressure, a contributing factor to failure of spontaneous fistula repair.

Pediatric Traumatic Dural Arteriovenous Fistula

Dural arteriovenous fistulas are uncommon lesions in children, with traumatic lesions suspected to arise from incomplete arterial injury in proximity to a vein or draining sinus. Management of symptomatic acquired lesions requires evaluation of patient presentation, neurological status, and pathoanatomic configuration, with special consideration required for surgery secondary to failed endovascular technique. A 12-year-old male sustained a bicycle fall causing a right temporo-parietal skull fracture associated with non-surgical right epidural hematoma and left contre-coup parietal contusion. Six-weeks later, he complained of a right temporal bruit with subsequent cerebral angiography demonstrating a dural-based fistula between the right middle meningeal artery and a dural vein draining into the sigmoid sinus. Endovascular treatment of this lesion with glue embolization and coiling was unsuccessful, with angiographic illustration of previously unobserved collateral vessels and coils occupying the sigmoid sinus. A right temporo-parietal craniectomy was required to excise the dural-based fistula, followed by dural defect repair with bovine pericardium and subsequent cranioplasty. Six years later the patient remains neurologically intact with no headaches or bruit. Dural arteriovenous fistula can uncommonly occur following traumatic injury in children. Partial injury to the middle mengineal artery may have established arterial communication with the draining vein that became ectatic and tortuous under high pressure. Failure of primary endovascular treatment may complicate secondary surgical intervention.

Transparent equine collagen biomatrix as dural repair. A prospective clinical study

Numerous materials have been used to replace defects in the dura mater as result of neurosurgical and spinal procedures. Tissudura is a biomatrix made of cross-linked equine collagen fibrils, mainly of the interstitial type I. The specially engineered dura-like layered structure provides a non porous primary water tight structure, is transparent and allows verification of the efficacy of cerebral hemostasis. A consecutive series of patients between 18 years and 75 years of age were prospectively enrolled from three separate European institutions between May 2007 and February 2008. All patients underwent elective cranial or spinal surgery and required implantation of a dural substitute. We assessed the efficacy and safety of the collagen biomatrix as a dural substitute, intraoperatively and postoperatively, with a median follow-up 4.3 months. Fifty-six patients had cranial surgery, four patients underwent a spinal operation. Surgical cranial approaches included supratentorial procedures in 45 patients and posterior cranial fossa exploration in 11. At 7-days follow-up, a CSF leak was reported in one patient after excision of a vestibular schwannoma and in another with a thoracic vertebral body fracture and spinal cord transaction. Neither needed reoperation. A subgaleal fluid collection in two patients who had been treated for a supratentorial lesion resolved after tapping. The transparency of the implant was beneficial to inspect the underlying surgical area at the end of the procedure in one patient in whom a hematoma formed after secondary to oozing glioblastoma removal. Of the 56 patients who reached the 3-month follow-up, none had a CSF leak, meningitis, wound infection or fistulae. No duroplasty failure was observed. In one patient who underwent reoperation after 40 days, histopathological findings revealed the replacement of the implant by ingrowth from the original dura. Tissudura is simple, efficacious and safe to use. The use of fibrin glue reduces suturing and facilitates the implantation of the collagen biomatrix. Its transparency makes it unique and beneficial in inspection of the underlying area of operation. The lack of adverse reaction indicates that this graft may be used as an option in the repair of dural defects.

Dural Repair With Grafts Using the Gastrointestinal Anastomosis Stapler

Repair of large dural defects requires patch duraplasty with grafts. The ideal dural repair is watertight, inert, and resistant to adhesions. When a sizable defect requires multiple grafts, the grafts can be hand sewn to form one large sheet. This method can add significant time to the operative course. In addition, the risk of cerebrospinal fluid leakage is high with multiple hand-sewn seams. To reduce operating time and decrease the risk of cerebrospinal fluid leakage, we have used the 80-mm gastrointestinal anastomosis stapler with 3.8-mm titanium staples to create large sheets of graft material for dural repair. In 3 patients requiring repair of large dural defects, this method has produced seams that were atraumatic and watertight.