Surgical Dural Repair Research Articles

P22. Recurrent CSF leak following repair of incidental durotomy in lumbar spinal stenosis surgery

P22. Recurrent CSF leak following repair of incidental durotomy in lumbar spinal stenosis surgery

Targeted Epidural Blood Patches Under Fluoroscopic Guidance For Incidental Durotomies Related To Spine Surgeries: A Case Series.

IntroductionIncidental durotomies are usually managed conservatively. However, 1.8% of patients require surgical dural repair for CSF leak. There are limited data available regarding the use of epidural blood patches (EBP) for persistent CSF leaks secondary to incidental durotomies. This case series aims to evaluate the efficacy of targeted EBPs under fluoroscopic guidance in the treatment of incidental durotomies.MethodsFour patients with incidental durotomies after spine surgeries (one cervical decompression, one revision of L5-S1 decompression and fusion, and two lumbar decompressions) were included in this series. These patients did not respond to conservative management and subsequently underwent EBPs. Magnetic resonance imaging (MRI) images were reviewed to confirm and identify the sites of CSF leak prior to the EBPs. We targeted the sites of CSF leak with fluoroscopic guidance. All four patients received an EBP with an 18-gauge epidural needle placed under fluoroscopic guidance. In some cases, epidural catheters were used to further target the sites of CSF leak. Contrast was used to confirm the appropriate placements of the needles and catheters. Approximately 5–14 mL of autologous blood was injected through the needles or catheters to the sites of dural leak.ResultsThree lumbar and two cervical EBPs were performed in four patients (two females and two males). Their age ranged from 44 to 73 years old. Two out of three patients who had lumbar EBP reported complete resolution of symptoms following EBP. The patient who had cervical epidural patches did not have improvement in her symptoms.ConclusionThis case series demonstrated that targeted EBP can be an effective treatment for CSF leak from incidental durotomies. However, dural tears in the cervical region may be more difficult to treat. Larger scale studies are required to evaluate efficacy of EBP in the treatment of symptomatic incidental durotomies.

Post-dural puncture headache: Epidemiology, onset mechanisms, clinical symptoms, diagnosis and therapy

Introduction. Post-dural puncture headache is classified as a secondary headache attributable to non-vascular intracranial disorders and belongs to the group of headaches caused by low cerebrospinal fluid pressure. Etiopathogenesis. The pathogenesis is not completely clear, but it is thought to be caused by the cerebrospinal fluid leak through the duct opening. Cerebrospinal fluid efflux leads to a decrease in intracranial pressure and stretching of the pain sensitive intracranial structures. A drop in intracranial pressure can cause compensatory cerebrovascular vasodilation, contributing to the onset of a headache. Diagnosis and Therapy. Post-dural puncture headache clinically presents as an orthostatic headache. In most cases, the diagnosis is made based on a typical clinical picture and it can be confirmed by magnetic resonance imaging and measurement of cerebrospinal fluid pressure. The condition is usually benign, most often with spontaneous recovery. The therapy involves conservative treatment, medications, as well as some invasive methods: epidural blood patches, blockage of the greater occipital nerve, and in most severe cases, epidural injection of fibrin sealant or surgical dural repair. Conclusion. Post-dural puncture headache is a common complaint in the clinical practice of neurologists and anesthesiologists. The prognosis is usually favourable, while the therapy may include conservative or invasive treatment procedures.

Reposing the herniated spinal nerves following accidental iatrogenic dural tear in spine surgery-The "no touch hip flexion technique".

Sir, During lumbosacral operations dura may get breached and the cerebrospinal fluid (CSF) with underlying nerve roots immediately come out from the dura vent like a flower vase. These nerves don’t go back easily and also if attempted to push it in, cause physical damage. The treatment of dural tear has evolved through time. There are several methods for the repair of dural tear including primary repair, tissue sealant, blood patch, tissue grafting, gelfoam and glue applications.[1] We report five cases of accidental dural tear after lumbar disc Figure 1: Surgery, its intradural reposition with no-touch hip flexion technique [Table 1]. Figure 1 L5/S1 PIVD Table 1 Relevant cases In all the cases during the operation, we noted that the ventral dura was severely adhered to the surrounding tissue. During dissection, the thinned dura was torn. There was CSF leakage and immediate rootlet herniation. We did not touch the herniated nerve roots, instead we put a cotton patty on the vent. Then semiprone position was made and back towards the operator. Then flexed the hip joint so that the intrathecal stretching of nerves transmitted through the lumbosacral nerves via sciatic nerve caused the herniated nerve roots to go inside spontaneously and immediately. Then water tight duraplasty was done without physical handling of herniated nerve roots. For confirmation of CSF leakage Valsalva maneuver was done before wound closure. Incidental dural tear is a common complication of spinal surgery (incidence from 3.1% to 14%).[2,3,4] The risk of dural tears is increased by conditions such as fibrotic adhesion in chronic cases, scar tissue from prior surgery, eroded dura, redundant dura in patients with large disc herniations,[4] advanced patient age and the surgeon's training level.[5] Good long-term outcomes have been reported when incidental dural tears were recognized intraoperatively and repaired primarily.[3] There are several methods for the repair of dural tear including primary repair, tissue sealant, blood patch, and tissue grafting.[1] Poor clinical outcome[4] have been reported like posttraumatic spinal cord or nerve root herniation through a dural defect site which may cause recurrence of radiating pain also headaches and wound infection in the short term and presence of a pseudomeningocele, persistent CSF leak, neurologic deficits, fistula formation, meningitis, arachnoiditis, or an epidural abscess in the long term. In addition, a pseudomeningocele may entrap nerve roots or the spinal cord and cause radicular symptoms. Nerve root herniation is an infrequent complication of incidental dural tear. Unrecognized or incidental dural tear was repaired using Gelfoam and fibrin glue. Treatment with gelfoam and fibrin glue alone may not prevent persistent CSF leakage.[6] Surgically the dorsal dural vent is primarily repaired by increasing the vent and then manually reposing the herniated nerves with non-toothed fine forceps. Although conservative treatments such as bed rest and closed subarachnoid drainage have been attempted, midline durotomy and meticulous surgical dural repair remain the definitive treatment for ventral dural vents. One study reported that bed rest is not a definitive treatment; in this study, the patients who did not undergo dural repair developed complications.[7] These patients eventually underwent dural repair. Another study reported that the Valsalva maneuver may help identify the dural tear in suspected cases.[8] In dural dorsal or ventrolateral vents the physical handling of the herniated nerve roots thus iatrogenic damage may be avoided by a very simple maneuver. We operate these patients usually in prone position. Immediately after incidental dural tear we put a cotton patty on the herniated nerves. Do not touch the nerves with any instrument, make semi-prone position and flex the hip joint so that the various lumbosacral plexus’ nerves stretch which in turn stretches the intrathecal nerve root causes them to go inside without increasing the vent and physical handling of the nerves. Iatrogenic dural vent causes rootlet herniation and a simple “no touch hip flexion technique” reposes the nerve roots effectively without physical handling to prevent nerve rootlet entrapment and other complications. Valsalva maneuver should be performed before and after the wound closure.

Use of a Novel Absorbable Hydrogel for Augmentation of Dural Repair: Results of a Preliminary Clinical Study

To evaluate the safety and performance of a synthetic dural sealant as an adjunct to standard surgical dural repair techniques to prevent cerebrospinal fluid (CSF) leakage. This study was designed as a prospective, nonrandomized, single-center clinical trial. The dural sealant is a synthetic absorbable hydrogel. Consecutive series of patients scheduled for elective cranial and intradural spinal surgery were included until a total of 50 applications were achieved. It was used primarily as an adjunct to ensure watertight dural closure. The end point was defined as no leak with the Valsalva maneuver after dural sealant application. The patients were followed up for 3 months after surgery to check for CSF leakage, standard laboratory and neurological examinations, and possible adverse advents. Of the 49 patients, 46 were included and treated with the dural sealant because of spontaneous leak (n = 34; 69%) or leak after the Valsalva maneuver (n = 12; 25%). There was no leak in the other patients (n = 3; 6%). After application of the dural sealant, there was no leak in all 46 patients (100%). Of the 46 patients included, there was one case of overt CSF leak. One patient had a pseudomeningocele. There were no adverse events other than those related to the disease or to the surgical procedure itself. The dural sealant, a synthetic absorbable hydrogel, is a useful adjunct to achieve watertight dural closure. Application resulted in 100% closure of intraoperative CSF leaks. There are no evident adverse effects.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair

Background The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. Methods A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. Results Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. Conclusions Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Fístula de líquido cefalorraquídeo y meningitis por estreptococo equisimilis 16 años después de un traumatismo craneoencefálico

A case of meningitis caused by Streptococcus Equisimilis and cerebrospinal fluid rhinorrhea, in which the head trauma occurred 16 years before, is presented. To the best of the author's knowledge this is the first case reported with such characteristics. Several precipitating factors could be responsible for the unusually late reopening of the fistula Streptococci equisimilis is an uncommon cause of the bacteremia. An appropriate antimicrobrial therapy against S. Equisimilis followed by surgical dural repair were performed.

Fractures of the middle third of the face and cerebrospinal fluid rhinorrhoea.

The incidence of cerebrospinal fluid (CSF) rhinorrhoea in patients with facial fractures is about 25%. Although the management of facial fractures is well documented, its timing and role in the presence of CSF leak is still open to debate. This study evaluates facial manipulation in 89 facial fractures associated with CSF rhinorrhoea, with a mean follow-up of 4 years. The facial fractures were reduced in 26 patients (29%) and the CSF fistula was repaired in 75 (84%). Twenty-three (25.8%) had both facial manipulation and dural repair with no deaths, post operative infection, failure or recurrence of CSF leak. On the other hand, when facial manipulation or dural repair was performed alone, the CSF rhinorrhoea either persisted or recurred in a significant number of patients requiring further intervention. Although this is a retrospective analysis of patients treated over several years and, there has been a change in the methods of investigation and treatment of these patients, one can conclude that manipulation of facial fractures and surgical dural repair can be carried out at the same sitting without increasing the surgical morbidity and mortality.

Post-traumatic CSF fistulae, the case for surgical repair

The management of acute post-traumatic CSF fistulae is still a matter of controversy. A long-term analysis of 160 patients with acute post-traumatic non-iatrogenic dural fistulae was undertaken to establish the value of surgical dural repair. One hundred and forty-nine patients underwent dural repairs following traumatic CSF rhinorrhoea. The risk of meningitis following surgical dural repair was 4%. The operative mortality was 1.3% (2/151), as was the negative exploration rate. The first dural repair was successful in 90% and a second dural repair was required in 10%. These results are in favour of surgical dural repair which can be undertaken with a low morbidity and mortality and is highly successful in preventing meningitis following traumatic CSF rhinorrhoea.

Acute traumatic CSF fistulae: the risk of intracranial infection

The management of acute traumatic cerebrospinal fluid (CSF) fistulae is still a matter of debate and hinges about what is perceived to be the risk of subsequent intracranial infection. We have therefore carried out a retrospective analysis of 160 cases of traumatic CSF leaks to assess the incidence, cumulative risk and prognosis of intracranial infection. The overall incidence of meningitis in this group before surgical dural repair was 30.6% (49/160), the cumulative risk exceeded 85% at 10 years follow-up and the meningitis was fatal in 4.1% (2/49). The recurrence of CSF leakage after initial spontaneous cessation was 7% and meningitis was recurrent in 30.6% (15/49). Prophylactic antibiotics had reduced the risk of meningitis from 61 to 34%. The commonest pathogen was pneumococcus and the CSF leakage had stopped within 7 days in 60% of those who developed meningitis and in 50% of those who did not develop meningitis. Meningitis is still a serious complication of post-traumatic CSF fistulae and is potentially fatal despite modern therapeutic agents.

Study and clinical application of a porcine biomembrane for the repair of dural defects.

A biomembrane was developed from pig peritoneum treated with 0.65% glutaraldehyde. This was evaluated for use as a dural substitute in an animal model and in a patient population. After being treated with the glutaraldehyde solution, the biomembrane lost its antigenicity while its collagen underwent an irreversible cross-linking reaction, causing it to become a stable nonviable polymer resistant to absorption by the host. The biomembrane was used experimentally in 43 procedures on 20 dogs and was applied clinically in 614 patients. The results demonstrated that it is an acceptable material for the repair of dural defects, with the following advantages: 1) it is nontoxic to the body and brain tissues, with minimal tissue reaction; 2) its biophysical properties facilitate watertight closure with sutures; 3) its distensibility makes it suitable for decompressive surgical dural repair; and 4) its visceral surface is extremely smooth, causing virtually no adhesions with the brain tissue while the outer surface readily heals with the subcutaneous tissue.