Efficacy and safety of a collagen matrix for cranial and spinal dural reconstruction using different fixation techniques

OBJECT: The use of dural grafts is frequently unavoidable when tension-free dural closure cannot be achieved following neurosurgical procedures or trauma. Biodegradable collagen matrices serve as a scaffold for the regrowth of natural tissue and require no suturing. The aim of this study was to investigate the efficacy and safety of dural repair with a collagen matrix using different fixation techniques. METHODS: A total of 221 patients (98 male and 123 female; mean age 55.6 +/- 17.8 years) undergoing cranial (86.4%) or spinal (13.6%) procedures with the use of a collagen matrix dural graft were included in this retrospective study. The indications for use, fixation techniques, and associated complications were recorded. RESULTS: There were no complications of the dural graft in spinal use. Five (2.6%) of 191 patients undergoing cranial procedures developed infections, 3 of which (1.6%) were deep infections requiring surgical revision. There was no statistically significant relationship between the operative field status before surgery and the occurrence of a postoperative wound infection (p = 0.684). In the 191 patients undergoing a cranial procedure, cerebrospinal fluid (CSF) collection occurred in 5 patients (2.6%) and a CSF fistula in 5 (2.6%), 3 of whom (1.6%) required surgical revision. No patient who underwent an operation with preexisting CSF leakage had postoperative CSF leakage. Postoperative infection significantly increased the risk for postoperative CSF leakage. The collagen matrix was used without additional fixation in 124 patients (56.1%), with single fixation in 55 (24.9%), and with multiple fixations in 42 (19%). There were no systemic allergic reactions or local skin changes. Follow-up imaging in 112 patients (50.7%) revealed no evidence of any adverse reaction to the collagen graft. CONCLUSIONS: The collagen matrix is an effective and safe cranial and spinal dural substitute that can be used even in cases of an existing local infection. Postoperative deep infection increases the risk for CSF leakage.     

Safety and efficacy of the porcine small intestinal submucosa dural substitute: results of a prospective multicenter study and literature review

OBJECT. Dural substitutes are often needed after neurosurgical procedures to expand or replace dura mater resected during surgery. A new dural repair material derived from porcine small intestinal submucosa (SIS) was evaluated in a prospective multicenter clinical study. METHODS. Between 2000 and 2003, 59 patients at five different institutions underwent dural reconstruction with the SIS dural substitute, with a minimum follow up of 6 months. The primary goals of the study were to assess the efficacy and safety of the SIS dural substitute according to the rate of cerebrospinal fluid (CSF) leakage, infection, and meningitis. Chiari malformation Type I decompression (32 patients) and tumor resection (18 patients) were the most common procedures performed, with 81% of SIS grafts implanted in the posterior fossa or spine. There was one case of a CSF leak (1.7%), two cases of wound infection (3.4%), and no cases of bacterial meningitis (0%) in the 58 patients available for follow up. In both cases of wound infection, the SIS graft acted as a barrier to infection and was not removed. Intraoperatively, a watertight seal was achieved in all 59 cases. On follow-up imaging available in 27 patients there was no evidence of any adverse reaction to the graft or of cerebral inflammation. CONCLUSIONS: The SIS dural substitute demonstrated substantial efficacy in these patients after a mean follow up of 7.3 +/- 2.2 months. Rates of infection, CSF leakage, and meningitis were comparable to those reported for other dural substitute materials. A lack of adverse reactions to the graft, favorable safety profile, and clinical efficacy all point to the utility of this material as an alternative for dural repair.     

Dural substitute with polyglycolic acid mesh and fibrin glue for dural repair: technical note and preliminary results

Background An ideal dural substitute that enables watertight closure, has sufficient strength, and can be absorbed without remnant materials that induce inflammation, adhesion, and infection is not available. The purpose of this study was to evaluate the efficacy of a bioabsorbable polyglycolic acid (PGA) mesh and fibrin glue as a substitute for dural repair. Methods Altogether, 10 patients with noted dural tears during extradural spinal surgery and 20 patients who underwent durotomy for intradural spinal surgery were included in this study. In a series of 20 consecutive cases, dural closure was performed by suture and fibrin glue. In the subsequent 10 consecutive patients, dural closure was performed by suture and fibrin glue with the use of absorbable PGA mesh. The medical records and magnetic resonance imaging (MRI) of the surgical site were retrospectively reviewed to evaluate the presence of a cerebrospinal fluid (CSF) fistula or leakage after the surgery. Results A CSF fistula occurred in five patients who underwent dural repair with fibrin glue alone, and postoperative MRI showed CSF leakage in two patients with incidental dural tears after laminectomy for ossification of ligamentum flavum. No CSF fistula was present in patients who underwent dural repair using PGA mesh and fibrin glue, and no adverse effects or complications were encountered postoperatively. Follow-up MRI revealed no evidence of CSF leakage around the reconstructed dura mater. Conclusions The use of PGA mesh and fibrin glue for the repair of dura mater is a useful method of preventing CSF leakage in spinal surgery.     

Nonsuture dural repair using polyglycolic acid mesh and fibrin glue: clinical application to spinal surgery

BACKGROUND: In spinal surgery, repair of the dura is difficult when it is torn or fragile or is ossified as in cases with ossification of posterior longitudinal ligament. We report our experience with a nonsuture dural repair technique in patients undergoing spinal surgery; it uses a dura substitute composed of polyglycolic acid (PGA) mesh and fibrin glue. Here, we report the efficacy and safety of nonsuture duroplasty using PGA mesh and fibrin glue (PGA-fibrin sheet). METHODS: The artificial dura mater is composed of a PGA-fibrin sheet. The dural defect is covered with a patch sprayed with fibrin glue without suturing to the dura mater. We first evaluated this technique in an experimental study by performing water leakage tests. Between May 2001 and January 2005, we used it in 160 spinal surgeries that required intraoperative dura repair. RESULTS: Our preliminary tests showed that the threshold for water pressure without leakage was 161 +/- 42 and 96.5 +/- 32 mm Hg when the unsprayed margin around the perimeter of the patch was 5 and 2 mm, respectively. Of the 160 operated patients, 10 (6.3%) experienced subcutaneous cerebrospinal fluid (CSF) leakage. Of these, 6 required a second operation; in the other 4, the CSF collection diminished spontaneously. There were no other complications such as allergic reaction, adhesion, or infection. CONCLUSION: In combination with CSF diversion, the PGA-fibrin sheet is a viable alternative method for dural repair in spinal surgery.     

Management of acute intraoperative cerebrospinal fluid leaks

Incidental durotomy in spinal surgery has been reported with incidences varying between 1 and over 16%, depending on the type of surgery and the region of the spine. When a dural tear occurs, immediate and meticulous repair is advised in order to minimize the risk of complications secondary to persistent leakage of cerebrospinal fluid (CSF). These complications include intracranial hypotension, pseudomeningocele formation and the development of a CSF fistula with secondary wound infection and meningitis. Most dural tears are caused during biting actions by Kerrison rongeurs, and dural adhesions, dural redundancy and thinned dura are known risk factors. Accurate visualization and thorough preparation of the surgical field are key steps in dural tear repair. Those tears that are amenable to it should be carefully sutured. Large defects may require a patch of dural substitute to be sewed in. Autologous fat has proven to be useful as onlay or plugin graft. The use of fibrin glue has become a widespread practice and its effectiveness as an adjunct to primary suturing and graft constructions has been well demonstrated. Hydrogel sealants and collagen matrix onlay grafts have become available to the surgeon as additional tools in dural tear repair. However, primary suturing — if possible — is still considered to be the most effective way of reducing the chance of persistent CSF leakage. Tight closure of the fascial layer is imperative. After lumbar durotomy repair, bed rest is advised. Postoperative lumbar or ventricular CSF drainage can also help as an additional protective measure. While numerous measures and tools are available, the key message is that the surgeon confronted with a dural tear should take his time and apply all intraoperative and postoperative means required to secure watertight closure.     

脊柱手术中硬脊膜损伤及术后脑脊液漏的处理

目的 探讨脊柱外科手术的常见并发症——术中硬脊膜损伤及术后脑脊液漏的外科处理措施，并观察其疗效。方法 回顾性分析2002年6月-2006年3月接受脊柱手术的405例患者资料。其中男298例，女107例；年龄11～78岁，平均46．2岁。病程3个月～5年。术中硬脊膜损伤或切开者28例（6．91％），其中颈椎3例，胸椎和腰椎19例，骶椎6例：28例中术后有6例发生脑脊液漏。术中未发现硬脊膜损伤而术后发生脑脊液漏2例。术后脑脊液漏的总发生率为1．98％。采用修复硬脊膜裂口、严密缝合切口各层、卧床休息和伤口加压包扎等综合措施处理。观察并记录处理疗效。结果 所有患者获随访3个月～4年，平均1年5个月。术前症状获不同程度缓解。8例术后脑脊液漏患者均获临床治愈，其中6例硬脊膜囊背侧瘘主要通过卧床休息、伤口加压包扎和再次手术缝合治愈，2例硬脊膜囊腹侧和侧方瘘尚需附加持续腰椎蛛网膜下腔引流。并发中枢神经系统感染1例，经多科协作治疗而愈合。结论 及时、正确地进行术中干预和术后处理，可有效治疗脊柱手术中硬脊膜损伤并预防术后脑脊液漏形成。     

Dural tear and resultant cerebrospinal fluid leaks after cervical spinal trauma

Purpose

Traumatic cervical spinal cord injuries (SCIs) frequently develop dural tears and resultant cerebrospinal fluid (CSF) leaks. They are not usually identified with advanced imaging, and there are no reports on managing CSF leaks after cervical trauma. Hence, the authors evaluated the incidence of CSF leaks after cervical SCIs and described how to predict and manage CSF leaks.

Methods

An observational retrospective study was done confirming intraoperative CSF leaks among 53 patients with anterior cervical surgery after cervical spine trauma between 2004 and 2011.

Results

Seven patients (13.2 %) had dural tears and resultant CSF leaks intraoperatively (M:F ratio of 6:1; mean age, 44.7 years). An initial poor American Spinal Injury Association (ASIA) scale was significantly associated with CSF leaks (p = 0.009). From magnetic resonance imaging (MRI), disruption of the ligamentum flavum was correlated with CSF leaks (p = 0.02). Intraoperative application of fibrin glue on the operated site, postoperative management through the early removal of the wound drain within the first 24 h and early rehabilitation were performed in patients with CSF leaks without perioperative insertion of a lumbar drain. During the follow-up period, none of the patients developed CSF-leak-related complications.

Conclusion

The incidence of CSF leaks after traumatic cervical SCI is relatively higher than that of degenerative cervical spinal surgery. An initial poor neurological status and disruption of the ligamentum flavum on the MRI in patients were predictable factors of dural tears and CSF leaks.     

Nontraumatic intradiploic arachnoid cysts--report of five cases.

Five cases of nontraumatic intradiploic arachnoid cysts in elderly patients are reported. All cysts were located in the occipital bone and appeared as well-demarcated radiolucent lesions. The cysts were multiple in three cases. Presenting symptoms included headache or dizziness, but most lesions were asymptomatic and found incidentally. In the most recent three cases, magnetic resonance (MR) imaging revealed intradiploic cysts containing cerebrospinal fluid (CSF) with cerebellar herniation. Operation found the cysts filled with CSF and dural defects through which cerebellar tissue was herniating. In two patients, CSF leakage from the outer table occurred. Intradiploic arachnoid cyst seems to be congenital in origin but commonly found in the elderly. MR imaging is the most useful diagnostic method for differential diagnosis from other osteolytic skull lesions.     

Perioperative lumbar subarachnoid drainage could not prevent postoperative CSF leakage after spinal cord tumor resection using an artificial dura mater

BackgroundCerebrospinal fluid (CSF) leakage occurs in patients who undergo dural repair using artificial dura mater. This study aimed to determine if perioperative lumbar subarachnoid drainage could reduce the incidence of postoperative CSF leakage in cases of dural repair using artificial dura mater.MethodsWe retrospectively analyzed 84 patients (41 men, 43 women; mean age, 52.2 ± 20.1 years) who underwent intradural spinal cord tumor resection and dural repair using artificial dura mater. These patients were divided according to whether they underwent perioperative lumbar subarachnoid drainage (39 patients: D group) or had no drainage (45 patients: ND group). The incidence of radiographic and symptomatic CSF leakage as well as baseline characteristics and operative data were compared between the two groups.ResultsRadiographic CSF leakage was observed in 21 patients (25.0%), including 10 (25.6%) in the D group and 11 (24.4%) in the ND group. Symptomatic CSF leakage was observed in 12 patients (14.2%), including six (15,4%) in the D group and 11 (13.3%) in the ND group. There were no significant differences in the incidence of subcutaneous CSF accumulation and symptomatic CSF leakage between the two groups. In cases with symptomatic CSF leakage, the onset time of CSF leakage tended to be earlier (5.7 days vs 15.7 days), and the treatment period tended to be longer (5.8 weeks vs 2.8 weeks) in the ND group than in the D group.ConclusionsPerioperative lumbar subarachnoid drainage did not reduce the incidence of either radiographic or symptomatic CSF leakage. However, it might shorten the treatment period and reduce refractory CSF leakage, which requires multiple treatments over a long period.     

An exceptional case of complete lumbosacral spine duplication and open myelomeningocele in adulthood

The authors describe the case of a 47-year-old woman with a wide (14 × 12-cm) ulcerated lumbosacral myelomeningocele. The patient had sought medical attention for a sudden copious CSF leak from the lumbosacral sac followed by clinical signs of CSF leakage. After admission, neuroradiological assessment (spinal MR and 3D CT imaging) revealed the uncommon finding of a complex malformation characterized by a complete spine duplication originating at the L2-3 level, both hemicords having a separate dural sac. The myelomeningocele sac originated medially at the L-2 level. Surgical repair of the lumbosacral myelomeningocele was performed. The placement of a ventriculoperitoneal shunt became necessary to treat secondary hydrocephalus. After reviewing accredited classifications on spinal cord malformations, the authors believe that, to date, complete duplication and separation of the spine and dural sac seems exceptional, and its report in adulthood appears exceedingly rare.     

Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery

Approximately one million spinal surgeries are performed in the United States each year. The risk of an incidental durotomy (ID) and resultant persistent cerebrospinal fluid (CSF) leakage is a significant concern for surgeons, as this complication has been associated with increased length of hospitalization, worse neurological outcome, and the development of CSF fistulae. Augmentation of standard dural suture repair with the application of fibrin glue has been suggested to reduce the frequency of these complications. This study examined unintended durotomies during lumbar spine surgery in a large surgical patient cohort and the impact of fibrin glue usage as part of the ID repair on the incidence of persistent CSF leakage. A retrospective analysis of 4,835 surgical procedures of the lumbar spine from a single institution over a 10-year period was performed to determine the rate of ID. The 90-day clinical course of these patients was evaluated. Clinical examination, B-2 transferrin assay, and radiographic imaging were utilized to determine the number of persistent CSF leaks after repair with or without fibrin glue. Five hundred forty-seven patients (11.3%) experienced a durotomy during surgery. Of this cohort, fibrin glue was used in the dural repair in 278 patients (50.8%). Logistic models evaluating age, sex, redo surgery, and the use of fibrin glue revealed that prior lumbar spinal surgery was the only univariate predictor of persistent CSF leak, conferring a 2.8-fold increase in risk. A persistent CSF leak, defined as continued drainage of CSF from the operative incision within 90 days of the surgery that required an intervention greater than simple bed rest or over-sewing of the wound, was noted in a total of 64 patients (11.7%). This persistent CSF leak rate was significantly higher (P < 0.001) in patients with prior lumbar surgery (21%) versus those undergoing their first spine surgery (9%). There was no statistical difference in persistent CSF leak between those cases in which fibrin glue was used at the time of surgery and those in which fibrin glue was not used. There were no complications associated with the use of fibrin glue. A history of prior surgery significantly increases the incidence of durotomy during elective lumbar spine surgery. In patients who experienced a durotomy during lumbar spine surgery, the use of fibrin glue for dural repair did not significantly decrease the incidence of a persistent CSF leak.     

Safety and efficacy of a novel polyethylene glycol hydrogel sealant for watertight dural repair

OBJECT: The authors prospectively evaluated the safety and efficacy of a novel polyethylene glycol (PEG) hydrogel sealant in patients undergoing elective cranial surgery with documented cerebrospinal fluid (CSF) leakage after sutured dural repair. METHODS: The PEG hydrogel sealant was used at 11 different study sites in 111 patients with documented intraoperative CSF leakage after neurosurgical dural repair for a variety of conditions. Intraoperative CSF leakage was either spontaneous or induced by a Valsalva maneuver. Patients were monitored for 3 months postoperatively with physical examinations, clinical laboratory analyses, and diagnostic imaging. The PEG hydrogel sealant was 100% effective in stopping CSF leakage in all patients. There were no sealant-related adverse events and all clinical outcomes were consistent with expectations for seriously ill patients undergoing prolonged neurosurgical procedures. CONCLUSIONS: The PEG hydrogel sealant provides a safe and effective watertight closure when used as an adjunct to sutured dural repair during cranial surgery.     

Use of resorbable collagen dural substitutes in the presence of cranial and spinal infections-report of 3 cases

BACKGROUND: Various allografts, xenografts, and synthetic materials are used in neurosurgery to repair dural defects when primary suture closure is impossible and autologous grafts are inadequate or inaccessible. When used in contaminated or infected wounds, however, nonautologous grafts promote chronic colonization and recurring infection. Recently, several resorbable dural substitutes that are broken down biologically and replaced by autologous tissues have been introduced. These include type 1 collagen matrix (DuraGen, Integra LifeSciences, Plainsboro, NJ) and a collagen implant derived from bovine skin (Durepair, Medtronic, Inc, Minneapolis, Minn), which can be applied as sutured or sutureless onlay grafts. The safety and efficacy of this material has not been reported in the setting of wound contamination or infection. CASE DESCRIPTIONS: We present 3 cases in which these new collagen dural substitutes were successfully used to close dural defects in the presence of wound contamination and infection. In one case, a lumbar dural defect was closed with DuraGen in the presence of a subdural empyema. In the second case, maceration of the cranial dura mater from extensive compound depressed skull fractures was repaired with DuraGen in the presence of a subgaleal abscess. In the third case, a large dural defect in the setting of frontal osteomyelitis was successfully closed with sutured Durepair. In all cases appropriate antibiotic coverage was provided for the infection, and the tissues healed with excellent biologic incorporation and without evidence of further infection. CONCLUSIONS: Resorbable collagen dural grafts appear to be effective alternatives to either primary dural closure or the use of autologous-harvested tissue grafts in the setting of grossly contaminated or infected wounds.     

A Clinical Study of a Fibrinogen-Based Collagen Fleece for Dural Repair in Neurosurgery

Summary. Summary.   Background: There is frequently a need for dural grafts to cover defects resulting from retraction, shrinkage, or excision following neurosurgical procedures. Many substances have been tried as possible dural substitution, and different tissues and materials have been evaluated for use in dural repair.   Method: The authors performed a retrospective review of 288 consecutive neurosurgical procedures using a fibrinogen based collagen fleece (TachoComb?), a resorbable mesh of collagen from horse tendons, coated with human fibrinogen, bovine thrombin, bovine aprotinin and riboflavin (for marking the coated side), for dural substitution. The fibrinogen and thrombin imitate the last step of the coagulation cascade. On contact with bleeding wounds or other body fluids the coagulation factors dissolve and a link is formed between the collagen carrier and the wound surface. Thrombin converts fibrinogen into fibrin by splitting off peptides. Aprotinin prevents premature lysis of the fibrin clot by plasmin.   Findings: Neither superficial or deep wound infections nor aseptic meningitis were noted. We found good fibrous incorporation of TachoComb? into the surrounding normal dura. Postoperative cerebrospinal-fluid (CSF) leaks developed in only five cases, who had to be re-operated, upon as well as one patient with a rebleeding. In another four cases, there was notable subcutaneous cerebrospinal-fluid accumulation without CSF-leak. They required a lumbar cerebrospinal-fluid drainage.   Interpretation: We conclude that TachoComb? is a valuable alternative to the patients fibrous tissues for dural repair in cases in which autogenous tissues are either unavailable or insufficient for proper reconstruction.     

Use of equine collagen foil as dura mater substitute in endoscopic endonasal transsphenoidal surgery

OBJECTIVE: This study describes the use of a novel collagen-based dural substitute in endoscopic endonasal transsphenoidal surgery. METHODS: Operative records were reviewed for a 12-month period for all patients who underwent surgery by means of an endoscopic endonasal transsphenoidal approach since we began using TissuDura (Baxter, Vienna, Austria) collagen-only dural substitute in January 2004. RESULTS: During the 12-month period evaluated, we performed an endoscopic endonasal transsphenoidal operation for a variety of pituitary lesions on 72 consecutive patients. Among these, 15 patients (20.8%) required the implant of the collagen foil. Nine patients (60%) presented an intraoperative CSF leak (3 small weeping of CSF and 6 larger leaks); in these cases, the TissuDura was used against the arachnoid membrane, followed by the other materials used for the repair. In 7 other subjects without any evidence of CSF escape, the collagen foil was used to protect and enforce the arachnoidal membrane descent into the sellar cavity to prevent its possible postoperative rupture and consequent CSF leak. Fibrin glue was used in all cases. A postoperative CSF leak with meningitis occurred in only 1 (6.7%) of the 15 subjects. The patient required a reoperation for CSF fistula repair and intravenous antibiotics. CONCLUSIONS: Even if based on a relatively small patient series, our experience demonstrated that the use of TissuDura in transsphenoidal surgery is safe and biocompatible, as compared with other dural substitutes.     

Axially loaded magnetic resonance image of the lumbar spine in asymptomatic individuals.

STUDY DESIGN: For this study, 43 asymptomatic individuals underwent magnetic resonance imaging of the lumbar spine in both supine psoas-relaxed position and supine axial compression in extension. The change in dural cross-sectional area between positions at each disc level was calculated. OBJECTIVES: To evaluate the effect of axial loading on asymptomatic individuals, as compared with the effect on patients who have clinical signs of lumbar spinal canal stenosis, and to assess the effect that different magnitude and duration of the applied load have on the dural cross-sectional area. SUMMARY OF BACKGROUND DATA: Degenerative changes in the spine are found in both symptomatic and asymptomatic individuals. A study of patients with suspected clinical lumbar spine encroachment examined in both psoas-relaxed position and axial compression in extension with computed tomographic myelography or magnetic resonance imaging of the lumbar spine is reported. A significant decrease in dural cross-sectional area was found, respectively, in 80% and 76% of the patients. METHODS: The study subjects underwent magnetic resonance imaging examinations in both psoas-relaxed position and axial compression in extension. The examination of the subject under axial compression in extension was performed with the lumbar spine in a supine position using a compression device. Degenerative changes in and adjacent to the spinal canal were registered. The dural cross-sectional areas were determined for psoas-relaxed position and axial compression in extension, then compared. In seven reexamined individuals, the dural cross-sectional area was calculated after an axial load corresponding to 25% and 50% of their body weight and a loading time of 5 to 60 minutes. RESULTS: A significant decrease in dural cross-sectional area from psoas-relaxed position to axial compression in extension was found in 24 individuals (56%), most frequently at L4-L5, and increasingly with age. In four individuals (5 disc levels), a decrease in dural cross-sectional area to less than 100 mm2 from psoas-relaxed position to axial compression in extension was found. In seven reexamined individuals, a significant decrease in dural cross-sectional area was found: in five after 5 minutes load of 25% of their body weight, and in two with 50% of their body weight. CONCLUSIONS: Using magnetic resonance imaging, a significant decrease in dural cross-sectional area after axial loading was found less frequently in asymptomatic than in symptomatic subjects. The decrease was more frequent at L4-L5, and increasingly with age. The load should be 50% of the subject's body weight applied for at least 5 minutes.     

BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series

BACKGROUND: The efficacy of BioGlue (CryoLife, Inc, Atlanta, Ga) surgical adhesive in transsphenoidal surgery was assessed as an adjunct in the prevention of postoperative CSF leaks. METHODS: All patients in whom BioGlue was used for an intraoperative skull base reconstruction were retrospectively identified. Intraoperative CSF leaks were graded according to size (grade 1, small weeping leak without obvious diaphragmatic defect; grade 2, moderate leak with a definite diaphragmatic defect; grade 3, large diaphragmatic and/or dural defect). CSF leak repair was tailored to CSF leak grade. BioGlue was applied as a reinforcement over collagen sponge as the last layer of the repair. RESULTS: Over 28 months, a total of 282 patients underwent endonasal surgery. Of these patients, 124 (79 women; age range, 8-84 years), in 128 procedures, had an intraoperative CSF leak repair reinforced with BioGlue. Pathology included 80 pituitary adenomas, 11 craniopharyngiomas, 7 Rathke's cleft cysts, 6 chordomas, 5 meningiomas, 4 spontaneous CSF leaks, 3 arachnoid cysts, and 8 other parasellar pathologies. There were 62 (48.4%) grade 1, 41 (32.0%) grade 2, and 25 (19.5%) grade 3 leak repairs. The overall repair failure rate was 1.6% (2 cases), with the failures occurring in patients with grade 3 leaks, including 1 who developed meningitis; there was no failure of grades 1 and 2 leaks. The 2 failures were attributed largely to technical aspects of the repair rather than to failure of BioGlue per se. CONCLUSIONS: BioGlue appears to be an effective adjunct in preventing postoperative CSF leaks after transsphenoidal surgery. However, careful attention to technical details of the repair is still required to prevent failures, especially when closing large dural and diaphragmatic defects.     

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.     

The use of Vicryl Collagen® as a dura substitute: A clinical review of 78 surgical cases

Summary We performed a retrospective review of 78 consecutive neurosurgical procedures using Vicryl Collagen^?, a resorbable mesh of polyglactin 910 coated with bovine collagen, for dural substitution. The complications we encountered were infrequent and mostly minor (5 cases of subcutaneous CSF collections, 2 cases of aseptic meningitis, 1 superficial wound infection), and not unusual for the surgical procedures studied. One patient, however, had a major infection, starting in the superficial tissues, and extending toward the brain. In this patient, the resorption of the dural substitute appeared to be the cause for the intracranial extension of the infection. Three patients were reoperated on for recurrent tumour after a longer interval. We found minimal adhesions and good fibrous incorporation of the Vicryl Collagen^? into the surrounding normal dura. We conclude that Vicryl Collagen^? is a valuable alternative to the patient’s own fibrous tissues when dural substitution is necessary.     

Dural repair reduces connective tissue scar invasion and cystic cavity formation after acute spinal cord laceration injury in adult rats

This study examined whether duraplasty after acute cervical laceration spinal cord injury (SCI) in a rat model could (1) improve cerebrospinal fluid (CSF) circulation adjacent to the injury; (2) minimize connective tissue scarring; and (3) reduce post-traumatic inflammation and cystic cavitation. Following a transverse dural/arachnoid incision and C5-6 dorsal spinal hemisection, a 5-mm2 cadaveric dura mater allograft was placed over the lesion and fixed with fibrin glue (n=12). Control animals received an identical dural/arachnoid incision and cervical dorsal hemisection without dural repair (n=12). At 1, 5, and 10 weeks post-injury, plain film myelograms were obtained to characterize CSF circulation, and stereological methods were used to compare the extent of tissue sparing between the two groups. Immunohistochemical studies were performed to assess the degree of inflammation (ED-1), connective tissue scarring (laminin and type IV collagen), and reactive astrogliosis (GFAP). Our results indicate that dural allograft can improve CSF flow adjacent to the site of injury, which may be due to reduced meningeal fibrosis/scarring at the lesion site. Stereological analysis demonstrated that duraplasty resulted in a significant reduction in lesion volume at each time-point (p<0.01) associated with a nearly complete attenuation of post-traumatic cystic cavitation (p<0.001). Immunofluorescence studies demonstrated that duraplasty reduced the infiltration of ED-1-positive macrophages/microglia into and surrounding the lesion site, which may be responsible for the marked reduction in secondary injury following duraplasty. We conclude that duraplasty following acute spinal cord laceration may (1) improve CSF flow by limiting meningeal fibrosis; (2) reduce connective tissue scar formation; and (3) attenuate macrophage accumulation and progressive secondary injury.