Clinical relation among dural adhesion,dural ossification,and dural laceration in the removal of ossification of the ligamentum flavum

Background Context

Dural laceration frequently occurs during surgery in patients with ossification of the ligamentum flavum (OLF), mainly because of dural adhesion (DA) and dural ossification (DO) between the ligamentum flavum and the dura mater. However, the radiological predictive factors of DA in OLF have rarely been reported.

Dural bridge sutures to prevent sinking of dural substitutes: technical note

Introduction  Following Simpson Grade 1 excision of large convexity meningioma there is often a need for synthetic dural substitutes. Discussion  One problem with some of these grafts is that they lack tensile strength when wet and therefore sink into the cavity left following removal of the meningioma. Conclusion  A simple method to prevent ‘sinking’ or sagging of such synthetic dural grafts is described and illustrated.     

Ectopic dural osteolytic meningiomas

Intracranial meningiomas usually originate from the arachnoidal cells of the internal dural layer: meningiomas that originate from different sites are ectopic. The authors describe the case of a small meningioma adhering to the external dural layer without involvement of the internal layer, accompanied by osteolysis of the internal surface of the skull. A review of the literature on cranial ectopic meningiomas yielded only four cases described as originating from the external dural layer. Osteolysis of the skull was always present and was not found to have prognostic significance. The authors suggest that these four primary ectopic meningiomas originating from the external dural layer should be differentiated from intraosseous meningiomas of the skull.     

下腰段硬脊膜囊缩窄症（附16例报告）

报告16例下腰段硬脊膜囊缩窄症。其临床表现酷似腰椎椎管狭窄和腰椎间盘突出症。主要区别是该症为双下肢痛伴会阴部麻木、间歇性跛行，休息后症状不减轻。16例中先天性2例，继发于椎管狭窄4例，术后硬脊膜内外粘连10例。缩窄长度0．2～1．2cm，12例蛛网膜下腔完全闭锁。手术的关键是行缩窄段硬脊膜纵行切开。平均随访4年2个月，优15例，良1例。     

聚乳酸薄板预防椎板切除术后硬脊膜外纤维瘢痕粘连的实验研究

以60只家兔全椎板（L3，L5）切除为实验模型，研究了自制的聚乳酸薄板、明胶海绵在预防硬膜外纤维瘢痕粘连中的作用。通过大体观察及组织学检查，结果显示，聚乳酸薄板生物相容性好，能降解，可吸收，局部存留时间长，能有效地防止椎板切除后硬膜外纤维瘢痕粘连；明胶海绵早期防止纤维瘢痕粘连有一定作用，晚期作用不明显。     

The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study

Background Context

Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery.

Dural ectasia in adolescent idiopathic scoliosis: quantitative assessment on magnetic resonance imaging

To our knowledge, the assessment of dural sac diameters in patients with adolescent idiopathic scoliosis (AIS) is not reported in the literature. The aim of this study was to find out if, dural ectasia occurs more frequently among patients with AIS, to define cut-off values for dural sac ratio and test the validity of such values. A total of 126 spine MRIs (79 patients with AIS and 47 control subjects) were included in this retrospective analysis (age range 7–25 years, 62% were females). Dural sac diameter (DSD) and vertebral body diameter (VBD) were estimated and dural sac ratio (DSR = DSD/VBD) was calculated at T5 and L3. DSR at T5 and L3 were 0.69 ± 0.12, and 0.52 ± 0.10, respectively, in patients with AIS compared with 0.62 ± 0.11, and 0.44 ± 0.07, respectively, in controls (P = 0.001 at T5 and <0.001 at L3). Our estimated cut-off values for DSR were 0.84 and 0.58 at T5 and L3, respectively. This resulted in 100% sensitivity compared with 74% when using the cut-off values proposed by Oosterhof et al. No statistically significant association was found between the occurrence of dural sac enlargement in patients with AIS and the severity of scoliotic deformity, the apical vertebral rotation, epidural fat thickness, occurrence of pain, neurological deficit, atypical scoliosis or rapid curve progression. Females were affected more frequently than males. As dural sac enlargement means thinning of the pedicles, we believe that the findings of this study have important clinical implications on the preoperative workup of AIS.     

Classification and management of early complications in open lumbar microdiscectomy

Complications and side effects in any kind of surgery, especially in spine surgery, should be evaluated to prevent those problems in the future. Since retrospective studies are of minor value and randomized controlled studies for complications are impossible to perform because of ethical and legal reasons, so-called "expert opinion" has to take their place in evidence-based medicine. On the basis of an analysis of the results of three spine centers together with the opinions of experienced spine surgeons, the authors have drawn up a classification of complications in open lumbar disc surgery and recommendations on how to manage common complications such as excessive bleeding, dural opening, nerve root lesions and recurrent disc herniation. The management of intraoperative complications should have the same training in microdiscectomy instructional courses as the operation itself.     

Dural tears in primary decompressive lumbar surgery. Is primary repair necessary for a good outcome?

Study design

Case control series with prospective data collection.

Objective

To establish whether incidental durotomy treated without primary suture repair adversely affects the outcome following lumbar surgery in the longer term.

Method

Outcome scores from a prospective database were used for an audit of dural tears in primary lumbar decompressive surgery. Outcome data collected includes the Short Form 36 General Health Questionnaire (SF36), the Oswestry Disability Index (ODI) and Visual Analogue Scores for leg pain (VAL) and back pain (VAB).

Results

Out of 200 consecutive procedures, a dural tear occurred in 19 (9.5 %) patients. Of 19 patients with a dural tear, data was incomplete in 4 patients, and 1 further patient who had their dural tear sutured was excluded, leaving 14 patients to be studied. There were seven males and seven females, with an average age of 50.8 years (31–69). These 14 patients (group 1) were compared to a matched group (age, sex, surgical diagnosis and duration of follow-up) of 14 patients (group 2) with no tear. Both groups had similar pre-operative scores. At 6-month follow-up, both groups had significant improvements in all outcomes measures except for the general health domain of the SF-36. At final follow-up, patients with dural tears appeared to have better improvements in outcome measures amongst the VAB, VAL and ODI with similar scores in the SF-36 domains.

Conclusion

Our study demonstrates that incidental durotomy in primary lumbar decompressive surgery can be successfully managed without primary suture repair with no adverse effect on surgical outcome in the longer term.     

Neuraxial labor analgesia failure rates in women with a body mass index ≥50 kg/m2: a single-center retrospective study

BackgroundThe failure rate of neuraxial labor analgesia has not been investigated in super-obese women (body mass index ≥50 kg/m²).MethodsWe performed a retrospective study of neuraxial labor analgesia in super-obese women (January 2012 to August 2019). The primary outcome was the failure rate of the first neuraxial catheter. Secondary outcomes were failure rates by neuraxial technique, at cesarean delivery, and rate of catheter replacement.ResultsNeuraxial labor analgesia was used by 233 super-obese women: 153 epidural catheters placed using a combined spinal-epidural (CSE) or dural puncture epidural techniques with visualization of cerebrospinal fluid; 63 placed without dural puncture (including procedures without attempted dural puncture or attempted CSE or dural puncture epidural); and 17 intrathecal catheters (seven intentional). Thirty-two of 233 neuraxial catheters failed (13.7%, 95% Confidence Interval [CI] 9.9 to 18.7%). Epidural catheters placed using CSE or dural puncture epidural had a lower failure rate than those placed without dural puncture (9.2%, 95% CI 5.5% to 14.7%) vs 28.6% (95% CI 18.9% to 40.7%; P<0.001). Catheter migration was documented for 29.4% (95% CI 16.8 to 46.2%) of catheters that failed.ConclusionsEpidural catheters placed using CSE or dural puncture epidural techniques were more reliable than those placed without dural puncture in super-obese parturients. It is unclear whether the result was driven by grouping procedures without attempted dural puncture with those in which dural puncture was attempted but cerebrospinal fluid was not obtained. Catheter migration was a major source of failure.     

硬脑膜动静脉瘘的血管内治疗进展

硬脑膜动静脉瘘是指发生在硬脑膜及其附属物上的异常动静脉分流,目前主要的治疗方式为血管内治疗和开颅手术治疗,但血管内治疗具有较好疗效。本文对血管内治疗的常用方法、适应证、并发症及术后评价的最新进展进行综述。     

A New Absorbable Synthetic Substitute With Biomimetic Design for Dural Tissue Repair

Dural repair products are evolving from animal tissue–derived materials to synthetic materials as well as from inert to absorbable features; most of them lack functional and structural characteristics compared with the natural dura mater. In the present study, we evaluated the properties and tissue repair performance of a new dural repair product with biomimetic design. The biomimetic patch exhibits unique three‐dimensional nonwoven microfiber structure with good mechanical strength and biocompatibility. The animal study showed that the biomimetic patch and commercially synthetic material group presented new subdural regeneration at 90 days, with low level inflammatory response and minimal to no adhesion formation detected at each stage. In the biological material group, no new subdural regeneration was observed and severe adhesion between the implant and the cortex occurred at each stage. In clinical case study, there was no cerebrospinal fluid leakage, and all the postoperation observations were normal. The biomimetic structure and proper rate of degradation of the new absorbable dura substitute can guide the meaningful reconstruction of the dura mater, which may provide a novel approach for dural defect repair.     

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors’ knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.     

Posterior fossa hemorrhage caused by dural arteriovenous fistula: case reports

BACKGROUND: Relatively few reports are available on dural arteriovenous fistulas (AVFs) accompanied by posterior fossa hemorrhage. We now report upon two such cases and discuss the differential diagnosis and imaging findings. CASE DESCRIPTION: A 36-year-old man was admitted after experiencing sudden headache. Computerized tomography (CT) showed vermian and fourth ventricular hematoma, and magnetic resonance imaging (MRI) revealed an abnormal signal void. Angiography demonstrated a dural AVF in the region of foramen magnum. The second case, a 57-year-old man, was also admitted for the evaluation of headache. CT scan revealed tentorial subdural, subarachnoid and vermian hemorrhage. MRI showed vermian hematoma and an abnormal signal void below the tentorium. Angiography demonstrated a dural AVF in the tentorium.The first case underwent transarterial embolization, after which the dural AVF disappeared completely. The second case underwent craniotomy immediately after failure of endovascular therapy. Postoperative angiography demonstrated no remaining dural AVF. CONCLUSIONS: Dural AVF should be considered as a causative lesion in cases with posterior fossa hemorrhage with no other definitive cause.     

硬脑膜动静脉瘘动物模型的研究

目的 探讨硬脑膜动静瘘（ＤＡＶＦ）的发病机理。方法 （１）对照组：１０条犬,结扎并剪断右侧颈外静脉;（２）实验１组：１５条犬,吻合右侧颈外静脉远心端与以颈总动脉近心端;（３）实验２组：１５条犬,结扎并剪断左侧颈外静脉,然后与实验１组做相同处理。结果 对照组无ＤＡＶＦ发生;实验１组有３条犬发生ＤＡＶＦ;实验２组有１条犬发生ＤＡＶＦ。结论 单纯升高静脉窦内压力可以诱发ＤＡＶＦ。     

胸椎黄韧带骨化合并硬脊膜骨化的手术策略

目的介绍黄韧带骨化合并硬脊膜骨化的手术策略并讨论手术的可行性。方法 2006年6月-2009年12月收治黄韧带骨化致胸椎管狭窄患者98例,其中18例经手术证实合并硬脊膜骨化。男11例,女7例;年龄46～73岁,平均58岁。病程5～48个月,平均20个月。所有患者均由于症状加重选择后路减压术,通过根黄通道八边形游离整块切除胸椎上关节突及骨化黄韧带和硬脊膜。手术前后采用日本骨科协会(JOA)评分、改良Oswestry功能障碍指数(ODI)和Cobb角测量进行疗效评价。结果术后患者初始症状均明显缓解。术后18例均出现暂时性脑脊液漏,保守治疗8～10 d后脑脊液漏停止。患者伤口均Ⅰ期愈合,无神经症状加重、蛛网膜下腔感染、伤口感染、窦道形成等并发症发生。18例均获随访,随访时间20～60个月,平均49个月。末次随访时无脊髓压迫复发、神经症状加重等。术后1、12个月患者JOA评分及ODI值均较术前明显改善(P<0.05);术后12个月JOA评分及疗效、ODI值均较术后1个月明显改善(P<0.05)。术后12个月患者Cobb角(8.0±1.2)°与术前(6.7±1.6)°比较差异有统计学意义(t=4.000,P=0.001)。术后2个月MRI水平位、矢状位和脂肪抑制像上显示受压节段脊髓膨起良好。结论根黄通道八边形游离整块切除胸椎上关节突及骨化黄韧带和硬脊膜的手术方法,对于治疗继发于黄韧带骨化和硬脊膜骨化的胸椎管狭窄安全可靠,无修补的方法对于硬脊膜缺损的处理也有效。     

Heat generation and heat protection in methylmethacrylate cementation of vertebral bodies

Summary For metastatic disease of the spine, anterior operations on the vertebral bodies often include methylmethacrylate cementation. The cement curing process may produce high temperatures in the surroundings, as demonstrated in joint replacement surgery, and there is a risk of thermal injury to the spinal nerves. In cadavers, we studied the heat arising during curing of cement on the dural sac, and the temperature of the cement surface was measured when the vertebral body was reconstructed using acrylic cement in the same way as in tumor surgery. The temperature increase on the surface of the dural sac during polymerization was between 4° and 12°C, depending on the amount of protection. Only a moderate temperature elevation was measured on the surface of the dural sac, provided that the posterior cortex of the vertebra was retained together with 0.5 cm of the spongious bone or a silicone membrane.     

Les plaies durales : à propos d’une série de 100 cas

IntroductionDural tears are a dreaded surgical incident because they are difficult to anticipate and may lead to serious complications.Materials and methodsThe French College of Neurosurgery analyzed 100 cases of dural tears declared on the physicians accreditation website from the Haute Autorité de santé (Regional Health Authority). A questionnaire on drainage, type of dural repair and bed rest duration was sent to 87 French neurosurgeons.ResultsThirty-six percent of patients with dural tears had a history of previous spinal surgery and the most common cause of tear was surgical fibrosis into the operative field for 30% of cases. Sixty-four percent had no history of spinal surgery and, in 33% of cases, the dural tear occurred during a surgery for herniated disc. Drainage was proposed case by case in 76% of cases, the patient was allowed to stand up at day 1 in 48% of cases. The treatment of dural tears combined different techniques including in situ injection of biological glue in 86% of cases. The most common complication was the need of wound repair procedure in 59.5% of cases, which was complicated by meningitis in 21.5% of cases.ConclusionThis study shows the lack of formal consensus about the procedure of repair, the method of drainage or the need to keep the patient bed ridden. This study highlights a relatively high frequency of dural tears, its potentially serious complications and stresses the need for prospective studies in order to define the appropriate action to undertake when faced with this type of incident.