Combined thrombin and autologous blood for repair of lumbar durotomy

Lumbar durotomy can be intended or unintended and can result in persistent cerebrospinal fluid (CSF) leak. Several methods are used to manage this complication including bed rest and CSF diversion. In this study, we theorize that the use of thrombin-soaked gel foam together with autologous blood laid on the sutured dural tear can prevent persistent CSF leak. A retrospective review of the records of patients who underwent lumbar surgery and had an unintended dural tear with CSF leak, comparing the outcome of patients who were submitted to thrombin-soaked gel foam together with autologous blood (group A) to patients treated by subfacial drain, tight bandage, and bed rest (group B). A total of 1371 patients had lumbar surgery, of whom 131 had dural tear. Group A included 62 patients, while group B included 69 patients. 8.1 % of group A patients had CSF leak as compared to 17.4 % of group B patients at postoperative day 14. The incidence of postoperative CSF leak and duration of postoperative hospital stay were statistically lower in group A than in group B (p?<?0.05). Combining thrombin and autologous blood for repair of lumbar durotomy is an effective and a relatively cheap way to decrease CSF leak in the early postoperative period as well as decreasing postoperative hospital stay. It also resulted in decreased complications rate in the late postoperative period.     

Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks

BACKGROUND: Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization. METHODS: A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak. RESULTS: In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed. CONCLUSION: Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.     

Headache caused by endocranial hypotension secondary to sacrococcygeal trauma in a patient with a congenital arachnoid cyst

Headache caused by intracranial hypotension after sacrococcygeal trauma, is a rare syndrome with very similar symptoms and physiopathology to post dural puncture headache. In both situations, cerebrospinal fluid (CSF) leaks through a dural tear, leading to a decrease in its pressure. A 13 year old patient presented a frontal and occipital positional headache, after undergoing sacrococcygeal trauma. In magnetic resonance images, the presence of a spinal arachnoid diverticulum (cyst) and CSF leak were confirmed. After the establishment of conservative medical treatment, complete clinical remission was observed. The diagnosis of intracranial hypotension headache syndrome is mainly clinical, once other possible headache etiologies have been discarded. Magnetic resonance imaging can be used to detect small CSF leaks, and in this case, magnetic resonance imaging clearly showed the existence of an arachnoid cyst. The presence of some meningeal diverticulums such as arachnoid cyst, constitute a risk to undergo this syndrome, due to the possibility of its rupture by minor traumatisms. The initial treatment should be conservative, as the dural tear seals spontaneously and the liquid is reabsorbed.     

Delayed Cerebrospinal Fluid Leak after Watertight Dural Closure with a Polyethylene Glycol Hydrogel Dural Sealant in Posterior Fossa Surgery: Case Report

A polyethylene glycol (PEG) hydrogel sealant recently has been approved as an adjunct to sutured dural closure in Japan. We treated consecutive six patients with PEG hydrogel sealant in posterior fossa operation. Three of six cases suffered delayed cerebrospinal fluid (CSF) leak after watertight dural closure with the PEG hydrogel sealant, although there was no leak case which was treated with fibrin glue, before 2 years until the adoption of the new material. These patients underwent posterior fossa craniotomy and discharged without remarkable CSF leak. The pseudomeningocele under the occipital wound caused the CSF leak occurr from 5th to 7th week postoperatively. All CSF leak cases needed surgical repair. At the repair, the PEG hydrogel was liquefied and almost absorbed. A fistula on the closure line and a dead space after the absorption of the PEG hydrogel was observed. When the absorbable PEG hydrogel sealant plugs in small gaps of sutured dura, its properties to prevent adhesion might suppress healing process of dural closure, so that CSF could leak through the gaps and collect as a pseudomeningocele in the dead space after absorption of the PEG hydrogel. In posterior fossa surgery a PEG hydrogel sealant should be applied when dural edges are closed tightly without any gaps.     

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.     

The Fixed Combination of Collagen With Components of Fibrin Adhesive—A New Hemostypic Agent in Skull Base Procedures

CSF leak still is one of the major sources of morbidity after extensive skull base procedures. Of the various standard closure techniques of traumatic or iatrogenic dural defects, none provides a really waterlight, persistent closure. Even the supplementary use of fluid fibrin glue did not substantially improve the rate of postoperative CSF leaks. The application of a collagen sheet covered with a fixed layer of solid components of a fibrin tissue glue (TachoComb®) overcomes the major drawbacks of dural sealing in skull base surgery. The dural defects of 58 patients undergoing extensive skull base procedures were sealed with this new hemostyptic agent. The series includes 44 patients undergoing primary surgery, 6 patients with traumatic or iatrogenic tears of venous sinuses, and 8 patients with postoperative leaks after previous skull base procedures in which other sealing methods were previously used. In the group of primary surgery, none of the patients had postoperative CSF leakage or venous rebleeding. One patient developed a delayed pneumatocephalus. All cases of patent CSF fistulas were resolved without any adjuvant therapy. Preliminary experience shows that the good sealing and hemostyptic performance of this new agent will considerably reduce the risk of postoperative CSF leak and infection after skull base procedures.     

Evaluation and treatment of dural tears in lumbar spine surgery: a review

Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.     

The fixed combination of collagen with components of fibrin adhesive-a new hemostypic agent in skull base procedures

CSF leak still is one of the major sources of morbidity after extensive skull base procedures. Of the various standard closure techniques of traumatic or iatrogenic dural defects, none provides a really waterlight, persistent closure. Even the supplementary use of fluid fibrin glue did not substantially improve the rate of postoperative CSF leaks. The application of a collagen sheet covered with a fixed layer of solid components of a fibrin tissue glue (TachoComb(R)) overcomes the major drawbacks of dural sealing in skull base surgery. The dural defects of 58 patients undergoing extensive skull base procedures were sealed with this new hemostyptic agent. The series includes 44 patients undergoing primary surgery, 6 patients with traumatic or iatrogenic tears of venous sinuses, and 8 patients with postoperative leaks after previous skull base procedures in which other sealing methods were previously used. In the group of primary surgery, none of the patients had postoperative CSF leakage or venous rebleeding. One patient developed a delayed pneumatocephalus. All cases of patent CSF fistulas were resolved without any adjuvant therapy. Preliminary experience shows that the good sealing and hemostyptic performance of this new agent will considerably reduce the risk of postoperative CSF leak and infection after skull base procedures.     

The use of titanium non-penetrating clips to close the spinal dura

We present the results of our initial experience in the use of non-penetrating titanium clips in the closure of spinal dura. A retrospective analysis of case notes of patients identified from the unit database was carried out, limited to adults. A proforma that included demographic details, the diagnosis, the procedure undertaken, whether or not additional dural closure methods were used, the use of bed rest and any complications, including cerebrospinal fluid (CSF) leak. There were 58 patients with a mean age of 53 years. The commonest diagnoses were meningioma, ependymoma and neurofibroma. Eight patients had additional methods of dural closure used and approximately half the patients had a period of postoperative bed rest. Eight patients (13.7%) had a CSF leak. Our early experience with the use of non-penetrating clips for the closure of the spinal dura is presented. We have found them easy to use, especially in anatomically-restricted spaces and rapid in their application. However, our results have revealed an unexpectedly high complication rate. A further prospective study to evaluate them more fully is planned.     

Comparative dural closure techniques: a safety study in rats

BACKGROUND: Some neurosurgical procedures have high morbidity and mortality rates due to cerebrospinal fluid (CSF) fistula development, particularly when dural defects are in relatively inaccessible areas or surrounded by friable dura. We used a rat model to test 4 different dural closure techniques to determine which one was significantly superior for achieving a watertight dural closure with minimal harm to brain tissue. METHODS: The rats were randomly divided into 2 groups. The first group (group A, n = 40) was used to test the strength of the adhesivity for CSF leakage. Histopathologic studies were used to evaluate the granulation tissue between the dura and dural graft. Effects on the brain tissue were studied in the second group (group B, n = 40) where lipid peroxidation was determined. These 2 groups consisted of 5 subgroups: control, methyl metacrylate, n-butyl cyanoacrylate, fibrin glue, and CO(2) laser. RESULTS: Methyl metacrylate and CO(2) laser techniques were inadequate for stopping dural leakage and had harmful effects on brain tissue. Cerebrospinal fluid leak was observed only in 1 rat in the n-butyl cyanoacrylate subgroup and this result was statistically significant (P = .0005), but lipid peroxidation levels for this material showed that it was not safe for dural closure in case it leaked through the dural defect. The lipid peroxidation levels of the fibrin glue subgroup were not statistically significantly different from the control group (P = .440). CONCLUSIONS: Fibrin glue was the safest material with a CSF leakage risk that was higher than n-butyl cyanoacrylate (25% vs 12.5%) but acceptable. This study showed no relationship between the CSF leak and histopathologic findings for sealant properties of the tissue adhesives.     

老年腰椎椎管狭窄症患者术中硬膜囊撕裂位置及术中术后处理对策

目的探讨老年腰椎椎管狭窄症患者手术发生硬膜囊撕裂的解剖学机制,比较撕裂位置及术中、术后处理对策。方法回顾性分析2012年01月~2014年01月本院行腰椎后路手术的216例〉70岁老年患者,记录患者一般资料、病程时间、术前诊断、手术方式和节段、术中硬膜囊撕裂的位置、术后脑脊液漏情况和处理方法以及并发症等。结果共计151例患者入选,其中男89例,女62例,年龄70~93岁,平均78.12岁。术中发生硬膜囊撕裂共计34例,术后出现脑脊液漏23例,硬膜囊撕裂位置发生率硬膜囊后外侧〉根袖〉硬膜囊外侧〉硬膜囊腹侧。术中采取硬膜囊缝合修补、明胶海绵压迫、生物蛋白胶粘合等处理,术后常规给予预防感染、神经根脱水、补液等治疗,均于术后3~10 d拔管,3~4周切口愈合,全部患者未出现严重并发症。结论 〉70岁老年腰椎椎管狭窄症患者术中硬膜囊撕裂及术后脑脊液漏的发生率高于整体人群,且多位于硬膜囊后外侧及根袖,术中及时发现并仔细缝合或修补破损的硬膜、术后间断夹闭引流管、延长拔管时间能获得良好的效果。     

Impact of Chemoradiotherapy on CSF Leak Repair after Skull Base Surgery

Background Transnasal endoscopic resection (TER) has become the treatment of choice for many skull base tumors. A major limitation of TER is the management of large dural defects and the need for repair of cerebrospinal fluid (CSF) leaks, particularly among patients who are treated with chemotherapy (CTX) or radiotherapy (RT). The objective of this study is to determine the impact of CTX and RT on the success of CSF leak repair after TER. Methods We performed a retrospective chart review of a single-institution experience of TER from 1992 to 2011. Results We identified 28 patients who had endoscopic CSF leak repair after resection of malignant skull base tumors. Preoperative RT was utilized in 18 patients, and 9 had undergone CTX. All patients required CSF leak repair with rotational flaps after cribriform and/or dural resection. CSF leak repair failed in three patients (11%). A history of RT or CTX was not associated with failed CSF leak repair. Conclusion Adjuvant or neoadjuvant CTX or RT is not associated with failed CSF leak repair. Successful CSF leak repair can be performed in patients with malignant skull base tumors with an acceptable risk profile.     

Novel laser tissue-soldering technique for dural reconstruction

OBJECT: The goal of this study was to use a modified version of the CO2 laser-soldering system to develop a simple and reliable technique for the repair of dural defects after excision of brain tumors. METHODS: The authors used a CO2 fiber optic laser system that they had developed for heating, monitoring, and controlling tissue temperature in situ and in real time, thereby reducing damage to the brain parenchyma. They adapted the system for dural closure by using free fascial grafts in a porcine model. Measures for estimation of reconstruction quality included visual assessment under magnification and direct measurements of adhesive strength and cerebrospinal fluid leak (CSF) pressure. Reliable soldering was achieved in 54 of 57 experiments, providing a 95% success rate. The average peak adhesive strength was 82 +/- 3 mN/cm2. The measured leak pressure of the fascia-dura mater bond was 66 +/- 5 mm Hg. Conventional suturing performed using Prolene stitches resulted in immediate CSF leakage from areas between the stitches and from the area of the needle hole itself. CONCLUSIONS: Fascia-dura mater soldering using the CO2 laser is feasible and may support CSF pressure up to six times higher than normal intracranial pressure. Findings of this study may provide a basis for the development of new tools for dural reconstruction.     

Cranial fat dissemination following fat grafting for lumbar dural tear: First case report in the literature

Introduction and importanceDural tear and cerebrospinal fluid (CSF) leak is among the most common complications in lumbar spine surgery. Although primary dural suturing is the preferred method for repair, this is not always achievable specially with ventrolateral tears. Autologous fat grafting is one of the oldest and effective methods for dural repair which can also be used along with other methods of repair. This case report highlights a unique post spinal surgery complication with comment on how to avoid it. To our knowledge, this has not been previously reported in the literature.Case presentationThe authors report a sixty-seven-year-old male with lumbar pseudomeningocele and cranial fat dissemination following fat grafting for non suturable lumbar dural tear. This was demonstrated on magnetic resonance imaging (MRI) after her presented with low-pressure headache.Clinical discussionIntraoperative dural tear is one of the most common complications in spinal surgery. Methods for optimal dural repair including fat grafting have been described but the choice still heavily dependent on the surgeon’s preference and experience. Fat graft can migrate leading to potential undesirable further complications like hydrocephalus and aseptic meningitis.ConclusionCranial fat dissemination following fat grafting for lumbar dural tear should be recognized as a post-operative complication in lumbar spine surgery. It should be considered in case of hydrocephalus or aseptic meningitis post dural fat grafting. Surgeons should utilize adjunct methods to minimize its incidence.     

Decreased Rate of CSF Leakage Associated with Complete Reconstruction of Suboccipital Cranial Defects

Background Cerebrospinal fluid (CSF) leakage represents a major source of morbidity following microvascular decompression (MVD) surgery. The objective of this study was to retrospectively assess whether complete versus incomplete reconstruction of the suboccipital cranial defect influences the incidence of CSF leakage following MVD.Methods We reviewed the charts of 100 patients who consecutively underwent MVD for trigeminal neuralgia by two attending neurosurgeons between July 2004 and April 2010. Operative variables including incomplete or complete calvarial reconstruction, primary dural closure or dural closure with adjunct, and use of lumbar drainage were recorded. The effect of complete calvarial reconstruction on the incidence of postoperative CSF leakage was examined using a multivariate logistic regression model.Results Of the 36 patients whose wound closure was reconstructed with a complete cranioplasty, 2 (5.6%) patients experienced a postoperative CSF leak. Of the 64 patients whose wound closure was augmented with an incomplete cranioplasty, 15 (23.4%) experienced a postoperative CSF leak. There was suggestive but inconclusive evidence that the risk of CSF leakage following MVD was smaller with complete reconstruction of calvarial defect than with incomplete reconstruction (two-sided p value = 0.059), after accounting for age, dural closure method, use of lumbar drainage, and previous MVD.Conclusion Complete reconstruction of the suboccipital cranial defect decreases the risk of CSF leakage.     

Comparative transoral dural closure techniques: a canine model

A watertight dural closure is difficult to achieve after transoral-transclival operation for ventral intradural lesions at the craniocervical junction. These procedures have a high morbidity and mortality from cerebrospinal fluid (CSF) fistula, meningitis, and abscess. We used a canine model to test three different techniques of dural closure after transoral intradural operation: primary suture closure, laser patch weld, and fibrin glue patch closures. The primary suture closure technique was inadequate. All eight leaked CSF at the time of operation, and five had radiographic leaks and were incompetent at autopsy. All seven of the laser closures leaked CSF at operation, yet only one was incompetent at autopsy. The fibrin glue technique was superior and provided a solid seal at operation, even with repeated Valsalva maneuvers to 40 mm Hg. The immediate and persistent seal at operation is clinically significant because it may prevent CSF leak, meningitis, and abscess formation in human patients after transoral surgery. Fibrin glue is excellent for repairing complex dural defects and merits evaluation in clinical trials.     

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.     

Endoscopic cerebrospinal fluid rhinorrhea repair: Is a lumbar drain necessary?

OBJECTIVES: To determine the necessity for lumbar drains during endoscopic cerebrospinal fluid (CSF) rhinorrhea repair. METHODS: Thirty-three patients underwent endoscopic repair of CSF rhinorrhea without a lumbar drain during a 7-year period. The size of the dural defect ranged from a microleak (less than 1 mm dural defect) to a 3-cm dural defect of the anterior skull base. RESULTS: All of the procedures in patients with smaller defects (<5 mm) were performed on an outpatient basis. Thirty-two patients (97%) had complete resolution of their CSF leak after 1 procedure without any recurrence (average follow-up 29 months). CONCLUSION: A lumbar drain is not routinely necessary for successful closure of CSF rhinorrhea of any size. Smaller dural defects may be safely performed on an outpatient basis without complications.     

Comparison of Different Wound Closure Techniques in Translabyrinthine Acoustic Neuroma Surgery

In a series of 277 patients with translabyrinthine acoustic neuroma, three techniques of wound closure were used to prevent cerebrospinal fluid (CSF) leakage. In the first group, we used a piece of fascia to cover the dural defect and then placed several pieces of fat on the fascia. The incidence of CSF leak was 28.2%; 7.7% required reoperation. In the second group, in addition to the fasia-fat complex, we made a large musculoperiosteal flap to compress the fat. The incidence of CSF leak and revision were not reduced, however. In recent cases, we placed several pieces of fat directly into the operative cavity without fascia graft; then it was covered with a musculoperiosteal flap. With this technique, CSF leak was significantly reduced to 7.4%, and reoperation was rare (3.7%). The direct application of fat into the translabyrinthine operation cavity appears to be effective to prevent CSF leaks.