Risk Factors for Postoperative Cerebrospinal Fluid Leakage After Intradural Spine Surgery

Platelet rich fibrin and commercial sealants for dural closure in neurosurgery: An in vitro study

BACKGROUND

Watertight closure of the dura mater is essential after neurosurgical interventions to avoid complications such meningitis, intracranial hypotension and surgical site infections. In addition to conventional suturing techniques, various biomaterials have been proposed as sealants to minimize the risk of leakage. We previously reported that patient derived platelet-rich fibrin (PRF), an autologous biomaterial, significantly improves watertight dural closure when applied as an onlay over a standard running suture. To demonstrate the efficacy of this method, we aimed to compare this orthobiological approach with other commercially available sealants.

METHODS

We utilized an in vitro testing device that allowed for the assessment of watertight dura mater closure via hydrostatic testing. On our testing phantom using freshly harvested bovine dura maters, a standardized 20-mm incision was closed using a running suture, and the leak pressure was measured initially without (primary leak pressure) and subsequently with on lay augmentation (secondary leak pressure) using either PRF, fibrinogen- and thrombin-coated collagen patch (TachoSil®), collagen matrix graft (DuraGen®), Polyethylenglykol (PEG) and polyethylene glycol ester and trilysine amine hydrogel solution (DuraSeal®), polyethylene glycol, protein-reactive polyethylene glycol monomer coated collagen matrix (Hemopatch®) or polyethylenimine component autospray sealant (Adherus®).

RESULTS

The outcomes demonstrate that the usage of a dural onlay in addition to the standard running suture exhibited a substantial improvement in leak pressure compared to the running suture alone. Specifically, the median leak pressure was improved by 3.5 times, where the combined approach was able to withstand 38 cm H2O, whereas the running suture alone had a median leak pressure of 11 cm H2O. Upon evaluating the performance of the sealants, we identified two categories of dural sealants: a medium performance group (30 ± 2 cm H2O) comprised of Adherus® (31 cm H2O), DuraGen® (31 cm H2O), and Hemopatch® (28 cm H2O), and a high-performance group composed of DuraSeal® (45.5 cm H2O), and TachoSil® (41 cm H2O). Patient-derived PRF was able to withstand a max pressure of 45 cm H2O, falling into the high-performance group. Of all the sealants tested in this study, the PRF based patch demonstrated the lowest variance in leak pressure among all the tested sealants.

CONCLUSIONS

Autologous platelet-rich fibrin in a two-step procedure displayed enhanced augmentation and reinforced watertight closure of the dura mater, exhibiting a four-fold increase in leak pressure compared to standard running suture alone. Among other commonly utilized commercial sealants, it ranked second with demonstrated consistency in its performance.

Cerebrospinal Fluid Leak Prevention in Intradural Spine Surgery: A Long Series Analysis of Closure with Non-Penetrating Titanium Clips

Background/Objectives: Postoperative cerebrospinal fluid (CSF) fistulas remain a significant concern in spinal neurosurgery, particularly following dural closure. The incidence of dural tears during spinal surgery is estimated between 1.6% and 10%. While direct suturing remains the gold standard, it has a failure rate of 5-10%. Various materials and techniques have been used to enhance dural closure. This study aims to assess the effectiveness of non-penetrating titanium clips (AnastoClip®) for dural closure in intradural spinal lesion surgeries. Methods: A prospective analysis was conducted on 272 patients who were operated on for intradural spinal lesions from August 2017 to December 2023. Dural closure was performed using non-penetrating titanium clips with sealant, and, in select cases, autologous grafts. Postoperative care included early mobilization and routine MRI to assess outcomes. A comparative analysis was performed with a cohort of 81 patients treated with traditional sutures. Results: Among the 272 patients, postoperative CSF leaks occurred in 32 cases (11.76%), requiring various management approaches. Thirteen cases required surgical revision, while others resolved with external lumbar drainage or fluid aspiration. Compared to the suture group, which had a fistula rate of 23.46%, the titanium clip group had a significantly lower fistula rate. Logistic regression analysis did not find statistically significant associations between fistula risk and clinical factors. Conclusions: Non-penetrating titanium clips provide an effective alternative to sutures for dural closure, reducing CSF leak rates. They preserve dural integrity, reduce operative time, and avoid imaging artifacts, making them a viable advancement in spinal surgery with outcomes comparable to, or better than, traditional techniques.

Does Early Mobilization Following Resection of Spinal Intra-Dural Pathology Increase the Risk of Cerebrospinal Fluid Leaks?-A Dual-Center Comparative Effectiveness Research

Background and Objectives: Prolonged bed rest after the resection of spinal intradural tumors is postulated to mitigate the development of cerebrospinal fluid leaks (CSFLs), which is one of the feared postoperative complications. Nonetheless, the empirical evidence supporting this conjecture remains limited and requires further investigation. The goal of the study was to investigate whether prolonged bed rest lowers the risk of CSFL after the resection of spinal intradural tumors. The primary outcome was the rate of CSFL in each cohort. Materials and Methods: To validate this hypothesis, we conducted a comparative effectiveness research (CER) study at two distinct academic neurosurgical centers, wherein diverse postoperative treatment protocols were employed. Specifically, one center adopted a prolonged bed rest regimen lasting for three days, while the other implemented early postoperative mobilization. For statistical analysis, case-control matching was performed. Results: Out of an overall 451 cases, we matched 101 patients from each center. We analyzed clinical records and images from each case. In the bed rest center, two patients developed a CSFL (n = 2, 1.98%) compared to four patients (n = 4, 3.96%) in the early mobilization center (p = 0.683). Accordingly, CSFL development was not associated with early mobilization (OR 2.041, 95% CI 0.365-11.403; p = 0.416). Univariate and multivariate analysis identified expansion duraplasty as an independent risk factor for CSFL (OR 60.33, 95% CI: 0.015-0.447; p < 0.001). Conclusions: In this CER, we demonstrate that early mobilization following the resection of spinal intradural tumors does not confer an increased risk of the development of CSFL.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

OBJECTIVE

Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

METHODS

This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

RESULTS

Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

CONCLUSIONS

Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Correlation between blood glucose level and poor wound healing after posterior lumbar interbody fusion in patients with type 2 diabetes

To investigate the correlation of blood glucose level with poor wound healing (PWH) after posterior lumbar interbody fusion (PLIF) in patients with type 2 diabetes (T2D). From January 2016 to January 2023, a case-control study was conducted to analyse the clinical data of 400 patients with T2D who were treated by PLIF and internal fixation at our hospital. The following data were recorded: gender; age; body mass index (BMI); surgical stage; average perioperative blood glucose level; perioperative blood glucose variance; perioperative blood glucose coefficient of variation; glycated haemoglobin level; preoperative levels of total protein, albumin and haemoglobin; postoperative levels of total protein, albumin and haemoglobin; surgical time; intraoperative bleeding volume; operator; postoperative drainage volume; and postoperative drainage tube removal time of each group. The indicators for monitoring blood glucose variability (GV) included the SD of blood glucose level (SDBG), coefficient of variation (CV) and maximum amplitude of variation (LAGE) before and after surgery. According to the diagnostic criteria for PWH, patients with postoperative PWH were determined and assigned to two groups: Group A (good wound healing group; n = 330 patients) and Group B (poor wound healing group; n = 70 patients). The preoperative and postoperative blood GV indicators, namely SDBG, CV and LAGE, were compared between these two groups. We also determined the relationship between perioperative blood GV parameters and PWH after PLIF surgery and its predictive value through correlation analysis and receiver-operating characteristic curve. Of the 400 enrolled patients, 70 patients had PWH. Univariate analysis revealed significant differences between the two groups in the course of diabetes, mean fasting blood glucose (MFBG), SDBG, CV, LAGE, preoperative hypoglycaemic program, surgical segment, postoperative drainage time, incision length and other factors (p < 0.05). However, no significant differences were noted in factors such as gender, age, body mass index, hypertension, coronary heart disease, admission fasting blood glucose, preoperative haemoglobin A1c, surgical time, intraoperative bleeding volume, intraoperative blood transfusion volume and postoperative drainage volume (p > 0.05). The area under the curve (AUC) values of preoperative SDBG, CV and LAGE were 0.6657, 0.6432 and 0.6584, respectively. The cut-off values were 1.13 mmol/L, 6.97% and 0.75 mmol/L, respectively. The AUC values for postoperative SDBG, CV and LAGE were 0.5885, 0.6255 and 0.6261, respectively. The cut-off values were 1.94 mmol/L, 24.32% and 2.75 mmol/L, respectively. The multivariate ridge regression analysis showed that preoperative MFBG, SDBG, CV and LAGE; postoperative SDBG, CV and LAGE; postoperative long drainage time; and multiple surgical segments were independent risk factors for T2D patients to develop surgical site infection after PLIF (p < 0.05). The perioperative blood GV in patients with T2D is closely related to the occurrence of PWH after PLIF. Reducing blood GV may help to reduce the occurrence of PWH after PLIF.

The safety and effectiveness of lumbar drainage for cerebrospinal fluid leakage after spinal surgery

PURPOSE

Cerebrospinal fluid (CSF) leakage is a frequent complication after spinal surgery. The lumbar drainage procedure (LDP) is the preferred method for early closure of a dural tear. This study was conducted to assess the safety and effectiveness of LDP after spinal surgery.

MATERIALS AND METHODS

We retrospectively reviewed 122 patients (55 male and 67 female) who underwent LDP after spinal surgery between January 2010 and June 2021. LDP was performed on patients with suspected CSF leakage due to a dural tear during spinal surgery or in whom mixed-color CSF was observed in the hemo-drain after surgery. LDP was performed aseptically by a resident according to our institution's protocol, and the amount drained was from 200cc to 300cc per day. Absolute bed rest was maintained during the lumbar drainage period. The hemo-drain was opened to confirm that CSF was no longer mixed or oozing, at which time the lumbar drain was removed. Culture was performed at the drain tip when the lumbar drain was removed.

RESULTS

The spinal surgery level was cervical in 23 patients, thoracic in 27 patients, and lumbar in 72 patients. The mean duration of the indwelling lumbar drain was 7.2 days (2 days-18 days), and the mean amount of drainage was 1198.2cc (100cc-2542cc). Among the 122 patients, the CSF leakage in 101 patients was resolved with the initial procedure, but 21 patients required re-insertion. Of those 21 patients, improper insertion due to a technical problem occurred in 15 patients, poor line fixation occurred in 2 patients, and CSF leakage was again observed after removal of the lumbar drain in 4 patients. In only 1 case was open surgery done after LDP because follow-up magnetic resonance imaging showed a suspected infection. During lumbar drainage, 76 patients used antibiotics, and 46 patients did not. Four patients showed bacterial growth in the tip culture, and 3 of them had been using antibiotics. All 4 of those patients were treated without complications and discharged. Among the 122 patients, 1 patient was discharged with left hemiparesis due to cerebral venous infarction (CVI) and hemorrhage after LDP, and 1 patient underwent re-operation because the CSF collection was not resolved.

CONCLUSIONS

No major complications such as systemic infection, deep vein thrombosis, or aspiration pneumonia occurred during the lumbar drainage, except for 1 patient (0.8%) with CVI caused by over-drainage. One patient (0.8%) required open surgery after LDP, but no cases of systemic infection occurred while maintaining lumbar drainage, irrespective of antibiotic use. In conclusion, LDP is a safe and effective treatment for CSF leakage after spinal surgery.

Dural reconstruction following resection of ventral and lateral spinal cord meningiomas: Fenestrated Durotomy with Oversized Graft technique

BACKGROUND

Meningiomas, although benign, often require complete resection due to their tendency for recurrence. However, dural reconstruction poses significant challenges, especially in the case of ventral meningiomas. While some reports have highlighted the usefulness of dural reconstruction using an artificial dura mater, no studies have yet confirmed dural canal enlargement through MRI post-surgically. This study aimed to assess the effectiveness of the Fenestrated Durotomy with Oversized Graft (FDOG) technique in cases of meningiomas and other intradural extramedullary tumors and evaluated dural canal dilation through MRI after using an artificial dura mater.

METHODS

This retrospective case series included 8 patients who underwent combined resection of intradural extramedullary tumors and dural repair using the FDOG technique. An artificial dura mater larger than that resected was inserted into the dural defect resulting from complete tumor resection on the ventral or lateral side of the spinal cord. The new dura mater was secured with a single dorsal suture. The dural incision was closed using watertight sutures following standard procedure. Measurement of the extent of dural canal enlargement was achieved via pre- and postoperative MRI scans.

RESULTS

None of the patients required additional treatments or lumbar drainage. All achieved independent ambulation without complications, and imaging tests indicated satisfactory dural expansion without signs of cerebrospinal fluid leakage.

CONCLUSIONS

The proposed method for dural repair in cases involving large dural defects on the ventral or lateral side of the spinal cord was shown to be a straightforward and effective approach with minimal postoperative complications.

The Role of Prolonged Bed Rest in Postoperative Cerebrospinal Fluid Leakage After Surgery of Intradural Pathology-A Retrospective Cohort Study

BACKGROUND

Postoperative cerebrospinal fluid leakage (CSFL) is a feared complication after surgery on intradural pathologies and may cause postoperative complications and subsequently higher treatment costs.

OBJECTIVE

To assess whether prolonged bed rest may lower the risk of CSFL.

METHODS

We performed a retrospective cohort study including patients with intradural pathologies who underwent surgery at our department between 2013 and 2021. Cohorts included patients who completed 3 days of postoperative bed rest and patients who were mobilized earlier. The primary end point was the occurrence of clinically proven CSFL.

RESULTS

Four hundred and thirty-three patients were included (female [51.7%], male [48.3%]) with a mean age of 48 years (SD ±20). Bed rest was ordered in 315 cases (72.7%). In 7 cases (N = 7/433, 1.6%), we identified a postoperative CSFL. Four of them (N = 4/118) did not preserve bed rest, showing no significant difference to the bed rest cohort (N = 3/315; P = .091). In univariate analysis, laminectomy (N = 4/61; odds ratio [OR] 8.632, 95% CI 1.883-39.573), expansion duraplasty (N = 6/70; OR 33.938, 95% CI 4.019-286.615), and recurrent surgery (N = 5/66; OR 14.959, 95% CI 2.838-78.838) were significant risk factors for developing CSFL. In multivariate analysis, expansion duraplasty was confirmed as independent risk factor (OR 33.937, 95% CI 4.018-286.615, P = .001). In addition, patients with CSFL had significant higher risk for meningitis (N = 3/7; 42.8%, P = .001).

CONCLUSION

Prolonged bed rest did not protect patients from developing CSFL after surgery on intradural pathologies. Avoiding laminectomy, large voids, and minimal invasive approaches may play a role in preventing CSFL. Furthermore, special caution is indicated if expansion duraplasty was done.

Cauda equina syndrome caused by the application of DuraSealTM in a microlaminectomy surgery: A case report

BACKGROUND

The management of dural tears is important. While a massive dura can be repaired with absorbable suture lines, cerebrospinal fluid leakage can be attenuated by dural sealant when an unintended tiny durotomy occurs intraoperatively. DuraSeal is often used because it can expand to seal tears. This case emphasizes the need for caution when DuraSeal is used as high expansion can cause complications following microlaminectomy.

CASE SUMMARY

A 77-year-old woman presented with L2/3 and L3/4 lateral recess stenosis. She underwent microlaminectomy, foraminal decompression, and disk height restoration using an IntraSPINE^® device. A tiny incident durotomy occurred intraoperatively and was sealed using DuraSeal^TM. However, decreased muscle power, urinary incontinence, and absence of anal reflexes were observed postoperatively. Emergent magnetic resonance imaging revealed fluid collection causing thecal sac indentation and central canal compression. Surgical exploration revealed that the gel-like DuraSeal had entrapped the hematoma and, consequently, compressed the thecal sac and nerve roots. While we removed all DuraSeal^TM and exposed the nerve root, the patient’s neurological function did not recover postoperatively.

CONCLUSION

DuraSeal expansion must not be underestimated. Changes in neurological status require investigation for cauda equina syndrome due to expansion.

Functional Outcome in Spinal Meningioma Surgery and Use of Intraoperative Neurophysiological Monitoring

Data on intraoperative neurophysiological monitoring (IOM) during spinal meningioma (SM) surgery are scarce. The aim of this study was to assess the role of IOM and its impact on post-operative functional outcome. Eighty-six consecutive surgically treated SM patients were included. We assessed pre and post-operative Modified McCormick Scale (mMCS), radiological and histopathological data and IOM findings. Degree of cord compression was associated with preoperative mMCS and existence of motor or sensory deficits (p < 0.001). IOM was used in 51 (59.3%) patients (IOM-group). Median pre and post-operative mMCS was II and I, respectively (p < 0.001). Fifty-seven (66.3%) patients showed an improvement of at least one grade in the mMCS one year after surgery. In the IOM group, only one patient had worsened neurological status, and this was correctly predicted by alterations in evoked potentials. Analysis of both groups found no significantly better neurological outcome in the IOM group, but IOM led to changes in surgical strategy in complex cases. Resection of SM is safe and leads to improved neurological outcome in most cases. Both complication and tumor recurrence rates were low. We recommend the use of IOM in surgically challenging cases, such as completely ossified or large ventrolateral SM.