Effective Repair of Dural Tear Using Bioabsorbable Sheet With Fibrin Glue

A Wet-Adhesive Hydrogel Patch with Rapid-Adhesion, Anti-Swelling, and Pro-Healing Properties for Sutureless Repair of Dural Tear

Dural tears and subsequent cerebrospinal fluid leakage are common and intractable in spinal surgery. However, the existing clinical treatments are still unsatisfactory and the effective closure and repair of dural tears remain a huge challenge. Herein, a bilayer wet-adhesive hydrogel patch (denoted as BMTP) with rapid-adhesion, anti-swelling, and pro-healing properties is developed, which comprises a tough poly(vinyl alcohol) (PVA) dissipative layer and a functionalized poly(acrylic acid)-based wet-adhesive layer modified with methyl acrylate (MA) and tannic acid (TA). Owing to the hydrophobic effect of MA moieties and the strong intermolecular hydrogen bonding interaction facilitated by TA, BMTP has a unique low swelling property (24.2%) without compromising wet adhesion. Meanwhile, attributed to the high mechanical strength of the PVA dissipative layer and its mechanical interlocking with the wet-adhesive layer, BMTP exhibits durable sealing capacities with a burst pressure tolerance of 325 mm Hg. Moreover, the TA-mediated promotion of fibroblast proliferation enables BMTP to accelerate the healing of dura wounds. The rabbit dural tear model demonstrates that the BMTP can effectively seal and promote the healing of the damaged dura without postoperative adhesion within 3 weeks. Therefore, this work may offer a promising solution for the sutureless treatment of dural tears.

A low-swelling hydrogel as a multirole sealant for efficient dural defect sealing and prevention of postoperative adhesion

Dural defects and subsequent complications, including cerebrospinal fluid (CSF) leakage, are common in both spine surgery and neurosurgery, and existing clinical treatments are still unsatisfactory. In this study, a tissue-adhesive and low-swelling hydrogel sealant comprising gelatin and o-phthalaldehyde (OPA)-terminated 4-armed poly(ethylene glycol) (4aPEG-OPA) is developed via the OPA/amine condensation reaction. The hydrogel shows an adhesive strength of 79.9 ± 12.0 kPa on porcine casing and a burst pressure of 208.0 ± 38.0 cmH2O. The hydrogel exhibits a low swelling ratio at physiological conditions, avoiding nerve compression in the limited spinal and intracranial spaces. In rat and rabbit models of lumbar and cerebral dural defects, the 4aPEG-OPA/gelatin hydrogel achieves excellent performance in dural defect sealing and preventing CSF leakage. Moreover, local inflammation, epidural fibrosis and postoperative adhesion in the defect areas are markedly reduced. Thus, these findings establish the strong potential of the hydrogel sealant for the effective watertight closure of dural defects.

Efficacy of patch technique for dural tear repair using hydrogel sealant: a pilot study

BACKGROUND CONTEXT

Dural tear is one of the common complications of lumbar spine surgery. Suture repair is often difficult due to the requirement of meticulous suture technique in limited space. Dural tear repair is particularly challenging in minimally invasive spine surgery. The patch technique, applying patch material and glue without suture, is an alternative method for dural tear repair.

PURPOSE

To verify the efficacy of patch technique for dural tear repair using polyethylene glycol hydrogel sealant and to compare patch materials.

STUDY DESIGN/SETTING

Basic research.

METHODS

There were three study groups: Group 1 (control group, n=4) had hydrogel sealant alone, Group 2 (n=8) had collagen sheet patch and hydrogel sealant, Group 3 (n=8) had mesh sheet patch and hydrogel sealant. A 4-mm durotomy was made in a piece of bovine dura using an arterial punch. Patch material (collagen or mesh sheet) was placed over the dural tear with 2 mm margin and then sprayed with hydrogel sealant. The pressure in the system was increased by 10 mm Hg and monitored. When the leakage occurred, the pressure threshold was measured.

RESULTS

The mean pressure threshold for leakage was 32.5 (Standard deviation=15.0), 66.3 (37.0), and 88.8 (27.5) mm Hg for Group 1, 2 and 3, respectively. The mean pressure threshold for leakage for Group 3 was significantly higher than that for Group 1 (p<.05). There was no significant difference in the mean pressure threshold for leakage between Groups 1 and 2, and Groups 2 and 3.

CONCLUSIONS

Patch technique using mesh sheet and hydrogel sealant demonstrated significantly higher mean pressure threshold for leakage compared with hydrogel sealant alone.

CLINICAL SIGNIFICANCE

Patch technique using mesh sheet and hydrogel sealant without suture is potentially a reasonable option for dural tear repair in lumbar spine surgery.

A hydrogel spinal dural patch with potential anti-inflammatory, pain relieving and antibacterial effects

CSFL caused by spinal dural defect is a common complication of spinal surgery, which need repair such as suture or sealants. However, low intracranial pressure symptoms, wound infection and prolonged hospital associated with pin-hole leakage or loose seal effect were often occurred after surgical suture or sealants repair. Stable, pressure resistance and high viscosity spinal dural repair patch in wet environment without suture or sealants was highly needed. Herein, a bioactive patch composed of alginate and polyacrylamide hydrogel matrix cross-linked by calcium ions, and chitosan adhesive was proposed. This fabricated patch exhibits the capabilities of promoting defect closure and good tight seal ability with the bursting pressure is more than 790 mm H₂O in wet environment. In addition, the chitosan adhesive layer of the patch could inhibit the growth of bacterial in vitro, which is meaningful for the postoperative infection. Furthermore, the patch also significantly reduced the expression of GFAP, IBA-1, MBP, TNF-α, and COX-2 in early postoperative period in vivo study, exerting the effects of anti-inflammatory, analgesic and adhesion prevention. Thus, the bioactive patch expected to be applied in spinal dural repair with the good properties of withstanding high pressure, promoting defect closure and inhibiting postoperative infection.

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A self-adhesive spinal dural patch that can be applied directly by pressing.

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A spinal dural patch maintains more than 790 mm H₂O sealing pressure in a wet environment.

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A spinal dural patch with potential anti-inflammatory, analgesic and anti-bacterial properties.

Management of Large Dural Defect with CSF Leak in Hypertelorism Correction

The Rationale

Dural tear is a serious complication during hypertelorism corrective surgeries. Identifying the tear and managing requires considerable expertise. Managing large dural tears correctly is necessary to prevent cerebrospinal fluid (CSF)-related complications in craniofacial surgery.

Patient Concerns

The patient presented with hypertelorism as a part of the Tessier Cleft 0 and sought to correct the widely placed eyes.

Diagnosis

Large critical-sized dural tear during modified box osteotomy surgery.

Treatment

Besides successful modified box osteotomy surgery, the critical-sized dural tear was managed with fascia lata and fibrin glue.

Outcomes

There was no CSF leak or related complication postsurgically indicating successful sealing and healing of the dural tear.

Take-Away Lessons

The synergistic mechanism by which fascia lata graft and fibrin glue help to hermetically seal the critical-sized defect, especially when there are variable amounts of hydrostatic-hydrodynamic forces of CSF exerting pressure on the patched area, is discussed.

Incidence of Unrecognized Incidental Durotomy during Surgery for Malignant Spinal Tumor

Introduction

Cerebral spinal fluid leak from durotomy is a well-known risk with spinal surgeries. The aim of this study is to identify the incidence of unrecognized incidental durotomy during posterior surgery for spinal metastases and its risk factors.

Methods

Participants comprised 75 patients who underwent posterior spine surgery for spinal metastases between January 2012 and December 2016. Cases with apparent durotomy noticed intraoperatively were excluded. Unrecognized durotomy was diagnosed as the presence of wide subcutaneous fluid retention on magnetic resonance imaging at least 3 months postoperatively. For comparison, 50 patients who underwent cervical laminoplasty due to cervical spondylotic myelopathy were examined using the same method. We also examined correlations between occurrence of durotomy and patient characteristics such as age, type of tumor, location of tumor (ventral or dorsal), extent of tumor, and history of radiotherapy before surgery.

Results

Unrecognized durotomy occurred in 21 cases of spinal metastasis (26.7%) and in 1 case of cervical spondylotic myelopathy (2%), representing a significant difference between groups. Age, type of tumor, location of tumor, extent of tumor, and history of radiotherapy before surgery did not correlate significantly with occurrence of durotomy. No local trouble was observed in durotomy cases, except in one case with subcutaneous local infection.

Conclusions

The incidence of unrecognized incidental durotomy is significantly higher during surgery for spinal metastases than that during surgery for degenerative disease.