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Patel AA, Davison MA, Lilly D, Shost MD, Meade S, Habboub G, Krishnaney A. The Use of Cranial Aneurysm Clips for Repair of Incidental Lumbar Durotomy: Operative Technique and Case Series. World Neurosurg 2024:S1878-8750(24)00729-0. [PMID: 38692570 DOI: 10.1016/j.wneu.2024.04.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Incidental durotomy is a common complication of posterior lumbar spine surgery; however, effective and durable methods for primary repair remain elusive. Multiple existing techniques have previously been reported and extensively described, including sutured repair and the use of nonpenetrating titanium clips. The use of cranial aneurysm clips for primary repair of lumbar durotomy serves as a safe and effective alternative to obtain watertight closure of a dural tear. METHODS We performed a retrospective review of patients at a single institution who underwent primary repair of an incidental lumbar durotomy with the use of an aneurysm clip during open posterior lumbar surgery between 2012 and 2023. Patient demographics, operative details, and postoperative metrics were collected and examined to evaluate the safety and efficacy of the novel technique. RESULTS A total of 51 patients were included for analysis. Four patients underwent durotomy repair with an aneurysm clip alone, 27 patients were repaired with an aneurysm clip and fibrin glue, and 20 patients underwent repair with an aneurysm clip, fibrin glue, and a collagen dural substitute. Three patients (5.9%) reported headaches: 2 (3.9%) with pseudomeningocele and 1 (2%) with wound leakage. Two patients (3.9%) had treatment failure with a return to the operating room for repair of a cerebrospinal fluid leak. CONCLUSIONS To the best of our knowledge, we report the largest series of patients undergoing primary repair of incidental durotomy with the use of an aneurysm clip. Use of an aneurysm clip is noted to be a safe, quick, and effective method of primary repair compared with existing repair techniques such as sutured repair or nonpenetrating titanium clips.
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Affiliation(s)
- Arpan A Patel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.
| | - Mark A Davison
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Daniel Lilly
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Michael D Shost
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Seth Meade
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ghaith Habboub
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Ajit Krishnaney
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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O'Neill BE, Godil JA, Brown NJ, Loya J, Silva A, Winer J. Application of nonpenetrating titanium clips for primary spinal dural closure following intradural tethered cord release in pediatric tethered cord syndrome: Profile of safety, efficacy, efficiency, and complications. World Neurosurg X 2024; 22:100348. [PMID: 38440374 PMCID: PMC10911848 DOI: 10.1016/j.wnsx.2024.100348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/04/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Surgical treatment for tethered cord syndrome (TCS) involves a laminotomy for intradural lysis of filum terminale (LFT), with the goal of releasing excess tension on the conus medullaris by dividing the filum terminale. While LFT alleviates clinical symptoms, it is associated with risks and complications, including cerebrospinal fluid (CSF) leak and infection, either superficial or deep. Some risks and complications of LFT relate to efficiency and quality of primary dural closure and its downstream effects. We sought to assess the utility of nonpenetrating titanium clips (TC) for primary dural closure with a particular focus on operative duration, associated costs, and complication profiles in a series of pediatric patients undergoing LFT, hypothesizing that TC utilization leads to more efficient closure and therefore potentially lower costs and potentially associated anesthetic length and risks. Methods A 4-surgeon, single institution series of 28 pediatric patients underwent LFT with subsequent dural closure performed with either the AnastoClip® nonpenetrating titanium clips or traditional suture technique between July 2022 and May 2023. In order to compare the safety, efficacy, and cost-effectiveness between the two dural closure techniques, relevant data were collected including patient demographics and rates of CSF leak, infection at three-month follow-up, and reoperation. Operative durations and times from beginning to end of dural closure were recorded. Results A total of 28 pediatric patients (mean age: 5.9 years, 43% female, range: 0.71-17 years) with TCS underwent LFT. All patients underwent procedures involving intradural surgery of the lumbar region. Dural closure was performed using traditional suturing in 19 patients (67.9%) and TC in 9 (32.1%). With respect to duration of dural closure, the average time to closure using traditional suturing techniques was 1271 s (or 21 min and 11 s), while the average time for TC was 265 s (or 4 min and 25 s). At three-month follow-up, one case of cerebrospinal fluid (CSF) leak or infection was observed in the suture cohort and required reoperation. Conclusion Clinical outcomes in the TC group were excellent, consistent with previous reports; our findings further suggest that TCs result in more efficient dural closure than traditional suturing techniques. Our findings suggest that TC may be a safe, efficacious, and more efficient alternative to traditional suture for achieving dural closure in pediatric patients with TCS undergoing LFT surgery.
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Affiliation(s)
- Brannan E. O'Neill
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jamila A. Godil
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nolan J. Brown
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Joshua Loya
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Ana Silva
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jesse Winer
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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Yoshihara H, Karakostas J, Hayes W. Efficacy of patch technique for dural tear repair using hydrogel sealant: a pilot study. Spine J 2023; 23:1563-1567. [PMID: 37369254 DOI: 10.1016/j.spinee.2023.06.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
| | - Jonathan Karakostas
- Department of Orthopedic Surgery & Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Westley Hayes
- Department of Orthopedic Surgery & Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Shahrestani S, Brown NJ, Loya J, Patel NA, Gendreau JL, Himstead AS, Pierzchajlo N, Singh R, Sahyouni R, Diaz-Aguilar LD, Rennert RC, Levy ML. Novel use of nonpenetrating titanium clips for pediatric primary spinal dural closure: A technical note. Clin Neurol Neurosurg 2022; 222:107422. [PMID: 36084429 DOI: 10.1016/j.clineuro.2022.107422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dural closure is an important part of any pediatric spinal procedure with intradural pathology to prevent post-operative cerebrospinal fluid (CSF) egress and associated complications. Utilization of nonpenetrating titanium clips is one closure option that may have technical advantages such as ease of use and amenability to a narrow surgical corridor. No data exist on the efficacy of these clips for pediatric spinal dural closure. METHODS A single surgeon case series of 152 pediatric patients underwent procedures involving lumbar durotomy with subsequent dural closure using the AnastoClip® nonpenetrating titanium clip closure system. Rates of infection and cerebrospinal fluid leak were measured during the follow-up period. RESULTS A total of 152 pediatric patients (mean age: 6.25 ± 5.85 years, 50.7 % female) underwent intradural surgery with clip closure. The mean follow-up time was 57.0 ± 28.5 months. All patients were initially indicated for procedures involving spinal durotomy, with a majority being isolated tethered cord release (84.2 %). Others required tethered cord release and excision of a lipomyelomeningocele, spinal meningioma or arachnoid cyst (15.8 %). Post operative CSF leak occurred in two (1.32 %) patients at 11 and 18 days. Only one (0.66 %) patient was diagnosed with an infection, which was in a separate patient from those that had CSF leaks. CONCLUSION The remarkably low incidence of post-operative CSF leak and infection with nonpenetrating titanium clips suggests a strong safety and efficacy profile for this form of dural closure in a pediatric cohort. Further research evaluating this technique is required to fully demonstrate its acceptability as a cost-effective alternative to traditional suture-based closure.
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Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, Orange, CA, USA.
| | - Joshua Loya
- Department of Neurosurgery, University of California, La Jolla, San Diego, CA, USA
| | - Neal A Patel
- School of Medicine, Mercer University, Columbus, GA, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | | | | | - Rohin Singh
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Ronald Sahyouni
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Luis Daniel Diaz-Aguilar
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, La Jolla, San Diego, CA, USA; Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
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Chang CY, Hung CC, Liu JM, Chiu CD. Tension pneumocephalus following endoscopic resection of a mediastinal thoracic spinal tumor: A case report. World J Clin Cases 2022; 10:725-732. [PMID: 35097100 PMCID: PMC8771397 DOI: 10.12998/wjcc.v10.i2.725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/12/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pneumocephalus is a rare complication presenting in the postoperative period of a thoracoscopic operation. We report a case in which tension pneumocephalus occurred after thoracoscopic resection as well as the subsequent approach of surgical management.
CASE SUMMARY A 66-year-old man who received thoracoscopic resection to remove an intrathoracic, posterior mediastinal, dumbbell-shaped, pathology-proven neurogenic tumor. The patient then reported experiencing progressively severe headaches, especially when in an upright position. A brain computed tomography scan at a local hospital disclosed extensive pneumocephalus. Revision surgery for resection of the pseudomeningocele and repair of the cerebrospinal fluid leakage was thus arranged for the patient. During the operation, we traced the cerebrospinal fluid leakage and found that it might have derived from incomplete endoscopic clipping around the tumor stump near the dural sac at the T3 level. After that, we wrapped and sealed all the possible origins of the leakage with autologous fat, tissue glue, gelfoam, and duraseal layer by layer. The patient recovered well, and the computed tomography images showed resolution of the pneumocephalus.
CONCLUSION This report and literature review indicated that the risk of developing a tension pneumocephalus cannot be ignored and should be monitored carefully after thoracoscopic tumor resection.
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Affiliation(s)
- Chao-Yuan Chang
- Department of Neurosurgery, China Medical University Hospital, Taichung 40447, Taiwan
| | - Cheng-Che Hung
- Department of Neurosurgery, China Medical University Hospital, Taichung 40447, Taiwan
| | - Ju-Mien Liu
- Department of Pathology, Puli Christian Hospital, Nantou 54041, Taiwan
| | - Cheng-Di Chiu
- Department of Neurosurgery, China Medical University Hospital, Taichung 40447, Taiwan
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Choi EH, Chan AY, Brown NJ, Lien BV, Sahyouni R, Chan AK, Roufail J, Oh MY. Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review. World Neurosurg 2021; 149:140-147. [PMID: 33640528 DOI: 10.1016/j.wneu.2021.02.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy. METHODS PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection. RESULTS The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques. CONCLUSIONS Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.
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Affiliation(s)
- Elliot H Choi
- Department of Neurological Surgery, University of California, Irvine, California, USA; Medical Scientist Training Program, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alvin Y Chan
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California, San Diego, California, USA
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - John Roufail
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Michael Y Oh
- Department of Neurological Surgery, University of California, Irvine, California, USA.
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Milton CK, Andrews BJ, Baker CM, O'Connor KP, Conner AK, Sughrue ME, McKinney KA, El Rassi ET, Sanclement JA, Glenn CA. Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma. J Neurol Surg B Skull Base 2020; 83:116-124. [DOI: 10.1055/s-0040-1718765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/19/2020] [Indexed: 10/22/2022] Open
Abstract
Abstract
Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae.
Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported.
Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation.
Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.
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Affiliation(s)
- Camille K. Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Bethany J. Andrews
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Cordell M. Baker
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Kyle P. O'Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Andrew K. Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Michael E. Sughrue
- Department of Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Kibwei A. McKinney
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Edward T. El Rassi
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Jose A. Sanclement
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Chad A. Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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Nicoletti GF, Umana GE, Graziano F, Florio A, Scalia G. Repair of a spinal pseudomeningocele in a delayed postsurgical cerebrospinal fluid leak using titanium U-clips: Technical note. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Incidental Durotomy During Endoscopic Stenosis Lumbar Decompression: Incidence, Classification, and Proposed Management Strategies. World Neurosurg 2020; 139:e13-e22. [DOI: 10.1016/j.wneu.2020.01.242] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/13/2022]
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10
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Chorath K, Krysinski M, Bunegin L, Majors J, Weitzel EK, McMains KC, Chen PG. Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue. ALLERGY & RHINOLOGY 2019; 10:2152656719879677. [PMID: 31632835 PMCID: PMC6769216 DOI: 10.1177/2152656719879677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips. Methods The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed. Results The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H2O, FG/CMG was 12.413 ± 5.114 cm H2O, and TC/FL was 8.330 ± 3.483 cm H2O. There were statistically significant differences in mean failure pressures among the 3 repair methods. Conclusion In this ex vivo model comparing skull base repairs’ ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP’s. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.
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Affiliation(s)
- Kevin Chorath
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Mason Krysinski
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Leonid Bunegin
- Department of Anesthesiology, University of Texas Health San Antonio, San Antonio, Texas
| | - Jacob Majors
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Erik Kent Weitzel
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Kevin Christopher McMains
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Philip G Chen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
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11
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Suter A, Spirig JM, Fornaciari P, Bachmann E, Götschi T, Klein K, Farshad M. Watertightness of wound closure in lumbar spine-a comparison of different techniques. JOURNAL OF SPINE SURGERY (HONG KONG) 2019; 5:358-364. [PMID: 31663047 PMCID: PMC6787369 DOI: 10.21037/jss.2019.08.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Since a primary watertight dural suture after incidental durotomies has a failure rate of 5-10%, a watertight closure technique of the overlying layers (fascia, subcutis and skin) is essential. The purpose of this cadaveric study was to find the most watertight closure technique for fascia, subcutis and skin. METHODS Different suturing techniques were tested for each layer in a sheep cadaveric model by measuring the leakage pressure. The specimens were mounted on a pressure chamber connected to a manometer and a water tube system. Subsequently, the leakage was over-sewed with a cross stitch and the experiment was repeated. RESULTS Cross stitch suturing [median =180 mbar (43; 660)] performed best compared to continuous [median =16 mbar (6; 52)] (P=0.003) but not to single knot [median =118 mbar (21; 387)] (P=1.0) or locking stitch suturing [median =109 mbar (3; 149)] (P=0.93) for fascia closure. Continuous suture [median =9 mbar (3; 14)] resulted in a higher leakage pressure than single knot [median =1 mbar (1; 6)] (P=0.017) for subcutaneous closure. No significant differences were found between intracutaneous, Donati-continuous, single knot and locking stitch for skin closures (P=0.075). However, the Donati-continuous stitch closure resulted in higher pressures in tendency. Over-sewing increased median leakage pressure from 8.0 to 11.0 mbar (P=0.068) and from 4.0 to 13.0 mbar (P=0.042) for single knot and for locking stitch skin closures, respectively. CONCLUSIONS Cross stitches for the fascia, continuous suturing technique for the subcutis and Donati-continuous stitch for the skin resulted in the most watertight closure within this experimental setting. If leakage occurs, over-sewing might relevantly improve the watertightness of the wound.
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Affiliation(s)
- Aline Suter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José Miguel Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paolo Fornaciari
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Elias Bachmann
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Switzerland Laboratory for Orthopedic Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ), Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Switzerland Laboratory for Orthopedic Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ), Zurich, Switzerland
| | - Karina Klein
- Vetsuisse, Musculoskeletal Research Unit (MSRU), University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Takenaka S, Makino T, Sakai Y, Kashii M, Iwasaki M, Yoshikawa H, Kaito T. Prognostic impact of intra- and postoperative management of dural tear on postoperative complications in primary degenerative lumbar diseases. Bone Joint J 2019; 101-B:1115-1121. [DOI: 10.1302/0301-620x.101b9.bjj-2019-0381.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT. Patients and Methods Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT. Results In total, 429/12 171 patients (3.5%) had a DT. Multivariable analysis revealed that PEG hydrogel significantly reduced the incidence of dural leak and prolonged bed rest, and that patients treated with sealants (fibrin glue and PEG hydrogel) significantly less frequently suffered from headache. A longer drainage duration significantly increased the incidence of headache, nausea/vomiting, and delayed wound healing. Headache and nausea/vomiting were significantly more prevalent in younger female patients. Postoperative neurological deficit and reoperation for DT significantly depended on the presence of cauda equina/nerve root herniation. A longer operative time was the sole independent risk factor for SSI and was also a risk factor for dural leak, prolonged bed rest, and nausea/vomiting. Conclusion Sealants, particularly PEG hydrogel, may be useful in reducing symptoms related to cerebrospinal fluid leakage, whereas prolonged drainage may be unnecessary. Younger female patients should be carefully treated when DT occurs. Cite this article: Bone Joint J 2019;101-B:1115–1121.
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Affiliation(s)
- Shota Takenaka
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Makino
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Sakai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Kashii
- Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, Osaka, Japan
| | - Motoki Iwasaki
- Department of Orthopaedic Surgery, Osaka-Rosai Hospital, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Marin Laut FM, Gómez Cárdenas EA, Dormido JR, Molina NM, López López JA. Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip. Neurocirugia (Astur) 2019; 30:173-178. [PMID: 30782504 DOI: 10.1016/j.neucir.2018.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/24/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought. OBJECTIVE The purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI). METHODS We performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018. RESULTS The mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks. CONCLUSIONS We describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging.
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Affiliation(s)
| | | | - Jesús Riqué Dormido
- Department of Neurosurgery, University Hospital of Puerta de Mar, Cádiz, Spain
| | | | - Jose A López López
- Department of Neurosurgery, University Hospital of Puerta de Mar, Cádiz, Spain
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14
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Kinaci A, Van Doormaal TP. Dural sealants for the management of cerebrospinal fluid leakage after intradural surgery: current status and future perspectives. Expert Rev Med Devices 2019; 16:549-553. [DOI: 10.1080/17434440.2019.1626232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Ahmet Kinaci
- Department of Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
- Brain Technology Institute, Utrecht, The Netherlands
| | - Tristan P.C. Van Doormaal
- Department of Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
- Brain Technology Institute, Utrecht, The Netherlands
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15
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Barber SM, Fridley JS, Konakondla S, Nakhla J, Oyelese AA, Telfeian AE, Gokaslan ZL. Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:217. [PMID: 31297382 DOI: 10.21037/atm.2019.01.04] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
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16
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Buchanan IA, Min E, Pham MH, Donoho DA, Bakhsheshian J, Minneti M, Zada G, Giannotta SL, Hsieh PC, Liu JC. Simulation of Dural Repair in Minimally Invasive Spine Surgery With the Use of a Perfusion-Based Cadaveric Model. Oper Neurosurg (Hagerstown) 2019; 17:616-621. [DOI: 10.1093/ons/opz041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees.
OBJECTIVE
To simulate dural repair in spine surgery using minimal-access techniques.
METHODS
A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model.
RESULTS
Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees—irrespective of postgraduate year—were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores.
CONCLUSION
Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.
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Affiliation(s)
- Ian A Buchanan
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elliot Min
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Martin H Pham
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Minneti
- Department of General Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven L Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Patrick C Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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17
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Glenn CA, Baker CM, Burks JD, Conner AK, Smitherman AD, Sughrue ME. Dural Closure in Confined Spaces of the Skull Base with Nonpenetrating Titanium Clips. Oper Neurosurg (Hagerstown) 2018; 14:375-385. [PMID: 28973649 DOI: 10.1093/ons/opx140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 07/06/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dural repair in areas with limited operative maneuverability has long been a challenge in skull base surgery. Without adequate dural closure, postoperative complications, including cerebrospinal fluid (CSF) leak and infection, can occur. OBJECTIVE To show a novel method by which nonpenetrating, nonmagnetic titanium microclips can be used to repair dural defects in areas with limited operative access along the skull base. METHODS We reviewed 53 consecutive surgical patients in whom a dural repair technique utilizing titanium microclips was performed from 2013 to 2016 at our institution. The repairs primarily involved difficult-to-reach dural defects in which primary suturing was difficult or impractical. A detailed surgical technique is described in 3 selected cases involving the anterior, middle, and posterior fossae, respectively. An additional 5 cases are provided in more limited detail to demonstrate clip artifact on postoperative imaging. Rates of postoperative CSF leak and other complications are reported. RESULTS The microclip technique was performed successfully in 53 patients. The most common pathology in this cohort was skull base meningioma (32/53). Additional surgical indications included traumatic dural lacerations (9/53), nonmeningioma tumors (8/53), and other pathologies (4/53). The clip artifact present on postoperative imaging was minor and did not interfere with imaging interpretation. CSF leak occurred postoperatively in 3 (6%) patients. No obvious complications attributable to microclip usage were encountered. CONCLUSION In our experience, intracranial dural closure with nonpenetrating, nonmagnetic titanium microclips is a feasible adjunct to traditional methods of dural repair.
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Affiliation(s)
- Chad A Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Cordell M Baker
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joshua D Burks
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Adam D Smitherman
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael E Sughrue
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Nagel SJ, Reddy CG, Frizon LA, Chardon MK, Holland M, Machado AG, Gillies GT, Howard MA, Wilson S. Spinal dura mater: biophysical characteristics relevant to medical device development. J Med Eng Technol 2018; 42:128-139. [PMID: 29569970 PMCID: PMC7053539 DOI: 10.1080/03091902.2018.1435745] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Understanding the relevant biophysical properties of the spinal dura mater is essential to the design of medical devices that will directly interact with this membrane or influence the contents of the intradural space. We searched the literature and reviewed the pertinent characteristics for the design, construction, testing, and imaging of novel devices intended to perforate, integrate, adhere or reside within or outside of the spinal dura mater. The spinal dura mater is a thin tubular membrane composed of collagen and elastin fibres that varies in circumference along its length. Its mechanical properties have been well-described, with the longitudinal tensile strength exceeding the transverse strength. Data on the bioelectric, biomagnetic, optical and thermal characteristics of the spinal dura are limited and sometimes taken to be similar to those of water. While various modalities are available to visualise the spinal dura, magnetic resonance remains the best modality to segment its structure. The reaction of the spinal dura to imposition of a foreign body or other manipulations of it may compromise its biomechanical and immune-protective benefits. Therefore, dural sealants and replacements are of particular clinical, research and commercial interest. In conclusion, existing devices that are in clinical use for spinal cord stimulation, intrathecal access or intradural implantation largely adhere to traditional designs and their attendant limitations. However, if future devices are built with an understanding of the dura's properties incorporated more fully into the designs, there is potential for improved performance.
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Affiliation(s)
- Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Chandan G. Reddy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Leonardo A. Frizon
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Matthieu K. Chardon
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marshall Holland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Andre G. Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Matthew A. Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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19
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The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study. Spine J 2017; 17:1335-1341. [PMID: 28412565 DOI: 10.1016/j.spinee.2017.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/14/2017] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery. PURPOSE The study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques. STUDY DESIGN/SETTING The study is set in a fresh tissue dissection laboratory. SAMPLE SIZE The sample includes eight fresh human cadavers. OUTCOME MEASURES A watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines. METHODS Fresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7-T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage. RESULTS Spinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p>.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p<.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p<.01) when compared with mean pressures without the hydrogel sealant. CONCLUSIONS We described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.
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20
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Yan S, Wang X, Lv C, Phan K, Wang Y, Wang J, Yang Y, Wu N. Mediastinal micro-vessels clipping during lymph node dissection may contribute to reduce postoperative pleural drainage. J Thorac Dis 2016; 8:415-21. [PMID: 27076936 DOI: 10.21037/jtd.2016.02.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative pleural drainage markedly influences the length of postoperative stay and financial costs of medical care. The aim of this study is to retrospectively investigate potentially predisposing factors related to pleural drainage after curative thoracic surgery and to explore the impact of mediastinal micro-vessels clipping on pleural drainage control after lymph node dissection. METHODS From February 2012 to November 2013, 322 consecutive cases of operable non-small cell lung cancers (NSCLC) undergoing lobectomy and mediastinal lymph node dissection with or without application of clipping were collected. Total and daily postoperative pleural drainage were recorded. Propensity score matching (1:2) was applied to balance variables potentially impacting pleural drainage between group clip and group control. Analyses were performed to compare drainage volume, duration of chest tube and postoperative hospital stay between the two groups. Variables linked with pleural drainage in whole cohort were assessed using multivariable logistic regression analysis. RESULTS Propensity score matching resulted in 197 patients (matched cohort). Baseline patient characteristics were matched between two groups. Group clip showed less cumulative drainage volume (P=0.020), shorter duration of chest tube (P=0.031) and postoperative hospital stay (P=0.022) compared with group control. Risk factors significantly associated with high-output drainage in multivariable logistic regression analysis were being male, age >60 years, bilobectomy/sleeve lobectomy, pleural adhesion, the application of clip applier, duration of operation ≥220 minutes and chylothorax (P<0.05). CONCLUSIONS This study suggests that mediastinal micro-vessels clipping during lymph node dissection may reduce postoperative pleural drainage and thus shorten hospital stay.
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Affiliation(s)
- Shi Yan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Xing Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Chao Lv
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kevin Phan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yuzhao Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Jia Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yue Yang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Nan Wu
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
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Cheng YP, Lin PY, Huang APH, Cheng CY, Chen CM, Hueng DY. Durotomy repair in minimally invasive transforaminal lumbar interbody fusion by nonpenetrating clips. Surg Neurol Int 2014; 5:36. [PMID: 24818043 PMCID: PMC4014817 DOI: 10.4103/2152-7806.129161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 02/14/2014] [Indexed: 12/11/2022] Open
Abstract
Background: Closure of the dura defect may be easy to perform in open lumbar surgery but could be difficult in minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) since MIS-TLIF was done through a small tube, which limited the use of standard dural repair instruments. We used nonpenetrating titanium clips that were originally designed for the vascular anastomoses to repair the dura defect, which is never described in the literature. Methods: We presented a case of spinal stenosis with incidental durotomy while performing MIS-TLIF. We closed the dura laceration with three medium-sized nonpenetrating titanium clips (AnastoClip Vessel Closure System, LeMaitre Vascular, Inc., Burlington, MA). Results: Nonpenetrating titanium clips have the benefits of being technically easy to use, reduced durotomy repair time, decreased bed rest due to related medical complications, superior postoperation with immediate hydrostatic strength, and better reapproximation if it fails to clip successfully. As for the postoperation follow up, clips are tiny and reveal no obvious artifact, especially in cases where the pedicle screws are already causing much artifact. Conclusion: Primary dural closure during MIS-TLIF with clips is an effective way in cases that involve limited tubular space.
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Affiliation(s)
- Yen-Po Cheng
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Yi Lin
- Transplant Medicine and Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan
| | - Abel Po-Hao Huang
- Department of Neurosurgery, Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Yuan Cheng
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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