Treatment experience for full-thickness wound dehiscence with cerebrospinal fluid leakage following posterior primary spine surgery: Three case reports

Cervical wound dehiscence following internal fixation of the cervical and thoracic spine: a report of three cases

Background

Wound dehiscence is a known postoperative complication, but in cervical spine surgery it is rare and there is a lack of documented literature. This case report discusses novel complications of wound dehiscence in three patients who were treated with spinous process ostectomies after posterior cervical surgeries.

Case Description

In total three cases are reported in these reports. Case one documents the management of a patient with full-thickness cervical wound dehiscence following a cervical paraspinal infection corrected with posterior spinal fixation and fusion. This patient was treated with resection of the prominent spinous processes. Case two documents the management of a patient with an odontoid fracture requiring revision surgery. The patient developed a full-thickness wound dehiscence and was treated with resection of the prominent spinous processes. Case three was a patient suffering from a T9 spinal cord injury who was also treated for multiple vertebral fractures. The patient eventually developed internal cervical wound dehiscence which resulted in removal of the prominent spinous processes.

Conclusions

This case report documents the successful treatment of cervical wound dehiscence which is a rare postoperative complication of cervical spinal surgery. This information is valuable as treatment strategies and research into cervical wound dehiscence are limited to a single case report.

Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery

INTRODUCTION AND OBJECTIVES

Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery.

MATERIALS AND METHODS

We conducted a single-center, double-blind, randomized -controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone (CP-A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP-A group (n = 36, 50%) and CP+A group (n = 36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position + dose of acetazolamide 20 mg/kg/day in 3-4 divided doses for 7 days), and CP-A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide).

RESULTS

Baseline characteristics between the two groups showed no significant differences: Sex (P < .637), Age (P < .988) and previous CNS operation at other location besides the spine (P < .496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36 (11.11%) of CP-A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081-2.748; OR = 0.471; P < .402; Adjusted P < .247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P < .489) and type of operation (P < .465).

CONCLUSION

Acetazolamide has no positive effect in controlling CSF leak after dural opening/dural tear in adult patients who undergo spinal surgery, when we considered alongside the one-week prone position. Therefore, acetazolamide administration may not be essential for postoperative spinal surgery for dural tear. Prospective studies involving a larger sample size may be needed to track long-term acetazolamide complications on patients with CSF leak.

Photo-Crosslinked Hyaluronic Acid/Carboxymethyl Cellulose Composite Hydrogel as a Dural Substitute to Prevent Post-Surgical Adhesion

A dural substitute is frequently used to repair dura mater during neurosurgical procedures. Although autologous or commercially available dural substitutes matched most of the requirements; difficulties during dural repair, including insufficient space for suturing, insufficient mechanical strength, easy tear and cerebrospinal fluid leakage, represent major challenges. To meet this need, a photo-crosslinked hydrogel was developed as a dural substitute/anti-adhesion barrier in this study, which can show sol-to-gel phase transition in situ upon short-time exposure to visible light. For this purpose, hyaluronic acid (HA) and carboxymethyl cellulose (CMC), materials used in abdominal surgery for anti-adhesion purposes, were reacted separately with glycidyl methacrylate to form hyaluronic acid methacrylate (HAMA) and carboxymethyl cellulose methacrylate (CMCMA). The HA/CMC (HC) hydrogels with different HA compositions could be prepared by photo-crosslinking HAMA and CMCMA with a 400 nm light source using lithium phenyl-2,4,6-trimethylbenzoylphosphinate as a photo-initiator. From studies of physico-chemical and biological properties of HC composite hydrogels, they are bio-compatible, bio-degradable and mechanically robust, to be suitable as a dural substitute. By drastically reducing attachment and penetration of adhesion-forming fibroblasts in vitro, the HC hydrogel can also act as an anti-adhesion barrier to prevent adhesion formation after dural repair. From in vivo study in rabbits, the HC hydrogel can repair dural defects as well as protect the dura from post-operative adhesion, endorsing the possible application of this hydrogel as a novel dural substitute.

Traumatic intradural disc herniation following a cervical facet dislocation: a case report

We report a unique case of a patient who sustained an intradural disc herniation from a left C5-6 unilateral facet dislocation after a fall. This was not easily identified on pre-operative imaging. We explain the details of our surgical approach in this case report. A 65-year-old male fell into a 2 m drain and sustained a left C5/6 unilateral facet dislocation. He then sustained an American Spinal Injury Association (ASIA) B cord injury. His power was 0/5 from C8 downwards bilaterally but sensation was intact throughout. Magnetic resonance imaging (MRI) showed severe compression at C5/6 but no overt intradural disc herniation. This patient subsequently underwent a closed reduction in the operating theatre followed by a combined anterior and posterior approach for the disc herniation. Cerebral spinal fluid (CSF) leakage was noted upon completion of the C5/6 discectomy and it was discovered that there was a traumatic dural tear from the traumatic disc herniation. The decision was made not to repair the dural tear due to the friable nature of the dura and the potential for adhesive glue to propagate through the spinal cord. An anterior drain was placed for 3 days and then removed, he subsequently underwent rehabilitation and was able to regain power in the affected myotomes. Intradural disc herniations can be easily missed on MRI in the setting of cervical spinal trauma. Hence, the anterior approach is an increasingly acceptable approach to tackle disc herniations in unilateral cervical facet dislocations (CFD) surgery.

Application of Color Doppler Ultrasound to Identify and Repair Postoperative Cerebrospinal Fluid Leak: A Technical Note

BACKGROUND

Incidental durotomy is a known complication of spinal surgery. Persistent cerebrospinal fluid (CSF) leak after unrecognized durotomy may lead to prolonged hospitalization and significant morbidity. If initial bed rest fails, the surgeon must choose between nontargeted methods such as oversewing the wound and lumbar drain placement or return to the operating room.

OBJECTIVE

To report the novel use of color flow doppler (CFD) in conjunction with ultrasound (US) to localize the point of CSF leak, assist with aspiration of the pseudomeningocele, and direct the application of fibrin sealant or epidural blood patch.

METHODS

This article includes a description of the technique as a technical note.

RESULTS

A 72-year-old man underwent L2-5 laminectomies for spinal stenosis. During the index operation, a durotomy occurred and was repaired primarily. The patient subsequently developed leg weakness, back pain, and bulging of the incision. Using CFD, the site of durotomy was determined. Under direct visualization, 34 mL of CSF was aspirated from the pseudomeningocele and 20 mL of fibrin sealant was placed opposing the durotomy. At 2-month follow-up, CFD confirmed absent flow and MRI demonstrated pseudomeningocele resolution.

CONCLUSION

This article represents the first report highlighting the utility of CFD US to guide epidural patch placement for postsurgical CSF leaks. CFD allows localization of the durotomy and direct application of blood or fibrin sealant, potentially increasing the success rate of epidural blood patch in postoperative patients. This approach is less invasive than revision surgery and does not require the prolonged hospitalization of lumbar drainage or other nontargeted interventions.

What is the role of incisional vacuum therapy in challenging spinal wounds? A single centre experience

OBJECTIVE

A surgical approach to the treatment of spinal defects and disorders has become more common because of the medical and technological advancements achieved in the last decade. This rising trend in spinal surgeries is associated with adverse events, most notably wound complications. From its introduction, negative pressure wound therapy (NPWT) has proved to be essential in the management of complex wounds and in speeding up wound recovery. The aim of this study is to investigate the use of incisional NPWT in patients undergoing spinal surgery and its role in the prevention of wound complications.

METHOD

This study is a retrospective medical chart review conducted on patients who underwent spinal surgery and received incisional vacuum therapy as part of their treatment. The apparatus was applied intraoperatively following the spinal surgery for all patients included in this study. All surgical procedures were conducted between September 2019 and May 2020. Data entry and analysis were performed between September and October 2020.

RESULTS

A total of five patients' records were reviewed. In our healthcare centre, three patients developed seroma, one developed haematoma, four required revision surgery and one patient required re-operation. There was no wound dehiscence and none of the wounds became infected. Mean length of hospital stay was 11.2 days (standard deviation (SD): 9.5 days) and mean operation time was 333 minutes (SD: 86.4 minutes).

CONCLUSION

There is a scarcity of data on the role of incisional vacuum therapy in the prevention of wound complications associated with spine surgeries. Our study showed promising results for the use of incisional NPWT in the management of spinal wounds. Further research is required in order to enhance wound care by exploiting this potentially beneficial approach.

Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch

BACKGROUND

Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time.

METHODS

A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele.

RESULTS

Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m², respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months.

CONCLUSIONS

This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.

A Novel Method for Practicing Fascial Closure with Suture

Closure of the fascial layer can be challenging to learn for junior level residents. Wound dehiscence involving the fascial layer can lead to complicated clinical courses for patients, including readmission to the hospital, wound vacuum placement, antibiotic regimens, and re-operation. Typical suturing techniques taught in medical school focus more on basic techniques of suture placement such as interrupted or running techniques. The aim of this study is to introduce a method of practicing fascial closure using easily obtainable items. Though there is no substitute for placement of suture and closure of fascia in vivo, this method allows one to practice the motor repetition of fascial suture placement and provides one with the ability to check their work.