Management of intended durotomy in minimally invasive intradural spine surgery

The Use of Cranial Aneurysm Clips for Repair of Incidental Lumbar Durotomy: Operative Technique and Case Series

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.

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.

Expanding the Horizons of Minimally Invasive Spine Surgery: Experience of the Destandau Technique for the Treatment of Multiple Spinal Diseases

OBJECTIVE

Minimally invasive spine surgery is rapidly gaining popularity because of its versatile nature. Traditionally, prolapsed disc has been the most common disease targeted using this technique. However, its usefulness for various other diseases has also been shown in studies. We present our experience of using this technique for various spinal diseases apart from prolapsed discs.

METHODS

This is a retrospective study in which patients operated on by a single surgeon from January 2019 to April 2023 were included. Cases that required conversion to open technique were excluded. Intraoperative findings and postoperative courses were obtained from patient records.

RESULTS

A total of 47 patients were included in the study, of whom 29 were male and 18 were female. The various diseases treated comprised intradural extramedullary (IDEM) tumors (n = 23), hypertrophied/ossified ligamentum flavum (n = 9), arachnoid cysts (n = 6), dermoid/epidermoid cysts (n = 4), detethering of cord (n = 3), and posterior cervical decompression for an ossified posterior longitudinal ligament (n = 2). The average duration of surgery was 2.1 ± 1.2 hours and the mean intraoperative blood loss was 138.4 ± 59.1 mL. The mean length of hospital stay was 2.3 ± 0.9 days. Two patients had superficial wound infection and none of the operated patients had cerebrospinal fluid leakage. Re-exploration was not required in any of the operated patients.

CONCLUSIONS

Minimally invasive techniques for dealing with multiple diseases involving the spine are as good as traditional open techniques, with some additional advantages of lesser tissue trauma, early return to work, and so on. However, one must overcome the steep learning curve before adopting them in day-to-day practice.

Surgical evolution in spinal dural arteriovenous fistula treatment-a 7 years monocentric experience

Accounting for 70% of all spinal vascular malformations, spinal dural arteriovenous fistulas (SDAVF) are the most common type of malformation. Interruption of the fistulous arterialized vein point is the goal of surgical treatment. The aim of the study was to compare open surgery (laminectomy) versus minimal invasive surgery (MIS) in SDAVF treatment. Between March 2013 and March 2020, we retrospectively collected 21 consecutive adult patients with SDAVF. Since March 2017, MIS has been routinely used for surgical treatment. Pre- and post-operative clinical evaluations used Aminoff-Logue score (ALS). Complication rate was noted. Post-operative occlusion of the malformation was confirmed by digital subtraction angiography (DSA) in all patients. MIS was compared to open surgery in terms of efficacy and complications with statistical evaluation. Standard laminectomy was performed in 12 patients and MIS technique in 9 patients. No difference was noted on pre-operative parameters. ALS and MRI signs of myelopathy were improved in all cases except for 1 patient in each group. All SDAVFs were excluded based on post-operative DSA. Significant differences were noted between the 2 groups in terms of perioperative blood loss (p<0.001), post-operative pain visual analog scale values (p<0.001), and first time out of bed (p<0.001). Wrong level surgery occurred in one patient in each group; patients were re-operated using the same technique. No infection or cerebrospinal fluid (CSF) leak was noted. In our experience, MIS is a safe alternative to open laminectomy for SDAVF treatment. MIS contributes to patient comfort and minimizes blood loss without increasing complication rate.

Microsurgical Tubular Resection of Intradural Extramedullary Spinal Tumors With 3-Dimensional-Navigated Localization

BACKGROUND

The safety and efficacy of minimally invasive spine surgical (MISS) approaches have stimulated interest in adapting MISS principles for more complex pathology including intradural extramedullary (IDEM) tumors. No study has characterized a repeatable approach integrating the MISS surgical technique and 3-dimensional intraoperative navigated localization for the treatment of IDEM tumors.

OBJECTIVE

To describe a safe and reproducible technical guide for the navigated MISS technique for the treatment of benign intradural and extradural spinal tumors.

METHODS

Retrospective review of prospectively collected data on 20 patients who underwent navigated microsurgical tubular resection of intradural extramedullary tumors over a 5-year period. We review our approach to patient selection and report demographic and outcomes data for the cohort.

RESULTS

Our experience demonstrates technical feasibility and safety with a 100% rate of gross total resection with no patients demonstrating recurrence during an average follow-up of 20.2 months and no instances of perioperative complications. We demonstrate favorable outcomes regarding blood loss, operative duration, and hospital length of stay.

CONCLUSION

Navigated localization and microsurgical tubular resection of IDEM tumors is safe and effective. Adherence to MISS principles and thoughtful patient selection facilitate successful management of these patients.

Cerebrospinal fluid leaks following intradural spinal surgery—Risk factors and clinical management

Background

Cerebrospinal fluid leakage (CSFL) following spinal durotomy can lead to severe sequelae. However, while several studies have investigated accidental spinal durotomies, the risk factors and influence of clinical management in planned durotomies remain unclear.

Methods

We performed a retrospective analysis of all patients who underwent planned intradural spinal surgery at our institution between 2010 and 2020. Depending on the occurrence of a CSFL, patients were dichotomized and compared with respect to patient and case-related variables as well as dural closure technique, epidural drainage placement, and timing of mobilization.

Results

A total of 351 patients were included. CSFL occurred in 4.8% of all cases. Surgical indication, tumor histology, location within the spine, previous intradural surgery, and medical comorbidities were not associated with an increased risk of CSFL development (all p > 0.1). Age [odds ratio (OR), 0.335; 95% confidence interval (CI), 0.105–1.066] and gender (OR, 0.350; 95% CI, 0.110–1.115) were not independently associated with CSFL development. There was no significant association between CSFL development and the dural closure technique (p = 0.251), timing of mobilization (p = 0.332), or placement of an epidural drainage (p = 0.321).

Conclusion

CSFL following planned durotomy pose a relevant and quantifiable complication risk of surgery that should be factored in during preoperative patient counseling. Our data could not demonstrate superiority of any particular dural closure technique but support the safety of both early mobilization within 24 h postoperatively and epidural drainage with reduced or no force of suction.

Complication Avoidance in Surgical Management of Vertebral Column Tumors

The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.

Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series

BACKGROUND

Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear.

OBJECTIVE

To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS.

METHODS

A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma.

RESULTS

A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported.

CONCLUSION

Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.

Outcomes and complications following minimally invasive excision of synovial cysts of the lumbar spine: A systematic review and meta-analysis

OBJECTIVE

Lumbar synovial cysts (LSC) are one of the manifestations of spinal degenerative cascade. Spinal stenosis or presence of instability in these patients can lead to various symptoms and surgery is indicated following failure of non-operative management for symptomatic synovial cysts. Surgery when performed consists of either decompression with resection of cyst with our without fusion. The efficacy and complications of minimally invasive techniques using tubular retractors (microscopic or endoscopic) in comparison to traditional open techniques remain to be studied.

METHODS

A comprehensive search of different databases was performed to retrieve studies describing the use of minimal invasive techniques using tubular retractors (both microscopic and endoscopic) in patients with LSC. Meta-analysis with subgroup analysis and metaregression was done.

RESULTS

Twenty articles were selected for the systematic review and meta-analysis with total of 388 patients. Eighty-six percent of patients (95% Confidence Interval (CI): 80-90%) had favorable outcome as per Macnab's criteria (excellent and good outcome) with the pooled standard mean difference between preoperative and postoperative Oswestry Disability Index (ODI) being -4.44 (95% CI -8.78 to -0.10, p-value=0.0474, I² 82%). The pooled percentage change in visual analogue scale (VAS) after surgery was 76.5% (95% CI 66.9-84%, I² 82%). The pooled proportion of incidental durotomies, cyst recurrence and patients requiring operation being 8% (95% CI 5-11%, I² 0%), 4% (95% CI 2-7%, I² 0%,) and 5% (95% CI 3-9%) respectively. Studies were homogeneous with an I² value of 0%. Subgroup analysis revealed no significant difference in the outcome rates or complication rates between the microscopic and endoscopic subgroups.

CONCLUSION

Minimally invasive techniques for the resection of LSC is a safe and effective alternative to traditional surgical approaches with no difference between the microscopic and endoscopic approaches.

Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review

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.

Primary Dural Closure in Minimally Invasive Spine Surgery Using an Extracorporeal Knot: Technical Note

BACKGROUND

Minimally invasive spine surgeries (MISS) are currently used for a wide variety of intradural spinal pathologies. Although MISS techniques have brought great benefits, primary dural closure can prove a challenge due to the narrow corridor of the tubular retractor systems.

OBJECTIVE

To present the surgical technique we developed for dural closure using an extracorporeal knot that is simple and reproducible.

METHODS

We describe the use of an extracorporeal knot for primary dural closure in MISS surgeries using standard instrumental. We illustrate this operative technique with figures and its application in a surgical case with images and demonstration video2.

RESULTS

Using our surgical technique, a watertight dural closure with separated knots was performed without specific instruments.

CONCLUSION

The use of extracorporeal knots facilitates primary dural closure in MISS surgeries.

Safe Discharge of Patients From an Ambulatory Care Center After Incidental Durotomy During Minimally Invasive Spine Surgery

Background

Incidental durotomy is a well-known complication of spinal surgery that may occur occasionally. Increasingly, minimally invasive techniques are being used for spinal decompressions in an ambulatory surgical center (ASC) setting. The management of this complication in an ASC setting has not been reported.

Methods

A total of 832 consecutive minimally invasive decompressive spinal surgeries were performed by a single surgeon in an ASC during the course of 1 year. Incidental durotomies with cerebrospinal fluid leakage were repaired and patients were discharged to home. Patients with a watertight suture dural repair did not receive any modifications to the usual discharge activities allowed. All other patients were treated with bed rest overnight and head of bed restrictions. A protocol for close patient follow-up after discharge was followed. The complications were collected prospectively and analyzed retrospectively.

Results

There were 30 incidental durotomies (3.6%), with all occurring in the lumbar spine. Suture repair was accomplished in 28 patients (93%). Patch repair was performed in 2 patients (7%). All patients were discharged to home from the ASC. There were 2 short-term complications noted after discharge. The patient safety protocols in place identified the complications and allowed timely interventions.

Conclusions

Incidental durotomy occurring during minimally invasive spinal decompressive surgery is an occasional event. Suture repair of the laceration is feasible in most instances. Lumbar spine patients may be safely discharged to home from the ASC. Patients can be stratified into those with, or without, a watertight suture dural closure. Those with such a closure, who are without symptoms of intracranial hypotension, do not require modification of their activities. A short period of bedrest with head of bed modification successfully treated the remainder. Hospitalization or routine prolonged bed rest is not necessary. Protocols must be put in place to identify and timely manage potentially serious sequelae.

Preferences of Spine Surgeons With Regard to Management of Intraoperative Durotomy: A Survey of Current Management

STUDY DESIGN

This was a cross-sectional study.

OBJECTIVE

The objective of this study was to determine spine surgeons' preferences for the intraoperative and postoperative management of intraoperative durotomy (IDT) in decompression and spinal fusion surgeries.

SUMMARY OF BACKGROUND DATA

Management guidelines for IDT remain elusive. Traditionally, management consists of intraoperative suturing and postoperative bed rest. However, preferences of North American spine surgeons may vary, particularly according to type of surgery.

MATERIALS AND METHODS

Spine surgeons of AO Spine North America (AOSNA) were surveyed online anonymously to determine which techniques they preferred to manage IDT in decompression and fusion. Differences in preferences according to surgery type were compared using the Fisher exact test. A series of linear regressions were conducted to identify demographic predictors of spine surgeons' preferences.

RESULTS

Of 217 respondents, most were male (95%), orthopedic surgeons (70%), practiced at an academic center (50%), were in practice 0-19 years (71%) and operated on 100-300 patients per year (70%). The majority of surgeons applied sutures (93%-96%) and sealant (82%-84%). Surgeons also used grafts (26%-27%), drains (18%), other techniques (4%-5%), blood patch (2%-3%), or no intraoperative management (1%-2%). Postoperatively, most surgeons recommended bed rest (74%-75%). Antibiotics (22%), immediate mobilization (18%-20%), reoperation (14%-16%), other techniques (6%), or no postoperative management (5%) were also preferred. Management preferences did not vary significantly between decompression and fusion surgeries (all P-values>0.05). Specialty, practice facility, years in practice, and patients per year were identified as independent predictors of IDT management preferences (P<0.05).

CONCLUSIONS

Although North American spine surgeons preferred to manage IDT with sutures augmented by sealant followed by bed rest after surgery, less common techniques were also preferred during the intraoperative and postoperative periods. Notably, intraoperative and postoperative IDT management preferences did not change in accordance to the type of surgery being conducted.

LEVEL OF EVIDENCE

Level V.

Obstructive Hydrocephalus Due to Intraventricular Hemorrhage After Incidental Durotomy During Lumbar Spine Surgery

STUDY DESIGN

Case report and review of literature.

OBJECTIVE

To present an exceedingly rare occurrence of obstructive hydrocephalus secondary to intraventricular hemorrhage after incidental durotomy during lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Incidental durotomies are uncommon but well recognized complications associated with spine surgery. Whereas mostly considered benign with no untoward clinical sequele, it can be symptomatic and present with spinal headaches, pseudomeningoceles, wound infection, meningitis and rarely intracerebral hemorrhage.

METHODS

A 76-year-old woman underwent L3-S1 laminectomies and fusion for lumbar spondylosis and stenosis. Intraoperatively, a small incidental durotomy was encountered and primarily repaired.

RESULTS

The patient developed altered mental status on postoperative day 2. Computed tomography of the brain revealed obstructive hydrocephalus and intraventricular hemorrhage. The patient was immediately transferred to the neurosurgery intensive care unit and an external ventricular drain was placed emergently with high opening pressure. Her mental status improved immediately after cerebral spinal fluid diversion. The external ventricular drain was successfully removed after 8 days. The patient made a full recovery and was discharged in stable condition.

CONCLUSION

Obstructive hydrocephalus after intraventricular hemorrhage is an exceptionally rare but potentially life-threatening complication of incidental durotomies. Spine surgeons should be aware of this rare but serious complication.

LEVEL OF EVIDENCE

4.

Minimally invasive repair of a pseudomeningocele caused by a sheared intrathecal catheter following implantation of a drug delivery system

Background:

Shearing of an intrathecal catheter during implantation of a drug delivery system is an underreported complication that can be challenging to manage.

Case Description:

A 53-year-old man with refractory cancer pain had an intrathecal pump system implanted. The procedure was complicated with catheter shear and retention in the intrathecal space. A second catheter was successfully placed but formation of a painful pseudomeningocele and ineffective pain relief complicated the outcome. A minimally invasive approach through a tubular retractor was employed to access the spinal canal via a laminotomy, the sheared catheter was removed and the dural defect repaired. Complete resolution of the pseudomeningocele and efficient pain control were observed at follow-up.

Conclusion:

Minimally invasive approach to the spine is demonstrated as a safe and effective alternative in this case of retained catheter induced cerebrospinal fluid (CSF) leak.

Minimally Invasive Treatment for a Sacral Tarlov Cyst Through Tubular Retractors

BACKGROUND

Tarlov cysts (TC) are focal dilations of arachnoid and dura mater of the spinal posterior nerve root sheath that appear as cystic lesions of the nerve roots typically in the lower spine, especially in the sacrum, which can cause radicular symptoms when they increase in size and compress the nerve roots. Different open procedures have been described to treat TCs, but no minimally invasive procedures have been described to effectively address this pathology.

CASE DESCRIPTION

A 29-year-old woman presented with right lower extremity pain and weakness. A magnetic resonance imaging scan demonstrated a lumbosacral TC that protruded through the right L5-S1 foramina. Through a small laminotomy, cyst drainage followed by neck ligation using a Scanlan modified technique through tubular retractors was performed. The patient recovered full motor function within the first days postoperatively and showed no signs of relapse at 6-month follow-up.

CONCLUSIONS

Minimally invasive spine surgery through tubular retractors can be safely performed for successful excision and ligation of TC using a Scanlan modified technique.

Ten-Step Minimally Invasive Spine Lumbar Decompression and Dural Repair Through Tubular Retractors

BACKGROUND: Minimally invasive spine (MIS) surgery utilizing tubular retractors has become an increasingly popular approach for decompression in the lumbar spine. However, a better understanding of appropriate indications, efficacious surgical techniques, limitations, and complication management is required to effectively teach the procedure and to facilitate the learning curve.

OBJECTIVE: To describe our experience and recommendations regarding tubular surgery for lumbar disc herniations, foraminal compression with unilateral radiculopathy, lumbar spinal stenosis, synovial cysts, and dural repair.

METHODS: We reviewed our experience between 2008 and 2014 to develop a step-by-step description of the surgical techniques and complication management, including dural repair through tubes, for the 4 lumbar pathologies of highest frequency. We provide additional supplementary videos for dural tear repair, laminotomy for bilateral decompression, and synovial cyst resection.

RESULTS: Our overview and complementary materials document the key technical details to maximize the success of the 4 MIS surgical techniques. The review of our experience in 331 patients reveals technical feasibility as well as satisfying clinical results, with no postoperative complications associated with cerebrospinal fluid leaks, 1 infection, and 17 instances (5.1%) of delayed fusion.

CONCLUSION: MIS surgery through tubular retractors is a safe and effective alternative to traditional open or microsurgical techniques for the treatment of lumbar degenerative disease. Adherence to strict microsurgical techniques will allow the surgeon to effectively address bilateral pathology while preserving stability and minimizing complications.

Multiple uses of fibrin sealant for nervous system treatment following injury and disease

Lesions to the nervous system often produce hemorrhage and tissue loss that are difficult, if not impossible, to repair. Therefore, scar formation, inflammation and cavitation take place, expanding the lesion epicenter. This significantly worsens the patient conditions and impairment, increasing neuronal loss and glial reaction, which in turn further decreases the chances of a positive outcome. The possibility of using hemostatic substances that also function as a scaffold, such as the fibrin sealant, reduces surgical time and improve postoperative recovery. To date, several studies have demonstrated that human blood derived fibrin sealant produces positive effects in different interventions, becoming an efficient alternative to suturing. To provide an alternative to homologous fibrin sealants, the Center for the Study of Venoms and Venomous Animals (CEVAP, Brazil) has proposed a new bioproduct composed of certified animal components, including a thrombin-like enzyme obtained from snake venom and bubaline fibrinogen. Thus, the present review brings up to date literature assessment on the use of fibrin sealant for nervous system repair and positions the new heterologous bioproduct from CEVAP as an alternative to the commercial counterparts. In this way, clinical and pre-clinical data are discussed in different topics, ranging from central nervous system to peripheral nervous system applications, specifying positive results as well as future enhancements that are necessary for improving the use of fibrin sealant therapy.

Postoperative Cerebrospinal Fluid Leak Rates with Subfascial Epidural Drain Placement after Intentional Durotomy in Spine Surgery

Study Design Retrospective chart review. Objective Postoperative cerebrospinal fluid (CSF) leak is a known complication of intraoperative durotomy. Intraoperative placement of subfascial epidural drains following primary dural repair has been proposed as a potential management strategy to prevent formation of CSF cutaneous fistula and symptomatic pseudomeningocele. Here we describe our experience with subfascial drain after intentional durotomy. Methods Medical records of patients who underwent placement of subfascial epidural drains during spinal procedures with intentional intraoperative durotomies over a 4-year period at two institutions were retrospectively reviewed. Primary outcomes of interest were postoperative CSF cutaneous fistula or symptomatic pseudomeningocele formation. Results Twenty-five patients were included. Mean length of follow-up was 9.5 months. Twelve patients (48%) underwent simultaneous arthrodesis. The average duration of the drain was 5.3 days with average daily output of 126.5 mL. Subgroup analyses revealed that average drain duration for the arthrodesis group was 6.33 days, which is significantly greater than that of the nonfused group, which was 3.7 days (p = 0.016). Similarly, the average daily drain output for the arthrodesis subgroup at 153.1 mL was significantly higher than that of the nonfused subgroup (86.8 mL, p = 0.04). No patient developed postoperative CSF cutaneous fistula or symptomatic pseudomeningocele or had negative sequelae associated with overdrainage of CSF. One patient had a delayed wound infection. Conclusions The intraoperative placement of subfascial epidural drains was not associated with postoperative development of CSF cutaneous fistula, symptomatic pseudomeningocele, overdrainage, or subdural hematoma in the cases reviewed. Subfascial closed wound drain placement is a safe and efficacious management method after intentional spinal durotomies. It is particularly helpful in those who undergo simultaneous arthrodesis, as those patients have statistically higher daily drain output and longer drain durations.

The Use Fibrin Sealant after Spinal Intradural Tumor Surgery: Is It Necessary?

OBJECTIVE

A fibrin sealant is commonly applied after closure of an incidental or intended durotomy to reduce the complications associated with the leakage of cerebrospinal fluid. Routine usage might not be essential after closure of an intended durotomy, which has clear cut-margins. We investigated the efficacy of fibrin sealants for primary intradural spinal cord tumor surgery.

METHODS

A retrospective review was performed for 231 consecutive surgically treated patients with primary intradural spinal cord tumors without extradural extension. Fibrin sealants were not used for 47 patients (group I: age, 51.57±16.75 years) and were applied to 184 patients (group II: age, 48.8±14.7 years). The surgical procedures were identical except for the use of a fibrin sealant after closure of the durotomy. The primary outcome was the occurrence of complications (wound problems, hematoma collection, infection, and neurological deterioration). The covariates were age, sex, body mass index, operation time, pre-/postoperative ambulation, number of laminectomies, and type of tumor.

RESULTS

Schwannoma was the most common pathology (n=134), followed by meningioma (n=35) and ependymoma (n=31). Complications occurred in 13 patients (3 in group I and 10 in group II, p=0.73). The postoperative ambulation status (p<0.01; odds ratio, 28.8; 95% confidence interval, 6.9-120.0) and operation time (p=0.04; cutoff, 229 minutes; sensitivity, 62%; specificity, 72%) were significant factors, whereas the use of a fibrin glue was not (p=0.47).

CONCLUSION

The use of a fibrin sealant might not be essential to reduce complications after surgery for primary spinal intradural tumor.