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Motov S, Stemmer B, Krauss P, Maurer C, Shiban E. Treatment of a symptomatic cervical cerebrospinal fluid fistula after full endoscopic cervical foraminotomy with CT-guided epidural fibrin patch. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:3124-3128. [PMID: 37804453 DOI: 10.1007/s00586-023-07973-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 09/06/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND There is only limited data on the management of cerebrospinal fluid (CSF) fistulas after cervical endoscopic spine surgery. We investigated the current literature for treatment options and present a case of a patient who was treated with CT-guided epidural fibrin patch. METHODS We present the case of a 47-year-old female patient with a suspected CSF fistula after endoscopic decompression for C7 foraminal stenosis. She was readmitted 8 days after surgery with dysesthesia in both upper extremities, orthostatic headache and neck pain, which worsened during mobilization. A CSF leak was suspected on spinal magnetic resonance imaging. A computer tomography (CT)-guided epidural blood patch was performed with short-term relief. A second CT-guided epidural fibrin patch was executed and the patient improved thereafter and was discharged at home without sensorimotor deficits or sequelae. We investigated the current literature for complications after endoscopic spine surgery and for treatment of postoperative CSF fistulas. RESULTS Although endoscopic and open revision surgery with dura repair were described in previous studies, dural tears in endoscopic surgery are frequently treated conservatively. In our case, the patient was severely impaired by a persistent CSF fistula. We opted for a less invasive treatment and performed a CT-guided fibrin patch which resulted in a complete resolution of patient's symptoms. DISCUSSION AND CONCLUSION CSF fistulas after cervical endoscopic spine procedures are rare complications. Conservative treatment or revision surgery are the standard of care. CT-guided epidural fibrin patch was an efficient and less invasive option in our case.
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Affiliation(s)
- Stefan Motov
- Klinik Für Neurochirurgie, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland.
- Klinik Für Neurochirurgie, Universitaetsklinik Augsburg, Augsburg, Germany.
| | - B Stemmer
- Klinik Für Neurochirurgie, Universitaetsklinik Augsburg, Augsburg, Germany
| | - P Krauss
- Klinik Für Neurochirurgie, Universitaetsklinik Augsburg, Augsburg, Germany
| | - C Maurer
- Klinik Für Diagnostische Und Interventionelle Radiologie Und Neuroradiologie, Universitaetsklinik Augsburg, Augsburg, Germany
| | - E Shiban
- Klinik Für Neurochirurgie, Universitaetsklinik Augsburg, Augsburg, Germany
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2
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Zhao R, Li N, Zhang J, Luo X, Zhang X. Endoscopic double line suture repair technique for repairing Iatrogenic dural tear: a technical case report. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08383-7. [PMID: 38937350 DOI: 10.1007/s00586-024-08383-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Introducing a suture repair technology, endoscopic double line suture repair technique, for iatrogenic dural injury during Percutaneous Endoscopic Lumbar Discectomy (PELD) surgery. METHODS A patient with dural injury and cauda equina herniation during PELD surgery was treated with endoscopic double line suture repair technique. RESULTS A patient with dural injury and cauda equina nerve herniation during PELD surgery was successfully treated using double-line suture technique. After the repair, no obvious cerebrospinal fluid leakage and cauda equina nerve re-herniation was seen. During the postoperative observation period, the wound healed well and there were no complications related to cerebrospinal leakage. During the follow-up period (1 year), the patient reported significant symptom relief and no complications. CONCLUSION This novel dural repair technology is safe and effective and can be used to treat dural injuries during PELD surgery.
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Affiliation(s)
- Runhan Zhao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China
- Orthopedic Laboratory of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China
| | - Ningdao Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China
- Orthopedic Laboratory of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China
| | - Jun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China
- Orthopedic Laboratory of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China
| | - Xiaoji Luo
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China.
- Orthopedic Laboratory of Chongqing Medical University, Yuzhong, Chongqing, 400016, P.R. China.
| | - Xifeng Zhang
- Minimally invasive spine center, Beijing Aiyuhua Hospital, Economic and Technological Development Area, Beijing, 100176, P.R. China.
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Albayar A, Spadola M, Blue R, Saylany A, Dagli MM, Santangelo G, Wathen C, Ghenbot Y, Macaluso D, Ali ZS, Ozturk AK, Welch WC. Incidental Durotomy Repair in Lumbar Spine Surgery: Institutional Experience and Review of Literature. Global Spine J 2024; 14:1316-1327. [PMID: 36426799 PMCID: PMC11289568 DOI: 10.1177/21925682221141368] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
STUDY DESIGN : Retrospective Chart Review. OBJECTIVES Incidental durotomies (IDs) are common spine surgery complications. In this study, we present a review on the most commonly utilized management strategies, report our institutional experience with case examples, and describe a stepwise management algorithm. METHODS A retrospective review was performed of the electronic medical records of all patients who underwent a thoracolumbar or lumbar spine surgery between March 2017 and September 2019. Additionally, a literature review of the current management approaches to treat IDs and persistent postoperative CSF leaks following lumbar spine surgeries was performed. RESULTS We looked at 1133 patients that underwent posterior thoracolumbar spine surgery. There was intraoperative evidence of ID in 116 cases. Based on our cohort and the current literature, we developed a progressive treatment algorithm for IDs that begins with a primary repair, which can be bolstered by dural sealants or a muscle patch. If this fails, the primary repair can be followed by a paraspinal muscle flap, as well as a lumbar drain. If the patient cannot be weaned from temporary CSF diversion, the final step in controlling postoperative leak is longterm CSF diversion via a lumboperitoneal shunt. In our experience, these shunts can be weaned once the patient has no further clinical or radiographic signs of CSF leak. CONCLUSIONS There is no standardized management approach of IDs and CSF leaks in the literature. This article intends to provide a progressive treatment algorithm and contribute to the development process of a treatment consensus.
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Affiliation(s)
- Ahmed Albayar
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Spadola
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Blue
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anissa Saylany
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gabrielle Santangelo
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yohannes Ghenbot
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dominick Macaluso
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zarina S. Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali K. Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William C. Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Makary MS, Koso M, Yoder M. Utility and Clinical Outcomes of Perioperative Inferior Vena Cava Filter Prophylaxis in Spine Surgery Patients. Spine (Phila Pa 1976) 2024; 49:569-576. [PMID: 37026776 DOI: 10.1097/brs.0000000000004670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
STUDY DESIGN Single-center retrospective chart review study. OBJECTIVE This study aimed to assess the clinical outcomes of prophylactic inferior vena cava (IVC) filter use for pulmonary embolism (PE) prevention in spine surgery patients. SUMMARY OF BACKGROUND DATA IVC filters can serve an important prophylactic role in preventing PE, though research involving spine surgery patients is sparse. MATERIALS AND METHODS This Institutional Review Board-approved single-center retrospective study assessed the characteristics and outcomes of patients who underwent spine surgery and received perioperative IVC filters for PE prophylaxis from January 2007 until December 2021. Clinical outcomes centered primarily on the occurrence of venous thromboembolism (VTE) as well as complications related to filter placement and retrieval. Thrombi that may have been entrapped by the filters were recorded incidentally on computed tomography or during the filter retrieval procedure. RESULTS This cohort included 380 spine surgery patients (female 51%/male 49%; median age, 61) who had received perioperative prophylactic IVC filters. The mean dwell time was 6.7 months (1-39 mo), with an overall 62% retrieval rate. Retrievals were further categorized by retrieval complexity, with 92% classified as routine and 8% as involving advanced removal techniques, while complications involved 1% (four retrievals) and were all minor. Regarding VTE event occurrence, deep vein thrombi (DVT) were experienced by 11% of patients in the postplacement period, with 1% (n=4) experiencing a PE. There were 11 incidences of thrombi that were found within or near the filters (2.9%). A multivariate analysis further assessed patient characteristics that correlated with the occurrence of PE, DVT, entrapped filter thrombi, advanced technique filter removal, and removal complications. CONCLUSIONS IVC filters in this high-risk spine surgery cohort achieved a relatively low rate of DVT and PE as well as a low complication rate, whereas several patient characteristics were identified that correlated with VTE events and filter retrieval outcomes.
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Affiliation(s)
- Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Faldini C, Barile F, D'Antonio G, Rinaldi A, Manzetti M, Viroli G, Vita F, Traversari M, Cerasoli T, Ruffilli A. Incidental dural tears do not affect the overall patients' reported outcome of spine surgery at long-term follow-up: results of a systematic review. Musculoskelet Surg 2024; 108:47-61. [PMID: 36877336 DOI: 10.1007/s12306-023-00777-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 03/07/2023]
Abstract
To conduct a systematic review of the literature in order to establish if there is an overall adverse effect of accidental durotomy on the long-term patients' reported outcome after elective spine surgery. A systematic literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about pre- and postoperative clinical outcomes of patients with accidental durotomy and patients without were extracted and analysed. After screening, eleven studies were included with a total of 80,541 patients. About 4112 of these patients (5.10%) had incidental dural tear. When comparing patients with dural tear to patients without, 9/11 authors found no patients' reported differences at last follow-up. One author found a slightly worse VAS back pain in dural tear patients, and another author found inferior SF-36 and ODI scores in dural tear patients (both below minimal clinically important difference). Accidental dural tear did not have a significant adverse effect on clinical outcome of elective spine surgery. More studies are needed to better demonstrate this result.
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Affiliation(s)
- C Faldini
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - F Barile
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - G D'Antonio
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - A Rinaldi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - M Manzetti
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - G Viroli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - F Vita
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - M Traversari
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136.
| | - T Cerasoli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
| | - A Ruffilli
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy, via G.C. Pupilli, 1, 40136
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Ahmady AA, Butt BB, Muscateli S, Aleem IS. Intraoperative and Postoperative Management of Incidental Durotomies During Open Degenerative Lumbar Spine Surgery: A Systematic Review. Clin Spine Surg 2024; 37:49-55. [PMID: 36727881 DOI: 10.1097/bsd.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Abstract
SUMMARY OF BACKGROUND DATA Incidental durotomy is a common intraoperative complication of lumbar spine surgery. Intra and postoperative protocols in the management of this common complication vary considerably, with no consensus in the literature. OBJECTIVE To systematically review (1) lumbar dural repair techniques for open degenerative procedures; (2) review described postoperative protocols after lumbar dural repairs. STUDY DESIGN Systematic review. MATERIALS AND METHODS A systematic review of the literature was performed for all articles published from inception until September 2022 using Pubmed, EMBASE, Medline, and Cochrane databases to identify articles assessing the management of durotomy in open surgery for degenerative diseases of the lumbar spine. Two independent reviewers assessed the articles for inclusion criteria, and disagreements were resolved by consensus. Outcomes included persistent leaks, return to the operating room, recurrent symptoms, medical complications, or patient satisfaction. RESULTS A total of 10,227 articles were initially screened. After inclusion criteria were applied, 9 studies were included (n=1270 patients) for final review. Repair techniques included; no primary repair, suture repair in running or interrupted manner with or without adjunctive sealants, sealants alone, or patch repair with muscle, fat, epidural blood patch, or synthetic graft. Postoperative protocols included the placement of a subfascial drain with varying durations of bed rest. Notable findings included no benefit of prolonged bedrest compared with early ambulation ( P =0.4), reduced cerebrospinal fluid leakage with fat graft compared with muscle grafts ( P <0.001), and decreased rates of revision surgery in studies that used subfascial drains (1.7%-2.2% vs 4.34%-6.66%). CONCLUSIONS Significant variability in intraoperative durotomy repair techniques and postoperative protocols exists. Primary repair with fat graft augmentation seems to have the highest success rate. Postoperatively, the use of a subfascial drain with early ambulation reduces the risk of pseudomenignocele formation, medical complications, and return to the operating room. Further research should focus on prospective studies with the goal to standardize repair techniques and postoperative protocols.
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Affiliation(s)
- Arya A Ahmady
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI
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Shankar D, Kaif M, Kumar K. Post-traumatic lumbar nerve root entrapment into the spinous process of the lumbar spine. BMJ Case Rep 2024; 17:e257802. [PMID: 38373811 PMCID: PMC10882333 DOI: 10.1136/bcr-2023-257802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Thoracolumbar fractures constitute a significant portion of spinal trauma, accounting for 15-20% of the cases. These fractures, caused by high-impact injuries, may involve tears of the posterior ligamentous complex, presenting a high chance of neurological injury ranging from dural tears to spinal root avulsion. This case report discusses a rare occurrence of avulsion of lumbosacral nerve roots posteriorly, becoming entrapped in the fractured spinous process of the L2 lumbar vertebra, leading to cauda equina syndrome following trauma and its implications during surgery.
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Affiliation(s)
- Diwakar Shankar
- Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mohammad Kaif
- Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Krishna Kumar
- Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Jiang L, Budu A, Khan MS, Goacher E, Kolias A, Trivedi R, Francis J. Predictors of Cerebrospinal Fluid Leak Following Dural Repair in Spinal Intradural Surgery. Neurospine 2023; 20:783-789. [PMID: 37798970 PMCID: PMC10562229 DOI: 10.14245/ns.2346432.216] [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: 04/06/2023] [Revised: 07/01/2023] [Accepted: 07/20/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE We aim to compare the effectiveness of dural closure techniques in preventing cerebrospinal fluid (CSF) leaks following surgery for intradural lesions and seek to identify additional factors associated with CSF leaks. Surgical management of spinal intradural lesions involves durotomy which requires a robust repair to prevent postoperative CSF leakage. The ideal method of dural closure and the efficacy of sealants has not been established in literature. METHODS We performed a retrospective analysis of all intradural spinal cases performed at a tertiary spine centre from 1 April 2015 to 29 January 2020 and collected data on patient bio-profile, dural repair technique, and CSF leak rates. Multivariate analysis was performed to identify predictors for postoperative CSF leak. RESULTS A total of 169 cases were reported during the study period. There were 15 cases in which postoperative CSF leak was reported (8.87%). Multivariate analysis demonstrated that patient age (odds ratio [OR], 0.942; 95% confidence interval [CI], 0.891-0.996), surgical indication listed in the "others" category (OR, 44.608; 95% CI, 1.706-166.290) and dural closure with suture, sealant and patch (OR, 22.235; 95% CI, 2.578-191.798) were factors associated with CSF leak. Postoperative CSF leak was associated with the risk of surgical site infection with a likelihood ratio of 8.704 (χ² (1) = 14.633, p < 0.001). CONCLUSION Identifying predictors for CSF leaks can assist in the counselling of patients with regard to surgical risk and expected postoperative recovery.
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Affiliation(s)
- Lei Jiang
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Muhammad Shuaib Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Edward Goacher
- Department of Neurosurgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Rikin Trivedi
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Jibin Francis
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Toci G, Lambrechts MJ, Issa T, Karamian B, Siegel N, Antonio ND, Canseco J, Kurd M, Woods B, Kaye ID, Hilibrand A, Kepler C, Vaccaro A, Schroeder G. Incidence, Risk Factors, and Outcomes of Incidental Durotomy during Lumbar Spine Decompression with or without Fusion. Asian Spine J 2023; 17:647-655. [PMID: 37226383 PMCID: PMC10460661 DOI: 10.31616/asj.2022.0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 05/26/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE The primary objective of this study was to determine the incidence and risk factors for incidental durotomies during lumbar decompression surgeries. In addition, we aimed to determine the changes in patient-reported outcome measures (PROMs) based on incidental durotomy status. OVERVIEW OF LITERATURE There is limited literature investigating the affect of incidental durotomy on patient reported outcome measures. While the majority of research does not suggest differences in complications, readmission, or revision rates, many studies rely on public databases, and their sensitivity and specificity for identifying incidental durotomies is unknown. METHODS Patients undergoing lumbar decompression with or without fusion at a single tertiary care center were grouped based on the presence of a durotomy. Multivariate analysis was performed for length of stay (LOS), hospital readmissions, and changes in PROMs. To identify surgical risk factors for durotomy, 3:1 propensity matching was performed using stepwise logistic regression. The sensitivity and specificity of the International Classification of Disease, 10th revision (ICD-10) codes (G96.11 and G97.41) were also assessed. RESULTS Of the 3,684 consecutive patients who underwent lumbar decompressions, 533 (14.5%) had durotomies, and a complete set of PROMs (preoperative and 1-year postoperative) were available for 737 patients (20.0%). Incidental durotomy was an independent predictor of increased LOS but not hospital readmission or worse PROMs. The durotomy repair method was not associated with hospital readmission or LOS. However, repair with collagen graft and suture predicted reduced improvement in Visual Analog Scale back (β =2.56, p=0.004). Independent risk factors for incidental durotomies included revisions (odds ratio [OR], 1.73; p<0.001), levels decompressed (OR, 1.11; p=0.005), and preoperative diagnosis of spondylolisthesis or thoracolumbar kyphosis. The sensitivity and specificity of ICD-10 codes were 5.4% and 99.9%, respectively, for identifying durotomies. CONCLUSIONS The durotomy rate for lumbar decompressions was 14.5%. No differences in outcomes were detected except for increased LOS. Database studies relying on ICD codes should be interpreted with caution due to the limited sensitivity in identifying incidental durotomies.
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Affiliation(s)
- Gregory Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark James Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tariq Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas D' Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Barrett Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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10
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Xu R, So RJ, Materi J, Nair SK, Alomari SO, Huang J, Lim M, Bettegowda C. Factors Predicting Cerebrospinal Fluid Leaks in Microvascular Decompressions: A Case Series of 1011 Patients. Oper Neurosurg (Hagerstown) 2023; 24:262-267. [PMID: 36656065 DOI: 10.1227/ons.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/07/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Microvascular decompression (MVD) using a retrosigmoid approach is a highly effective, open-surgical procedure for neurovascular conflict in the posterior fossa, although there is a risk of postoperative cerebrospinal fluid (CSF) leak. OBJECTIVE To identify factors associated with postoperative CSF leakage after MVD. METHODS We retrospectively reviewed all patients who underwent MVDs at our institution from 2007 to 2020. Patient demographics, clinical diagnoses, and procedural characteristics were recorded and compared. Factors leading to CSF leak were analyzed using χ 2 , univariate, and multivariate regression. RESULTS Of 1011 patients who underwent MVDs, 37 (3.7%) presented with postoperative CSF leaks. In univariate analysis, the use of Cranios/Norian to obliterate the air cells was protective against CSF leak ( P = .01). Craniotomies ( P = .002), the use of dural substitutes such as Durepair ( P = .04), dural onlays such as DuraGen ( P = .04), muscle/fascia ( P = .03), and titanium mesh cranioplasty >5 cm ( P = .03) were associated with CSF leak. On multivariate analysis, only the presence of craniotomies ( P = .04) and nonprimary dural closure ( P = .03) were significant risk factors for CSF leak. When excluding the 34 (3.4%) patients who underwent a craniotomy, the lack of primary dural closure still remained significantly associated with postoperative CSF leak ( P = .04). CONCLUSION Our results represent one of the largest series of posterior fossa surgeries for a uniform indication in North America. Our study demonstrates increased risk for postoperative CSF leak when craniotomies are performed and when primary dural closure is not established. Given the small sample of patients who received a craniotomy, however, future studies corroborating this finding should be performed.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raymond J So
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Safwan O Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Najjar E, Hassanin MA, Komaitis S, Karouni F, Quraishi N. Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:778-786. [PMID: 36609888 DOI: 10.1007/s00586-023-07526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/02/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND An incidental durotomy (IDT) is a frequent complication of spinal surgery. The conventional management involving a period of flat bed rest is highly debatable. Indeed, there are scanty data and no consensus regarding the need or ideal duration of post-operative bed rest following IDT. OBJECTIVE To systematically evaluate the literature regarding the outcomes of mobilization within 24 h and after 24 h following IDT in open lumbar or thoracic surgery with respect to the length of hospital stay, minor and major complications. METHODS A systematic review of the literature using PubMed, Embase and Cochrane and dating up until September 2022 was undertaken following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. RESULTS Out of 532 articles, 6 studies met the inclusion criteria (1 Level-I, 4 level-III and 1 Level-IV evidence) and were analyzed. Overall, 398 patients of mean age 59.9 years were mobilized within 24 h. The average length of stay (LOS) for this group was 5.7 days. Thirty-four patients (8.5%) required reoperation while the rate of minor complications was 25.4%. Additionally, 265 patients of mean age 63 years with IDT were mobilized after 24 h. The average LOS was 7.8 days. Twenty patients (7.54%) required reoperation while the rate of minor complications was 55%. Meta-analysis comparing early to late mobilization, showed a significant reduction in the risk of minor complications and shorter overall LOS due to early mobilization, but no significant difference in major complications and reoperation rates. CONCLUSIONS Although early mobilization after repaired incidental dural tears in open lumbar and thoracic spinal surgery has a similar major complication/ reoperation rates compared to late mobilization, it significantly decreases the risk of minor complications and length of hospitalization.
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Affiliation(s)
- Elie Najjar
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Mohamed A Hassanin
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,Department of Orthopedic Surgery, Assiut University, Asyut, Egypt
| | - Spyridon Komaitis
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - Faris Karouni
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Nasir Quraishi
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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Usevitch DE, Bronheim RS, Reyes MC, Babilonia C, Margalit A, Jain A, Armand M. Review of Enhanced Handheld Surgical Drills. Crit Rev Biomed Eng 2023; 51:29-50. [PMID: 37824333 PMCID: PMC10874117 DOI: 10.1615/critrevbiomedeng.2023049106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
The handheld drill has been used as a conventional surgical tool for centuries. Alongside the recent successes of surgical robots, the development of new and enhanced medical drills has improved surgeon ability without requiring the high cost and consuming setup times that plague medical robot systems. This work provides an overview of enhanced handheld surgical drill research focusing on systems that include some form of image guidance and do not require additional hardware that physically supports or guides drilling. Drilling is reviewed by main contribution divided into audio-, visual-, or hardware-enhanced drills. A vision for future work to enhance handheld drilling systems is also discussed.
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Affiliation(s)
- David E. Usevitch
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD, United States
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Rachel S. Bronheim
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Miguel C. Reyes
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Carlos Babilonia
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Adam Margalit
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Amit Jain
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Mehran Armand
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD, United States
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, United States
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13
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Schebesch KM, Hrbac T, Jančálek R, Krska L, Marquez-Rivas J, Solar P. Real-World Data on the Usage of Hemopatch® as a Hemostat and Dural Sealant in Cranial and Spinal Neurosurgery. Cureus 2023; 15:e34387. [PMID: 36874754 PMCID: PMC9977205 DOI: 10.7759/cureus.34387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 01/31/2023] Open
Abstract
Background and objectives Cerebrospinal fluid (CSF) leakage is a significant complication in cranial and spinal interventions. Hemostatic patches such as Hemopatch® are therefore used to support the watertight closure of the dura mater. Recently, we published the results of a large registry documenting the effectiveness and safety of Hemopatch® in various surgical specialties, including neurosurgery. Here we aimed to analyze the outcomes from the neurological/spinal cohort of this registry in more detail. Methods Based on the data from the original registry, we performed a post hoc analysis for the neurological/spinal cohort. The Hemopatch® registry was designed as a prospective, multicenter, single-arm observational study. All surgeons were familiar with the application of Hemopatch® and it was used at the discretion of the responsible surgeon. The neurological/spinal cohort was open for patients of any age if they had received Hemopatch® during an open or minimally invasive cranial or spinal procedure. Patients with known hypersensitivity to bovine proteins or brilliant blue, intraoperative pulsatile severe bleeding, or an active infection at the potential target application site (TAS) were excluded from the registry. For the posthoc evaluation, we stratified the patients of the neurological/spinal cohort into two sub-cohorts: cranial and spinal. We collected information about the TAS, intraoperative achievement of watertight closure of the dura, and occurrence of postoperative CSF leaks. Results The registry comprised 148 patients in the neurological/spinal cohort when enrolment was stopped. The dura was the application site for Hemopatch® in 147 patients (in one patient in the sacral region after tumor excision), of which 123 underwent a cranial procedure. Twenty-four patients underwent a spinal procedure. Intraoperatively, watertight closure was achieved in 130 patients (cranial sub-cohort: 119; spinal sub-cohort: 11). Postoperative CSF leakage occurred in 11 patients (cranial sub-cohort: nine; spinal sub-cohort: two). We observed no serious adverse events related to Hemopatch®. Conclusion Our post hoc analysis of real-world data from a European registry confirms the safe and effective use of Hemopatch® in neurosurgery, including cranial and spinal procedures, as also observed in some case series.
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Affiliation(s)
| | - Tomas Hrbac
- Department of Neurosurgery, Faculty Hospital Ostrava, University of Ostrava, Ostrava, CZE
| | - Radim Jančálek
- Department of Neurosurgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, CZE
| | - Lukas Krska
- Department of Neurosurgery, Faculty Hospital Ostrava, University of Ostrava, Ostrava, CZE
| | - Javier Marquez-Rivas
- Department of Pediatric Surgery, Hospital Universitario Virgen del Rocío, Sevilla, ESP
| | - Peter Solar
- Department of Neurosurgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, CZE
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Are Octogenarians at Higher Risk of Complications After Elective Lumbar Spinal Fusion Surgery? Analysis of a Cohort of 7880 Patients From the Kaiser Permanente Spine Registry. Spine (Phila Pa 1976) 2022; 47:1719-1727. [PMID: 35943246 DOI: 10.1097/brs.0000000000004451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study with chart review. OBJECTIVE To determine if there is a difference in risk of adverse outcomes following elective posterior instrumented lumbar spinal fusions for patients aged 80 years and above compared with patients aged 50 to 79 years. SUMMARY OF BACKGROUND DATA Patients aged 80 years and above are undergoing elective lumbar spinal fusion surgery in increasing numbers. There are conflicting data on the risks of intraoperative and postoperative complications in these patients. MATERIALS AND METHODS Patients aged 80 years and above were compared with 50 to 79 years (reference group) using time-dependent multivariable Cox proportional hazards regression with a competing risk of death for longitudinal outcomes and multivariable logistic regression for binary outcomes. Outcome measures used were: (1) intraoperative complications (durotomy), (2) postoperative complications: 30-day outcomes (pneumonia); 90-day outcomes (deep vein thrombosis, pulmonary embolism, emergency room visits, readmission, reoperations, and mortality); and two-year outcomes (reoperations and mortality). RESULTS The cohort consisted of 7880 patients who underwent primary elective posterior instrumented lumbar spinal fusion (L1-S1) for degenerative disk disease or spondylolisthesis. This was subdivided into 596 patients were aged 80 years and above and 7284 patients aged 50 to 79. After adjustment, patients aged 80 years and above had a higher likelihood of durotomy [odds ratio (OR)=1.43, 95% confidence interval (CI)=1.02-2.02] and 30-day pneumonia (OR=1.81, 95% CI=1.01-3.23). However, there was a lower risk of reoperation within two years of the index procedure (hazard ratio=0.69, 95% CI=0.48-0.99). No differences were observed for mortality, readmissions, emergency room visits, pulmonary embolism, or deep vein thrombosis. CONCLUSIONS In a cohort of 7880 elective posterior instrumented lumbar fusion patients for degenerative disk disease or spondylolisthesis, we did not observe any significant risks of adverse events between patients aged 80 years and above and those aged 50 to 79 except for higher durotomies and 30-day pneumonia in the former. We believe octogenarians can safely undergo lumbar fusions, but proper preoperative screening is necessary to reduce the risks of 30-day pneumonia.
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Hagan MJ, Telfeian AE, Sastry R, Ali R, Lewandrowski KU, Konakondla S, Barber S, Lane K, Gokaslan ZL. Awake transforaminal endoscopic lumbar facet cyst resection: technical note and case series. J Neurosurg Spine 2022; 37:843-850. [PMID: 35986734 DOI: 10.3171/2022.6.spine22451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to describe a minimally invasive transforaminal surgical technique for treating awake patients presenting with lumbar radiculopathy and compressive facet cysts. METHODS Awake transforaminal endoscopic decompression surgery was performed in 645 patients over a 6-year period from 2014 to 2020. Transforaminal endoscopic decompression surgery utilizing a high-speed endoscopic drill was performed in 25 patients who had lumbar facet cysts. All surgeries were performed as outpatient procedures in awake patients. Nine of the 25 patients had previously undergone laminectomies at the treated level. A retrospective chart review of patient-reported outcome measures is presented. RESULTS At the 2-year follow-up, the mean (± standard deviation) preoperative visual analog scale leg score and Oswestry Disability Index improved from 7.6 ± 1.3 to 2.3 ± 1.4 and 39.7% ± 8.1% to 13.0% ± 7.4%, respectively. There were no complications, readmissions, or recurrence of symptoms during the 2-year follow-up period. CONCLUSIONS A minimally invasive awake procedure is presented for the treatment of lumbar facet cysts in patients with lumbar radiculopathy. Approximately one-third of the treated patients (9 of 25) had postlaminectomy facet cysts.
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Affiliation(s)
- Matthew J Hagan
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Albert E Telfeian
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rahul Sastry
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rohaid Ali
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Sanjay Konakondla
- 3Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania; and
| | - Sean Barber
- 4Houston Methodist Department of Neurosurgery, Houston, Texas
| | - Kendall Lane
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ziya L Gokaslan
- 1Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Gupta A, Madriz VC, Carroll IR, Tawfik VL. Successful epidural fibrin glue patch to treat intracranial hypotension in a patient with bacteraemia and malignancy. BJA OPEN 2022; 4:100091. [PMID: 37588781 PMCID: PMC10430854 DOI: 10.1016/j.bjao.2022.100091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/19/2022] [Indexed: 08/18/2023]
Abstract
Cerebrospinal fluid leaks after diagnostic lumbar puncture are often treated using an epidural blood patch; however, there are situations in which this may not be a desirable or safe option. We describe a case of a 55-yr-old male who developed a cerebrospinal fluid leak with intracranial hypotension and subdural haematoma after multiple diagnostic lumbar punctures who also had Klebsiella bacteraemia, malignancy, and low platelets. Given concern about bacterial and malignant seeding of the epidural space, we considered several options including a patch with banked blood or neurosurgical intervention. To treat impending brain herniation, we opted to perform an epidural patch using fibrin glue. The fibrin patch is an absorbable surgical sealing patch that is placed on wound tissue. In this case, it was used to close the assumed dural tear, which resulted in a good outcome for the patient without need for neurosurgical intervention.
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Affiliation(s)
- Abhinav Gupta
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Victoria C. Madriz
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Ian R. Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Vivianne L. Tawfik
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, 94305, USA
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Kankam SB, Amini E, Khoshnevisan K, Khoshnevisan A. Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:293-299. [PMID: 35811251 DOI: 10.1016/j.neucie.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/29/2021] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Samuel Berchi Kankam
- Department of Neurosurgery, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Amini
- Pharmaceutical Care Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamyar Khoshnevisan
- Biosensor Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshnevisan
- Department of Neurosurgery, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Lenschow M, Perrech M, Telentschak S, von Spreckelsen N, Pieczewski J, Goldbrunner R, Neuschmelting V. Cerebrospinal fluid leaks following intradural spinal surgery—Risk factors and clinical management. Front Surg 2022; 9:959533. [PMID: 36204341 PMCID: PMC9530256 DOI: 10.3389/fsurg.2022.959533] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/29/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Taniguchi Y, Matsubayashi Y, Ikeda T, Kato S, Doi T, Oshima Y, Okazaki H, Tanaka S. Clinical Feasibility of Completely Autologous Fibrin Glue in Spine Surgery. Spine Surg Relat Res 2022; 6:388-394. [PMID: 36051679 PMCID: PMC9381088 DOI: 10.22603/ssrr.2021-0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Fibrin glue is widely used in spine surgery. Nevertheless, no report has demonstrated the feasibility of completely autologous fibrin glue (CAFG) in spine surgery. This study aims to investigate the safety, efficacy, and effect of bone fusion of CAFG on spine surgery. Methods We retrospectively extracted data of patients who underwent primary spine surgery with preoperatively prepared CAFG. Primary outcomes were the incidence of wound-related unplanned reoperations within 90 days following primary surgery and the occurrence of reoperation for the management of cerebrospinal fluid (CSF) leakage in patients who had been treated with CAFG used as dural sealants. The effect of CAFG on bone fusion was also assessed by detecting implant failure at one year postoperatively in patients aged 25 years or less undergoing primary fusion for idiopathic scoliosis. Results We identified 131 eligible patients (47 males and 84 females) with a mean age of 32.3 years. CAFG was used most frequently as an adhesive for fixation of graft bone (110 patients), followed by as a dural sealant for CSF leakage in 17 patients, and as a local hemostatic agent in four patients. Wound-related reoperations were identified in four patients (3.1%), which included three for surgical site infection, and one for postoperative epidural hematoma. There was no reoperation required for the management of CSF leakage among 17 patients with dural incision or incidental durotomy. Compared with the control cohort, the use of CAFG was not associated with early wound-related reoperations or implant failure in patients with spinal deformity. Conclusions We demonstrated the clinical feasibility of CAFG in spine surgery. The use of CAFG was not associated with the incidence of reoperations for wound-related complications. CAFG worked effectively as a dural sealant for preventing CSF leakage. CAFG had no beneficial or adverse effect on spinal bone fusion.
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Affiliation(s)
- Yuki Taniguchi
- Department of Orthopedic Surgery, The University of Tokyo Hospital
| | | | - Toshiyuki Ikeda
- Department of Blood Transfusion, The University of Tokyo Hospital
| | - So Kato
- Department of Orthopedic Surgery, The University of Tokyo Hospital
| | - Toru Doi
- Department of Orthopedic Surgery, The University of Tokyo Hospital
| | - Yasushi Oshima
- Department of Orthopedic Surgery, The University of Tokyo Hospital
| | - Hitoshi Okazaki
- Department of Blood Transfusion, The University of Tokyo Hospital
| | - Sakae Tanaka
- Department of Orthopedic Surgery, The University of Tokyo Hospital
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Perioperative lumbar subarachnoid drainage could not prevent postoperative CSF leakage after spinal cord tumor resection using an artificial dura mater. J Orthop Sci 2022:S0949-2658(22)00176-2. [PMID: 35811252 DOI: 10.1016/j.jos.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/03/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage occurs in patients who undergo dural repair using artificial dura mater. This study aimed to determine if perioperative lumbar subarachnoid drainage could reduce the incidence of postoperative CSF leakage in cases of dural repair using artificial dura mater. METHODS We retrospectively analyzed 84 patients (41 men, 43 women; mean age, 52.2 ± 20.1 years) who underwent intradural spinal cord tumor resection and dural repair using artificial dura mater. These patients were divided according to whether they underwent perioperative lumbar subarachnoid drainage (39 patients: D group) or had no drainage (45 patients: ND group). The incidence of radiographic and symptomatic CSF leakage as well as baseline characteristics and operative data were compared between the two groups. RESULTS Radiographic CSF leakage was observed in 21 patients (25.0%), including 10 (25.6%) in the D group and 11 (24.4%) in the ND group. Symptomatic CSF leakage was observed in 12 patients (14.2%), including six (15,4%) in the D group and 11 (13.3%) in the ND group. There were no significant differences in the incidence of subcutaneous CSF accumulation and symptomatic CSF leakage between the two groups. In cases with symptomatic CSF leakage, the onset time of CSF leakage tended to be earlier (5.7 days vs 15.7 days), and the treatment period tended to be longer (5.8 weeks vs 2.8 weeks) in the ND group than in the D group. CONCLUSIONS Perioperative lumbar subarachnoid drainage did not reduce the incidence of either radiographic or symptomatic CSF leakage. However, it might shorten the treatment period and reduce refractory CSF leakage, which requires multiple treatments over a long period.
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21
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Dural Injury Treatment with a Full-Endoscopic Transforaminal Approach: A Case Report and Description of Surgical Technique. Case Rep Orthop 2022; 2022:6570589. [PMID: 35341206 PMCID: PMC8941566 DOI: 10.1155/2022/6570589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction The objective of this study was to describe a surgical technique that uses transforaminal full-endoscopic access, which is different from the existing protocol, and to demonstrate another method of dural tear repair during endoscopic spine surgery. Background Endoscopic spine surgery was initially described for lumbar disc pathologies. Technical advances and new materials have made it possible to treat cervical and thoracic spinal degenerative disorders. These advances have also made it possible to treat surgical complications, notably dural tears with CSF fistulas. The literature indicates that the incidence of these injuries ranges from 1% to 17%. Materials and Methods Descriptive technical note of innovative and improved endoscopic surgical procedure exemplified with illustrative clinical case and comparative literature review. Results There is only one report describing a full-endoscopic suture technique for dural sac repair. The gold standard for treatment of the most significant nonpunctate lesions continues to be a conversion to open surgery for lesion closure. Conversion can be problematic because most surgeries are performed under sedation and local anesthesia. Conclusions In this case report and the new endoscopic suture technique described here, we show that primary correction of dural tears through endoscopy is possible. In addition to representing a paradigm break in solving one of the main complications of these procedures, it can expand the possibilities of spine endoscopy.
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Reier L, Fowler JB, Arshad M, Siddiqi J. Drains in Spine Surgery for Degenerative Disc Diseases: A Literature Review to Determine Its Usage. Cureus 2022; 14:e23129. [PMID: 35464540 PMCID: PMC9001810 DOI: 10.7759/cureus.23129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 11/21/2022] Open
Abstract
No guidelines currently exist for surgeons to follow regarding drain use after spine surgery for degenerative disc disease. Therefore, we conducted a literature review to determine what situations warrant drain placement versus those which do not. When placed, we further investigate optimal drain duration. The goal of this article is to provide spine surgeons insight into the current literature and guidance when deciding if a drain should be used or discontinued. We performed a PubMed search and analyzed 44peer-reviewed journal articles. Only studies that had the full article available were included. The highest-quality studies that were reviewed, demonstrated that in most situations using a drain is not associated with superior outcomes. It revealed that when drains are retained for a longer duration they run a greater risk of surgical site infection (SSI). Additionally, drains are associated with increased blood loss, a greater chance of requiring blood transfusions, and longer hospital stays. We conclude that drains are currently being overused in spine surgery for cases of degenerative disc disease, which exposes patients to unnecessary complications while providing minimal benefit.
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Aimar E, Iess G, Mezza F, Gaetani P, Messina AL, Todesca A, Tartara F, Broggi G. Complications of degenerative lumbar spondylolisthesis and stenosis surgery in patients over 80 s: comparative study with over 60 s and 70 s. Experience with 678 cases. Acta Neurochir (Wien) 2022; 164:923-931. [PMID: 35138487 PMCID: PMC8913488 DOI: 10.1007/s00701-022-05118-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022]
Abstract
Purpose Degenerative spondylolisthesis (DS) is a debilitating condition that carries a high economic burden. As the global population ages, the number of patients over 80 years old demanding spinal fusion is constantly rising. Therefore, neurosurgeons often face the important decision as to whether to perform surgery or not in this age group, commonly perceived at high risk for complications. Methods Six hundred seventy-eight elder patients, who underwent posterolateral lumbar fusion for DS (performed in three different centers) from 2012 to 2020, were screened for medical, early and late surgical complications and for the presence of potential preoperative risk factors. Patients were divided in three categories based on their age: (1) 60–69 years, (2) 70–79 years, (3) 80 and over. Multiple logistic regression was used to determine the predictive power of age and of other risk factors (i.e., ASA score; BMI; sex; presence or absence of insulin-dependent and -independent diabetes, use of anticoagulants, use of antiaggregants and osteoporosis) for the development of postoperative complications. Results In univariate analysis, age was significantly and positively correlated with medical complications. However, when controls for other risk factors were added in the regressions, age never reached significance, with the only noticeable exception of cerebrovascular accidents. ASA score and BMI were the two risk factors that significantly correlated with the higher numbers of complication rates (especially medical). Conclusion Patients of different age but with comparable preoperative risk factors share similar postoperative morbidity rates. When considering octogenarians for lumbar arthrodesis, the importance of biological age overrides that of chronological. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05118-9.
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Affiliation(s)
- Enrico Aimar
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Columbus Clinic Center, Milan, Italy
- Department of Vertebral Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy
| | - Guglielmo Iess
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, University of Milan, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Federica Mezza
- Department of Economics, University of California, Los Angeles, CA USA
| | - Paolo Gaetani
- Department of Vertebral Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy
- IRCCS Istituto Neurologico Mondino, Pavia, Italy
| | | | - Andrea Todesca
- Department of Vertebral Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy
| | - Fulvio Tartara
- Department of Vertebral Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy
- IRCCS Istituto Neurologico Mondino, Pavia, Italy
| | - Giovanni Broggi
- Columbus Clinic Center, Milan, Italy
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, University of Milan, Milan, Italy
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Lazarus D, Hawks C, Kumar N, McCaffrey T, Jenkins AL. A novel two-layer, intradural and extradural patch graft approach to treating dural defects and tears: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21639. [PMID: 36130557 PMCID: PMC9379758 DOI: 10.3171/case21639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Dural tears must be quickly addressed to avoid the development of positional headaches and pseudomeningoceles, among other complications. However, sizeable areas of friable or absent dura create unique challenges when attempting to achieve a watertight seal. We have developed a two-layer subdural and epidural fibrous patch technique to treat expansive or challenging dural tears as a result of our experience treating spinal fluid leaks. OBSERVATIONS The authors present the treatment of a large necrotic (5 × 1.5 cm) dural defect refractory to initial attempts at standard primary repair with dural patch grafting and requiring a revision with a dual-layer patch to manage persistent cerebrospinal fluid leakage. LESSONS The use of a two-layer (subdural and epidural) patch is both a safe and effective dural repair technique for creating a watertight seal in challenging large areas in which the dura may be damaged, scarred, or absent. We also propose that this technique may be able to be used for smaller challenging tears, as well as potentially for repairs of large blood vessels or other fluid-filled structures in the body.
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Affiliation(s)
| | | | | | | | - Arthur L. Jenkins
- Jenkins NeuroSpine, New York, New York; and
- Departments of Orthopedics and
- Neurosurgery, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
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Xiong GX, Tobert D, Fogel H, Cha T, Schwab J, Shin J, Bono C, Hershman S. Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study. Spine J 2021; 21:2010-2018. [PMID: 34144204 DOI: 10.1016/j.spinee.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/18/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence. PURPOSE The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique. STUDY DESIGN/SETTING Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded. OUTCOME MEASURES The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group). METHODS The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data. RESULTS Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration. CONCLUSIONS An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | | | | | - Thomas Cha
- Massachusetts General Hospital, Boston, MA
| | | | - John Shin
- Massachusetts General Hospital, Boston, MA
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Makia MA, Alawamry A, Elsharkawy AM. Posterior and postero-lateral incidental durotomy during lumbar spine surgery: primary repair versus augmented primary repair. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00123-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of lumbar spine surgical procedures. Many surgical techniques were described in literature for repair of durotomy, however it is a matter of debate if one technique is a gold standard method of repair. Our study described two groups with posterior and postero-lateral ID that occurred during lumbar spine surgery: group A with 34 cases with a mean age of 49.85 years repaired by primary water tight closure using prolene or silk sutures, and group B with 34 cases with a mean age of 47.18 years treated with augmented primary repair (sutures augmented with a graft from lumbar fascia and tissue sealant "Fibrin glue"). Patients were evaluated for risk factors for durotomy, post-operative clinical outcome, and need for revision surgery.
Results
Eleven cases of group A and nine cases of group B had previous spine surgery. The dural tear was < 2 cm in 41.7% of group A and 83.3% of group B. Better outcome was achieved in 32 patients of group A and 30 patients of group B. Among our study cases 2 patients from group A and 4 patients from group B needed revision surgery due to CSF leak which failed to stop with conservative management and percutaneous blood patch.
Conclusions
Dural closure technique after ID does not seem to influence revision surgery rates due to cerebrospinal fluid (CSF) leakage and its complications. Durotomies that were immediately recognized and treated did not lead to any significant consequences.
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Kankam SB, Amini E, Khoshnevisan K, Khoshnevisan A. Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery. Neurocirugia (Astur) 2021. [DOI: 10.1016/j.neucir.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Aljoghaiman M, Ellenbogen Y, Takroni R, Yang K, Farrokhyar F, Reddy K. Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:1-5. [PMID: 33609122 DOI: 10.1093/ons/opab041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/03/2021] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Majid Aljoghaiman
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada.,Division of Neurosurgery, Department of Surgery, King Faisal University, Alahsa, Saudi Arabia
| | - Yosef Ellenbogen
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Radwan Takroni
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Kaiyun Yang
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kesava Reddy
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
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Andereggen L, Luedi MM. Dural leakage due to ipsilateral needle placement for spinal level localization in unilateral decompression surgery: A case report. Surg Neurol Int 2021; 12:205. [PMID: 34084632 PMCID: PMC8168678 DOI: 10.25259/sni_245_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/03/2021] [Indexed: 11/28/2022] Open
Abstract
Background: A spinal dural defect caused by needle placement for spinal level localization is an uncommon complication of cerebrospinal fluid leak with the potential for the development of intracranial hypertension. Case Description: Our 48-year-old patient underwent unilateral fenestration and sequestrectomy for intractable L5 radiculopathy due to disc herniation at the level L4–5 on the right side. The spinal level was identified with fluoroscopy after placement of a 24-gauge Sprotte spinal needle on the right side. Intraoperatively, a sub-millimeter spinal dural defect was visualized on the ipsilateral side. Conclusion: Caution is needed when needle placement is used to localize the spinal level for unilateral surgery.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse, Aarau.,Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrassse, Switzerland
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Incidental Durotomy in Lumbar Spine Surgery; Risk Factors, Complications, and Perioperative Management. J Am Acad Orthop Surg 2021; 29:e279-e286. [PMID: 33539059 DOI: 10.5435/jaaos-d-20-00210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 11/14/2020] [Indexed: 02/01/2023] Open
Abstract
Incidental durotomy (ID) can occur in up to 14% of all lumbar spine surgeries. The risk of this complication is markedly higher among elderly patients with advanced spinal pathology. In addition, revision cases and other more invasive procedures increase the risk of ID. When unrepaired, IDs can increase the risk of developing meningitis and can lead to the formation of cerebrospinal fluid fistulas and pseudomeningoceles. Intraoperative recognition and repair are essential to ID management, although repair techniques vary considerably. Although primary suture repair is considered the "benchmark," indirect repair alone has shown comparable outcomes. Given the concern for infection after ID, many have indicated for prolonged prophylactic antibiotic regimens. However, there is little clinical evidence that this is necessary after adequate repair. The addition of subfascial drains have been shown to promote wound healing and early ambulation, whereas no consensus on duration of indwelling drains exists and such management is largely case dependent. Early ambulation after surgery has not shown to be associated with increased risk of further ID complications and decreases rehabilitation time, length of stay, and risk of venous thromboembolism. However, there remains a role for conservation mobilization protocols in more severe cases where notable symptoms are observed.
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Xu H, Huang Y, Zhong Y, Lu G. Fascia lata packing and tension suturing for symptomatic pseudomeningocele after recurrent cervical intradural tumour resection. Sci Rep 2021; 11:4934. [PMID: 33654138 PMCID: PMC7925664 DOI: 10.1038/s41598-021-84193-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/11/2021] [Indexed: 02/05/2023] Open
Abstract
In recurrent posterior cervical intradural tumour resections, serious complications can be developed. The dural can become affected by inflammatory factors or removed during tumor resection; if cerebrospinal fluid (CSF) leakage cannot be stopped by duraplasty, artificial meninges or fascia repair, large pseudomeningocele can develop posteriorly within the soft tissue of the neck. When the pressure of the CSF cannot be maintained steadily, persistent clinical symptoms can occur, such as postural headache or central fever. Moreover, the skin can also be penetrated in a few patients even after extension of the drainage duration, lumbar cistern drainage or skin suturing, leading to the induction of life-threatening intra-cranial infections. Is there a simple and effective surgical method to address this scenario? The aim of this study was, therefore, to investigate the effectiveness of fascia lata packing and tension suturing in the treatment of symptomatic pseudomeningocele after recurrent posterior cervical intradural tumour resection. In our study, nine consecutive spinal surgery patients were recruited from January 2008 to January 2018. All pseudomeningoceles were combined with postural headache, central neurological fever or wound non-union. There were 3 cases of melanocytoma, 3 cases of nasopharyngeal carcinoma metastasis, 2 cases of breast cancer metastasis, and 1 case of spinal canal lymphadenoma. Standard patient demographics, diagnosis, post-operative symptoms, wound healing time, and the largest pre- and last follow-up pseudomeningocele area on axial MRI sections were recorded. All cases were followed-up successfully, from 12 to 24 months, with an average of 15.3 months. Our observations indicate that all wounds healed successfully. The wound union time was 20.7 days on average. After wound union, these patients became symptom free. The largest cerebrospinal fluid area on axial MRI sections improved significantly from 42.9 ± 5.01 cm2 at p re-operation to 6.6 ± 1.89 cm2 at 1 year post-operation (P < 0.05); Our data indicate that .the proposed procedure is simple, safe and effective. And more importantly, it allows rapid closure of any cerebrospinal fluid leakage pools.
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Affiliation(s)
- Huanbo Xu
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515000, China
| | - Yangliang Huang
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510700, China
| | - Yi Zhong
- Department of Physiology, Guangzhou Medical University, 195 Dongfeng Xi Road, Guangzhou, 510000, China
| | - Guowang Lu
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515000, China.
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Allouch H, Abu Nahleh K, Mursch K, Shousha M, Alhashash M, Boehm H. Symptomatic Intracranial Hemorrhage after Dural Tear in Spinal Surgery-A Series of 10 Cases and Review of the Literature. World Neurosurg 2021; 150:e52-e65. [PMID: 33640532 DOI: 10.1016/j.wneu.2021.02.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Intracranial hemorrhage (IH) after spinal surgery is a rare but potentially life-threatening complication. Knowledge of predisposing factors and typical clinical signs is essential for early recognition, helping to prevent an unfavorable outcome. METHODS A retrospective analysis was performed of patients with IH after spinal surgery treated in our institution between 2012 and 2018. The literature dealing with IH complicating spinal surgery was reviewed. RESULTS Our investigation found 10 patients with IH (6 female and 4 male). To the best of our knowledge, this is the largest series reported so far. The assumable incidence of IH after spinal surgery in our population was 0.0657%. Durotomy was noticed in 6 patients, all of whom were treated according to a local standard protocol. In 4 patients, the dural tear was occult. Hemorrhage occurred mostly in the cerebellar compartment. Eight of 10 patients had long-standing arterial hypertension, which seems to be a risk factor (hazard ratio, 1.58). Five patients were treated conservatively, whereas 3 required a cerebrospinal fluid (CSF) diversion procedure. In 2 patients, revision surgery with duraplasty was necessary. Seven patients were discharged with little to no neurologic symptoms, and 3 had significant deterioration. One patient died because of brainstem herniation. Review of the literature identified 54 articles with 72 patients with IH complicating spinal surgery. CONCLUSIONS Patients with intraoperative CSF loss should be kept under close supervision postoperatively. After opening of the dura, a watertight closure should be attempted. The use of subfascial suction drainage in cases of a dural tear as well as preexistent arterial hypertension seems to be a risk factor for the development of IH. Intracranial bleeding must be considered in every patient with unexplained neurologic deterioration after spinal surgery and should be ruled out by cranial imaging. To ensure early recognition and prevent an unfavorable outcome, a high index of suspicion is required, especially in revision spinal surgery. The treatment is specific to the extent and location of the IH, thus dictating the outcome. In most patients, conservative treatment led to a good outcome. CSF diversion measures may be necessary in patients with compression or obstruction of the fourth ventricle. Large hematomas with mass effect may require decompressive surgery.
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Affiliation(s)
- Hassan Allouch
- Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany.
| | - Kais Abu Nahleh
- Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Kay Mursch
- Department of Neurosurgery, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Mootaz Shousha
- Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany; Department of Orthopedic Surgery, Alexandria University, Alexandria, Egypt
| | - Mohammed Alhashash
- Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany; Department of Orthopedic Surgery, Alexandria University, Alexandria, Egypt
| | - Heinrich Boehm
- Department of Spine Surgery, Zentralklinik Bad Berka, Bad Berka, Germany
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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: 22] [Impact Index Per Article: 7.3] [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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Wach J, Yildiz ÖC, Sarikaya-Seiwert S, Vatter H, Haberl H. Predictors of postoperative complications after selective dorsal rhizotomy. Acta Neurochir (Wien) 2021; 163:463-474. [PMID: 32691268 DOI: 10.1007/s00701-020-04487-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/06/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP). We analyzed potential preoperative predictors of complications after SDR via single-level laminectomy at the conus medullaris. METHODS One hundred and forty SDRs performed in children (2-17 years) with CP were included in this retrospective study (March 2016 to July 2019). Of these children, 69% were ambulatory (Gross Motor Functional Classification System (GMFCS) II and III). Variables associated with wound dehiscence and infections, cerebrospinal fluid (CSF) leaks, and prolonged epidural pain management were analyzed statistically. RESULTS Five children (3.6%) showed prolonged wound healing, which was associated with obesity (BMI z-score ≥ 1.64; odds ratio (OR) 24.4; 95% confidence interval (CI) 3-199; p = 0.003). Two cases (1.4%) had superficial surgical site infections (SSIs), which was associated with obesity (p = 0.004) and thrombocytopenia (< 180,000 G/l; p = 0.028). The area under the curve at ≥ 1.55 BMI z-score for SSI was 0.97 (95% CI 0.93-0.99, p = 0.024), with a sensitivity and specificity for SSI of 100 and 94.9%, respectively. CSF leaks occurred in four (2.9%) children, associated with age ≤ 5 years (p = 0.029). Fifteen (10.7%) children required prolonged (4-5 days) epidural pain treatment, which was associated with non-ambulatory GMFCS levels (IV and V) (OR 3.6; 95% CI 1.2-10.8; p = 0.008). CONCLUSIONS SDR is safe for all GMFCS levels. Obesity predicts prolonged wound healing and SSI. Prolonged pain management via epidural pain catheter is safe, but care should be taken with non-ambulatory children.
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Affiliation(s)
- Johannes Wach
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany.
| | - Ömer Can Yildiz
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Sevgi Sarikaya-Seiwert
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
| | - Hannes Haberl
- Department of Neurosurgery, University of Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Germany
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Venier A, Croci D, Robert T, Distefano D, Presilla S, Scarone P. Use of Intraoperative Computed Tomography Improves Outcome of Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Single-Center Retrospective Cohort Study. World Neurosurg 2021; 148:e572-e580. [PMID: 33482416 DOI: 10.1016/j.wneu.2021.01.041] [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: 09/12/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To provide data about surgical workflow, accuracy, complications, radiation exposure, and learning curve effect in patients who underwent minimally invasive (MIS) transforaminal lumbar interbody fusion with navigation coupled with mobile intraoperative computed tomography. METHODS A retrospective analysis was performed of data from consecutive patients who underwent single- or double-level MIS transforaminal lumbar interbody fusion at a single institution; mobile intraoperative computed tomography combined with a navigation system was used as the sole intraoperative imaging method to place pedicular screws; decompression and interbody fusion were performed through a 22-mm tubular retractor. Clinical data, perioperative complications, accuracy of pedicular screw placement, and radiation exposure were analyzed. A learning curve effect on surgical time and accuracy was assessed. RESULTS A total of 408 screws in 100 patients were analyzed. In all cases, spinal navigation allowed for identification of pedicular trajectories and greatly facilitated nerve root decompression through the MIS approach. Overall accuracy according to Heary classification was 95.3%. Nineteen screws (4.7%) presented a minor lateral breach (<2 mm), not clinically significant. Surgical time, blood loss, and patient radiation exposure compared favorably with reported values from other series using three-dimensional navigation. A learning curve effect on surgical time, but not on screw accuracy, was identified. CONCLUSIONS MIS transforaminal lumbar interbody fusion can now be performed without any radiation exposure to the surgeon and operating room staff, with almost absolute accuracy during screw positioning and tubular decompression. A learning curve effect on surgical time, but not on overall screw accuracy, may be expected.
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Affiliation(s)
- Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Davide Croci
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland; Facoltà di scienze biomediche, Università della Svizzera italiana, Lugano, Switzerland
| | - Daniela Distefano
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Stefano Presilla
- Medical Physics Service, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Pietro Scarone
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland.
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Song Y, Xia Z, Qiu S, Gao P, Yang B, Bao N. Surgical Treatment of Congenital Dermal Sinus: An Experience of 56 Cases. Pediatr Neurosurg 2021; 56:416-423. [PMID: 34352798 DOI: 10.1159/000515515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/26/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aims to assess the impact of early diagnosis and surgery on children with congenital dermal sinus, investigate the relationship between MRI findings and extent of surgical exploration, and summarize our clinical experience with the surgical management in cases with central nervous system (CNS) infection. METHODS The skin features, preoperative MRI images, intraoperative findings, postoperative pathological characteristics, and prognoses of 56 children with congenital dermal sinus were analyzed retrospectively. RESULTS All the children had a pinpoint ostium in the skin, and 52 out of the 56 children (92.9%) had intraspinal dermoid cysts or epidermoid cysts. Before surgery, MRI did not show intraspinal lesions in 13 children, and surgery revealed intradural lesions in 9 of these children (69.2%). Among 46 children without CNS infection, 16 children had neurological impairment before surgery. After surgery, recovery was complete in 36 children, partial in 9 children, and absent in 3 children. All children with CNS infection had neurological impairment before surgery. After surgery, the condition improved in 8 children and exacerbated in 2 children. Children without CNS infection had statistically significantly better prognosis than children with CNS infection (p = 0.03). CONCLUSION A pinpoint ostium in the dorsal midline is the characteristic feature of congenital dermal sinus. In cases without intraspinal lesions on MRI, the spinal canal should be explored intraoperatively to ensure complete removal of the lesion and prevent recurrences. In cases without CNS infection, early diagnosis and timely surgery are beneficial to the recovery of nerve function.
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Affiliation(s)
- YunHai Song
- Neurosurgery Department, Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai, China
| | - ZeYang Xia
- Neurosurgery Department, Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai, China
| | - ShanShan Qiu
- Neurosurgery Department, Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai, China
| | - PingPing Gao
- Neurosurgery Department, Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai, China
| | - Bo Yang
- Neurosurgery Department, Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai, China
| | - Nan Bao
- Neurosurgery Department, Shanghai Children's Medical Center Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai, China
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Kotaka S, Fujiwara Y, Ota R, Manabe H, Adachi N. Delayed symptomatic cerebrospinal fluid leakage after spine surgery with an intraoperative occult dural tear: An institutional experience and literature review. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Wu S, Cui X, Zhang S, Tian W, Liu J, Wu Y, Wu M, Han Y. Economic burden of readmission due to postoperative cerebrospinal fluid leak in Chinese patients. J Comp Eff Res 2020; 9:1105-1115. [PMID: 33112181 DOI: 10.2217/cer-2020-0067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Aim: This real-world data study investigated the economic burden and associated factors of readmissions for cerebrospinal fluid leakage (CSFL) post-cranial, transsphenoidal, or spinal index surgeries. Methods: Costs of CSFL readmissions and index hospitalizations during 2014-2018 were collected. Readmission cost was measured as absolute cost and as percentage of index hospitalization cost. Factors associated with readmission cost were explored using generalized linear models. Results: Readmission cost averaged US$2407-6106, 35-94% of index hospitalization cost. Pharmacy costs were the leading contributor. Generalized linear models showed transsphenoidal index surgery and surgical treatment for CSFL were associated with higher readmission costs. Conclusion: CSFL readmissions are a significant economic burden in China. Factors associated with higher readmission cost should be monitored.
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Affiliation(s)
| | - Xin Cui
- Shanghai Information Center for Health, Shanghai, PR China
| | - Shaoyu Zhang
- Shanghai Information Center for Health, Shanghai, PR China
| | - Wenqi Tian
- Shanghai Information Center for Health, Shanghai, PR China
| | - Jiazhen Liu
- Shanghai Information Center for Health, Shanghai, PR China
| | - Yiqing Wu
- Johnson & Johnson Medical Shanghai, Shanghai, PR China
| | - Man Wu
- Johnson & Johnson Medical Shanghai, Shanghai, PR China
| | - Yi Han
- Health Economics Research Institute, Sun Yat-Sen University, Guangzhou, Guangdong Province, PR China
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Policicchio D, Boccaletti R, Dipellegrini G, Doda A, Stangoni A, Veneziani SF. Pedicled Multifidus Muscle Flap To Treat Inaccessible Dural Tear In Spine Surgery: Technical Note And Preliminary Experience. World Neurosurg 2020; 145:267-277. [PMID: 32956892 DOI: 10.1016/j.wneu.2020.09.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the usefulness, feasibility, and limitations of pedicled multifidus muscle flaps (PMMFs) for the treatment of inaccessible dural tears during spine surgery. METHODS The technique of PMMF harvesting was investigated together with relevant anatomy. We prospectively evaluated 8 patients treated with the PMMF technique between January 2017 and December 2019. Results were compared with a retrospective series of 9 patients treated with a standard technique between January 2014 and December 2016. Inclusion criteria were inaccessible dural tear or dural tear judged not amenable to direct repair because of tissue loosening. Exclusion criteria were surgical treatment of intradural disease. Clinical and demographic data of all patients were collected. Clinical evaluations were performed according to American Spinal Injury Association criteria and Oswestry Disability Index. Preoperative and postoperative computed tomography was performed in all patients. The primary end point was wound healing (cerebrospinal fluid leakage, infection, and fluid collection); secondary end points were neurologic outcome and complications. RESULTS Control group: 1 death as a result of wound infection secondary to cerebrospinal fluid fistula and 2 patients needed lumbar subarachnoid drain; neurologic outcome: 3 patients improved and 6 were unchanged. Flap group: no wound-related complications were observed; neurologic outcome: 3 patients improved and 5 were unchanged. No flap-related complications were described. Flap harvesting was feasible in all cases, with an average 20 minutes adjunctive surgical time. CONCLUSIONS The PMMF technique was feasible and safe; in this preliminary experience, its use is associated with lower complications as a result of dural tears but larger series are needed to confirm its effectiveness.
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Affiliation(s)
- Domenico Policicchio
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy.
| | - Riccardo Boccaletti
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Giosuè Dipellegrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Artan Doda
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Andrea Stangoni
- University of Sassari Faculty of Medicine and Surgery, Sassari, Italy
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Askar M, Gakhar H. Cauda equina syndrome after use of dural sealant in revision lumbar decompression surgery. Br J Neurosurg 2020:1-3. [PMID: 32897107 DOI: 10.1080/02688697.2020.1817855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We report a case of cauda equina syndrome related to the use of fibrin glue dural sealant "TISSEEL". BACKGROUND Incidental durotomy (ID) is not uncommon in revision spinal surgery. Augmentation of the dural repair after primary closure is gaining popularity. The use of dural sealants is not risk-free. METHOD A 65-year old man who underwent revision lumbar decompression surgery developed postoperative cauda equina syndrome. He had urinary retention, bilateral leg pain and perianal numbness on the third postoperative day. We believe this complication was related to the use of fibrin glue to manage an ID. RESULT After the urgent surgical removal of the fibrin glue patch, the patient fully recovered with no residual neurological deficit. CONCLUSION Cauda equina syndrome development is a potential complication after the use of fibrin glue to augment intraoperative ID. Surgeons should be aware of this potential risk so it can be managed in a timely fashion.
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Affiliation(s)
- Mohamed Askar
- Trauma and Orthopaedics Department, Royal Derby Hospital, Derby, UK.,Orthopaedic Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Harinder Gakhar
- Trauma and Orthopaedics Department, Royal Derby Hospital, Derby, UK
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Ehresman J, Pennington Z, Karhade AV, Huq S, Medikonda R, Schilling A, Feghali J, Hersh A, Ahmed AK, Cottrill E, Lubelski D, Westbroek EM, Schwab JH, Sciubba DM. Incidental durotomy: predictive risk model and external validation of natural language process identification algorithm. J Neurosurg Spine 2020; 33:342-348. [PMID: 32357334 DOI: 10.3171/2020.2.spine20127] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Incidental durotomy is a common complication of elective lumbar spine surgery seen in up to 11% of cases. Prior studies have suggested patient age and body habitus along with a history of prior surgery as being associated with an increased risk of dural tear. To date, no calculator has been developed for quantifying risk. Here, the authors' aim was to identify independent predictors of incidental durotomy, present a novel predictive calculator, and externally validate a novel method to identify incidental durotomies using natural language processing (NLP). METHODS The authors retrospectively reviewed all patients who underwent elective lumbar spine procedures at a tertiary academic hospital for degenerative pathologies between July 2016 and November 2018. Data were collected regarding surgical details, patient demographic information, and patient medical comorbidities. The primary outcome was incidental durotomy, which was identified both through manual extraction and the NLP algorithm. Multivariable logistic regression was used to identify independent predictors of incidental durotomy. Bootstrapping was then employed to estimate optimism in the model, which was corrected for; this model was converted to a calculator and deployed online. RESULTS Of the 1279 elective lumbar surgery patients included in this study, incidental durotomy occurred in 108 (8.4%). Risk factors for incidental durotomy on multivariable logistic regression were increased surgical duration, older age, revision versus index surgery, and case starts after 4 pm. This model had an area under curve (AUC) of 0.73 in predicting incidental durotomies. The previously established NLP method was used to identify cases of incidental durotomy, of which it demonstrated excellent discrimination (AUC 0.97). CONCLUSIONS Using multivariable analysis, the authors found that increased surgical duration, older patient age, cases started after 4 pm, and a history of prior spine surgery are all independent positive predictors of incidental durotomy in patients undergoing elective lumbar surgery. Additionally, the authors put forth the first version of a clinical calculator for durotomy risk that could be used prospectively by spine surgeons when counseling patients about their surgical risk. Lastly, the authors presented an external validation of an NLP algorithm used to identify incidental durotomies through the review of free-text operative notes. The authors believe that these tools can aid clinicians and researchers in their efforts to prevent this costly complication in spine surgery.
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Affiliation(s)
- Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Aditya V Karhade
- 2Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sakibul Huq
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ravi Medikonda
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Andrew Schilling
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Andrew Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - A Karim Ahmed
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ethan Cottrill
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Joseph H Schwab
- 2Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Aljoghaiman M, Martyniuk A, Farrokhyar F, Cenic A, Kachur E. Survey of lumbar discectomy practices: 10 years in the making. JOURNAL OF SPINE SURGERY 2020; 6:572-580. [PMID: 33102894 DOI: 10.21037/jss-20-519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Lumbar discectomy is a common spinal procedure. The purpose of this survey is to ascertain neurosurgeons' practices in the surgical management of one-level lumbar discectomies in the Canadian adult population and to determine changes over a 10-year period. Methods One-page questionnaire distributed electronically to neurosurgeons in Canada and results were compared with similarly completed survey from 2007. Results A total of 109 completed surveys were returned representing 43.8% response rate. This is compared to 112 completed surveys in 2007 reaching 64.4% response rate. Statistically significant differences between the two points in time were noted. There was an increase in spine fellowship training [26 (33.3%) 2017 vs. 15 (15.3%) 2007 (P=0.007)], use of pre-operative magnetic resonance imaging (MRI) [65 (83.3%) 2017 vs. 27 (27.6%) 2007] (P<0.001), use of intramuscular injection [58 (74.4%) 2017 vs. 43 (43.9%) 2007 (P<0.001)], use of both microscope and loupes [20 (25.6%) 2017 vs. 3 (3.1%) 2007 (P<0.001)], use of tubular retraction [26 (33.3%) 2017 vs. 12 (12.2%) 2007 (P=0.001)], use of fibrin glue for a durotomy [72 (92.3%) 2017 vs. 75 (76.5%) 2007 (P=0.007)]. There was an increased rate of same-day discharge in 2017 [46 (59.0%) vs. 18 (18.4%) 2007 (P<0.001)], and quicker return to work [62.8% in 6 weeks or less vs. 39.7% (P=0.003)]. No statistical differences were noted with pre-incision localization, pre-op antibiotics, pre-incision local anesthetic use, use of fat graft or epidural steroids. In either survey the majority would not perform lumbar discectomy on a patient whose primary complaint is back pain. Conclusions Our survey identified changes in practice patterns amongst Canadian neurosurgeons with respect to performing one-level lumbar discectomy over the past 10 years. These changes include increased preference for minimally invasive surgical technique, same-day discharge and sooner return to work. Randomized trials would be helpful to provide evidence regarding which practices are associated with better outcomes.
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Affiliation(s)
- Majid Aljoghaiman
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, King Faisal University, Alahsa, Saudi Arabia
| | - Amanda Martyniuk
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Epidemiology and Biostatistics, Office of Surgical Research Services, Surgical Research Methodology, McMaster University, Hamilton, Ontario, Canada
| | - Aleksa Cenic
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Edward Kachur
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Schnellbächer GJ, Mull M, Reich A. Persistence and regredience of intraspinal fluid collection determine symptom control in intracranial hypotension syndrome. Neurol Sci 2020; 42:1087-1095. [PMID: 32748098 PMCID: PMC7870625 DOI: 10.1007/s10072-020-04609-w] [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: 02/01/2020] [Accepted: 07/18/2020] [Indexed: 11/30/2022]
Abstract
Background and purpose An intraspinal fluid collection (ISFC) can be observed on spinal MRI in cases of intracranial hypotension syndrome (IHS). The goal of this study was to analyze the possible persistence of ISFC after therapy and its correlation to clinical disease activity and secondary complications. Materials and methods Twenty patients in our database of 57 patients, who were treated for IHS between 2009 and 2015, fulfilled the inclusion criteria of (a) diagnosed and treated IHS as well as (b) an ISFC in MRI imaging. Ten of these participated in our study. We performed follow-up visits, which included a history, a clinical examination, and a spinal MRI. Results A MRI-confirmed ISFC was seen in six patients, five of which had symptoms attributable to chronic IHS. There were two cases of superficial siderosis. One patient had a persisting ISFC and was free of symptoms. Four patients did not have an ISFC and were free of symptoms (Fisher’s exact test; p < 0.048). Conclusion There is statistically significant correlation between the persistence of an ISFC after IHS treatment and ongoing clinical symptoms. Resolved symptoms seem to correlate with absorbed extradural ISFC and hypothetically closed leakage site. ISFC as confirmed by MRI proofs to be a reliable follow-up marker for disease activity in chronic IHS that is possibly even superior to clinical examination.
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Affiliation(s)
| | - Michael Mull
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany.,Department of Neuroradiology, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany
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d'Astorg H, Szadkowski M, Vieira TD, Dauzac C, Lonjon N, Bougeard R, Litrico S, Dupuy M. Management of Incidental Durotomy: Results from a Nationwide Survey Conducted by the French Society of Spine Surgery. World Neurosurg 2020; 143:e188-e192. [PMID: 32711151 DOI: 10.1016/j.wneu.2020.07.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To obtain real-life data on the most common practices used for management of incidental durotomy (ID) in France. METHODS Data were collected from spinal surgeons using a practice-based online questionnaire. The survey comprised 31 questions on the current management of ID in France. The primary outcome was the identification of areas of consensus and uncertainty on ID follow-up. RESULTS A total of 217 surgeons (mainly orthopaedic surgeons and neurosurgeons) completed the questionnaire and were included in the analysis. There was a consensus on ID repair with 94.5% of the surgeons considering that an ID should always be repaired, if repairable, and 97.2% performing a repair if an ID occurred. The most popular techniques were simple suture or locked continuous suture (48.3% vs. 57.8% of surgeons). Nonrepairable IDs were more likely to be treated with surgical sealants than with an endogenous graft (84.9% vs. 75.5%). Almost two thirds of surgeons (71.6%) who adapted their standard postoperative protocol after an ID recommended bed rest in the supine position. Among these, 48.8% recommended 24 hours of bed rest, while 53.5% recommended 48 hours of bed rest. The surgeons considered that the main risk factors for ID were revision surgery (98.6%), patient's age (46.8%), surgeon's exhaustion (46.3%), and patient's weight (21.3%). CONCLUSIONS This nationwide survey reflects the lack of a standardized management protocol for ID. Practices among surgeons remain very heterogeneous. Further consensus studies are required to develop a standard management protocol for ID.
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Affiliation(s)
- Henri d'Astorg
- Centre Orthopédique Santy, Lyon, France; Hopital Privé Jean, Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Marc Szadkowski
- Centre Orthopédique Santy, Lyon, France; Hopital Privé Jean, Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France; Hopital Privé Jean, Mermoz, Ramsay-Générale de Santé, Lyon, France.
| | - Cyril Dauzac
- Centre du Rachis, Clinique du Dos, Neuilly sur Seine, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Gui de Chauliac Hospital Montpellier, Montpellier, France; Mécanismes Moléculaires dans les Démences Neurodégénératives, University of Montpellier, Montpellier, France; Ecole Pratique des Hautes Études, Institut National de la Santé et de la Recherche Médicale U1198, Montpellier, France
| | - Renaud Bougeard
- Service de Neurochirurgie, Clinique du Val d'Ouest, Ecully, France
| | - Stephane Litrico
- Service de Neurochirurgie, Centre Hospitalier Universitaire de Nice, Hôpital Pasteur, Nice, France
| | - Martin Dupuy
- Service de Neurochirurgie, Clinique de l'Union, Saint-Jean, France
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Alshameeri ZAF, El-Mubarak A, Kim E, Jasani V. A systematic review and meta-analysis on the management of accidental dural tears in spinal surgery: drowning in information but thirsty for a clear message. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1671-1685. [DOI: 10.1007/s00586-020-06401-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/21/2020] [Accepted: 03/28/2020] [Indexed: 12/29/2022]
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Vasilikos I, Beck J, Ghanaati S, Grauvogel J, Nisyrios T, Grapatsas K, Hubbe U. Integrity of dural closure after autologous platelet rich fibrin augmentation: an in vitro study. Acta Neurochir (Wien) 2020; 162:737-743. [PMID: 32034495 PMCID: PMC8349340 DOI: 10.1007/s00701-020-04254-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/28/2020] [Indexed: 11/30/2022]
Abstract
Background Watertight closure of the dura mater is fundamental in neurosurgery. Besides the classical suturing techniques, a variety of biomaterials have been proposed as sealants. Platelet rich fibrin (PRF) is an autologous biomaterial which can readily be obtained through low-speed centrifugation of patient’s own blood. It is rich in fibrin, growth factors, leucocytes and cytokines and has shown adhesive properties while promoting the physiological wound healing process. In this study, we investigated the effect of applying PRF in reinforcing the watertight dura mater closure. Methods We created an in vitro testing device, where the watertight dura mater closure could be hydrostatically assessed. On 26 fresh harvested bovine dura maters, a standardised 20-mm incision was closed with a running suture, and the leak pressure was measured first without (primary leak pressure) and then with PRF augmentation (secondary leak pressure). The two groups of measurements have been statistically analysed with the Student’s paired t test. Results The “running suture only group” had a leak pressure of 10.5 ± 1.2 cmH2O (mean ± SD) while the “PRF-augmented group” had a leak pressure of 47.2 ± 2.6 cm H2O. This difference was statistically significant (p < 0.001; paired t test). Conclusions Autologous platelet rich fibrin augmentation reliably reinforced watertight closure of the dura mater to a > 4-fold increased leak pressure after failure of the initial standard running suture technique. Electronic supplementary material The online version of this article (10.1007/s00701-020-04254-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- I Vasilikos
- Department of Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacher Str. 64, D-79106, Freiburg, Germany.
- Laboratory of Experimental Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacherstr. 64, Freiburg, Germany.
| | - J Beck
- Department of Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacher Str. 64, D-79106, Freiburg, Germany
- Laboratory of Experimental Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacherstr. 64, Freiburg, Germany
| | - S Ghanaati
- Frankfurt Oral Regenerative Medicine, Clinic for Maxillofacial and Plastic Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - J Grauvogel
- Department of Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacher Str. 64, D-79106, Freiburg, Germany
| | - T Nisyrios
- Department of Oral and Craniomaxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - K Grapatsas
- Department of Thoracic Surgery, Faculty of Medicine, Medical Centre-University of Freiburg, Freiburg, Germany
| | - U Hubbe
- Department of Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacher Str. 64, D-79106, Freiburg, Germany
- Laboratory of Experimental Neurosurgery, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Neurozentrum, Breisacherstr. 64, Freiburg, Germany
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Sheha ED, Derman PB. Complication avoidance and management in ambulatory spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S181-S190. [PMID: 31656873 DOI: 10.21037/jss.2019.08.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The positive safety profile and potential cost savings associated with ambulatory spine surgery have resulted in an increasing number of spine procedures being performed on an outpatient basis. As indications become more inclusive and the variety and volume of ambulatory procedures grow, the incidence of complications may rise. Limiting adverse events in the outpatient setting starts with patient selection. Surgeons should be aware of the potential complications and associated risk factors for common ambulatory spine procedures and employ strategies to limit and appropriately manage them. Protocols which include patient education, multimodal anesthesia and analgesia, standardized post-operative monitoring, and safe discharge planning are also essential for maximizing safety in the ambulatory setting.
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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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Brazdzionis J, Ogunlade J, Elia C, Wacker MR, Menoni R, Miulli DE. Effectiveness of Method of Repair of Incidental Thoracic and Lumbar Durotomies: A Comparison of Direct Versus Indirect Repair. Cureus 2019; 11:e5224. [PMID: 31565626 PMCID: PMC6758957 DOI: 10.7759/cureus.5224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Incidental durotomy (ID) is a well-known complication in spine surgery. Surveys have not identified a consensus for repair method among neurosurgeons. IDs may lead to complications such as cerebrospinal fluid (CSF) fistula, which may predispose patients to infection, additional procedures, increased length of stay and morbidity. This study aims to compare durotomy repair methods with clinical outcomes. Methods The neurosurgery database at a single institution, Arrowhead Regional Medical Center, was screened for all patients who underwent thoracic and lumbar spine surgery from 2007-2017. Retrospective chart review of operative reports identified patients with an ID. Data collection included: length of stay, infection, additional procedures, time lying flat, CSF fistula formation (primary endpoint) with analysis using t-tests. Results A total of 384 patients underwent initial analysis. Of the 384 patients, 25 had an incidental durotomy based on operative reports. Four patients were excluded from this subset: two were repaired with muscle graft (low N), two were excluded for unclear repair method. The remaining 21 were stratified into two groups, those repaired directly with suture with or without adjunct (N=9) and those repaired indirectly with sealant (N=12). No patients developed a CSF fistula. The indirect group had a length of stay of six days, while the direct group had a length of stay of four days, p=0.184. Two of the nine patients in the direct group and two of the twelve patients in the indirect group developed an infection, p=0.586. Conclusion No patients developed CSF fistulas. Secondary endpoints of length of stay and infection rate did not differ. This study was unable to determine if direct versus indirect repair was a more effective repair method for ID. It is possible that if an incidental durotomy is identified and repaired with a water-tight seal, the repair method does not affect the outcome. It is up to the surgeon to individualize repair based on ability and circumstances.
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Affiliation(s)
- James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - John Ogunlade
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Christopher Elia
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | | | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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Papavero L, Kothe R. [Incidental durotomy: intraoperative aid in ten steps]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:335-350. [PMID: 31324953 DOI: 10.1007/s00064-019-0618-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/23/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Management of the intradural structures safely, closure of the dura according to the tear, and minimizing the epidural dead space. INDICATIONS Incidental durotomy (ID). CONTRAINDICATIONS None. SURGICAL TECHNIQUE 1. Bone removal until whole dural tear is visible (if necessary); 2. intradural inspection; 3. reposition the fibers; 4. perform an inside patch (if ID > 5 mm); 5. dural closure; 6. outside patch; 7. Valsalva maneuver; 8. epidural pedicled muscle flap; 9. multilayer wound closure; 10. lumbar drainage of cerebrospinal fluid (if necessary). POSTOPERATIVE MANAGEMENT Bed rest up to 48 h; analgesics. RESULTS The intraspinal part of 4020 surgeries performed with the aid of a microscope were evaluated. The overall prevalence of ID was 4.4%. The prevalence was lowest in virgin microdiscectomies (1.7%) and varied from 3.6% in decompression for spinal canal stenosis up to 14.5% in revision procedures. Of the overall 195 IDs, 127 occurred in primary surgeries and 68 in revision surgeries. In 107 primary surgeries, the individual surgical technique (InT) achieved a single stage closure of the ID in 96 procedures (89.7%). Among 20 virgin surgeries, the ten-step technique (10 ST) was successful in all cases (P = 0.21). Among 42 revision procedures following failed attempts to stop the CSF leakage, the InT achieved single-stage closure in 36 procedures (85.7%), whereas after introduction of the 10 ST, closure was successful in all 26 cases (P = 0.03).
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Affiliation(s)
- L Papavero
- Klinik für Spinale Chirurgie, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland.
| | - R Kothe
- Klinik für Spinale Chirurgie, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland
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