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Montgomery CT, Blue R, Spadola M, Ajmera S, Jabarkheel R, Schuster J. Navigated lumbar drain placement: A description of technique and case example. Surg Neurol Int 2023; 14:116. [PMID: 37151471 PMCID: PMC10159304 DOI: 10.25259/sni_100_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
Background:
Lumbar drain (LD) placement can be a difficult procedure leading to postprocedure complications, particularly in patients with persistent cerebrospinal fluid leaks or a large body habitus. The objective of this technical case report is to describe the use of Medtronic’s SureTrak Navigation system for navigated LD placement.
Case Description:
The patient was an 18-year-old morbidly obese male who initially underwent a suboccipital craniectomy with duraplasty and a C1 laminectomy for Chiari Malformation. Postoperatively, he developed a pseudomeningocele and was taken to the operating room for wound revision, duraplasty repair, and LD placement. Medtronic’s SureTrak Navigation system was used for LD placement before wound revision. Successful LD placement was achieved in a single pass using the SureTrak Navigation. The patient did well postoperatively, and LD removal occurred on postoperative day 6. The patient was discharged in good condition without evidence of a cerebral spinal fluid leak.
Conclusion:
Navigation using the SureTrak system is a reasonable option to use in patients with a high body mass index and a persistent cerebrospinal fluid leak. When the patient is already undergoing an operative procedure, it can aid in an efficient low-risk intervention completed in a single prone positioning.
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Ng JJ, Blum JD, Cho DY, Cheung L, Romeo DJ, Low DW, Taylor JA, Heuer GG, Swanson JW, Flanders TM. Spinal pseudomeningocele closure: capsulofascial interposition technique. Childs Nerv Syst 2023; 39:1045-1049. [PMID: 36790495 DOI: 10.1007/s00381-023-05849-9] [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: 12/06/2022] [Accepted: 01/14/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION The development of a spinal pseudomeningocele is a complication of dural repair or reconstruction that carries significant morbidity for pediatric patients. In addition to cerebrospinal fluid (CSF) hypotension and positional headaches, CSF leaking into the extradural space increases the risk for incisional breakdown, meningitis, and cosmetic deformity. Spinal pseudomeningocele management is challenging, and reported techniques range from local wound revisions/exploration to shunt placement for permanent CSF diversion. METHODS At our institution, we have recently implemented a multidisciplinary approach of capsulofascial interposition for the surgical repair of the symptomatic spinal pseudomeningocele with a combined neurosurgery-plastic surgery team. To our knowledge, this technique has not previously been characterized, and we describe the technical aspects of this surgery here. RESULTS Among 10 patients treated with this technique, none required reoperation or developed infections following pseudomeningocele closure; 2 patients received postoperative transfusions; and 2 patients underwent CSF diversion procedures. CONCLUSION We propose that this capsulofascial interposition technique should be employed in the surgical treatment of symptomatic spinal pseudomeningoceles.
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Affiliation(s)
- Jinggang J Ng
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Jessica D Blum
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Daniel Y Cho
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Liana Cheung
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Dominic J Romeo
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - David W Low
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Jesse A Taylor
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Gregory G Heuer
- The Childrens Hospital of Philadelphia, Division of Neurosurgery, Philadelphia, PA, 19104, USA
| | - Jordan W Swanson
- The Childrens Hospital of Philadelphia, Division of Plastic Surgery, Philadelphia, PA, 19104, USA
| | - Tracy M Flanders
- The Childrens Hospital of Philadelphia, Division of Neurosurgery, Philadelphia, PA, 19104, USA.
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Liang B, Zhang Y, Lyon K, Soto JM, Nguyen A, Huang JH, Feng D. Successful Management of Iatrogenic Cranial Pseudomeningocele With Subgaleal Shunt. Cureus 2023; 15:e34513. [PMID: 36874315 PMCID: PMC9984227 DOI: 10.7759/cureus.34513] [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] [Received: 11/17/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Iatrogenic pseudomeningocele is a common complication of cranial surgeries. However, there are no evidence-based guidelines on how to manage this condition. We report two cases of iatrogenic postoperative cranial pseudomeningocele that failed conservative management including compressive head dressing. Subgaleal shunt placement was utilized with successful resolution in both cases. We postulate that subgaleal shunt placement may be an effective method in the management of iatrogenic subgaleal pseudomeningocele.
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Affiliation(s)
- Buqing Liang
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | - Yilu Zhang
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | | | - Jose M Soto
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | | | - Jason H Huang
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | - Dongxia Feng
- Neurosurgery, Baylor Scott & White Health, Temple, USA
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Balasa A, Kunert P, Bielecki M, Kujawski S, Marchel A. Significance of Pseudomeningocele After Decompressive Surgery for Chiari I Malformation. Front Surg 2022; 9:895444. [PMID: 36034387 PMCID: PMC9406808 DOI: 10.3389/fsurg.2022.895444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPseudomeningoceles (PMCs) as abnormal collections of cerebrospinal fluid are quite common findings on follow-up MRI after Chiari decompression surgery (CDS). However, the importance of their identification has not been truly determined, especially when PMCs are described occasionally in the process of radiological follow-up. We retrospectively analyzed surgical outcomes and imaging findings after CDS depending upon the occurrence and thickness of PMCs.MethodsA total of 76 adult patients who underwent CDS were analyzed. The clinical and radiological outcomes of patients with a pseudomeningocele (wPMC) were evaluated and compared to those of patients without a pseudomeningocele (w/oPMC). Radiological morphometric measurements were performed and compared between groups. Comparisons of the maximal PMC thickness were made within the wPMC group.ResultsPMCs were recognized in 27 (35.5%) patients, of whom 3 (11.1%) required reoperation. Differences in satisfactory result rates regarding gestalt assessment and Chicago Chiari Outcome Scale were statistically insignificant between the w/oPMC and wPMC groups (p = 1 and p = 0.56, respectively). The postoperative syringomyelia decrease and cerebellar tonsil elevation were similar between the groups (p = 1 and p = 0.74, respectively) in the long-term follow-up. Additionally, the clinical or radiological outcomes with radiological details were not related to PMC thickness in the long-term follow-up. However, radiological details showed the cooccurrence of PMCs with a postsurgical of cerebello-tentorial distance increase (p < 0.05), basion-pontomedullary sulcus distance decrease (p < 0.05) and tonsillo-graft distance decrease (p < 0.05).ConclusionsWe found no significant relationships between PMC presence or thickness and clinical or radiological outcomes. However, postoperative changes within the posterior fossa associated with PMCs resemble brain sagging, which occurs in intracranial hypotension. Therefore, extradural cerebrospinal fluid escape may also be responsible for symptoms in some patients with PMCs after CDS.
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Affiliation(s)
- Artur Balasa
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
- Correspondence: Przemysław Kunert
| | - Mateusz Bielecki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun´, Bydgoszcz, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Mishinov S, Samokhin A, Panchenko A, Stupak V. A titanium implant for Chiari malformation Type 1 surgery. Surg Neurol Int 2021; 12:72. [PMID: 33767876 PMCID: PMC7982118 DOI: 10.25259/sni_960_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/21/2021] [Indexed: 11/04/2022] Open
Abstract
Background Concepts of Chiari malformation Type 1 (CM1) surgery in the present time significantly different. The most common complications are pseudomeningocele (12%) and postoperative CSF leak (5%). The development of pseudomeningocele may be associated with inappropriate restoration of bone and muscles relations. Methods The pilot study involved 11 patients aged 24-64 years with a diagnosis of CM1 who had indications for surgical treatment. Special titanium implant enabling fixation of the occipital and cervical muscles at the projections of their normal attachments was developed, it was placed to occipital bone on the final stages of surgical intervention. Surgical technique promoted tightened wound closure neutralizing formation of "dead space" at the place of occipital craniectomy and between muscle layers. The implant was produced by direct metal laser sintering method for each patient individually. Results There were no complications during the hospitalization and follow-up period. Postoperative MRI demonstrated adequate formation of the cisterna magna and the absence of pseudomeningocele. During follow-up period there were no signs of pseudomeningocele, CSF leak, surgical scar complications, implant-associated infections, and other complications. Conclusion In the study group, no pseudomeningocele cases as long as any other complications associated with surgery had been revealed. The efficacy of the proposed surgical technique using the developed implant should be evaluated in clinical trials with larger patient samples. To simplify preoperative planning and manufacturing of the implant for each patient individually, a set of implants with different specified sizes was developed.
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Affiliation(s)
- Sergey Mishinov
- Department of Neurosurgery, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
| | - Alexander Samokhin
- Department of Experimental, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
| | - Andrey Panchenko
- Department of 3D Printing, LLC Logeeks MS, Novosibirsk, Russian Federation
| | - Vyacheslav Stupak
- Department of Neurosurgery, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
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Giammattei L, Messerer M, Daniel RT, Aghakhani N, Parker F. Long-term outcome of surgical treatment of Chiari malformation without syringomyelia. J Neurosurg Sci 2020; 64:364-368. [DOI: 10.23736/s0390-5616.17.04063-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Azzam D, Romiyo P, Nguyen T, Sheppard JP, Alkhalid Y, Lagman C, Prashant GN, Yang I. Dural Repair in Cranial Surgery Is Associated with Moderate Rates of Complications with Both Autologous and Nonautologous Dural Substitutes. World Neurosurg 2018; 113:244-248. [PMID: 29374609 DOI: 10.1016/j.wneu.2018.01.115] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Duraplasty, a common neurosurgical intervention, involves synthetic or biological graft placement to ensure dural closure. The objective of this study is to advance our understanding of the use of dural substitutes in cranial surgery. METHODS The PubMed database was systematically searched to identify studies published over the past decade (2007-2017) that described duraplasty procedures. Clinical data were disaggregated and analyzed for the comparisons of biological versus synthetic grafts. RESULTS A total of 462 cases were included in the quantitative synthesis. Overall, the most common indication for duraplasty was tumor resection (53%). Allografts were more frequently used in decompression for Chiari malformations compared with xenografts and synthetic grafts (P < 0.001). Xenografts were more frequently used in decompressive hemicraniectomy procedures for evacuation of acute subdural hematomas over allografts and synthetics (P < 0.001). Synthetic grafts were more frequently used in tumor cases than biological grafts (P = 0.002). The cumulative complication rate for dural substitutes of all types was 11%. There were no significant differences in complication rates among the 3 types of dural substitutes. CONCLUSIONS Dural substitutes are commonly used to ensure dural closure in a variety of cranial procedures. This study provides greater insight into duraplasty practices and highlights the moderate complication rate associated with the procedure. Future studies are needed to determine the safety and efficacy of such procedures in larger prospective cohorts.
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Affiliation(s)
- Daniel Azzam
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Yasmine Alkhalid
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, California, USA; Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA.
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