Effectiveness of Sealants in Prevention of Cerebrospinal Fluid Leakage after Spine Surgery: A Systematic Review

Microsurgical Repair of Ventral Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Efficacy and Safety of Patch-Sealing Versus Suturing

BACKGROUND AND OBJECTIVES

In patients with spontaneous intracranial hypotension (SIH), microsurgical repair is recommended in Type 1 (ventral) dural leaks, when conservative measures fail. However, there is lacking consensus on the optimal surgical technique for permanent and safe closure of ventral leaks.

METHODS

We performed a retrospective analysis of surgically treated SIH patients with Type 1 leaks at our institution between 2013 and 2023. Patients were analyzed according to the type of surgical technique: (1) Microsurgical suture vs (2) extradural and intradural patching (sealing technique). End points were resolution of spinal longitudinal epidural cerebrospinal fluid collection (SLEC), change in brain SIH-Score (Bern-Score), headache resolution after 3 months, surgery time, complications, and reoperation rates.

RESULTS

In total, 85 (66% women) patients with consecutive SIH (mean age 47 ± 11 years) underwent transdural microsurgical repair. The leak was sutured in 53 (62%) patients (suture group) and patch-sealed in 32 (38%) patients (sealing group). We found no significant difference in the rates of residual SLEC and resolution of headache between suture and sealing groups (13% vs 22%, P = .238 and 89% vs 94%, P = .508). No changes were found in the postoperative Bern-Score between suture and sealing groups (1.4 [±1.6] vs 1.7 [±2.1] P = 1). Mean surgery time was significantly shorter in the sealing group than in the suture group (139 ± 48 vs 169 ± 51 minutes; P = .007). Ten patients of the suture and 3 of the sealing group had a complication (23% vs 9%, P = .212), whereas 6 patients of the suture and 2 patients of the sealing group required reoperation (11% vs 6%, P = .438).

CONCLUSION

Microsurgical suturing and patch-sealing of ventral dural leaks in patients with SIH are equally effective. Sealing alone is a significantly faster technique, requiring less spinal cord manipulation and may therefore minimize the risk of surgical complications.

Risk Factors Associated with Postoperative Cerebrospinal Fluid Leaks After Intrathecal Drug Delivery System and an External Pump Implantation in Cancer Patients: A Retrospective Study

INTRODUCTION

To determine risk factors associated with postoperative cerebrospinal fluid leaks (CSFLs) after intrathecal drug delivery system (IDDS) and external pump implantation.

METHODS

The clinical data of 248 patients with advanced cancer who underwent IDDS implantation from January 2021 to December 2022 at the Department of Pain Medicine at the Hunan Cancer Hospital were retrospectively reviewed. Information regarding age, gender, height, weight, body mass index (BMI), tumour type, albumin levels, haemoglobin levels, history of diabetes and pre- and postoperative anti-tumour therapy was collected and analysed.

RESULTS

Postoperative CSFLs occurred in 7 of 231 patients (3.30%). Statistical analysis indicated that gender, age, height, weight, BMI, tumour type, albumin levels, haemoglobin levels, history of diabetes, pre- and postoperative chemotherapy, pre- and postoperative radiotherapy, preoperative immunotherapy and postoperative targeted therapy were not independent factors for CSFLs. Preoperative targeted therapy [odds ratio (OR): 16.64; 95% confidence interval (CI): 1.42, 195.56; P = 0.01] and postoperative immunotherapy (OR: 13.38; 95% CI: 1.60, 111.65; P = 0.017) were factors associated with an increased postoperative CSFL rate. Of the two locations where CSFLs can occur, the back (puncture site of catheter, n = 4) and the hypochondriac region (location of infusion port implanted, n = 3), back CSFLs occurred earlier than in the hypochondriac region (18.25 ± 6.45 vs 115 ± 62.02 days, P = 0.032).

CONCLUSION

Based on the data from our study, the timing of preoperative targeted therapy and postoperative immunotherapy should be considered to prevent the occurrence of CSFLs in cancer pain patients who have an IDDS and external pump.

A tough bioadhesive hydrogel supports sutureless sealing of the dural membrane in porcine and ex vivo human tissue

Complete sequestration of central nervous system tissue and cerebrospinal fluid by the dural membrane is fundamental to maintaining homeostasis and proper organ function, making reconstruction of this layer an essential step during neurosurgery. Primary closure of the dura by suture repair is the current standard, despite facing technical, microenvironmental, and anatomic challenges. Here, we apply a mechanically tough hydrogel paired with a bioadhesive for intraoperative sealing of the dural membrane in rodent, porcine, and human central nervous system tissue. Tensile testing demonstrated that this dural tough adhesive (DTA) exhibited greater toughness with higher maximum stress and stretch compared with commercial sealants in aqueous environments. To evaluate the performance of DTA in the range of intracranial pressure typical of healthy and disease states, ex vivo burst pressure testing was conducted until failure after DTA or commercial sealant application on ex vivo porcine dura with a punch biopsy injury. In contrast to commercial sealants, DTA remained adhered to the porcine dura through increasing pressure up to 300 millimeters of mercury and achieved a greater maximum burst pressure. Feasibility of DTA to repair cerebrospinal fluid leak in a simulated surgical context was evaluated in postmortem human dural tissue. DTA supported effective sutureless repair of the porcine thecal sac in vivo. Biocompatibility and adhesion of DTA was maintained for up to 4 weeks in rodents after implantation. The findings suggest the potential of DTA to augment or perhaps even supplant suture repair and warrant further exploration.

Shape-changing electrode array for minimally invasive large-scale intracranial brain activity mapping

Large-scale brain activity mapping is important for understanding the neural basis of behaviour. Electrocorticograms (ECoGs) have high spatiotemporal resolution, bandwidth, and signal quality. However, the invasiveness and surgical risks of electrode array implantation limit its application scope. We developed an ultrathin, flexible shape-changing electrode array (SCEA) for large-scale ECoG mapping with minimal invasiveness. SCEAs were inserted into cortical surfaces in compressed states through small openings in the skull or dura and fully expanded to cover large cortical areas. MRI and histological studies on rats proved the minimal invasiveness of the implantation process and the high chronic biocompatibility of the SCEAs. High-quality micro-ECoG activities mapped with SCEAs from male rodent brains during seizures and canine brains during the emergence period revealed the spatiotemporal organization of different brain states with resolution and bandwidth that cannot be achieved using existing noninvasive techniques. The biocompatibility and ability to map large-scale physiological and pathological cortical activities with high spatiotemporal resolution, bandwidth, and signal quality in a minimally invasive manner offer SCEAs as a superior tool for applications ranging from fundamental brain research to brain-machine interfaces.

Photosealing of dural defects using a biocompatible patch

PURPOSE

Photosealing of many biological tissues can be achieved using a biocompatible material in combination with a dye that is activated by visible light to chemically bond over the tissue defect via protein cross-linking reactions. The aim of this study was to test the efficacy of photosealing using a commercially available biomembrane (AmnioExcel Plus) to securely close dural defects in comparison to another sutureless method (fibrin glue) in terms of repair strength.

METHODS

Two-millimeter diameter holes were created in dura harvested from New Zealand white rabbits and repaired ex vivo using one of two methods: (1) in n = 10 samples, photosealing was used to bond a 6-mm-diameter AmnioExcel Plus patch over the dural defect, and (2) in n = 10 samples, fibrin glue was used to attach the same patch over the dural defect. Repaired dura samples were then subjected to burst pressure testing. Histological analysis was also performed of photosealed dura.

RESULTS

The mean burst pressures of rabbit dura repaired with photosealing and fibrin glue were 302 ± 149 mmHg and 26 ± 24 mmHg, respectively. The increased repair strength using photosealing was statistically significant and considerably higher than the normal intracranial pressure of ~ 20 mmHg. Histology demonstrated a tight union at the interface between the dura surface and patch with no disruption of the dura structure.

CONCLUSION

The results of this study suggest that photosealing performs better than fibrin glue for the fixation of a patch for ex vivo repair of small dural defects. Photosealing is worthy of testing in pre-clinical models for the repair of dural defects.

Poly-Catecholic Functionalization of Biomolecules for Rapid Gelation, Robust Injectable Bioadhesion, and Near-Infrared Responsiveness

Mussel-inspired catechol-functionalization of degradable natural biomaterials has garnered significant interest as an approach to achieve bioadhesion for sutureless wound closure. However, conjugation capacity in standard coupling reactions, such as carbodiimide chemistry, is limited by low yield and lack of abundant conjugation sites. Here, a simple oxidative polymerization step before conjugation of catechol-carrying molecules (i.e., 3,4-dihydroxy-l-phenylalanine, l-DOPA) as a potential approach to amplify catechol function in bioadhesion of natural gelatin biomaterials is proposed. Solutions of gelatin modified with poly(l-DOPA) moieties (GelDOPA) are characterized by faster physical gelation and increased viscosity, providing better wound control on double-curved tissue surfaces compared to those of l-DOPA-conjugated gelatin. Physical hydrogels treated topically with low concentrations of NaIO4 solutions are crosslinked on-demand via through-thickness diffusion. Poly(l-DOPA) conjugates enhance crosslinking density compared to l-DOPA conjugated gelatin, resulting in lower swelling and enhanced cohesion in physiological conditions. Together with cohesion, more robust bioadhesion at body temperature is achieved by poly(l-DOPA) conjugates, exceeding those of commercial sealants. Further, poly(l-DOPA) motifs introduced photothermal responsiveness via near-infrared (NIR) irradiation for controlled drug release and potential applications in photothermal therapy. The above functionalities, along with antibacterial activity, render the proposed approach an effective biomaterial design strategy for wound closure applications.

Clinical management of dural defects: A review

Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

Histological and magnetic resonance imaging assessment of Liqoseal in a spinal in vivo pig model

BACKGROUND

Liqoseal (Polyganics, B.V.) is a dural sealant patch for preventing postoperative cerebrospinal fluid (CSF) leakage. It has been extensively tested preclinically and CE (Conformité Européenne) approved for human use after a first cranial in-human study. However, the safety of Liqoseal for spinal application is still unknown. The aim of this study was to assess the safety of spinal Liqoseal application compared with cranial application using histology and magnetic resonance imaging characteristics.

METHODS

Eight female Dutch Landrace pigs underwent laminectomy, durotomy with standard suturing and Liqoseal application. Three control animals underwent the same procedure without sealant application. The histological characteristics and imaging characteristics of animals with similar survival times were compared to data from a previous cranial porcine model.

RESULTS

Similar foreign body reactions were observed in spinal and cranial dura. The foreign body reaction consisted of neutrophils and reactive fibroblasts in the first 3 days, changing to a chronic granulomatous inflammatory reaction with an increasing number of macrophages and lymphocytes and the formation of a fibroblast layer on the dura by day 7. Mean Liqoseal plus dura thickness reached a maximum of 1.2 mm (range 0.7-2.0 mm) at day 7.

CONCLUSION

The spinal dural histological reaction to Liqoseal during the first 7 days was similar to the cranial dural reaction. Liqoseal did not swell significantly in both application areas over time. Given the current lack of a safe and effective dural sealant for spinal application, we propose that an in-human safety study of Liqoseal is the logical next step.

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

Background

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

Methods

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

Results

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

Conclusion

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

Clinical Feasibility of Completely Autologous Fibrin Glue in Spine Surgery

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.

Application of autologous fibrin glue for skull base defect closure in transsphenoidal surgery. Case report and literature review

Nasal CSF leakage is the most common complication after transsphenoidal surgery, especially in case of extended transsphenoidal access. It is one of the main and obvious risk factors of meningitis. Introduction of effective reconstructive techniques made it possible to reduce the incidence of postoperative CSF leakage. Fibrin glue is one of the main components in transsphenoidal surgery for skull base defect closure. The use of autologous fibrin glue excludes immune response due to its biocompatibility. Modern technologies of preparation of autologous fibrin glue make it possible to obtain a large volume of glue that ensures complete sealing of skull base defect. At the same time, autologous glue contains factors promoting rapid tissue regeneration. It is of great importance for engraftment of autologous transplants in the area of skull base defect.

Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study

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.

Safety and biodegradability of a synthetic dural sealant patch (Liqoseal) in a porcine cranial model

Background

Liqoseal consists of a watertight layer of poly(ester)ether urethane and an adhesive layer containing polyethylene glycol-N-hydroxysuccinimide (PEG-NHS). It is designed to prevent cerebrospinal fluid (CSF) leakage after intradural surgery. This study assessed the safety and biodegradability of Liqoseal in a porcine craniotomy model.

Methods

In 32 pigs a craniotomy plus durotomy was performed. In 15 pigs Liqoseal was implanted, in 11 control pigs no sealant was implanted and in 6 control pigs a control dural sealant (Duraseal or Tachosil) was implanted. The safety of Liqoseal was evaluated by clinical, MRI and histological assessment. The degradation of Liqoseal was histologically estimated.

Results

Liqoseal, 2 mm thick before application, did not swell and significantly was at maximum mean thickness of 2.14 (±0.37) mm at one month. The foreign body reaction induced by Liqoseal, Duraseal and Tachosil were comparable. Liqoseal showed no adherence to the arachnoid layer and was completely resorbed between 6 and 12 months postoperatively. In one animal with Liqoseal, an epidural fluid collection containing CSF could not be excluded.

Conclusion

Liqoseal seems to be safe for intracranial use and is biodegradable. The safety and performance in humans needs to be further assessed in clinical trials.

High efficacy of tetra-PEG hydrogel sealants for sutureless dural closure

Advances in meticulous dural closure technique remain a great challenge for watertight dural closure in the aged society, because the cerebrospinal fluid (CSF) leakage after spinal surgery is often accompanied with the disgusting wound infection, meningitis and pseudomeningocele. Here, a tetra-poly (ethylene glycol) (PEG)-based hydrogel sealant is developed with collective advantages of facile operation, high safety, quick set time, easy injectability, favorable mechanical strength and powerful tissue adhesion for effective sutureless dural closure during the surgery procedure. Impressively, this tetra-PEG sealant can instantaneously adhere to the irregular tissue surfaces even in a liquid environment, and effectively prevent or block off the intraoperative CSF leakage for sutureless dural closure and dura regeneration. Together, this sutureless tetra-PEG adhesive can be utilized as a very promising alternative for high-efficient watertight dural closure of the clinical patients who incidentally or deliberately undergo the durotomy during the spinal surgery.

Cerebrospinal Fluid Leak after Transsphenoidal Surgery: A Systematic Review and Meta-analysis

Background Cerebrospinal fluid (CSF) leak is widely recognized as a challenging and commonly occurring postoperative complication of transsphenoidal surgery (TSS).

The primary objective of this study is to benchmark the current prevalence of CSF leak after TSS in the adult population.

Methods The authors followed the PRISMA guidelines. The PubMed, Embase, and Cochrane Library databases were searched for articles reporting CSF leak after TSS in the adult population. Meta-analysis was performed using the Untransformed Proportion metric in OpenMetaAnalyst. For two between-group comparisons a generalized linear mixed model was applied.

Results We identified 2,408 articles through the database search, of which 70, published since 2015, were included in this systematic review. These studies yielded 24,979 patients who underwent a total of 25,034 transsphenoidal surgeries. The overall prevalence of postoperative CSF leak was 3.4% (95% confidence interval or CI 2.8–4.0%). The prevalence of CSF leak found in patients undergoing pituitary adenoma resection was 3.2% (95% CI 2.5–4.2%), whereas patients who underwent TSS for another indication had a CSF leak prevalence rate of 7.1% (95% CI 3.0–15.7%) (odds ratio [OR] 2.3, 95% CI 0.9–5.7). Patients with cavernous sinus invasion (OR 3.0, 95% CI 1.1–8.7) and intraoperative CSF leak (OR 5.9, 95% CI 3.8–9.0) have increased risk of postoperative CSF leak. Previous TSS and microscopic surgery are not significantly associated with postoperative CSF leak.

Conclusion The overall recent prevalence of CSF leak after TSS in adults is 3.4%. Intraoperative CSF leak and cavernous sinus invasion appear to be significant risk factors for postoperative CSF leak.

Late Postoperative Cervical Spinal Cord Herniation with Pseudomeningocele

We report a middle-aged man with a history of traumatic cervical spinal cord injury with extensive edema. Decompressive surgery of posterior laminectomy and fixation was performed. An irreparable dural rupture on dorsal-lateral side of the cord was found during operation. The patient was managed with a myofascial and fibrin glue assisted closure and underwent watertight closure of fascia and skin. No cerebrospinal fluid leakage was detected in the postoperative period and the wound was healing, thus the patient was discharged. Clinical symptoms resolved. Half a year later, however, the patient presented with C5 nerve palsy. Magnetic resonance imaging revealed cervical spinal cord herniation with pseudomeningocele. Late postoperative cervical spinal cord herniation with pseudomeningocele may occur in any cervical spine trauma cases with dural rupture and/or defect, and close follow-up and observation are needed in the postoperative period.

Ex vivo evaluation of a multilayered sealant patch for watertight dural closure: cranial and spinal models

Cerebrospinal fluid leakage is a frequent complication after cranial and spinal surgery. To prevent this complication and seal the dura watertight, we developed Liqoseal, a dural sealant patch comprising a watertight polyesterurethane layer and an adhesive layer consisting of poly(DL-lactide-co-ε-caprolactone) copolymer and multiarmed N-hydroxylsuccinimide functionalized polyethylene glycol. We compared acute burst pressure and resistance to physiological conditions for 72 h of Liqoseal, Adherus, Duraseal, Tachosil, and Tisseel using computer-assisted models and fresh porcine dura. The mean acute burst pressure of Liqoseal in the cranial model (145 ± 39 mmHg) was higher than that of Adherus (87 ± 47 mmHg), Duraseal (51 ± 42 mmHg) and Tachosil (71 ± 16 mmHg). Under physiological conditions, cranial model resistance test results showed that 2 of 3 Liqoseal sealants maintained dural attachment during 72 hours as opposed to 3 of 3 for Adherus and Duraseal and 0 of 3 for Tachosil. The mean burst pressure of Liqoseal in the spinal model (233 ± 81 mmHg) was higher than that of Tachosil (123 ± 63 mmHg) and Tisseel (23 ± 16 mmHg). Under physiological conditions, spinal model resistance test results showed that 2 of 3 Liqoseal sealants maintained dural attachment for 72 hours as opposed to 3 of 3 for Adherus and 0 of 3 for Duraseal and Tachosil. This novel study showed that Liqoseal is capable of achieving a strong watertight seal over a dural defect in ex vivo models.

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

BACKGROUND

Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy.

METHODS

PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection.

RESULTS

The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques.

CONCLUSIONS

Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.

Direct Pars Defect Tubular Decompression and TLIF for the Treatment of Low-Grade Adult Isthmic Spondylolisthesis: Surgical Challenges and Nuances of a Muscle-Sparing Minimally Invasive Approach

We present an illustrative report on the use of a minimally invasive, muscle-sparing, direct pars defect decompression with transforaminal lumbar interbody fusion (TLIF) and instrumentation for the treatment of low-grade adult isthmic spondylolysis with spondylolisthesis and discuss the surgical challenges and nuances associated with the technique.

Tisseel® versus Hemopatch® for dural sealing in neurosurgery. A prospective study in a tertiary center

BACKGROUND

Dural repair is a potential source of complications in neurosurgery. We make a comparison in pseudomeningocele and CSF leak incidence with the sealants Tisseel® and Hemopatch®.

METHODS

We collected 147 patients from September 2017 to December 2018 in a prospective observational study. Inclusion criteria were adult patients with an intradural cranial or spinal surgery whose dura was closed with a fibrin sealant. Primary endpoints were the incidence of pseudo meningocele and CSF leak. Secondary endpoints were the surgical-site infection, epidural hematoma, and the influence of previous surgery.

RESULTS

In 65 and 82 patients Tisseel® and Hemopatch® were used as sealants respectively. The incidence of CSF leak presented a significant statistical relation with the use of Tisseel® in a univariate and multivariate analysis. Infratentorial surgery presented a higher incidence of pseudomeningocele and CSF leak, but the approach used was not a significant factor in multivariate analysis. Patients who were operated previously had a higher risk present a postoperative complication.

CONCLUSIONS

The incidence of pseudomeningocele and CSF leak was higher with Tisseel® compared with Hemopatch® with a statistic significant relation in case of CSF fistulae. The procedure done may be a confusion factor in our study. There was no report of adverse effects or a higher incidence of complications. However, it is recommended to plan randomized trials with larger samples to get stronger evidence.