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Martin A, Zahir J, Smith N, Raji O, Nelles D, Kondrashov D. High incidence of dural tears with 3-column osteotomies: a systematic review of adult spinal deformity surgery literature for the past decade. Spine Deform 2024; 12:1253-1260. [PMID: 38914908 DOI: 10.1007/s43390-024-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/03/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Dural tear (DT) is a well-known complication of spinal surgery. We aimed to systematically review the literature from the past decade and determine the incidence and risk factors for DT in the adult spinal deformity (ASD) population to improve both the surgical strategy and counseling of patients undergoing ASD correction. METHODS A systematic review from 2013 to 2023 utilizing PRISMA guidelines was performed. The MEDLINE database was used to collect primary English language articles. The inclusion criterion for patients was degenerative ASD. Pediatric studies, animal studies, review articles, case reports, studies investigating minimally invasive surgery (MIS), studies lacking data on DT incidence, and articles pertaining to infectious, metastatic or neoplastic, traumatic, or posttraumatic etiologies of ASD were excluded. RESULTS Our results demonstrate that the incidence of DT in ASD surgery ranges from 2.0% to 35.7%, which is a much broader range than the reported incidence for non deformity surgery. Moreover, the average rate of DT during ASD surgery stratified by surgical technique was greater for osteotomy overall (19.5% +/- 7.9%), especially for 3-column osteotomy (3CO), and lower for interbody fusion (14.3% +/- 9.9%). Risk factors for DT in the ASD surgery cohort included older age, revision surgery, chronic severe compression, higher-grade osteotomy, complexity of surgery, rheumatoid arthritis (RA), and higher Anesthesiology Society of America (ASA) grade. CONCLUSION To our knowledge, this is the first systematic review discussing the incidence of and risk factors for DT in the ASD population. We found that the risk factors for DT in ASD patients were older age, revision surgery, chronic severe compression, a greater degree of osteotomy, complexity of surgery, RA, and a higher ASA grade. These findings will help guide spine surgeons in patient counseling as well as surgical planning.
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Affiliation(s)
- Anna Martin
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - Jamal Zahir
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - Nathan Smith
- Penn State College of Medicine, Hershey, PA, USA
| | - Oluwatodimu Raji
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - David Nelles
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA
| | - Dimitriy Kondrashov
- Department of Orthopaedic Surgery, San Francisco Orthopaedic Residency Program, St. Mary's Spine Center, 450 Stanyan St, San Francisco, CA, 94117, USA.
- The Taylor Collaboration Orthopaedic Biomechanics Laboratory, San Francisco, CA, USA.
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Petutschnigg T, Häni L, Goldberg J, Dobrocky T, Piechowiak EI, Raabe A, Jesse CM, Schär RT. Microsurgical Repair of Ventral Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Efficacy and Safety of Patch-Sealing Versus Suturing. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01274. [PMID: 39132996 DOI: 10.1227/ons.0000000000001310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/25/2024] [Indexed: 08/13/2024] Open
Abstract
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.
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Affiliation(s)
- Thomas Petutschnigg
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - C Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Ralph T Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Pruttikul P, Sutthiwongkit T, Kunakornsawat S, Paiboonsirijit S, Pongpirul K. Enhanced technique of dural closure using autologous fat graft and Gelfoam for effective management of dural tear following interlaminar endoscopic lumbar spine surgery. 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; 33:2886-2891. [PMID: 38687394 DOI: 10.1007/s00586-024-08262-1] [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: 12/11/2023] [Revised: 01/26/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Incidental dural tears are common complications in lumbar spine surgery, particularly in endoscopic procedures where primary closure via suturing is challenging. The absence of a standardized approach for dural closure in endoscopic spine surgery necessitates exploring alternative techniques. OBJECTIVE This study introduces a surgical technique for dural closure utilizing fat graft and Gelfoam, offering an effective alternative to standard approaches in endoscopic spine surgery. METHODS Surgical data from patients who underwent interlaminar endoscopic discectomy or stenosis decompression at Lerdsin Hospital from October 2014 to October 2021 were analyzed. RESULTS Among 393 cases, dural tears occurred in 2% (8 patients). Our technique achieved successful closure in all these cases, with no incidents of cerebrospinal fluid leakage or wound complications. The majority of patients showed favorable clinical outcomes, except for one case involving concomitant nerve root injury. CONCLUSION This study demonstrates that using fat graft and Gelfoam for dural closure is a simple, reliable, and safe technique, particularly effective for challenging-to-repair areas in interlaminar endoscopic lumbar spine surgery.
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Affiliation(s)
- Pritsanai Pruttikul
- Bumrungrad International Hospital, 33 Sukhumvit 3, Wattana, Bangkok, 10110, Thailand
| | | | | | | | - Krit Pongpirul
- Bumrungrad International Hospital, 33 Sukhumvit 3, Wattana, Bangkok, 10110, Thailand.
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
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Patel AA, Davison MA, Lilly D, Shost MD, Meade S, Habboub G, Krishnaney A. The Use of Cranial Aneurysm Clips for Repair of Incidental Lumbar Durotomy: Operative Technique and Case Series. World Neurosurg 2024; 187:e707-e713. [PMID: 38692570 DOI: 10.1016/j.wneu.2024.04.155] [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: 03/07/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Incidental durotomy is a common complication of posterior lumbar spine surgery; however, effective and durable methods for primary repair remain elusive. Multiple existing techniques have previously been reported and extensively described, including sutured repair and the use of nonpenetrating titanium clips. The use of cranial aneurysm clips for primary repair of lumbar durotomy serves as a safe and effective alternative to obtain watertight closure of a dural tear. METHODS We performed a retrospective review of patients at a single institution who underwent primary repair of an incidental lumbar durotomy with the use of an aneurysm clip during open posterior lumbar surgery between 2012 and 2023. Patient demographics, operative details, and postoperative metrics were collected and examined to evaluate the safety and efficacy of the novel technique. RESULTS A total of 51 patients were included for analysis. Four patients underwent durotomy repair with an aneurysm clip alone, 27 patients were repaired with an aneurysm clip and fibrin glue, and 20 patients underwent repair with an aneurysm clip, fibrin glue, and a collagen dural substitute. Three patients (5.9%) reported headaches: 2 (3.9%) with pseudomeningocele and 1 (2%) with wound leakage. Two patients (3.9%) had treatment failure with a return to the operating room for repair of a cerebrospinal fluid leak. CONCLUSIONS To the best of our knowledge, we report the largest series of patients undergoing primary repair of incidental durotomy with the use of an aneurysm clip. Use of an aneurysm clip is noted to be a safe, quick, and effective method of primary repair compared with existing repair techniques such as sutured repair or nonpenetrating titanium clips.
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Affiliation(s)
- Arpan A Patel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.
| | - Mark A Davison
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Daniel Lilly
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Michael D Shost
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Seth Meade
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ghaith Habboub
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Ajit Krishnaney
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA; Center for Spine Health, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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El Husseini H, Chenisz da Silva JF, Giacomelli Leal A, Dering LM, Ramina R, Alves da Silva I, El Husseini M. Dural Closure Training With Prototyped Model. Cureus 2024; 16:e61688. [PMID: 38975561 PMCID: PMC11227629 DOI: 10.7759/cureus.61688] [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: 06/04/2024] [Indexed: 07/09/2024] Open
Abstract
INTRODUCTION The hermetic closure of the dura mater is a critical step in neurosurgical training, often undervalued but crucial to preventing serious complications such as cerebrospinal fluid (CSF) leaks leading to meningitis and death. Inadequate closure, often due to insufficient training, can result in challenging complications, including prolonged hospitalization and reoperation. OBJECTIVE To address the deficiencies in dural closure training, this study aims to describe a 3D prototype for simulating post-craniotomy dura mater suturing. The objective is to reduce the incidence of CSF leaks and improve the training of neurosurgery residents. DESIGN The study involves the creation of a 3D prototype based on magnetic resonance imaging and computed tomography scans. The additive manufacturing of structures is performed using ABS filament, and a silicone rubber membrane is used to simulate the meningeal dura mater. Neurosurgery residents undergo training using this model, and the effectiveness is evaluated. SETTING The study is conducted at the Institute of Neurology of Curitiba (Hospital INC), focusing on neurosurgery residents from the first to fifth year of residency. PARTICIPANTS Seven residents participate in the study, with varying levels of experience in dural closure procedures. The training involves a simulated surgical environment using the 3D prototype. RESULTS After training, residents show improvements in confidence and theoretical knowledge related to dural closure. Binary questions indicate a strong desire for more practical training on dural closure, with 85.7% believing in the essential role of 3D molds in their neurosurgery training. CONCLUSION The study highlights the importance of adequate training for dural closure to prevent serious complications in neurosurgery. The use of 3D simulation models, despite some limitations, proves to be an effective educational strategy. The emerging technology of bioprinting holds promise for further enhancing simulation materials, bringing medical education closer to realistic tissue replication.
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Affiliation(s)
| | | | | | - Lorena Maria Dering
- Technology and 3D Printing, Neurological Institute of Curitiba (Hospital INC), Curitiba, BRA
| | - Ricardo Ramina
- Neurosurgery, Neurological Institute of Curitiba (Hospital INC), Curitiba, BRA
| | - Igor Alves da Silva
- Neurosurgery, Neurological Institute of Curitiba (Hospital INC), Curitiba, BRA
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Cheng X, Zhang Z, Ren H, Zou Z, Zhang Y, Qu Y, Chen X, Zhao J, He C. A low-swelling hydrogel as a multirole sealant for efficient dural defect sealing and prevention of postoperative adhesion. Natl Sci Rev 2024; 11:nwae160. [PMID: 38867893 PMCID: PMC11168225 DOI: 10.1093/nsr/nwae160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/30/2024] [Accepted: 04/28/2024] [Indexed: 06/14/2024] Open
Abstract
Dural defects and subsequent complications, including cerebrospinal fluid (CSF) leakage, are common in both spine surgery and neurosurgery, and existing clinical treatments are still unsatisfactory. In this study, a tissue-adhesive and low-swelling hydrogel sealant comprising gelatin and o-phthalaldehyde (OPA)-terminated 4-armed poly(ethylene glycol) (4aPEG-OPA) is developed via the OPA/amine condensation reaction. The hydrogel shows an adhesive strength of 79.9 ± 12.0 kPa on porcine casing and a burst pressure of 208.0 ± 38.0 cmH2O. The hydrogel exhibits a low swelling ratio at physiological conditions, avoiding nerve compression in the limited spinal and intracranial spaces. In rat and rabbit models of lumbar and cerebral dural defects, the 4aPEG-OPA/gelatin hydrogel achieves excellent performance in dural defect sealing and preventing CSF leakage. Moreover, local inflammation, epidural fibrosis and postoperative adhesion in the defect areas are markedly reduced. Thus, these findings establish the strong potential of the hydrogel sealant for the effective watertight closure of dural defects.
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Affiliation(s)
- Xueliang Cheng
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun 130014, China
| | - Zhen Zhang
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
| | - Hui Ren
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei 230026, China
| | - Zheng Zou
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei 230026, China
| | - Yu Zhang
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
| | - Yang Qu
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun 130014, China
| | - Xuesi Chen
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei 230026, China
| | - Jianwu Zhao
- Department of Orthopedics, The Second Norman Bethune Hospital of Jilin University, Changchun 130014, China
| | - Chaoliang He
- CAS Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei 230026, China
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O'Neill BE, Godil JA, Brown NJ, Loya J, Silva A, Winer J. Application of nonpenetrating titanium clips for primary spinal dural closure following intradural tethered cord release in pediatric tethered cord syndrome: Profile of safety, efficacy, efficiency, and complications. World Neurosurg X 2024; 22:100348. [PMID: 38440374 PMCID: PMC10911848 DOI: 10.1016/j.wnsx.2024.100348] [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: 06/27/2023] [Revised: 12/04/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Surgical treatment for tethered cord syndrome (TCS) involves a laminotomy for intradural lysis of filum terminale (LFT), with the goal of releasing excess tension on the conus medullaris by dividing the filum terminale. While LFT alleviates clinical symptoms, it is associated with risks and complications, including cerebrospinal fluid (CSF) leak and infection, either superficial or deep. Some risks and complications of LFT relate to efficiency and quality of primary dural closure and its downstream effects. We sought to assess the utility of nonpenetrating titanium clips (TC) for primary dural closure with a particular focus on operative duration, associated costs, and complication profiles in a series of pediatric patients undergoing LFT, hypothesizing that TC utilization leads to more efficient closure and therefore potentially lower costs and potentially associated anesthetic length and risks. Methods A 4-surgeon, single institution series of 28 pediatric patients underwent LFT with subsequent dural closure performed with either the AnastoClip® nonpenetrating titanium clips or traditional suture technique between July 2022 and May 2023. In order to compare the safety, efficacy, and cost-effectiveness between the two dural closure techniques, relevant data were collected including patient demographics and rates of CSF leak, infection at three-month follow-up, and reoperation. Operative durations and times from beginning to end of dural closure were recorded. Results A total of 28 pediatric patients (mean age: 5.9 years, 43% female, range: 0.71-17 years) with TCS underwent LFT. All patients underwent procedures involving intradural surgery of the lumbar region. Dural closure was performed using traditional suturing in 19 patients (67.9%) and TC in 9 (32.1%). With respect to duration of dural closure, the average time to closure using traditional suturing techniques was 1271 s (or 21 min and 11 s), while the average time for TC was 265 s (or 4 min and 25 s). At three-month follow-up, one case of cerebrospinal fluid (CSF) leak or infection was observed in the suture cohort and required reoperation. Conclusion Clinical outcomes in the TC group were excellent, consistent with previous reports; our findings further suggest that TCs result in more efficient dural closure than traditional suturing techniques. Our findings suggest that TC may be a safe, efficacious, and more efficient alternative to traditional suture for achieving dural closure in pediatric patients with TCS undergoing LFT surgery.
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Affiliation(s)
- Brannan E. O'Neill
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jamila A. Godil
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nolan J. Brown
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Joshua Loya
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Ana Silva
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jesse Winer
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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Encarnación-Santos D, Chmutin G, Bozkurt I, Chaurasia B, Umana GE, Nicoletti GF, Scalia G. Letter to the Editor Regarding "Minimally Invasive Spine Surgery: An Overview". World Neurosurg 2024; 184:353-354. [PMID: 38590064 DOI: 10.1016/j.wneu.2023.11.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 04/10/2024]
Affiliation(s)
| | - Gennady Chmutin
- Department of Neurosurgery, Peoples' Friendship University, Moscow, Russia
| | - Ismail Bozkurt
- Department of Neurosurgery, Medical Park Ankara Hospital, Ankara, Turkey; Department of Neurosurgery, School of Medicine, Yuksek Ihtisas University, Ankara, Turkey
| | - Bipin Chaurasia
- Department of Neurosurgery, Bhawani Hospital and Research Center, Birgunj, Nepal
| | | | | | - Gianluca Scalia
- Neurosurgery Unit, Department of Head and Neck Surgery, Garibaldi Hospital, Catania, Italy
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Alessa M, Ababneh F, Al Taimeh F, Haddad S, Al Rabadi J, Hjazeen A. Incidental Dural Tears During Lumbar Spine Surgery: Prevalence and Evaluation of Management Outcomes. Cureus 2024; 16:e54212. [PMID: 38362037 PMCID: PMC10868713 DOI: 10.7759/cureus.54212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Incidental dural tears (IDTs) are sometimes observed as an intraoperative complication associated with lumbar spine surgery. Commonly, this complication is recognized and repaired during surgery, but if it is undiagnosed or inadequately treated, a variety of consequences may occur. Many techniques have been developed to treat cerebrospinal fluid (CSF) leakage, and each has its limitations. Objectives: To assess the prevalence of incidental dural tears in lumbar spine surgeries and evaluate the outcomes of the sandwich technique in the management of this complication. METHODS A total of 92 patients who underwent lumbar spine surgery at the Royal Rehabilitation Center in Amman from January 2018 to December 2021 were retrospectively reviewed. Patients were divided into two groups: group A (patients without IDT) and group B (patients with IDT), where group B was repaired using the sandwich technique. The follow-up period was six months. Further, the sandwich technique involves repairing the dural defect with interlocking sutures, painting medical glue around the dural incision, covering this with gelatin sponge, and finally covering the gelatin sponge with medical glue again. RESULTS The overall prevalence of IDT in the study group was 14.1%. IDT was more common among elderly patients above the age of 60 (17.2%), females (16.7%), patients with multiple lumbar levels treated (66.7%), open approaches (21%), and those who had previous spinal surgery (72.7%). Most IDTs were diagnosed and managed intraoperatively (84.6%). Among those patients, only one complained of a surgical site infection. Patients in group B had a significantly higher postoperative length of hospital stay, amount of drainage, and operative time compared to group A (P<0.001). Regarding postoperative pain, patients in group B had significantly higher pain on the Numerical Pain Scale at day three post-operation compared to patients in group A (P<0.001). CONCLUSION Based on our results, the sandwich technique was effective in the management and prevention of CSF leakage. Further prospective studies with long-term follow-up are needed to confirm our findings.
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Affiliation(s)
- Monther Alessa
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | - Faris Ababneh
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | | | - Saad Haddad
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | | | - Anees Hjazeen
- Department of Biostatistics, Royal Medical Services, Amman, JOR
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Issa TZ, Trenchfield D, Mazmudar AS, Lee Y, McCurdy MA, Haider AA, Lambrechts MJ, Canseco JA, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery. World Neurosurg 2024; 181:e615-e619. [PMID: 37890770 DOI: 10.1016/j.wneu.2023.10.100] [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: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion. METHODS All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group. RESULTS There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups. CONCLUSIONS For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
| | - Delano Trenchfield
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Aditya S Mazmudar
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael A McCurdy
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ameer A Haider
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, Missouri, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, Missouri, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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11
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Kim JY, Oh BH, Kim IS, Hong JT, Sung JH, Lee HJ. The safety and effectiveness of lumbar drainage for cerebrospinal fluid leakage after spinal surgery. Neurochirurgie 2023; 69:101501. [PMID: 37741364 DOI: 10.1016/j.neuchi.2023.101501] [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: 07/03/2023] [Revised: 09/03/2023] [Accepted: 09/12/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE Cerebrospinal fluid (CSF) leakage is a frequent complication after spinal surgery. The lumbar drainage procedure (LDP) is the preferred method for early closure of a dural tear. This study was conducted to assess the safety and effectiveness of LDP after spinal surgery. MATERIALS AND METHODS We retrospectively reviewed 122 patients (55 male and 67 female) who underwent LDP after spinal surgery between January 2010 and June 2021. LDP was performed on patients with suspected CSF leakage due to a dural tear during spinal surgery or in whom mixed-color CSF was observed in the hemo-drain after surgery. LDP was performed aseptically by a resident according to our institution's protocol, and the amount drained was from 200cc to 300cc per day. Absolute bed rest was maintained during the lumbar drainage period. The hemo-drain was opened to confirm that CSF was no longer mixed or oozing, at which time the lumbar drain was removed. Culture was performed at the drain tip when the lumbar drain was removed. RESULTS The spinal surgery level was cervical in 23 patients, thoracic in 27 patients, and lumbar in 72 patients. The mean duration of the indwelling lumbar drain was 7.2 days (2 days-18 days), and the mean amount of drainage was 1198.2cc (100cc-2542cc). Among the 122 patients, the CSF leakage in 101 patients was resolved with the initial procedure, but 21 patients required re-insertion. Of those 21 patients, improper insertion due to a technical problem occurred in 15 patients, poor line fixation occurred in 2 patients, and CSF leakage was again observed after removal of the lumbar drain in 4 patients. In only 1 case was open surgery done after LDP because follow-up magnetic resonance imaging showed a suspected infection. During lumbar drainage, 76 patients used antibiotics, and 46 patients did not. Four patients showed bacterial growth in the tip culture, and 3 of them had been using antibiotics. All 4 of those patients were treated without complications and discharged. Among the 122 patients, 1 patient was discharged with left hemiparesis due to cerebral venous infarction (CVI) and hemorrhage after LDP, and 1 patient underwent re-operation because the CSF collection was not resolved. CONCLUSIONS No major complications such as systemic infection, deep vein thrombosis, or aspiration pneumonia occurred during the lumbar drainage, except for 1 patient (0.8%) with CVI caused by over-drainage. One patient (0.8%) required open surgery after LDP, but no cases of systemic infection occurred while maintaining lumbar drainage, irrespective of antibiotic use. In conclusion, LDP is a safe and effective treatment for CSF leakage after spinal surgery.
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Affiliation(s)
- Jee Yong Kim
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, College of Medicine, Suwon, Korea
| | - Byeong Ho Oh
- Department of Neurosurgery, Chungbuk National University Hospital, College of Medicine, Cheongju, Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, College of Medicine, Suwon, Korea
| | - Jae Taek Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, College of Medicine, Suwon, Korea
| | - Ho Jin Lee
- Department of Neurosurgery, St. Vincent Hospital, The Catholic University of Korea, College of Medicine, Suwon, Korea.
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12
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Linzey JR, Lillard J, LaBagnara M, Park P. Complications and Avoidance in Adult Spinal Deformity Surgery. Neurosurg Clin N Am 2023; 34:665-675. [PMID: 37718113 DOI: 10.1016/j.nec.2023.06.012] [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: 09/19/2023]
Abstract
Adult spinal deformity (ASD) is a complex disease that can result in significant disability. Although surgical treatment has been shown to be of benefit, the complication rate in the perioperative and postoperative periods can be as high as 70%. Some of the most common complications of ASD surgery include intraoperative cerebrospinal fluid leak, high blood loss, new neurologic deficit, hardware failure, proximal junctional kyphosis/failure, pseudarthrosis, surgical site infection, and medical complications. For each of these complications, one or more strategies can be utilized to avoid and/or minimize the consequences.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jock Lillard
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA
| | - Michael LaBagnara
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA
| | - Paul Park
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA.
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13
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Mekonnen M, Hovis G, Mahgerefteh N, Chandla A, Malkhasyan Y, Zhang AB, Yang I. A Case Series of DuraMatrix-Onlay ® Plus in Cranial Surgery Is Associated With a Low Complication Profile. Brain Tumor Res Treat 2023; 11:232-238. [PMID: 37953446 PMCID: PMC10641318 DOI: 10.14791/btrt.2023.0021] [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: 06/07/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND DuraMatrix-Onlay® Plus is a collagen dura membrane derived from purified bovine Achilles tendon. The matrix provides a scaffold for collagen synthesis and is intended to be used as an onlay without the need for dural sutures. The study aims to describe our experience with 33 consecutive patients who underwent a duraplasty procedure using the novel DuraMatrix-Onlay® Plus collagen dura membrane. METHODS This is a retrospective case series of 33 patients who underwent a duraplasty procedure at a single academic hospital in Los Angeles, CA, USA between May 2016 and March 2017. The primary outcome was the incidence rate of cerebrospinal fluid (CSF) leak. Secondary outcomes included rates of patient infection, dural substitute complication, and removal. RESULTS Thirty-three patients underwent a duraplasty procedure using the DuraMatrix-Onlay® Plus material. The average age of the patients was 41.12±7.34 years (range 2-75 years). There were 18 (54.5%) females and 15 (45.5%) males. The majority of procedures were elective operations for the resection of a lesion (n=19, 58%), and the average graft size was 17.69±4.73 cm². At an average follow-up of 3 months, there were no postoperative CSF leaks. The rates of patient infection, dural substitute complication, and removal were 6%, 6%, and 3%, respectively. CONCLUSION DuraMatrix-Onlay® Plus is associated with a low rate of postoperative CSF leakage and an acceptable complication profile. This result supports the use of collagen matrices for dural closure in general neurosurgical procedures.
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Affiliation(s)
- Mahlet Mekonnen
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gabrielle Hovis
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Natalie Mahgerefteh
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anubhav Chandla
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yelena Malkhasyan
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ashley B Zhang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center of the David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
- Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, CA, USA
- Los Angeles Biomedical Research Institute (LA BioMed), Harbor-UCLA Medical Center, Torrance, CA, USA.
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14
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杨 意, 张 扬, 雷 伟. [Research status of dural injury types and repair]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:1177-1182. [PMID: 37718434 PMCID: PMC10505634 DOI: 10.7507/1002-1892.202306064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/31/2023] [Indexed: 09/19/2023]
Abstract
Objective To evaluate the current status of classification and repair methods for dural injury caused by spinal surgery or trauma, providing new strategies and ideas for the clinical repair of dural injury and the development of related materials. Methods The literature related to dural injury both at home and abroad in recent years was thoroughly reviewed and analyzed in order to draw meaningful conclusions. Results There have been numerous retrospective studies on dural injury, but there is a scarcity of prospective and multi-center studies, resulting in a low level of evidence-based research. The incidence and risk factors of dural injury have primarily been studied in relation to common degenerative spinal diseases of the cervical and lumbar spine, with insufficient research on thoracic spine-related diseases. Currently, a universally recognized method for grading and classifying dural injury has not been established, which hampers the development of clinical guidelines for their repair. Furthermore, although there are repair materials and surgical strategies available to address clinical issues such as suture leakage and surgical repair of dural injury in complex locations, there is a lack of comprehensive clinical research and evidence-based data to validate their scientificity and reliability. Conclusion Regardless of the classification of dural injury, suture remains the most important repair method. It is important to further develop new patches or sealants that can meet clinical needs and reduce the difficulty of repair.
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Affiliation(s)
- 意鹏 杨
- 空军军医大学第一附属医院骨科(西安 710032)Department of Orthopedics, the First Affiliated Hospital of Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China
| | - 扬 张
- 空军军医大学第一附属医院骨科(西安 710032)Department of Orthopedics, the First Affiliated Hospital of Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China
| | - 伟 雷
- 空军军医大学第一附属医院骨科(西安 710032)Department of Orthopedics, the First Affiliated Hospital of Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China
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15
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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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16
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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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17
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King NC, Guastaldi FPS, Khanna AR, Redmond RW, Winograd JM. Photosealing of dural defects using a biocompatible patch. Acta Neurochir (Wien) 2023; 165:2293-2298. [PMID: 37284839 DOI: 10.1007/s00701-023-05653-z] [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: 04/18/2023] [Accepted: 05/27/2023] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Nicholas C King
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA, 02114, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Fernando P S Guastaldi
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA
| | - Arjun R Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Robert W Redmond
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan M Winograd
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA, 02114, USA.
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18
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Dong RP, Zhang Q, Yang LL, Cheng XL, Zhao JW. Clinical management of dural defects: A review. World J Clin Cases 2023; 11:2903-2915. [PMID: 37215425 PMCID: PMC10198091 DOI: 10.12998/wjcc.v11.i13.2903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/03/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023] Open
Abstract
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.
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Affiliation(s)
- Rong-Peng Dong
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Qi Zhang
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Li-Li Yang
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Xue-Liang Cheng
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Jian-Wu Zhao
- Department of Spinal Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
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19
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Abd El-Aziz ME, Morsi SMM, Kamal KH, Khattab TA. Preparation of Isopropyl Acrylamide Grafted Chitosan and Carbon Bionanocomposites for Adsorption of Lead Ion and Methylene Blue. Polymers (Basel) 2022; 14:polym14214485. [PMID: 36365479 PMCID: PMC9656127 DOI: 10.3390/polym14214485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/11/2022] [Accepted: 10/20/2022] [Indexed: 01/11/2023] Open
Abstract
Wastewater, which is rich with heavy elements, dyes, and pesticides, represents one of the most important environmental pollutants. Thus, it has been significant to fabricate environmentally friendly polymers with high adsorption ability for those pollutants. Herein, crosslinked chitosan (C-Cs) was prepared using isopropyl acrylamide and methylene bisacrylamide. Carbon nanoparticles (C-NPs) were also obtained by the treatment of the agricultural wastes, which was used with C-Cs to prepare C-Cs/C-NPs nanocomposite (C-Cs/C-NC). Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), and transmission electron microscope (TEM) were used to investigate the prepared adsorbent. C-Cs, C-NPs, and C-Cs/C-NC were used in water treatment for the adsorption of lead ions (Pb+2) and methylene blue (MB). The adsorption process occurred by the prepared samples was investigated under different conditions, including contact time, as well as different doses and concentrations of adsorbents. The findings exhibited that the adsorption of Pb+2 and MB by C-Cs/C-NC was higher than C-Cs and C-NPs. In addition, the kinetic and isotherm models were studied, where the results showed that the adsorption of Pb+2 and MB by various adsorbents obeys pseudo-second-order and Langmuir isotherms, respectively.
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Affiliation(s)
- Mahmoud Essam Abd El-Aziz
- Polymer and Pigments Department, National Research Centre, 33 El Bohoth St., Dokki, Giza P.O. Box 12622, Egypt
| | - Samir M. M. Morsi
- Polymer and Pigments Department, National Research Centre, 33 El Bohoth St., Dokki, Giza P.O. Box 12622, Egypt
| | - Kholod H. Kamal
- Water Pollution Research Department, National Research Centre, 33 El Bohouth St., Dokki, Giza P.O. Box 12622, Egypt
| | - Tawfik A. Khattab
- Dyeing, Printing and Auxiliaries Department, National Research Centre, 33 El Bohoth St., Dokki, Giza P.O. Box 12622, Egypt
- Correspondence: ; Tel.: +20-1011014356
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Cefazolin Loaded Oxidized Regenerated Cellulose/Polycaprolactone Bilayered Composite for Use as Potential Antibacterial Dural Substitute. Polymers (Basel) 2022; 14:polym14204449. [PMID: 36298027 PMCID: PMC9607362 DOI: 10.3390/polym14204449] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022] Open
Abstract
Oxidized regenerated cellulose/polycaprolactone bilayered composite (ORC/PCL bilayered composite) was investigated for use as an antibacterial dural substitute. Cefazolin at the concentrations of 25, 50, 75 and 100 mg/mL was loaded in the ORC/PCL bilayered composite. Microstructure, density, thickness, tensile properties, cefazolin loading content, cefazolin releasing profile and antibacterial activity against S. aureus were measured. It was seen that the change in concentration of cefazolin loading affected the microstructure of the composite on the rough side, but not on the dense or smooth side. Cefazolin loaded ORC/PCL bilayered composite showed greater densities, but lower thickness, compared to those of drug unloaded composite. Tensile modulus was found to be greater and increased with increasing cefazolin loading, but tensile strength and strain at break were lower compared to the drug unloaded composite. In vitro cefazolin release in artificial cerebrospinal fluid (aCSF) consisted of initial burst release on day 1, followed by a constant small release of cefazolin. The antibacterial activity was observed to last for up to 4 days depending on the cefazolin loading. All these results suggested that ORC/PCL bilayered composite could be modified to serve as an antibiotic carrier for potential use as an antibacterial synthetic dura mater.
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21
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Li J, Tian J, Li C, Chen L, Zhao Y. A hydrogel spinal dural patch with potential anti-inflammatory, pain relieving and antibacterial effects. Bioact Mater 2022; 14:389-401. [PMID: 35386815 PMCID: PMC8964987 DOI: 10.1016/j.bioactmat.2022.01.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
CSFL caused by spinal dural defect is a common complication of spinal surgery, which need repair such as suture or sealants. However, low intracranial pressure symptoms, wound infection and prolonged hospital associated with pin-hole leakage or loose seal effect were often occurred after surgical suture or sealants repair. Stable, pressure resistance and high viscosity spinal dural repair patch in wet environment without suture or sealants was highly needed. Herein, a bioactive patch composed of alginate and polyacrylamide hydrogel matrix cross-linked by calcium ions, and chitosan adhesive was proposed. This fabricated patch exhibits the capabilities of promoting defect closure and good tight seal ability with the bursting pressure is more than 790 mm H2O in wet environment. In addition, the chitosan adhesive layer of the patch could inhibit the growth of bacterial in vitro, which is meaningful for the postoperative infection. Furthermore, the patch also significantly reduced the expression of GFAP, IBA-1, MBP, TNF-α, and COX-2 in early postoperative period in vivo study, exerting the effects of anti-inflammatory, analgesic and adhesion prevention. Thus, the bioactive patch expected to be applied in spinal dural repair with the good properties of withstanding high pressure, promoting defect closure and inhibiting postoperative infection. A self-adhesive spinal dural patch that can be applied directly by pressing. A spinal dural patch maintains more than 790 mm H2O sealing pressure in a wet environment. A spinal dural patch with potential anti-inflammatory, analgesic and anti-bacterial properties.
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Affiliation(s)
- Jiahao Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjing Tian
- Medical Science Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunxu Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Longyun Chen
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Corresponding author.
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22
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Dural tear repair surgery comparative analysis: a stitch in time saves nine. 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 2021; 31:575-595. [PMID: 34889999 DOI: 10.1007/s00586-021-07081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/14/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE A dural tear is a common iatrogenic complication of spinal surgery associated with a several post-operative adverse events. Despite their common occurrence, guidelines on how best to repair the defect remain unclear. This study uses five post-operative outcomes to the compare repair methods used to treat 106 dural tears to determine which method is clinically favourable. METHODS Data were retrospectively collected from Southampton General Hospital's online databases. 106 tears were identified and grouped per repair method. MANOVA was used to compare the following five outcomes: Length of stay, numbers of further admissions or revision surgeries, length of additional admissions, post-operative infection rate and dural tear associated neurological symptoms. Sub-analysis was conducted on patient demographics, primary vs non-primary closure and type of patch. Minimal clinically important difference (MCID) was calculated via the Delphi procedure. RESULTS Age had a significant impact on patient outcomes and BMI displayed positive correlation with three-fifth of the predefined outcome measures. No significant difference was observed between repair groups; however, primary closure ± a patch achieved an MCID percentage improvement with regards to length of original stay, rate of additional admissions/surgeries and post-operative infection rate. Artificial over autologous patches resulted in shorter hospital stays, fewer readmissions, infections and neurological symptoms. CONCLUSION This study reports primary closure ± dural patch as the most efficient repair method with regards to the five reported outcomes. This study provides limited evidence in favour of artificial over autologous patches and recommends that dural patches be used in conjunction with primary closure. LEVEL OF EVIDENCE I Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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23
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Zhu T, Wang H, Jing Z, Fan D, Liu Z, Wang X, Tian Y. High efficacy of tetra-PEG hydrogel sealants for sutureless dural closure. Bioact Mater 2021; 8:12-19. [PMID: 34541383 PMCID: PMC8424082 DOI: 10.1016/j.bioactmat.2021.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/07/2021] [Accepted: 06/20/2021] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Tengjiao Zhu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Hufei Wang
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zehao Jing
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Daoyang Fan
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Zhongjun Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Xing Wang
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yun Tian
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
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