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Gazzeri R, Galarza M, Callovini G. Use of tissue sealant patch (TachoSil) in the management of cerebrospinal fluid leaks after anterior cervical spine discectomy and fusion. Br J Neurosurg 2023; 37:1406-1409. [PMID: 33538190 DOI: 10.1080/02688697.2021.1881444] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to evaluate a fast, sutureless technique to repair anterior cervical dural tears. Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of cervical degenerative diseases. Although uncommon, incidental durotomy with cerebrospinal fluid (CSF) leak during ACDF is a potentially serious complication. Yet, its technical management for the prevention of CSF leak is controversial. METHODS Between September 2012 and June 2018 we encountered seven cases (2 female/5 male) presenting with intraoperative CSF leaks secondary to incidental dural tears during ACDF surgery. All the cases were surgically treated using a topical fibrin sealant patch (TachoSil) with high adesive strength and fibrin glue (Tisseel). Intraoperative source of leakage, time to leakage control, quantity of Sealant Sponge used and postoperative complications were evaluated. RESULTS Dural tears were tipically the result of dissection of adherent posterior longitudinal ligament and/or calcified disc from the cervical dural sac to allow full decompression of the spinal cord. Effective repair of dural tear defined as cessation of CSF leak after topical sealant agents application was achieved no later than one minute in all cases. Evident clinical and/or radiological postoperative CSF leak was used to determine the patient's postoperative result. Postoperative CSF leak was not evident during a minimum 6 months follow up. CONCLUSIONS In the present study, we have reported our experience with a new sealing technique to manage CSF leaks from iatrogenic cervical dural lacerations. Tachosil tissue sealant patch is a rapid sutureless technique that may help in repairing introperatively incidental dural tears, thus reducing the risk of postoperative CSF leaks. To our knowledge, this is the first series to report the use of Tachosil adhesive sealant patch for the treatment of incidental dural tears during anterior cervical discectomy.
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Affiliation(s)
- Roberto Gazzeri
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
- Department of Neurosurgery, Istituto Nazionale Tumori "Regina Elena", Rome, Italy
| | - Marcelo Galarza
- Regional Service of Neurosurgery, "Virgen de la Arrixaca" University Hospital, Murcia, Spain
| | - Giorgio Callovini
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
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2
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Sinha S, George KJ. Spinal cord herniation following multilevel anterior cervical discectomy and fusion: A case report and literature review. Surg Neurol Int 2020; 11:327. [PMID: 33194261 PMCID: PMC7656024 DOI: 10.25259/sni_508_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal operations. Spinal cord herniation following these procedures is rare, more typically being described as occurring posteriorly rather than following anterior corpectomy and fusion (e.g., reported in four corpectomy cases). Here, we describe a case in which spinal cord herniation was attributed to a three-level ACDF. Case Description: A 31-year-old male initially presented with a 1 year’s duration of increasing myelopathy attributed to MR documented three-level disc disease (C4-C7). He successfully underwent a three-level ACDF without complications/durotomy. One year later, he again presented, with myelopathy (i.e., recurrent neck pain and stiffness) newly attributed to MR documented anterolateral C4-C5 cord herniation. As he declined further surgery, he was treated medically (e.g., utilizing analgesia and physiotherapy) and was no worse 6 months later. Conclusion: The occurrence of spinal cord herniation through a prior ACDF defect must be considered when patients present with recurrent myelopathy following previous ACDF surgery.
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Affiliation(s)
- Siddharth Sinha
- Department of Neurosurgery, Salford Royal Foundation Trust, Salford Royal Foundation Trust, Stott Lane Manchester, Greater Manchester, United Kingdom
| | - K Joshi George
- Department of Neurosurgery, Salford Royal Foundation Trust, Salford Royal Foundation Trust, Stott Lane Manchester, Greater Manchester, United Kingdom
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Oh LJ, Ong S, Ghozy S, Dmytriw AA, Zuccato J, Mobbs R, Phan K, Dibas M, Faulkner H. Dysphagia rates in single- and multiple-level anterior cervical discectomy and fusion surgery: a meta-analysis. JOURNAL OF SPINE SURGERY 2020; 6:581-590. [PMID: 33102895 DOI: 10.21037/jss-20-506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery. Methods Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I2 was used to explore heterogeneity. Results Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR =1.42, 95% CI: 1.05-1.91, I2=32%). Conclusions Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12-24 months.
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Affiliation(s)
- Lawrence J Oh
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Sam Ong
- Department of Surgery, Bedford Hospital South Wing, Bedford, UK
| | - Sherief Ghozy
- Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Neurosurgery Department, El Sheikh Zayed Specialized Hospital, Giza, Egypt
| | - Adam A Dmytriw
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Zuccato
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ralph Mobbs
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Neurospine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia.,Department of Neurosurgery, Prince of Wales Hospital, Sydney, Australia
| | - Kevin Phan
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Neurospine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia
| | - Mahmoud Dibas
- Sulaiman Al Rajhi Colleges, College of Medicine, Al Bukayriyah, Saudi Arabia
| | - Harrison Faulkner
- Faculty of Medicine, University of New South Wales, Sydney, Australia
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Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. JOURNAL OF SPINE SURGERY 2020; 6:302-322. [PMID: 32309668 DOI: 10.21037/jss.2020.01.14] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Kevin Swong
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Abstract
STUDY DESIGN/SETTING This was a retrospective cohort study. PURPOSE The purpose of this study was to examine the association between postoperative cerebrospinal fluid (CSF) leak and anterior cervical discectomy and fusion (ACDF). Specifically, we evaluated: (1) demographic risk factors; (2) comorbid risk factors; (3) indications for surgery; and (4) lengths of stay. SUMMARY OF BACKGROUND DATA CSF leak is a rare but serious complication of ACDF. Currently, there is a paucity of literature describing the risk factors for CSF leak following ACDF. METHODS The Nationwide Inpatient Sample was used to identify all patients who underwent cervical fusion using the anterior approach with excision of intervertebral disc between 1998 and 2010. Patients who had a diagnosis of ossification of the posterior longitudinal ligament in the cervical region were excluded. All patients who had a CSF leak were identified. Demographics and comorbidities were compared via χ analysis, and logistic regression to calculate the odds of having a CSF leak. RESULTS Of the 1,261,140 patients identified, 3048 patients (0.24%) had a postoperative CSF leak. Patients who were between the ages of 55 and 69 years (P=0.038) and 70 years or older (P=0.001) were at an increased risk of CSF leak compared with patients who were aged 40-54 years. Non-white race (P=0.021), obesity, (P<0.001) and hypertension (P=0.025) were associated with an increased risk of CSF leak, but diabetes (P=0.966) and hyperlipidemia (P=0.226) were not. Herniated disc diagnosis was associated with decreased risk of CSF leak (P=0.032), but cervical spondylosis with myelopathy patients had an increased risk (P<0.001). Patients with CSF leak had a mean length of stay of 6.0 days compared with 2.1 days among controls. CONCLUSIONS Surgical candidates who are older and non-white should be counseled of their increased risk for CSF leak in preoperative planning. Patients who are obese and have hypertension may benefit from medical optimization before surgery. LEVEL OF EVIDENCE Level III.
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Oropharyngeal CSF Leak Secondary to Anterior Cervical Discectomy and Fusion. Case Rep Otolaryngol 2018; 2018:7629184. [PMID: 30155333 PMCID: PMC6091331 DOI: 10.1155/2018/7629184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/20/2018] [Indexed: 11/23/2022] Open
Abstract
We present a case of an oropharyngeal cerebrospinal fluid (CSF) fistula in a patient that presented with headache, rhinorrhea, and pneumocephalus years after an anterior cervical discectomy and fusion. Imaging suggested a defect in the fovea ethmoidalis, but endoscopic surgery revealed the defect in the oropharynx. A second procedure was performed to remove the spinal hardware and repair the leak. This case is not only unique in the literature but also highlights the importance of maintaining a broad differential diagnosis to include rare complications and shows that despite dramatic improvements in imaging, locating CSF leaks still presents a challenge.
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Management of Cerebrospinal Fluid Leakage During Anterior Cervical Discectomy and Fusion and Its Effect on Spinal Fusion. World Neurosurg 2016; 89:636-40. [DOI: 10.1016/j.wneu.2015.11.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 11/19/2022]
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SUGAWARA T. Anterior Cervical Spine Surgery for Degenerative Disease: A Review. Neurol Med Chir (Tokyo) 2015; 55:540-6. [PMID: 26119899 PMCID: PMC4628186 DOI: 10.2176/nmc.ra.2014-0403] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/16/2015] [Indexed: 12/23/2022] Open
Abstract
Anterior cervical spine surgery is an established surgical intervention for cervical degenerative disease and high success rate with excellent long-term outcomes have been reported. However, indications of surgical procedures for certain conditions are still controversial and severe complications to cause neurological dysfunction or deaths may occur. This review is focused mainly on five widely performed procedures by anterior approach for cervical degenerative disease; anterior cervical discectomy, anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion, anterior cervical foraminotomy, and arthroplasty. Indications, procedures, outcomes, and complications of these surgeries are discussed.
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Affiliation(s)
- Taku SUGAWARA
- Department of Spinal Surgery, Research Institute for Brain and Blood Vessels-Akita, Akita, Akita
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Dysphagia Secondary to Anterior Cervical Fusion: Radiologic Evaluation and Findings in 74 Patients. AJR Am J Roentgenol 2015; 204:768-75. [DOI: 10.2214/ajr.14.13148] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Cerebrospinal fluid leaks and their management after anterior cervical discectomy and fusion: a report of 13 cases and a review of the literature. Spine (Phila Pa 1976) 2014; 39:E936-43. [PMID: 25010015 DOI: 10.1097/brs.0000000000000404] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective medical record review and literature review. OBJECTIVE To identify cases where a cerebrospinal fluid (CSF) leak occurred during an anterior cervical discectomy and fusion (ACDF) and to create a management algorithm based on the findings. SUMMARY OF BACKGROUND DATA ACDF is a commonly performed spinal operation. It is effective with very low complication rates. One rare complication of ACDF is a CSF leak. There is limited information on the management of CSF leaks after ACDF and management is on a surgeon-by-surgeon basis. METHODS We reviewed 3 surgeons' case logs and identified cases where a CSF leak was encountered during ACDF and reviewed the patients' medical records, operative reports and imaging to determine how these leaks were managed. We also performed a PubMed search for articles about the presentation and management of CSF leaks after ACDF. RESULTS Thirteen CSF leaks were identified in 1223 ACDFs, corresponding to a CSF leak rate of 1%. Of these, 9 were successfully treated with intraoperative repair. Postoperative lumbar drainage was used in the remaining 4 patients and was successful in 1 patient. Three patients underwent neck re-exploration and attempted delayed repair. Three patients, including one who was found to have hydrocephalus, ultimately required continuous CSF diversion via shunting. We identified 7 case reports of CSF leak in ADCF in the literature and 1 article that reviewed the prevalence and management of this complication. CONCLUSION CSF leak after ACDF is an uncommon complication that can usually be repaired. We provide a stepwise management strategy for CSF leaks in ACDF.
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Bydon M, Xu R, Papademetriou K, Sciubba DM, Wolinsky JP, Witham TF, Gokaslan ZL, Jallo G, Bydon A. Safety of spinal decompression using an ultrasonic bone curette compared with a high-speed drill: outcomes in 337 patients. J Neurosurg Spine 2013; 18:627-33. [DOI: 10.3171/2013.2.spine12879] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Unintended durotomies are a common complication of spine surgery and are often correlated with increased postoperative morbidity. Recently, ultrasonic bone curettes have been introduced in spine surgery as a possible alternative to the conventional high-speed drill, offering the potential for greater bone-cutting precision and less damage to surrounding soft tissues. To date, however, few studies have investigated the safety and efficacy of the ultrasonic bone curette in reducing the rates of incidental durotomy compared with the high-speed drill.
Methods
The authors retrospectively reviewed the records of 337 consecutive patients who underwent posterior cervical or thoracic decompression at a single institution between January 2009 and September 2011. Preoperative pathologies, the location and extent of spinal decompression, and the use of an ultrasonic bone curette versus the high-speed drill were noted. The rates of incidental durotomy, as well as hospital length of stay (LOS) and perioperative outcomes, were compared between patients who were treated using the ultrasonic bone curette and those treated using a high-speed drill.
Results
Among 88 patients who were treated using an ultrasonic bone curette and 249 who were treated using a high-speed drill, 5 (5.7%) and 9 (3.6%) patients had an unintentional durotomy, respectively. This finding was not statistically significant (p = 0.40). No patients in either cohort experienced statistically higher rates of perioperative complications, although patients treated using an ultrasonic bone curette tended to have a longer hospital LOS. This difference may be attributed to the fact that this series contained a statistically higher number of metastatic tumor cases (p < 0.0001) in the ultrasonic bone curette cohort, likely increasing the LOS for that patient population. In 13 patients, the dural defect was repaired intraoperatively. No patients who experienced an incidental durotomy had new-onset or permanent neurological deficits postoperatively.
Conclusions
The safety and efficacy of ultrasonic bone curettes in spine surgery has not been well established. This study shows that the ultrasonic bone curette has a similar safety profile compared with the high-speed drill, although both are capable of causing iatrogenic dural tears during spine surgery.
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Affiliation(s)
- Mohamad Bydon
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - Risheng Xu
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
- 3Medical Scientist Training Program, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kyriakos Papademetriou
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - Daniel M. Sciubba
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - Jean-Paul Wolinsky
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - Timothy F. Witham
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - Ziya L. Gokaslan
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - George Jallo
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
| | - Ali Bydon
- 1Department of Neurosurgery, and
- 2Spinal Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins Hospital; and
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Abstract
Cervical arthroplasty has developed as an alternative to spinal fusion for the treatment of cervical radiculopathy and myelopathy. The popularity of artificial discs has grown as the evidence of complications following arthrodesis has increased, making the theoretical advantages (motion preservation, altering the natural history of disease, prevention of adjacent segment disease) of disc replacement more attractive. However, as more discs are implanted and the length of follow-up increases, reported complications such as heterotopic ossification, device migration and spontaneous fusion of arthroplasty devices are growing. As a result, surgeons and patients face a challenge when deciding between motion-preserving or fusion surgery. Currently, there is inadequate evidence to promote extensive use of artificial discs for cervical spondylosis, despite promising short-term and intermediate clinical outcomes. However, there is also insufficient evidence to cease using them completely. The use of arthroplasty over fusion in the long term can only be justified if the incidence of adjacent segment disease decreases as a result. Despite the level of investment and research into arthroplasty outcomes, long-term follow-up has yet to be completed and has not convincingly demonstrated the effect of artificial discs on adjacent segment disease. Further long-term randomised trials are necessary to determine whether cervical arthroplasty is able to reduce the incidence of adjacent segment disease and, in doing so, replace arthrodesis as the gold standard treatment for cervical spondylosis.
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Affiliation(s)
- O Richards
- School of Medicine, University of Leeds, Leeds, UK.
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Viswanathan A, Whitehead WE, Luerssen TG, Jea A. Use of lumbar drainage of cerebrospinal fluid for brain relaxation in occipital lobe approaches in children: technical note. ACTA ACUST UNITED AC 2009; 71:681-4, discussion 684. [DOI: 10.1016/j.surneu.2008.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 04/01/2008] [Indexed: 11/26/2022]
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