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Talamonti G, Horaczek JA, Torres RT, Deppo LD, Carter MJ. PEG hydrogel sealant versus fibrin glue in posterior fossa surgery: an economic comparison across five European countries. J Comp Eff Res 2024; 13:e230047. [PMID: 38389409 PMCID: PMC11044953 DOI: 10.57264/cer-2023-0047] [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: 03/30/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Aim: Posterior cranial fossa (PCF) surgery is associated with complications, including cerebrospinal fluid (CSF) leakage. Dural sealants such as polyethylene glycol (PEG)-based hydrogels and fibrin glue can prevent CSF leaks, with evidence suggesting PEG hydrogels may outperform fibrin glue. However, the budget impact of using PEG hydrogels in PCF surgeries in Europe is unclear. Materials & methods: A decision tree was developed based on a previous US model, to assess the budget impact of switching from fibrin glue to PEG hydrogel in PCF surgery across five European countries. Input costs were derived from published sources for the financial year 2022/2023. Health outcomes, including CSF leaks, were considered. Results: The model predicted that using PEG hydrogel instead of fibrin glue in PCF surgery can lead to cost savings in five European countries. Cost savings per patient ranged from EUR 419 to EUR 1279, depending on the country. Sensitivity analysis showed that the incidence of CSF leaks and pseudomeningoceles had a substantial impact on the model's results. Conclusion: PEG hydrogels may be a cost-effective alternative to fibrin glue in PCF surgery. The model predicted that cost savings would be mainly driven by a reduction in the incidence of postoperative CSF leaks, resulting in reduced reliance on lumbar drains, reparative surgery and shortened hospital stays.
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Affiliation(s)
- Giuseppe Talamonti
- Neurosurgery Ospedale Niguarda Ca’ Granda, 20162, Milano, Lombardia, Italy
| | | | | | - Lisa Da Deppo
- Integra LifeSciences, 20079, Basiglio, Milano, Italy
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Lobo G, Lobo SRJ. Postoperative CSF Leak: Blood Patch-A New Avenue. Asian J Neurosurg 2023; 18:761-763. [PMID: 38161614 PMCID: PMC10756804 DOI: 10.1055/s-0043-1768599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Introduction Cerebrospinal fluid leak (CSF) after a neurosurgical procedure is a known complication that may result in bad outcomes (1). The incidence of CSF leak varies based on the site involved; it ranges from 4 to 32% for transsphenoidal to posterior fossa procedures. The costs involved in treating postoperative CSF leaks increases exponentially that becomes a barrier in continuing optimum treatment. There are many studies that compare the different treatment modalities and even use of sealing agents but none give an algorithm of management. Our study aims at known technique that can help to treat these kinds of low-pressure CSF leaks. Materials and Methods This was a prospective study done over a period of 5 years from January 2014 to January 2019. All patients who underwent procedures in which durotomy was done were included in the study. Results A total of six patients were enrolled for the study. The duration of the study spanned 5 years from January 2014 to January 2019. All the patients after taking informed consent underwent the necessary investigations and a blood patch was done. Five of the patients the CSF stopped but in one patient it persisted. This patient again underwent investigation and under image guidance another blood patch was put after which the CSF leak stopped. Conclusion Blood patch under imaging guidance is a safe and simple technique. The success rates of cessation of CSF leaks are good. Also, it is a cost-effective method using an autograft (patient's blood).
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Affiliation(s)
- Geover Lobo
- Department of Neurosurgery, Father Muller Medical College, Mangalore, Karnataka, India
| | - Sarita R. J. Lobo
- Department of Ophthalmology, Father Muller Medical College, Mangalore, Karnataka, India
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Nakamura A, Aihara Y, Chiba K, Matsumine H, Sakurai H, Kawamata T. Efficacy of the pedicle trapezius muscle flap for the multisurgical removal of pediatric posterior fossa anaplastic ependymoma. Childs Nerv Syst 2023; 39:1635-1639. [PMID: 37016090 DOI: 10.1007/s00381-023-05941-0] [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: 02/10/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVE Exceedingly refractory, pediatric anaplastic ependymoma in many cases requires multisurgical removal. The high risk of poor wound healing and CSF leakage especially at the posterior fossa make this tumor difficult to treat. CASE A 9-year-old girl has had 4th ventricular anaplastic ependymoma since the age of 3. She experienced tumor removal 8 times including 4 posterior fossa craniotomies because tumors were disseminated not only to the posterior fossa but also to the cerebral hemispheres. She also underwent a dermal graft using a free flap. She experienced CSF leaks and meningitis frequently because the wound healing was poor. We performed a dermal flap closure using a pedicle trapezius muscle flap with a plastic surgeon when we performed the 5th tumor removal. RESULT We achieved complete wound closure in spite of broad deficiencies in subcutaneous and epidermal tissues. After that, recurrences of posterior fossa tumors presented within a short term, and tumor removal via an incision of a pedicle trapezius muscle flap was performed without recurrence of CSF leaks and meningitis. DISCUSSION AND CONCLUSION For the first time, we are able to report on the efficacy of using the pedicle trapezius muscle flap for multisurgical removal of pediatric posterior fossa anaplastic ependymoma. The muscle flap was found to be effective because of the multiple surgeries expected, and the pedicle trapezius muscle flap was found to be resilient to multiple surgical procedures. Although advantageous, the dorsal scapular artery which is required for flap creation is actually difficult to harvest. Compared to a flee flap, the pedicle trapezius muscle flap maintains vascular supply. Furthermore, this technique has the possibility of being applied to defective dura mater closure that cannot be watertight due to multiple surgeries. However, it is very important to inform the patient's family not only about the improved efficacy of surgery, but also to raise awareness on consequential cosmetic issues.
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Affiliation(s)
- Akikazu Nakamura
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Yasuo Aihara
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan.
| | - Kentaro Chiba
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Hajime Matsumine
- Department of Plastic Surgery, Tokyo Woman's Medical University, Tokyo, Japan
| | - Hiroyuki Sakurai
- Department of Plastic Surgery, Tokyo Woman's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
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Xiao Y, Wang B, Chen Y, Chen L, Lou Z, Gong Z. Risk Factors of Postoperative Cerebrospinal Fluid Leak After Craniovertebral Junction Anomalies Surgery: A Case-Control Study. Neurospine 2023; 20:255-264. [PMID: 37016872 PMCID: PMC10080451 DOI: 10.14245/ns.2244772.386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/05/2022] [Indexed: 04/03/2023] Open
Abstract
Objective: To identify potential risk factors for cerebrospinal fluid (CSF) leakage after craniovertebral junction (CVJ) anomaly surgery and to provide a reference for clinical practice.Methods: Sixty-six patients who underwent elective CVJ anomaly surgery during a 6-year period (April 2013 to September 2019) were retrospectively included. Research data were collected from the patients’ medical records and imaging systems. Patients were divided into CSF leak and no CSF leak groups. Univariate tests were performed to identify potential risk factors. For statistically significant variables in the univariate tests, a logistic regression test was used to identify independent risk factors for CSF leakage.Results: The overall prevalence of CSF leakage was 13.64%. Univariate tests showed that a basion-dental interval (BDI) > 10 mm and occipitalized atlas had significant intergroup differences (p < 0.05). Multivariate analysis indicated that a BDI > 10 mm was an independent risk factor for CSF leakage, and patients with CVJ anomalies with a BDI > 10 mm were more likely to have postoperative CSF leaks (odds ratio, 14.67; 95% confidence interval, 1.48–30.88; p = 0.004).Conclusion: It is necessary to maintain vigilance during CVJ anomaly surgery in patients with a preoperative BDI > 10 mm to avoid postoperative CSF leaks.
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Affiliation(s)
- Yu Xiao
- Department of Orthopaedics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Bing Wang
- Department of Orthopaedics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
- Corresponding Author Bing Wang Department of Orthopaedics, The First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan, China
| | - Yulian Chen
- Department of ENT, The First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lingqiang Chen
- Department of Orthopaedics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhenkai Lou
- Department of Orthopaedics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhiqiang Gong
- Department of Orthopaedics, The First Affiliated Hospital of Kunming Medical University, Kunming, China
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Alhantoobi MR, Kesserwan MA, Khayat HA, Lawasi M, Sharma S. Rates of cerebrospinal fluid leak and pseudomeningocele formation after posterior fossa craniotomy versus craniectomy: A systematic review and meta-analysis. Surg Neurol Int 2023; 14:140. [PMID: 37151452 PMCID: PMC10159278 DOI: 10.25259/sni_125_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/18/2023] [Indexed: 05/09/2023] Open
Abstract
Background Postoperative cerebrospinal fluid (CSF) leak is a major concern after posterior fossa surgery with significant clinical implications. It has been postulated that replacing the bone flap, performing a craniotomy, would reinforce the surgical closure and decrease rates of CSF leak. This systematic review and meta-analysis compared the rate of CSF leak after posterior fossa craniotomies versus craniectomies. Methods Three databases were searched for English studies comparing the primary outcome, rate of CSF leak, after adult posterior fossa craniotomies versus craniectomies. Secondary outcomes included the rate of postoperative pseudomeningocele formation, CSF leak and pseudomeningocele formation, CSF diversion, revision surgery, and infection. Pooled estimates and relative risks for dichotomous outcomes were calculated using Review Manager 5.4, with corresponding 95% confidence intervals (CIs). Results A total of 1250 patients (635 craniotomies and 615 craniectomies), from nine studies, were included in the final analysis. Even though rates of CSF leak favored craniotomies, the difference did not reach statistical significance in our pooled analysis (Risk Ratio: 0.71, 95% Confidence Interval: 0.45-1.14, p-value = 0.15, Heterogeneity I-squared = 0%). On the other hand, comparing the rates of pseudomeningocele formation and CSF leak, as a combined outcome, or pseudomeningocele formation only showed a significant difference favoring craniotomies. The quality of evidence in this meta-analysis was graded as having a high risk of bias based on the risk of bias in non-randomized studies - of exposure criteria. Conclusion Based on evidence with high risk of bias, rates of postoperative CSF leak and pseudomeningocele formation favored posterior fossa craniotomies over craniectomies. Further research with more robust methodology is required to validate these findings.
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Affiliation(s)
- Mohamed Rashed Alhantoobi
- Department of Neurosurgery, Hamilton General Hospital, McMaster University Medical Centre, Ontario, Canada
- Corresponding author: Mohamed Rashed Alhantoobi, Department of Neurosurgery, Hamilton General Hospital, McMaster University Medical Centre, Ontario, Canada.
| | - Mohamad Ali Kesserwan
- Department of Neurosurgery, Hamilton General Hospital, McMaster University Medical Centre, Ontario, Canada
| | - Hassan A. Khayat
- Department of Neurosurgery, Hamilton General Hospital, McMaster University Medical Centre, Ontario, Canada
| | - Mohammad Lawasi
- Faculty of Medicine and Medical Sciences, University of Balamand, El-Koura, Lebanon
| | - Sunjay Sharma
- Department of Neurosurgery, Hamilton General Hospital, McMaster University Medical Centre, Ontario, Canada
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Kustono H, Parenrengi MA. MANAGEMENT OF RECURRENT CSF LEAK AFTER OCCIPITAL TUMOR SURGERY: A CASE REPORT. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1796-1800. [PMID: 35962701 DOI: 10.36740/wlek202207134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We present the case of a 10-year-old male with recurrent CSF leakage after surgery for an occipital tumor. Initial management of the CSF leak, including debridement, re-exploration, and lumbar drain insertion, failed to address the problem. The last resort was the insertion of the EVD, which managed to stop the leak. Cerebrospinal fluid leakage remains one of the most common complications in neurosurgery. CSF leakage can prolong hospitalization, require further surgery, and cause tension pneumocephalus, CSF infection, and wound dehiscence. Management of postoperative cerebrospinal fluid leakage includes suturing the surgical wound and applying pressure dressings or through surgical means such as cerebrospinal fluid diversion and re-exploration.
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Vychopen M, Hadjiathanasiou A, Brandecker S, Borger V, Schuss P, Vatter H, Güresir E. Rapid closure technique in suboccipital decompression. Eur J Trauma Emerg Surg 2021; 48:2407-2412. [PMID: 34562136 PMCID: PMC9192370 DOI: 10.1007/s00068-021-01779-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022]
Abstract
Objective Suboccipital decompression has been established as standard therapeutic procedure for raised intracranial pressure caused by mass-effect associated pathologies in posterior fossa. Several different surgical techniques of dural closure have been postulated to achieve safe decompression. The aim of this study was to examine the differences between fibrin sealant patch (FSP) and dural reconstruction (DR) in suboccipital decompression for acute mass-effect lesions. Methods We retrospectively analyzed our institutional data of patients who underwent suboccipital decompression due to spontaneous intracerebellar hemorrhage, cerebellar infarction and acute traumatic subdural hematoma between 2010 and 2019. Two different dural reconstruction techniques were performed according to the attending neurosurgeon: (1) fibrin sealant patch (FSP), and (2) dural reconstruction (DR) including the use of dural patch. Complications, operative time, functional outcome and the necessity of a ventriculoperitoneal shunt (VP Shunt) were assessed and further analyzed. Results Overall, 87 patients were treated at the authors’ institution (44 in FSP group, 43 in DR group). Glasgow coma scale on admission and preoperative coagulation state did not differ between the groups. Postoperatively, we found no difference in cerebrospinal fluid leakage or chronic hydrocephalus between the groups (p = 0.47). Revision rates were 2.27% (1/44 patients) in the FSP group, compared to 16.27% (7/43) in the DR group (p < 0.023). Operative time was significantly shorter in the FSP group (90.3 ± 31.0 min vs. 199.0 ± 48.8 min, p < 0.0001). Conclusion Rapid closure technique in suboccipital decompression is feasible and safe. Operative time is hereby reduced, without increasing complication rates.
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Affiliation(s)
- Martin Vychopen
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Alexis Hadjiathanasiou
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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8
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Marton E, Giordan E, Gallinaro P, Curzi C, Trojan D, Paolin A, Guerriero A, Rossi S, Bendini M, Longatti P, Canova G. Homologous amniotic membrane as a dural substitute in decompressive craniectomies. J Clin Neurosci 2021; 89:412-421. [PMID: 34052070 DOI: 10.1016/j.jocn.2021.05.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/19/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION A dura mater substitute in decompressive craniectomies must protect the brain while providing a dissection plane between the cortex and myocutaneous layer. The human amniotic membrane (AM) has anti-inflammatory, wound healing, and differentiation properties. We tested AM properties as a dural substitute by comparing the outcomes to biological ones. METHODS We prospectively collected data on 25 patients who randomly underwent decompressive craniectomy with lyophilized AM patches and 25 in which biological substitutes were utilized between 2015 and 2019. The AM was laid with the epithelial side facing the brain because of the anti-adhesive proprieties, while the chorion facing the myocutaneous flap. We collected data on demographics, neurological status, comorbidities, and surgical outcomes. Additionally, we created a score - dura mimicking score- and reviewed postoperative imaging and pathological specimens. RESULTS The majority (96%) of AM grafts were integrated into native dura. Thirteen patients scored as excellent and 11 good on our "dura mimicking score", showing tissue integration ability but no cerebral cortex adhesion. The histopathological analysis showed that AM had thick plates of dense fibrous tissue with small reactive vessels, reactive fibroblasts, and lymphocytes infiltrate. The AM group's first outcomes were not different from the biological substitute patients but higher integration rate to the dura and less adhesion to the myocutaneous flap in AM patients. CONCLUSIONS We documented the anti-adhesive, protective, and integrative properties of AM dural substitute patches in patients who underwent decompressive craniectomies, comparing the intraoperative differences and postoperative outcomes to biological dural substitutes.
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Affiliation(s)
| | - Enrico Giordan
- Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Italy.
| | - Paolo Gallinaro
- Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Italy
| | - Christian Curzi
- Department of Neuroscience, University of Padova, Padova, Italy
| | | | | | - Angela Guerriero
- Department of Pathology, Aulss 2 Marca Trevigiana, Treviso, Italy
| | - Sabrina Rossi
- Department of Pathology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Matteo Bendini
- Department of Radiology, Aulss 2 Marca Trevigiana, Treviso, Italy
| | | | - Giuseppe Canova
- Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Italy
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Abstract
Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.
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Affiliation(s)
- Sungmin Nam
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
| | - David Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
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Bird J, Mirza AH, King E. Caution in the use of TissuePatchDS-P ™ in drainless benign superficial parotidectomy, a pilot study: Our experience in three patients. Clin Otolaryngol 2020; 45:837-840. [PMID: 32506702 DOI: 10.1111/coa.13594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/16/2020] [Accepted: 05/25/2020] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Emma King
- Poole NHS Foundation Trust, Poole, UK
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Han HJ, Jeong JH, Kim JW, Seung WB. Postoperative Thecal Sac Compression Induced by Hydrogel Dural Sealant after Spinal Schwannoma Removal. Korean J Neurotrauma 2020; 16:99-104. [PMID: 32395458 PMCID: PMC7192801 DOI: 10.13004/kjnt.2020.16.e10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/23/2020] [Accepted: 04/07/2020] [Indexed: 11/15/2022] Open
Abstract
Cerebrospinal fluid (CSF) leak is a common complication of spinal and cranial surgery, and patients undergoing spinal tumor surgery are probably particularly predisposed due to the presence of an intradural tumor and many other factors. Furthermore, a meticulous dural closure technique does not always result in watertight closure. A number of adjunctive methods have been used to assist with dural closure. Synthetic, absorbable polyethylene glycol hydrogel dural sealants are widely used and have been approved for use as adjuncts for cranial applications requiring sutured dural closure. We report a case of thecal sac compression by DuraSeal® Dural Sealant used to repair the CSF leak after intentional durotomy during lumbar schwannoma extirpation.
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Affiliation(s)
- Hong Joon Han
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
| | - Ju Ho Jeong
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
| | - Won Bae Seung
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
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Go KO, Hwang K, Han JH. Surgical Nuances to Reduce and Manage Cerebrospinal Fluid Leaks after Microvascular Decompression. J Clin Med 2020; 9:jcm9040902. [PMID: 32218220 PMCID: PMC7230255 DOI: 10.3390/jcm9040902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: No dural substitute has proven to be complication-free in a large clinical trial, even suggesting some benefit during watertight closure. However, primary dural closure is not always possible due to dural shrinkage from electrocautery for dural bleeding. Objective: This study is performed to analyze the clinical outcomes related to cerebrospinal fluid (CSF) leakage after microvascular decompression (MVD) using a simple surgical technique. Methods: Three hundred and sixty consecutive cases were treated with MVD and followed up for more than one month after surgery. Bleeding from the cut veins during dural incision was controlled by pulling stay sutures instead of electrocautery to avoid dural shrinkage. Additionally, a wet cottonoid was placed on the cerebellar side dural flap to prevent dural dehydration. During dural closure, primary dural closure was always attempted. If not possible, a “plugging muscle” method was used for watertight dural closure. Results: The mean age was 54.1 ± 10.8 years (range, 24–85 years), and 238 (66.1%) were female. Primary MVD was performed in 345 (95.8%) patients. The mean operation time (from skin incision to skin closure) was 96.7 ± 33.0 min (range, 38–301 min). Primary dural closure was possible in 344 (95.6%) patients. The “plugging muscle method” was performed more frequently in patients older than 60 years (8 of 99 cases, 8.08%) than in younger cases (8 of 261 cases, 3.07%) (p = 0.039; chi-squared test). After surgery, 5 (1.4%) patients were treated for middle ear effusion, and another 5 (1.4%) patients experienced transient CSF rhinorrhea, which was spontaneously resolved within 1 to 7 days. No patients required additional treatments for CSF leakage. Conclusion: A simple technique using pulling stay sutures to stop bleeding from the dural edges and placing a wet cottonoid on the exposed dura can make primary dural closure easier.
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Affiliation(s)
- Kyeong-O Go
- Department of Neurosurgery, Gyeongsang National University Hospital, Gyengsangnam-do 52727, Korea;
| | - Kihwan Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do 13620, Korea;
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jung Ho Han
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do 13620, Korea;
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence:
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Tahami SA, Afshar-Fereydonian N, Kazemi F, Taheri M. Comparing the results of duraplasty using amniotic membrane versus pericranium as dural graft; concerning CSF leakage and pseudomeningocele. Br J Neurosurg 2019; 34:51-54. [PMID: 31656091 DOI: 10.1080/02688697.2019.1680797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Seyed Ahmad Tahami
- Department of Neurosurgery, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | | | - Farid Kazemi
- Department of Neurosurgery, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | - Morteza Taheri
- Department of Neurosurgery, Iran University of Medical Sciences, 7Tir Hospital, Tehran, Iran
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Strong MJ, West GA, Woo H, Couture DE, Wilson JA, Munoz LF, Rosen CL, Greenlee JD, van Loveren HR, Iantosca M, Baird CJ, Smith M, McGirt M, Parish J, Asher AL. A Pivotal Randomized Clinical Trial Evaluating the Safety and Effectiveness of a Novel Hydrogel Dural Sealant as an Adjunct to Dural Repair. ACTA ACUST UNITED AC 2019; 13:204-212. [PMID: 28927211 DOI: 10.1093/ons/opw004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 10/18/2016] [Indexed: 11/13/2022]
Abstract
BACKGROUND A watertight dural repair is critical to minimizing the risk of postoperative complications secondary to cerebrospinal fluid (CSF) leaks. OBJECTIVE To evaluate the safety and efficacy of a novel hydrogel, Adherus Dural Sealant, when compared with control, DuraSeal Dural Sealant System, as an adjunct to standard methods of dural repair. METHODS In this 17-center, prospective, randomized clinical trial designed as a noninferiority, single-blinded study, 124 patients received Adherus Dural Sealant (test sealant) and 126 received DuraSeal (control). The primary composite endpoint was the proportion of patients who were free of any intraoperative CSF leakage during Valsalva maneuver after dural repair, CSF leak/pseudomeningocele, and unplanned retreatment of the surgical site. Each component was then analyzed individually as a secondary endpoint. Patients were followed for 4 mo after surgery. RESULTS The primary composite endpoint at the 120-d follow-up was achieved in 91.2% of the test sealant group compared with 90.6% of the control, thus showing that the test sealant was statistically significantly noninferior to DuraSeal ( P = .0049). Post hoc analysis of the primary composite endpoint at 14 d demonstrated superiority of the test sealant over the control ( P = .030). Primary endpoint failures in the control group tended to occur early in follow-up period, while a majority of test dural sealant failures were identified through protocol-required radiographic imaging at the 120-d follow-up visit. CONCLUSION The test sealant, Adherus Dural Sealant, is a practical, safe, and effective adjunct to achieving a watertight dural closure after primary dural closure in cranial procedures.
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Affiliation(s)
| | - G Alexander West
- Department of Neurosurgery, Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas
| | - Henry Woo
- Department of Neurosurgery, SUNY Stony Brook, Stony Brook, New York
| | - Daniel E Couture
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - John A Wilson
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Lorenzo F Munoz
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Charles L Rosen
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | | | | | - Mark Iantosca
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Mark Smith
- Carolina Neurosu-rgery & Spine Associates, Charlotte, North Carolina.,The Carolinas Health-care System Neuroscience Institute, Charlotte, North Carolina
| | - Matt McGirt
- Carolina Neurosu-rgery & Spine Associates, Charlotte, North Carolina.,The Carolinas Health-care System Neuroscience Institute, Charlotte, North Carolina
| | - Jonathan Parish
- Carolina Neurosu-rgery & Spine Associates, Charlotte, North Carolina.,The Carolinas Health-care System Neuroscience Institute, Charlotte, North Carolina
| | - Anthony L Asher
- Carolina Neurosu-rgery & Spine Associates, Charlotte, North Carolina.,The Carolinas Health-care System Neuroscience Institute, Charlotte, North Carolina
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Effectiveness of Dural Sealants in Prevention of Cerebrospinal Fluid Leakage After Craniotomy: A Systematic Review. World Neurosurg 2018; 118:368-376.e1. [PMID: 29969744 DOI: 10.1016/j.wneu.2018.06.196] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Cerebrospinal fluid (CSF) leakage is one of the most challenging complications in neurosurgery. We sought to evaluate the efficacy of dural sealants in preventing CSF leakage after cranial surgery. METHODS A literature search was performed in the PubMed, Embase, and Cochrane databases. The inclusion criteria were defined to include articles describing regular cranial procedures combined with the use of any dural sealant reporting CSF leakage. The primary outcome was CSF leakage (pseudomeningocele formation or incisional CSF leakage), secondary outcomes were pseudomeningocele formation, incisional CSF leakage, and surgical-site infection. RESULTS Twenty articles were included. Ten of these were comparative studies (sealant vs. no sealant) including 3 randomized controlled trials. In the 20 articles, a total of 3682 surgical procedures were reported. The number of CSF leakages in general did not differ between the sealant group (8.2%) and control group (8.4%), risk ratio (RR) 0.84 (0.50-1.42), I2 = 56%. Exclusion of non-randomized controlled trials did not alter the results. Meta-analyses for secondary outcomes showed no difference between number of incisional CSF leakage, RR 0.30 (0.05-1.59), I2 = 38%. Also, no difference was found in the pseudomeningocele formation, RR 1.50 (0.43-5.17), I2 = 0%. Surgical-site infection was seen less in the sealant group (1.0%) compared with the control group (5.6%), RR 0.25 (0.13-0.48), I2 = 0%. CONCLUSIONS This systematic review showed that dural sealants did not reduce the number of CSF leaks in general, the number of incisional CSF leaks alone, or the number of pseudomeningocele formations alone. However, dural sealants reduced the risk of surgical-site infection.
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16
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Pitskhelauri D, Kudieva E, Moshchev D, Ananev E, Shifrin M, Danilov G, Melnikova-Pitskhelauri T, Kachkov I, Bykanov A, Sanikidze A. Cisterna magna arachnoid membrane suturing decreases incidence of pseudomeningocele formation and incisional CSF leakage. Acta Neurochir (Wien) 2018; 160:1079-1087. [PMID: 29557532 DOI: 10.1007/s00701-018-3507-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE A pseudomeningocele and an incisional cerebrospinal fluid leak are considered frequent complications following neurosurgical operations. The rate of these complications especially increases following neurosurgical procedures on the posterior cranial fossae. According to some publications, the rate of pseudomeningoceles has been reported as high as 40%, whereas that of incisional cerebrospinal fluid leaks is up to 17%. For the purposes of reducing the risk of these complications after a midline suboccipital craniotomy, we propose suturing the arachnoid membrane of the cisterna magna. In this paper, we present a retrospective analysis of arachnoid membrane suturing. METHODS Seventy patients underwent midline suboccipital craniotomy by the first author between 2012 and 2016 at Burdenko Neurosurgery Institute. In this group was included a consecutive group of patients with posterior fossae tumors where the approach was performed through the cisterna magna arachnoid membrane following midline suboccipital craniotomy and dural opening. The patients were divided into two groups. Group 1 included 38 patients to whom cisterna magna arachnoid membrane suturing was performed with monofilament nonabsorbable suture 7.0., and additionally, the suture was sealed with fibrin adhesive sealant TachoComb®. Group 2 included 32 patients without arachnoid membrane suturing. There was no other significant difference in terms of clinical signs and surgical procedures between these groups. In the postoperative period, the frequency of developing a pseudomeningocele and an incisional cerebrospinal fluid leak was assessed in these two groups. The results were evaluated on the basis of clinical, CT, and MRI data performed in the postoperative period. RESULTS In the patients who underwent arachnoid membrane suturing (group I), pseudomeningocele formation was observed in one (2.6%) and CSF leak in one (2.6%) of the 38 patients. In group II, in which patients had no arachnoid membrane suturing, we observed pseudomeningocele formation in 11 (34.4%) patients and a CSF leak in 7 (25.0%) out of 28 patients with known follow-up. Statistical analysis of the data indicates a significantly higher risk of postoperative pseudomeningocele formation and/or an incisional cerebrospinal fluid leak in a group of patients who did not undergo arachnoid membrane suturing (p < 0.05). CONCLUSIONS Suturing of the arachnoid membrane of the cisterna magna and its further sealing with fibrin adhesive sealant TachoComb® create an additional barrier for preventing cerebrospinal fluid collection in the extradural space. This technique significantly reduces the risk of postoperative pseudomeningocele formation and/or an incisional cerebrospinal fluid leak in patients with midline suboccipital craniotomy.
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17
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George B, Matula C, Kihlström L, Ferrer E, Tetens V. Safety and Efficacy of TachoSil (Absorbable Fibrin Sealant Patch) Compared With Current Practice for the Prevention of Cerebrospinal Fluid Leaks in Patients Undergoing Skull Base Surgery: A Randomized Controlled Trial. Neurosurgery 2018; 80:847-853. [PMID: 28327892 DOI: 10.1093/neuros/nyx024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 01/18/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage associated with incomplete sealing of the dura mater is a major complication of intradural procedures. OBJECTIVE To compare the efficacy and safety of adjunctive TachoSil (Takeda Pharma A/S, Roskilde, Denmark) with current practice for the prevention of postoperative CSF leaks in patients undergoing elective skull base surgery involving dura mater closure. METHODS Patients were intraoperatively randomized to TachoSil or current practice immediately before primary dura closure by suturing ± duraplasty. Choice of adjunctive treatment in the current practice group was at the surgeon's discretion. Primary efficacy endpoint was occurrence of clinically evident verified postoperative CSF leak or clinically evident pseudomeningocele within 7 weeks after surgery or treatment failure (third application of trial treatment or use of other treatment). RESULTS A total of 726 patients were randomized to TachoSil (n = 361) or current practice (n = 365). More current practice patients had sutures plus duraplasty for primary dura closure compared with TachoSil (49.6% vs 35.7%) and fewer had sutures only (45.5% vs 63.2%). The primary endpoint of estimated leak rate favored TachoSil with events in 25 (6.9%) patients vs 30 (8.2%) current practice patients; however, this was not statistically significant (odds ratio: 0.82; 95% confidence interval: 0.47, 1.43; P = .485). Both treatments were well tolerated with similar frequency of adverse events. CONCLUSION Very low rates of postoperative CSF leaks can be achieved in patients undergoing skull base surgery of various indications. Although the study did not meet its primary endpoint, TachoSil appears to be safe and effective for the prevention of CSF leaks and associated complications.
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Affiliation(s)
- Bernard George
- Department of Neurosurgery, Hôpital Lariboisière, Paris, France
| | - Christian Matula
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Lars Kihlström
- Department of Clinical Neuroscience, Karolinska University Hospital, Stockholm, Sweden
| | - Enrique Ferrer
- Department of Neurosurgery, Hospital Clinic Barcelona, Barcelona, Spain
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18
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Venable GT, Roberts ML, Lee RP, Michael LM. Primary Dural Closure for Retrosigmoid Approaches. J Neurol Surg B Skull Base 2017; 79:330-334. [PMID: 30009112 PMCID: PMC6043179 DOI: 10.1055/s-0037-1607455] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 07/10/2017] [Indexed: 11/19/2022] Open
Abstract
Object
Primary closure of posterior fossa dura can be challenging, and postoperative cerebrospinal fluid (CSF) leaks continue to represent a common complication of the retrosigmoid approach. We describe a simple technique to allow for primary closure of the dura following retrosigmoid approaches. The incidence of CSF leaks using this method is reported.
Methods
A retrospective chart review was conducted on all cases of retrosigmoid craniotomies performed by the senior surgeon from February 2009 to February 2015. The primary outcome was development of postoperative CSF leak or pseudomeningocele. Length of stay, lesion type, and other surgical complications were also reported.
Results
Eighty-six patients underwent a retrosigmoid craniotomy during the study period. The most common indications for retrosigmoid craniotomy were microvascular decompression (58%) and tumor resection (36%). No allo- or autografts to repair the dural defect were needed, and no lumbar drains were used. No patients developed CSF otorrhea, rhinorrhea, or incisional leak postoperatively.
Conclusion
Primary dural closure is possible in retrosigmoid approaches without the use of allo- or autografts and may prevent postoperative CSF leaks when combined with other posterior fossa closure techniques. Careful attention to the handling of the dural flap is necessary to achieve this.
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Affiliation(s)
- Garrett T Venable
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mallory L Roberts
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Ryan P Lee
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee, United States
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19
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Das S, Rea PA. Novel middle ear applications for a synthetic cerebrospinal fluid (CSF) sealant. Clin Otolaryngol 2017; 43:683-685. [PMID: 28981202 DOI: 10.1111/coa.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 11/26/2022]
Affiliation(s)
- S Das
- Department of Otolaryngology, Leicester Royal Infirmary, Leicester, UK
| | - P A Rea
- Department of Otolaryngology, Leicester Royal Infirmary, Leicester, UK
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20
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Jalan D, Saini N, Zaidi M, Pallottie A, Elkabes S, Heary RF. Effects of early surgical decompression on functional and histological outcomes after severe experimental thoracic spinal cord injury. J Neurosurg Spine 2017; 26:62-75. [DOI: 10.3171/2016.6.spine16343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
In acute traumatic brain injury, decompressive craniectomy is a common treatment that involves the removal of bone from the cranium to relieve intracranial pressure. The present study investigated whether neurological function following a severe spinal cord injury improves after utilizing either a durotomy to decompress the intradural space and/or a duraplasty to maintain proper flow of cerebrospinal fluid.
METHODS
Sixty-four adult female rats (n = 64) were randomly assigned to receive either a 3- or 5-level decompressive laminectomy (Groups A and B), laminectomy + durotomy (Groups C and D), or laminectomy + duraplasty with graft (Group E and F) at 24 hours following a severe thoracic contusion injury (200 kilodynes). Duraplasty involved the use of DuraSeal, a hydrogel dural sealant. Uninjured and injured control groups were included (Groups G, H). Hindlimb locomotor function was assessed by open field locomotor testing (BBB) and CatWalk gait analysis at 35 days postinjury. Bladder function was analyzed and bladder wall thickness was assessed histologically. At 35 days postinjury, mechanical and thermal allodynia were assessed by the Von Frey hair filament and hotplate paw withdrawal tests, respectively. Thereafter, the spinal cords were dissected, examined for gross anomalies at the injury site, and harvested for histological analyses to assess lesion volumes and white matter sparing. ANOVA was used for statistical analyses.
RESULTS
There was no significant improvement in motor function recovery in any treatment groups compared with injured controls. CatWalk gait analysis indicated a significant decrease in interlimb coordination in Groups B, C, and D (p < 0.05) and swing speed in Groups A, B, and D. Increased mechanical pain sensitivity was observed in Groups A, C, and F (p < 0.05). Rats in Group C also developed thermal pain hypersensitivity. Examination of spinal cords demonstrated increased lesion volumes in Groups C and F and increased white matter sparing in Group E (p < 0.05). The return of bladder automaticity was similar in all groups. Examination of the injury site during tissue harvest revealed that, in some instances, expansion of the hydrogel dural sealant caused compression of the spinal cord.
CONCLUSIONS
Surgical decompression provided no benefit in terms of neurological improvement in the setting of a severe thoracic spinal cord contusion injury in rats at 24 hours postinjury. Decompressive laminectomy and durotomy did not improve motor function recovery, and rats in both of these treatment modalities developed neuropathic pain. Performing a durotomy also led to increased lesion volumes. Placement of DuraSeal was shown to cause compression in some rats in the duraplasty treatment groups. Decompressive duraplasty of 3 levels does not affect functional outcomes after injury but did increase white matter sparing. Decompressive duraplasty of 5 levels led to neuropathic pain development and increased lesion volumes. Further comparison of dural repair techniques is necessary.
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Affiliation(s)
- Devesh Jalan
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Neginder Saini
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Mohammad Zaidi
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Alexandra Pallottie
- 2Graduate School of Biomedical Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Stella Elkabes
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Robert F. Heary
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
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21
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Altaf I, Vohra AH, Shams S. Management of Cerebrospinal Fluid Leak following Posterior Cranial Fossa Surgery. Pak J Med Sci 2016; 32:1439-1443. [PMID: 28083041 PMCID: PMC5216297 DOI: 10.12669/pjms.326.9956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Cerebrospinal fluid leakage remains a significant cause of morbidity following posterior fossa surgery, and its treatment remains a difficult problem. The aim of the study was to propose a treatment algorithm for its management. METHODS A retrospective, single-center study was conducted on 147 patients who underwent elective posterior fossa surgery for a variety of diseases . Patients with post operative CSF leakage had either been treated initially with conservative measures including re-suturing of the wound, with CSF lumbar drainage to be employed in case the CSF leakage didn't stop, or the initial intervention was the institution of CSF lumbar drainage simultaneously with conservative measures. VP (ventriculo-peritoneal) shunt was done in patients with gross hydrocephalus on postoperative CT brain. RESULTS There were 25 (17%) cases of CSF leakage, including 24 incisional CSF leaks and one case of CSF otorrhea. In eight patients with incisional CSF leakage treated initially with conservative measures including re-suturing of the wound, CSF leakage stopped in only two cases. CSF lumbar drainage instituted later on in six cases with persistent leakage stopped the CSF leakage. In fourteen patients managed initially with re-suturing of the wound and concomitant CSF lumbar drainage, CSF leakage settled in all the cases. Two patients with gross hydrocephalus on post operative CT were managed successfully with VP shunt. Re-suturing of the wound with concomitant CSF lumbar drainage was found to be significantly associated (p=0.003) with the stoppage of CSF leakage, and the settlement of meningitis (p= 0.014). CONCLUSION Incisional CSF leaks after posterior fossa surgery should be managed with re-suturing of the wound and concomitant CSF lumbar drainage, instead of an initial trial of conservative therapy alone.
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Affiliation(s)
- Imran Altaf
- Dr. Imran Altaf, MS. Department of Neurosurgery, Khawja Muhammad Safdar Medical College, Sialkot, Pakistan
| | - Anjum Habib Vohra
- Dr. Anjum Habib Vohra, FRCS, Department of Neurosurgery, Post Graduate Medical Institute, Lahore General Hospital, Lahore, Pakistan
| | - Shahzad Shams
- Dr. Shahzad Shams, FRCS, FCPS, Department of Neurosurgery, Post Graduate Medical Institute, Lahore General Hospital, Lahore, Pakistan
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22
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Heymanns V, Oseni AW, Alyeldien A, Maslehaty H, Parvin R, Scholz M, Petridis AK. Sandwich Wound Closure Reduces the Risk of Cerebrospinal Fluid Leaks in Posterior Fossa Surgery. Clin Pract 2016; 6:824. [PMID: 27478578 PMCID: PMC4943098 DOI: 10.4081/cp.2016.824] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 11/28/2022] Open
Abstract
Posterior fossa surgery is demanding and hides a significant number of obstacles starting from the approach to the wound closure. The risk of cerebrospinal fluid (CSF) leakage in posterior fossa surgery given in the literature is around 8%. The present study aims to introduce a sandwich closure of the dura in posterior fossa surgery, which reduces significantly the number of CSF leaks (3.8%) in the patients treated in our department. Three hundred and ten patients treated in our hospital in the years 2009-2013 for posterior fossa pathologies were retrospectively evaluated. The dura closure method was as following: lyophilized dura put under the dura and sealed with fibrin glue and sutures, dura adapting stitches, TachoSil® (Takeda Pharma A/S, Roskilde, Denmark), Gelfoam® (Pfizer Inc., New York, NY, USA) and polymethylmethacrylate (osteoclastic craniotomy). The incidence of postsurgical complications associated with the dural closure like CSF leakage, infections, bleeding is evaluated. Only 3.8% of patients developed CSF leakage and only 0.5% needed a second surgery for CSF leakage closure. Two percent had a cerebellar bleeding with no need for re-operation and 3% had a wound infection treated with antibiotics. The sandwich wound closure we are applying for posterior fossa surgery in our patients correlates with a significant reduction of CSF leaks compared to the literature.
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Affiliation(s)
- Verena Heymanns
- Department of Neurosurgery, Sana Kliniken , Duisburg, Germany
| | - Abidemi W Oseni
- Department of Neurosurgery, Sana Kliniken , Duisburg, Germany
| | - Ameer Alyeldien
- Department of Neurosurgery, Sana Kliniken , Duisburg, Germany
| | | | - Richard Parvin
- Department of Neurosurgery, Sana Kliniken , Duisburg, Germany
| | - Martin Scholz
- Department of Neurosurgery, Sana Kliniken , Duisburg, Germany
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23
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Giammattei L, Messerer M, Aghakhani N, David P, Herbrecht A, Richard S, Parker F. Surgical resection of medulla oblongata hemangioblastomas: outcome and complications. Acta Neurochir (Wien) 2016; 158:1333-41. [PMID: 27185165 DOI: 10.1007/s00701-016-2834-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
OBJECT The purpose of this study was to analyze the surgical outcome and complications of a single-center series of medulla oblongata (MO) hemangioblastomas. METHODS We retrospectively reviewed the medical charts of all medulla oblongata hemangioblastomas operated on at our institution between 1996 and 2015. All patients had a pre- and postoperative MRI and a minimum follow-up of 6 months. Patients were scored according to the Karnofsky Performance Scale (KPS) and McCormick Scale at the moment of admission, discharge and the last follow-up. RESULTS Thirty-one surgical procedures were performed on 27 patients (16 females and 11 males). The mean age was 33 years, and 93 % of patients had von Hippel Lindau (VHL) disease. Three patients experienced very complicated postoperative courses, with one case ending in the death of the patient. Two patients required tracheostomy. According to McCormick's classification, 7 (23 %) of the 31 operations resulted in aggravation and 23 (74 %) in no change. Considering the seven patients with aggravation at discharge, four patients (60 %) returned to their preoperative status, one (14 %) improved but remained below his preoperative McCormick grade and two (29 %) did not improve. At last follow-up, KPS was ameliorated in 53 %, stable in 40 % and worsened in 7 % of cases. CONCLUSION Surgery of medulla oblongata hemangioblastomas is a challenging procedure characterized by an acceptable morbidity. Transient morbidity is not negligible even if the long-term outcome is in most cases favorable. A compromised neurological condition seems to be the best predictor of unfavorable outcome.
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24
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Surda P, Syed I, Modayil P, Little S, Toma A. A purely synthetic and biodegradable material for repair of cerebrospinal fluid rhinorrhoea. Clin Otolaryngol 2016; 41:179-82. [DOI: 10.1111/coa.12469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2015] [Indexed: 11/28/2022]
Affiliation(s)
- P. Surda
- Department of Otolaryngology; St Georges’ Hospital; London UK
| | - I. Syed
- Department of Otolaryngology; St Georges’ Hospital; London UK
| | - P.C. Modayil
- Department of Otolaryngology; St Georges’ Hospital; London UK
| | - S.A. Little
- Department of Otolaryngology; St Georges’ Hospital; London UK
| | - A. Toma
- Department of Otolaryngology; St Georges’ Hospital; London UK
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25
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Zhang H, Zhao T, Duffy P, Dong Y, Annaidh AN, O'Cearbhaill E, Wang W. Hydrolytically degradable hyperbranched PEG-polyester adhesive with low swelling and robust mechanical properties. Adv Healthc Mater 2015; 4:2260-8. [PMID: 26346527 DOI: 10.1002/adhm.201500406] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/27/2015] [Indexed: 11/07/2022]
Abstract
Photocrosslinkable and water soluble hyperbranched PEG-polyester polymers (HPEGDA) have been developed as robust degradable adhesives. The HPEGDA polymers have been synthesized from controlled homopolymerization of poly(ethylene glycol) diacrylate (PEGDA700 ) via in situ deactivation enhanced atom transfer radical polymerization (DE-ATRP). By introducing a high initiator-to-monomer ratio, the obtained HPEGDA polymer is composed of extremely short carbon-carbon backbones interconnected together by the long PEG chains as well as pendent photocrosslinkable acrylate moieties. Due to the extremely short C-C backbone, the long PEG chains can therefore be seen as the main chain, thus, HPEGDA polymers behave more like polyester which is a category of polymers that contain the ester functional group in their main chain. Photo-cured HPEGDA can be readily adhered to tissue forming a patch with robust mechanical and adhesive strengths. The degradation profile by hydrolysis of polyester blocks as well as a significantly low swelling ratio of HPEGDA gels in an aqueous environment allow them to have great potential for sealing and repair of internal tissue. Furthermore, HPEGDA gels appear to have minor significant cytotoxicity in vitro. These unique properties indicate that the reported HPEGDA polymers are well poised for the development of adhesive tissue engineering matrixes, wound dressings, and sealants.
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Affiliation(s)
- Hong Zhang
- The Charles Institute of Dermatology; School of Medicine and Medical Science; University College Dublin; 4 Dublin Ireland
| | - Tianyu Zhao
- The Charles Institute of Dermatology; School of Medicine and Medical Science; University College Dublin; 4 Dublin Ireland
| | - Patrick Duffy
- The Charles Institute of Dermatology; School of Medicine and Medical Science; University College Dublin; 4 Dublin Ireland
| | - Yixiao Dong
- The Charles Institute of Dermatology; School of Medicine and Medical Science; University College Dublin; 4 Dublin Ireland
| | - Aisling Ní Annaidh
- Conway Institute of Biomolecular and Biomedical Research; University College Dublin; 4 Dublin Ireland
| | - Eoin O'Cearbhaill
- Conway Institute of Biomolecular and Biomedical Research; University College Dublin; 4 Dublin Ireland
- School of Mechanical & Materials Engineering; University College Dublin; 4 Dublin Ireland
| | - Wenxin Wang
- The Charles Institute of Dermatology; School of Medicine and Medical Science; University College Dublin; 4 Dublin Ireland
- School of Materials Science and Engineering; Tianjin University; Tianjin 30072 China
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