scholarly journals Utility of nonpenetrating titanium clips for dural closure during spinal surgery to prevent postoperative cerebrospinal fluid leakage

2015 ◽  
Vol 23 (6) ◽  
pp. 812-819 ◽  
Author(s):  
Kiyoshi Ito ◽  
Tatsuro Aoyama ◽  
Tetsuyoshi Horiuchi ◽  
Kazuhiro Hongo
Keyword(s):  
Cerebrospinal Fluid ◽  
Dura Mater ◽  
Spinal Surgery ◽  
Water Pressure ◽  
Cerebrospinal Fluid Leakage ◽  
Fluid Leakage ◽  
Dural Closure ◽  
Significant Difference ◽  
Csf Leakage ◽  
Titanium Clips

OBJECT The nonpenetrating titanium clip has been successfully used in peripheral arterial bypass surgery. The purpose of this study was to evaluate the leakage pressures and patterns of nonpenetrating titanium clips using a simple model that mimicked spinal surgery. In addition, the authors describe their surgical experience with these clips and the follow-up results in 31 consecutive patients. METHODS The authors compared nonpenetrating titanium clips and expanded polytetrafluoroethylene (ePTFE) sutures in relation to the water pressure that could be tolerated by sutured ePTFE sheets, and the leakage pressure patterns were determined. The changes in leakage pressures at 5 minutes, 30 minutes, and 12 hours were examined when the clips and sutures were used in combination with the mesh-and-glue technique in an in vitro study. Thirty-one patients underwent spinal intradural procedures using nonpenetrating titanium clips to suture the dura maters using the meshand-glue technique, involving fibrin glue and polyglycolic acid-fibrin sheets. RESULTS A significant difference was apparent between the ePTFE suture group and the nonpenetrating titanium clip group, with the latter showing a leakage pressure that could be sustained and was 1508% higher than that of the former (p = 0.001). In relation to leakage patterns, the nonpenetrating titanium clips did not make any suture holes in the ePTFE sheet and fluid leakage occurred between the clips, whereas fluid leakage was associated with the pressure elevation that occurred at the suture holes made by the ePTFE sutures. Of the 31 patients who underwent spinal intradural procedures using nonpenetrating titanium clips, 1 (3.2%) experienced cerebrospinal fluid (CSF) leakage postoperatively. No other complications—for example, allergic reactions, adhesions, or infections—were encountered. CONCLUSIONS The interrupted placement of nonpenetrating titanium clips enables dural closure without creating any holes. These clips facilitate improvements in the initial leakage pressure and reduce postoperative CSF leakage following spinal surgery. The authors conclude that it is very beneficial to suture the spinal dura mater using nonpenetrating titanium clips given the anatomical characteristics of the spinal dura mater and the fact that the clips do not create suture holes.

Novel Dural Closure Technique Using Polyglactin Acid Sheet Prevents Cerebrospinal Fluid Leakage after Spinal Surgery

2005 ◽  
Vol 57 (suppl_4) ◽  
pp. ONS-290-ONS-294 ◽  
Author(s):  
Taku Sugawara ◽  
Yasunobu Itoh ◽  
Yoshitaka Hirano ◽  
Naoki Higashiyama ◽  
Yoichi Shimada ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Fibrin Glue ◽  
Spinal Surgery ◽  
Cerebrospinal Fluid Leakage ◽  
Resonance Imaging ◽  
Closure Technique ◽  
Dural Closure ◽  
Csf Leakage

Abstract OBJECTIVE: Extradural or subcutaneous cerebrospinal fluid (CSF) leakage is a common complication after spinal surgery and is associated with the risks of poor wound healing, meningitis, and pseudomeningocele. Numerous methods to prevent postoperative CSF leakage are available, but pressure-tight dural closure remains difficult, especially with synthetic surgical membranes. The efficacy of a novel dural closure technique was assessed by detecting extradural or subcutaneous CSF leakage on magnetic resonance imaging. METHODS: The novel dural closure technique using absorbable polyglactin acid sheet and fibrin glue and the conventional procedure using only fibrin glue were evaluated retrospectively by identifying extradural or subcutaneous CSF leakage on magnetic resonance imaging scans in the acute (2–7 d) and chronic (3–6 mo) postoperative stages after spinal intradural surgery in 53 patients. RESULTS: The incidence of extradural and subcutaneous CSF leakage was significantly lower (P < 0.05) in the acute (20%) and chronic (0%) stages using polyglactin acid sheet and fibrin glue in 15 patients compared with that in the acute (81%) and chronic (24%) stages using only fibrin glue in 38 patients. One patient in the fibrin glue-only group required repair surgery for cutaneous CSF leakage. CONCLUSION: The combination of polyglactin acid sheet and fibrin glue can achieve water-tight closure after spinal intradural surgery and can minimize the risk of intractable postoperative CSF leakage. This simple, economical technique is recommended for dural closure after spinal intradural surgery.

Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial

2014 ◽  
Vol 121 (3) ◽  
pp. 735-744 ◽  
Author(s):  
Gregor Hutter ◽  
Stefanie von Felten ◽  
Martin H. Sailer ◽  
Marianne Schulz ◽  
Luigi Mariani
Keyword(s):  
Diabetes Mellitus ◽  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Controlled Trial ◽  
Cerebrospinal Fluid Leakage ◽  
Control Group ◽  
Fluid Leakage ◽  
Dural Closure ◽  
Csf Leakage ◽  
Dural Patch

Object Cerebrospinal fluid leakage is an immanent risk of cranial surgery with dural opening. Recognizing the risk factors for this complication and improving the technique of dural closure may reduce the associated morbidity and its surgical burden. The aim of this paper was to investigate whether the addition of TachoSil on top of the dural suture reduces postoperative CSF leakage compared with dural suturing alone and to assess the frequency and risk factors for dural leakage and potentially related complications after elective craniotomy. Methods The authors conducted a prospective, randomized, double-blinded single-center trial in patients undergoing elective craniotomy with dural opening. They compared their standard dural closure by running suture alone (with the use of a dural patch if needed) to the same closure with the addition of TachoSil on top of the suture. The primary end point was the incidence of CSF leakage, defined as CSF collection or any open CSF fistula within 30 days. Secondary end points were the incidence of infection, surgical revision, and length of stay in the intensive care unit (ICU) or intermediate care (IMC) unit. The site of craniotomy, a history of diabetes mellitus, a diagnosis of meningioma, the intraoperative need of a suturable dural substitute, and blood parameters were assessed as potential risk factors for CSF leakage. Results The authors enrolled 241 patients, of whom 229 were included in the analysis. Cerebrospinal fluid leakage, mostly self-limiting subgaleal collections, occurred in 13.5% of patients. Invasive treatment was performed in 8 patients (3.5%) (subgaleal puncture in 6, lumbar drainage in 1, and surgical revision in 1 patient). Diabetes mellitus, a higher preoperative level of C-reactive protein (CRP), and the intraoperative need for a dural patch were positively associated with the occurrence of the primary end point (p = 0.014, 0.01, and 0.049, respectively). Cerebrospinal fluid leakage (9.7% vs 17.2%, OR 0.53 [95% CI 0.23–1.15], p = 0.108) and infection (OR 0.18 [95% CI 0.01–1.18], p = 0.077) occurred less frequently in the study group than in the control group. TachoSil significantly reduced the probability of staying in the IMC unit for 1 day or longer (OR 0.53 [95% CI 0.27–0.99], p = 0.048). Postoperative epidural hematoma and empyema occurred in the control group but not in the study group. Conclusions Dural leakage after elective craniotomy/durotomy occurs more frequently in association with diabetes mellitus, elevated preoperative CRP levels, and the intraoperative need of a dural patch. This randomized controlled trial showed no statistically significant reduction of postoperative CSF leakage and surgical site infections upon addition of TachoSil on the dural suture, but there was a significant reduction in the length of stay in the IMC unit. Dural augmentation with TachoSil was safe and not related to adverse events. Clinical trial registration no. NCT00999999 (http://www.ClinicalTrials.gov).

scholarly journals Novel dural incision and closure procedure for preventing postoperative cerebrospinal fluid leakage during the surgical removal of dumbbell-shaped spinal tumors: technical note

2016 ◽  
Vol 25 (5) ◽  
pp. 620-625 ◽  
Author(s):  
Kiyoshi Ito ◽  
Tatsuro Aoyama ◽  
Takuya Nakamura ◽  
Yoshiki Hanaoka ◽  
Tetsuyoshi Horiuchi ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Dura Mater ◽  
Clinical Results ◽  
Technical Note ◽  
Spinal Tumors ◽  
Cerebrospinal Fluid Leakage ◽  
Surgical Removal ◽  
Dural Closure ◽  
Csf Leakage ◽  
Dural Defects

The authors report on a new method for removing dumbbell-shaped spinal tumors that avoids the risk of postoperative cerebrospinal fluid (CSF) leakage. Adequate visualization of the intra- and extradural components of the tumor is achieved with the use of separate dural incisions. First, the dura mater is opened along the dural theca to provide adequate visualization of the intradural portion of the mass; then, a second incision is made along the nerve root to remove the extradural component. Meticulous suturing is essential in intradural lesion cases; however, the dura mater is usually thin and fragile in such cases. During suturing with a needle and thread, the dura mater can become lacerated proximal to the needle holes and result in CSF leakage. In the authors' technique, instead of using a needle and thread, nonpenetrating vascular clips were used to close the dural incisions. When operating on dumbbell-shaped spinal tumors, the authors found that the “separate-dural-incision method” was preferable to the conventional T-shaped dural incision method because no dural defects occurred after the intradural procedure and meticulous dural closure with vascular clips was achieved. The authors conclude that the novel separate-dural-incision method for removing dumbbell-shaped tumors and the use of nonpenetrating vascular clips permits reliable dural closure, prevents postoperative CSF leakage, and promises good postoperative clinical results.

Cerebrospinal fluid leakage into the subdural space: possible influence on the pathogenesis and recurrence frequency of chronic subdural hematoma and subdural hygroma

2008 ◽  
Vol 108 (2) ◽  
pp. 275-280 ◽  
Author(s):  
Rudolf A. Kristof ◽  
Jochen M. Grimm ◽  
Birgit Stoffel-Wagner
Keyword(s):  
Cerebrospinal Fluid ◽  
Recurrence Rate ◽  
Subdural Hematoma ◽  
Chronic Subdural Hematoma ◽  
Postoperative Recurrence ◽  
Cerebrospinal Fluid Leakage ◽  
Subdural Space ◽  
Subdural Hygroma ◽  
Fluid Leakage ◽  
Csf Leakage

Object The purpose of this study was to clarify whether cerebrospinal fluid (CSF) leakage into the subdural space is involved in the genesis of chronic subdural hematoma (CSDH) and subdural hygroma (SH) and to clarify whether this leakage of CSF into the subdural space influences the postoperative recurrence rate of CSDH and SH. Methods In this prospective observational study, 75 cases involving patients treated surgically for CSDH (67 patients) or SH (8 patients) were evaluated with respect to clinical and radiological findings at presentation, the content of β -trace protein (β TP) in the subdural fluid (βTPSF) and serum (βTPSER), and the CSDH/SH recurrence rate. The βTPSF was considered to indicate an admixture of CSF to the subdural fluid if βTPSF/βTPSER > 2. Results The median β TPSF level for the whole patient group was 4.29 mg/L (range 0.33–51 mg/L). Cerebrospinal fluid leakage, as indicated by βTPSF/βTPSER > 2, was found to be present in 93% of the patients with CSDH and in 100% of the patients with SH (p = 0.724). In patients who later had to undergo repeated surgery for recurrence of CSDH/SH, the βTPSF concentrations (median 6.69 mg/L, range 0.59–51 mg/L) were significantly higher (p = 0.04) than in patients not requiring reoperation (median 4.12 mg/L, range 0.33–26.8 mg/L). Conclusions As indicated by the presence of βTP in the subdural fluid, CSF leakage into the subdural space is present in the vast majority of patients with CSDH and SH. This leakage could be involved in the pathogenesis of CSDH and SH. Patients who experience recurrences of CSDH and SH have significantly higher concentrations of βTPSF at initial presentation than patients not requiring reoperation for recurrence. These findings are presented in the literature for the first time and have to be confirmed and expanded upon by further studies.

scholarly journals Single-Arm, Open-Label, Multicenter Study to Evaluate the Safety and Performance of Dura Sealant Patch in Reducing Cerebrospinal Fluid Leakage Following Elective Cranial Surgery: The ENCASE Trial Study Protocol

Neurosurgery ◽  
2019 ◽  
Author(s):  
Tristan P C van Doormaal ◽  
Menno R Germans ◽  
Mariska Sie ◽  
Bart Brouwers ◽  
Jorn Fierstra ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Primary Endpoint ◽  
Multicenter Study ◽  
Controlled Trial ◽  
Cerebrospinal Fluid Leakage ◽  
Open Label ◽  
Cranial Surgery ◽  
Dural Closure ◽  
Csf Leakage ◽  
And Performance

Abstract BACKGROUND Cerebrospinal fluid (CSF) leakage is one of the most common neurosurgical complications, occurring in 4% to 32% of surgical cases, with a higher incidence in complicated skull base surgery, intradural spine surgery, and the surgery of the posterior fossa. Our group developed a Dural Sealant Patch (DSP) for watertight dural closure after cranial surgery. OBJECTIVE To clinically study for the first time the safety and performance of the DSP as a means of reducing CSF leakage in patients undergoing elective cranial intradural surgery with a dural closure procedure. METHODS We will conduct an open-label, single-arm, multicenter study with a 360 d (12 mo) follow-up. A total of 40 patients will be enrolled at 3 sites. The primary endpoint is a combination of occurrences of one of the following events: postoperative percutaneous CSF leakage, intraoperative leakage at 20 cm H2O, or postoperative wound infection. The secondary endpoints are pseudomeningocele and thickness of dura + DSP. EXPECTED OUTCOMES Not more than 3 patients will meet the primary endpoint suggesting safety and efficacy. DISCUSSION As a next step, a randomized controlled trial against the best current practice will follow to evaluate if DSP reduces CSF leakage while its safety is noninferior.

Use of ligamentum nuchae graft for dural closure in posterior fossa surgery

1998 ◽  
Vol 89 (1) ◽  
pp. 155-156 ◽  
Author(s):  
Edward J. Kosnik
Keyword(s):  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leakage ◽  
Posterior Fossa Surgery ◽  
Content Type ◽  
Fluid Leakage ◽  
Dural Closure ◽  
Fine Print

✓ The technique of harvesting the ligamentum nuchae and its use in posterior fossa surgery are discussed. By using this technique the author has avoided postoperative cerebrospinal fluid leakage in more than 200 procedures.

Mesh-and-Glue Method to Prevent Cerebrospinal Fluid Leakage After Implantation of a Synthetic Dura Mater Substitute: Pressure Resistance and Histologic Studies

2003 ◽  
Vol 13 (4) ◽  
pp. 275-281
Author(s):  
Kazuya Nagata ◽  
Yoji Shiobara ◽  
Hiroyuki Kobayashi ◽  
Toshiharu Shiba ◽  
Akira Yanagisawa ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Dura Mater ◽  
Cerebrospinal Fluid Leakage ◽  
Fluid Leakage ◽  
Glue Method ◽  
Pressure Resistance

Cerebrospinal fluid leakage in Gorham-Stout disease due to dura mater involvement after progression of an osteolytic lesion in the thoracic spine

2014 ◽  
Vol 21 (6) ◽  
pp. 956-960 ◽  
Author(s):  
Eric Jose Suero Molina ◽  
Thomas Niederstadt ◽  
Vincent Ruland ◽  
Gian Kayser ◽  
Walter Stummer ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Disease Control ◽  
Dura Mater ◽  
Thoracic Spine ◽  
Osteolytic Lesion ◽  
Bone Matrix ◽  
Lymphatic Vessels ◽  
Cerebrospinal Fluid Leakage ◽  
Csf Leakage ◽  
Neurosurgical Intervention

Patients with Gorham-Stout disease (GSD), a rare disease of poorly understood etiopathophysiology, suffer from progressive osteolysis. Destruction of bone matrix is caused by lymphatic vessels, which can lead to CSF leakage if parts of bony structures adjacent to CSF spaces are involved. So far, fewer than 200 patients have been reported in the literature; only 4 of these patients presented with CSF leakage. The authors report the case of a 30-year-old man with GSD and CSF leakage due to dura mater involvement after progression of an osteolytic lesion in the thoracic spine. Neurosurgical intervention, including dura repair, was needed. Experimental medical therapy with rapamycin was started, leading to disease control for more than 12 months. Progression of GSD can lead to destruction of the meninges, causing CSF leakage. The authors review 4 other cases reported in the literature and discuss therapeutic options.

scholarly journals Cerebrospinal fluid leakage repair of various grades developing during endoscopic transnasal transsphenoidal surgery

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0248229
Author(s):  
Il Hwan Lee ◽  
Do Hyun Kim ◽  
Jae-Sung Park ◽  
Sin-Soo Jeun ◽  
Yong-Kil Hong ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Retrospective Chart Review ◽  
Pedicled Flap ◽  
Cerebrospinal Fluid Leakage ◽  
Dural Defect ◽  
Endoscopic Endonasal ◽  
Tertiary Referral Center ◽  
Fluid Leakage ◽  
Csf Leakage ◽  
Grade 3

Objectives We describe the strategy used to repair intraoperative leaks of various grades and define factors for preventing postoperative cerebrospinal fluid leakage (CSF) after surgery via the endoscopic endonasal transsphenoidal approach (EETA). Study design Retrospective chart review at a tertiary referral center. Methods Patients who underwent surgery via EETA from January 2009 to May 2020 were retrospectively reviewed. Intraoperative CSF leakage was graded 0–3 in terms of the dural defect size; various repairs were used depending on the grade. Results A total of 777 patients underwent 869 operations via EETA; 609 (70.1%) experienced no intraoperative CSF leakage (grade 0) but 260 (29.9%) did. Leakage was of grade 1 in 135 cases (15.5%), grade 2 in 83 (9.6%), and grade 3 in 42 (4.8%). In 260 patients with intraoperative CSF leakage, a buttress was wedged into the sellar defect site in 178 cases (68.5%) and a pedicled flap was placed in 105 cases (40.4%). Autologous fat (108 cases, 41.5%) and a synthetic dural substitute (91 cases, 35%) were used to fill the dead space of the sellar resection cavity. Postoperative CSF leakage developed in 21 patients: 6 of grade 1, 7 of grade 2, and 8 of grade 3. Buttress placement significantly decreased postoperative leakage in grade 1 patients (p = 0.041). In patients of perioperative leakage grades 2 and 3, postoperative CSF leakage was significantly reduced only when both fat and a buttress were applied (p = 0.042 and p = 0.043, respectively). Conclusion A buttress prevented postoperative CSF leakage in grade 1 patients; both fat and buttress were required by patients with intraoperative leakage of grades 2 and 3.

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