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

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.

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

Journal of Neurosurgery Spine ◽

10.3171/2015.3.spine141215 ◽

2015 ◽

Vol 23 (6) ◽

pp. 812-819 ◽

Cited By ~ 16

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.

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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 ◽

10.1093/neuros/nyz396 ◽

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.

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

Journal of Neurosurgery Spine ◽

10.3171/2014.8.spine131064 ◽

2014 ◽

Vol 21 (6) ◽

pp. 956-960 ◽

Cited By ~ 8

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.

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Management of cerebrospinal fluid leak after surgical removal of pituitary adenomas

Medicina ◽

10.3390/medicina44040039 ◽

2008 ◽

Vol 44 (4) ◽

pp. 302 ◽

Cited By ~ 33

Author(s):

Arimantas Tamašauskas ◽

Kęstutis Šinkūnas ◽

Wolfgang Draf ◽

Vytenis Deltuva ◽

Algimantas Matukevičius ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Sella Turcica ◽

Cerebrospinal Fluid Leak ◽

Surgical Removal ◽

Dural Defect ◽

Sphenoidal Sinus ◽

Autologous Fat ◽

Csf Leakage ◽

Dural Defects ◽

Fluid Leak

Objectives. The aim of the study was to evaluate the frequency and the causes of the intra- and postoperative cerebrospinal fluid (CSF) leaks and to discuss the sella closure methods. Methods. During the period from 1995 to 2005, 313 patients underwent 356 transsphenoidal operations for pituitary adenoma. Microadenoma was found in 80 (22.5%) cases, and in 276 (77.5%) cases, macroadenoma was removed. Two different methods to close the sella were used. The first one consisted packing the sella turcica and sphenoidal sinus with autologous fat and restoring the defect of sella turcica with autologous bone. In more resent practice, the regenerated oxidized cellulose (Surgicel®) and collagen sponge with human fibrin (TachoSil®) were used to cover the sella membrane defect, followed by packing the sella with autologous fat and covering the dural defect with Surgicel® and TachoSil®. Results. Adenoma was totally removed in 198 (55.6%) cases out of 356. Microadenoma was totally removed in 91.3% and macroadenoma in 45.3% of cases, respectively. Postoperative complications were noted in 40 (11.2%) patients. Two (0.6%) patients died after surgery. Intraoperative CSF leakage was observed in 58 (16.3%) cases. Postoperative CSF leakages were observed in 3 cases, when the method of packing the sella with just autologous fat was used, whereas in 29 cases when the sella fat packing was used together with Surgicel® and TachoSil® to cover the sella membrane and dural defects, no postoperative CSF leakages were observed. Conclusions. The technique of covering the sella membrane and dural defects with Surgicel® and TachoSil® in the presence of intraoperative CSF leakage appeared to be the most reliable one, as no postoperative CSF leakage applying this technique has been observed.

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Spinal endoscopy combined with selective CT myelography for dural closure of the spinal dural defect with superficial siderosis: technical note

Journal of Neurosurgery Spine ◽

10.3171/2017.5.spine17233 ◽

2018 ◽

Vol 28 (1) ◽

pp. 96-102 ◽

Cited By ~ 4

Author(s):

Hidetaka Arishima ◽

Yoshifumi Higashino ◽

Shinsuke Yamada ◽

Ayumi Akazawa ◽

Hiroshi Arai ◽

...

Keyword(s):

Endoscopic Examination ◽

Technical Note ◽

Drainage Tube ◽

Superficial Siderosis ◽

Dural Defect ◽

Ct Myelography ◽

Dural Closure ◽

Spinal Subarachnoid Space ◽

Csf Leakage ◽

Dural Defects

The authors describe a new procedure to detect the tiny dural hole in patients with superficial siderosis (SS) and CSF leakage using a coronary angioscope system for spinal endoscopy and selective CT myelography using a spinal drainage tube. Under fluoroscopy, surgeons inserted the coronary angioscope into the spinal subarachnoid space, similar to the procedure of spinal drainage, and slowly advanced it to the cervical spine. The angioscope clearly showed the small dural hole and injured arachnoid membrane. One week later, the spinal drainage tube was inserted, and the tip of the drainage tube was located just below the level of the dural defect found by the spinal endoscopic examination. This selective CT myelography clarifies the location of the dural defect. During surgery, the small dural hole could be easily located, and it was securely sutured. It is sometimes difficult to detect the actual location of the small dural hole even with thin-slice MRI or dynamic CT myelography in patients with SS. The use of a coronary angioscope for the spinal endoscopy combined with selective CT myelography may provide an effective examination to assess dural closure of the spinal dural defect with SS in cases without obvious dural defects on conventional imaging.

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

Operative Neurosurgery ◽

10.1227/01.neu.0000176410.65750.c0 ◽

2005 ◽

Vol 57 (suppl_4) ◽

pp. ONS-290-ONS-294 ◽

Cited By ~ 17

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.

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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

Journal of Neurosurgery ◽

10.3171/2014.6.jns131917 ◽

2014 ◽

Vol 121 (3) ◽

pp. 735-744 ◽

Cited By ~ 27

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).

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Autologous fibrin glue in the repair of dural defects in craniofacial resections

The Journal of Laryngology & Otology ◽

10.1017/s0022215100119486 ◽

1992 ◽

Vol 106 (4) ◽

pp. 356-357 ◽

Cited By ~ 19

Author(s):

Abbad G. Toma ◽

Edward W. Fisher ◽

Anthony D. Cheesman

Keyword(s):

Cerebrospinal Fluid ◽

Fibrin Glue ◽

Cerebrospinal Fluid Leakage ◽

Craniofacial Resection ◽

Simple Method ◽

Dural Repair ◽

Fluid Leakage ◽

Csf Leakage ◽

Autologous Fibrin Glue ◽

Dural Defects

AbstractCerebrospinal fluid leakage is a serious and well recognized complication of craniofacial resection for ethmoidal tumours in which the integrity of the dura has been breached. Autologous fibrin glue is a safe, inexpensive and simple method of improving the seal of dural repair and hence minizing CSF leakage. The principles and method of autologous fibrin glue preparation are described. The technique has proven satisfactory in 20 consecutive craniofacial resections with dural defects and is recommended as an adjunct to current techniques of dural repair.

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Cerebrospinal fluid leakage after cranial surgery in the pediatric population—a systematic review and meta-analysis

Child s Nervous System ◽

10.1007/s00381-021-05036-8 ◽

2021 ◽

Author(s):

Emma M. H. Slot ◽

Kirsten M. van Baarsen ◽

Eelco W. Hoving ◽

Nicolaas P. A. Zuithoff ◽

Tristan P. C van Doormaal

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Cerebrospinal Fluid ◽

Pediatric Population ◽

Meta Analysis ◽

Leakage Rate ◽

Csf Leak ◽

Cerebrospinal Fluid Leakage ◽

Cranial Surgery ◽

Csf Leakage

Abstract Background Cerebrospinal fluid (CSF) leakage is a common complication after neurosurgical intervention. It is associated with substantial morbidity and increased healthcare costs. The current systematic review and meta-analysis aim to quantify the incidence of cerebrospinal fluid leakage in the pediatric population and identify its risk factors. Methods The authors followed the PRISMA guidelines. The Embase, PubMed, and Cochrane database were searched for studies reporting CSF leakage after intradural cranial surgery in patients up to 18 years old. Meta-analysis of incidences was performed using a generalized linear mixed model. Results Twenty-six articles were included in this systematic review. Data were retrieved of 2929 patients who underwent a total of 3034 intradural cranial surgeries. Surprisingly, only four of the included articles reported their definition of CSF leakage. The overall CSF leakage rate was 4.4% (95% CI 2.6 to 7.3%). The odds of CSF leakage were significantly greater for craniectomy as opposed to craniotomy (OR 4.7, 95% CI 1.7 to 13.4) and infratentorial as opposed to supratentorial surgery (OR 5.9, 95% CI 1.7 to 20.6). The odds of CSF leakage were significantly lower for duraplasty use versus no duraplasty (OR 0.41 95% CI 0.2 to 0.9). Conclusion The overall CSF leakage rate after intradural cranial surgery in the pediatric population is 4.4%. Risk factors are craniectomy and infratentorial surgery. Duraplasty use is negatively associated with CSF leak. We suggest defining a CSF leak as “leakage of CSF through the skin,” as an unambiguous definition is fundamental for future research.

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CT-Guided Autologous Blood Patch for High-Level Cervical Cerebrospinal Fluid Leakage: Imaging Characteristics and Treatment Safety and Efficiency

European Neurology ◽

10.1159/000515590 ◽

2021 ◽

pp. 1-7

Author(s):

Xiaofeng He ◽

Yueyong Xiao ◽

Xiao Zhang ◽

Xiaobo Zhang ◽

Xin Zhang ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Epidural Space ◽

Autologous Blood ◽

Cerebrospinal Fluid Leakage ◽

Imaging Features ◽

Ct Guided ◽

Iodinated Contrast ◽

Blood Patch ◽

Csf Leakage ◽

High Level

Introduction: Epidural blood patches (EBPs) are rarely performed at the high-level cervical levels. The aim of the study was to investigate the imaging features, safety, and effectiveness of CT-guided percutaneous EBPs for high-level cervical cerebrospinal fluid (CSF) leakage. Methods: Twenty-five patients with spontaneous high-level (C1–C3) CSF leakage on MRI and CT imaging, including 2 patients with intracranial epidural hematoma caused by CSF, were treated with EBP. Two needles were inserted into the C1–3 bilateral epidural space. The needle location was confirmed by injection of both 3–5mL sterile air and a diluted iodinated contrast agent to delineate its spatial diffusion. The patient’s blood 11.1 ± 3.1 mL was slowly injected to make a patch; the distribution in epidural space was monitored with intermittent CT scanning. Results: The typical manifestation of CSF leakage was the high signal outside the C1–3 cervical dura on MR T2W fat inhibition images and low density in cervical muscle space on CT images. Twenty patients suffered from headaches and were able to sit and walk 24 h after the operation. Four patients, with partial relief of headache and a small but persistent CSF leakage, were re-treated with EBS. One patient underwent a third operation because of a persistent CSF leakage on MRI. Conclusions: Imaging of water at the surrounding epidural space of high cervical level is a typical feature of dural rupture on both MRI and CT. CT-guided EBP is safe and efficient for the high-level cervical CSF leakage, especially for cases in which conservative treatments failed.

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