Delayed chemical meningitis after Chiari decompression with duraplasty: illustrative cases

BACKGROUND Dural reconstruction to achieve expansion duraplasty is important in suboccipital decompression for Chiari malformation type 1 (CM1). Although various dural substitutes are available, including synthetic collagen matrix grafts and dural xenografts, they have the potential to induce an inflammatory response. In this case series, the authors present their experience and discuss the incidence and possible mechanism of aseptic meningitis after the use of bovine collagen matrix graft as a dural substitute in patients with CM1 after suboccipital decompression. OBSERVATIONS Three consecutive adult female patients who underwent suboccipital decompression at a single institution by a single neurosurgeon were retrospectively reviewed. They all presented with signs of aseptic meningitis in a delayed fashion, responded well to steroid administration, but had recurrence of their symptoms. Bovine collagen dural substitutes are resorbed in a process that induces an inflammatory response manifesting with signs of aseptic meningitis and is only alleviated with removal of the dural substitute. LESSONS DuraMatrix Suturable, a dural xenograft derived from bovine dermis, though a viable choice for dural repair, is a potential cause of chemical meningitis after duraplasty in Chiari decompression surgery. In patients presenting with delayed and persistent aseptic meningitis after intervention, removal of this dural substitute led to improved symptomatology.

Incidental Durotomy Following Surgery for Degenerative Lumbar Disease and the Impact of Minimally Invasive Surgical Technique on the Rate and Need for Surgical Revision: A Case Series

BACKGROUND Incidental durotomy (ID) is a common complication during lumbar spine surgery. A paucity of literature has studied the impact of minimally invasive surgery (MIS) on durotomy rates and strategies for repair as compared to open surgery. OBJECTIVE To examine the impact that MIS techniques have on the durotomy rate, repair techniques, and need for surgical revision following surgery for degenerative lumbar disease as compared to open technique. METHODS A single-center retrospective review of consecutive cases between 2013 and 2016 was performed. All patients underwent lumbar decompression with or without instrumented fusion for degenerative pathology using either open posterior or MIS techniques. ID rate, closure technique, and need for surgical revision related to the durotomy were recorded. RESULTS A total of 1,196 patients were included with an overall ID rate of 6.8%. There was no difference between open or minimally invasive surgical techniques (P = .14). There was a higher durotomy rate with open technique in patients that underwent decompression with fusion (P = .03) as well as in revision cases (P = .02). Primary repair was feasible more frequently in the open group (P = .001), whereas use of dural substitute (P < .001) was more common in the MIS group. Fibrin sealant was used routinely in both groups (P = .34). There were no failed repairs, regardless of technique used. CONCLUSION MIS techniques may reduce durotomies in cases involving instrumentation or revisions. Use of dural substitute onlay and fibrin sealant was effective at preventing reoperation. Both MIS and open techniques result in a low rate of future surgical revision when a durotomy occurs.

A double-layer dura mater based on poly(caprolactone-co-lactide) film and polyurethane sponge: preparation, characterization, and biodegradation study

A double-layer composite of the PCLA film and PU sponge with good biodegradability and biocompatibility was designed as a potential dural substitute.

A Single Layer Synthetic Dural Substitute Inlay is an Effective Sellar Reconstruction Technique in Endoscopic Transsphenoidal Pituitary Surgery

Objectives A variety of endonasal sellar repair techniques have been described; many are complex, multilayered, and carry potential morbidity. We propose an effective, technically simple single-layer repair for select sellar defects, including those with an intraoperative cerebrospinal fluid (CSF) leak. Our technique utilizes only a synthetic dural substitute inlay and dural sealant glue without packing or lumbar drainage. Design This is a retrospective review-based study. Setting This study was conducted at tertiary care center. Participants Patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with the aforementioned inlay technique. Patients were selected for this technique if they had an identified intraoperative CSF leak, a patulous diaphragm (expanded and thinned diaphragma sella), or a comorbidity excluding them from a simpler onlay only reconstruction. Outcome Measures Postoperative CSF leak and sinonasal morbidity included in the study Results A total of 409 subjects were identified; 368 were initial resections. Gross total resection of the pituitary adenoma was achieved in 356 (87.0%) cases. Average tumor size was 2.6 ± 1.1 cm. Average tumor volume was 10.8 ± 12.1 cm3. There were 135 intraoperative CSF leaks and 196 patulous diaphragms. There were five postoperative CSF leaks (1.2%), all of which occurred in the first half of our series. Pre- and postoperative sino-nasal outcomes test-22 scores were 19.2 ± 18.2 and 18.8 ± 21.3 (p = 0.492), respectively. Conclusion A synthetic dural substitute inlay and dural sealant glue is an excellent single-layer repair for sellar defects, even those with an intraoperative CSF leak. This technique is highly effective in preventing postoperative CSF leaks and does not utilize packing or lumbar drainage. It also avoids the potential cost and morbidity associated with more complex and multilayered closures.

A Randomised Interventional Study to Compare Autologous and Nonautologous Dural Substitutes Among Traumatic Brain Injury (TBI) Patients

Objectives To determine and compare the effectiveness and safety of galea-pericranium autologous dural graft with nonautologous polypropylene (G-patch) dural substitute among traumatic brain injury (TBI) patients. Methods A prospective interventional randomized comparative study was conducted at the Department of Neurosurgery from November 2013 to March 2015 after obtaining approval from the Institutional Ethical Committee. The study population included 50 cases of TBI which were divided into two groups of 25 each by the randomization technique and were treated either with autologous duraplasty (galea-pericranium) or nonautologous polypropylene (G-patch) dural substitute. The outcomes measured were time to duraplasty, blood loss, hospital stay, and the incidence of complications with the two techniques. The data were entered in a MS Excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. A p value of < 0.05 was considered statistically significant. Results The average time to harvest galea-pericranium was 5 minutes. Compared with the patients undergoing G-patch, the patients in group pericranium had comparable duraplasty time (minutes) (34.32 vs. 27.80, p = 0.44), significantly lower drain output (54.8 vs. 74.5, p = 0.017), comparable blood loss (322 vs. 308, p = 0.545), comparable blood transfusion (24% vs. 16%, p = 0.48), significantly lesser duration of hospital stay (8.6 vs. 10.44, p = 0.028), comparable wound infection (8% vs. 16%, p = 0.384), and comparable cerebrospinal fluid (CSF) leak (0% vs. 8%, p = 0.149). Conclusion The study showed that galea-pericranium and polypropylene dural patch are equally effective and safe dural substitutes in providing a dural seal to minimize the CSF leaks and infections among posttraumatic brain injury patients.

Performance evaluation of bilayer oxidized regenerated cellulose/poly ε-caprolactone knitted fabric-reinforced composites for dural substitution

Ideally, alloplastic dural substitute should have functional properties resembling human dura mater and retain a watertight closure to prevent cerebrospinal leakage. Therefore, functional properties for successful dural closure application of newly developed bilayer oxidized regenerated cellulose knitted fabric/poly ε-caprolactone knitted fabric-reinforced composites were studied and compared with human cadaveric dura mater and three commercial dural substitutes including two collagen matrices and one synthetic poly-L-lactide patch. It was found that oxidized regenerated cellulose knitted fabric/poly ε-caprolactone knitted fabric-reinforced composites uniquely contained a bilayer structure consisting of micropores distributed within the relatively dense microstructure. Density, tensile properties and stitch tear strength of oxidized regenerated cellulose knitted fabric/poly ε-caprolactone knitted fabric-reinforced composites were found to be closed to human cadaveric dura mater than those of dense-type and porous-type dural substitutes. Water tightness performance in both sutured and non-sutured forms of oxidized regenerated cellulose knitted fabric/poly ε-caprolactone knitted fabric-reinforced composites was slightly inferior to human cadaveric dura mater, but still better than those of commercial dural substitutes. This study revealed that oxidized regenerated cellulose knitted fabric/poly ε-caprolactone knitted fabric-reinforced composite showed better functional properties than typical dural substitutes and was found to be a good candidate for being employed as a dural substitute. The role and relationship of both microstructure and the type of materials on the functional properties and water tightness of the dural substitutes were also elucidated.