Fetoscopic Multilayer, Dural Patch Closure Technique for Intrauterine Myelomeningocele Repair: 2-Dimensional Operative Video

Myelomeningocele (MMC) is the most common open neural tube defect associated with long-term survival. In 2011, The Management of Myelomeningocele Study (MOMS) trial demonstrated that fetal repair for MMC reduced the rate of shunted hydrocephalus and improved developmental, motor, and ambulation outcomes at 30 mo compared to postnatal intervention.1 Recent studies have demonstrated the safety and feasibility of fetoscopic MMC repair as well as reduction in preterm birth, lower risk of uterine dehiscence, and the option of vaginal delivery with this approach compared to open fetal repair.2-4 The patient is a 25-yr-old female, G4 P2, who presented at 20 wk's gestation with ultrasound findings concerning for MMC and Chiari II malformation. These findings were further corroborated with fetal magnetic resonance imaging. After extensive prenatal counseling in a multidisciplinary fashion and discussion regarding risks and benefits of prenatal closure of the MMC, the patient chose to undergo prenatal repair and surgical consent was obtained. At 25 wk's gestation, the patient underwent a fetoscopic multilayer closure with dural patch repair using a standardized, 3-port, carbon dioxide insufflation technique for the intrauterine treatment of MMC without any postoperative complications. The duration of the entire procedure was 275 min. At 36 wk's and 1 d's gestational age, the patient had a spontaneous vaginal delivery, resulting in a healthy male newborn. The surgical site was well healed without complications, and follow-up radiographic imaging was reassuring. This edited, 2-dimensional operative video highlights the key steps of the fetoscopic closure with follow-up postnatal clinical and radiographic outcomes.

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.

Human Amniotic Membrane for the Prevention of Intradural Spinal Cord Adhesions: Retrospective Review of its Novel Use in a Case Series of 14 Patients

BACKGROUND Tethering after spinal surgery is caused by adhesions that arise from intradural tissue manipulation. Microsurgical detethering is the only treatment for symptomatic patients, but retethering occurs commonly and no treatment is widely available to prevent this complication. OBJECTIVE To apply human amniotic membrane (HAM) grafts, which are immune-privileged and known to possess antifibrogenic properties, in patients requiring microsurgical detethering. For this first-in-human use, we evaluated the safety and potential efficacy of these grafts for preventing retethering. METHODS We retrospectively reviewed the medical records of all patients who required detethering surgery and received an HAM graft between 2013 and 2016 at our institution after various previous intradural spinal surgeries. In all 14 cases, intradural lysis of adhesions was achieved, an HAM graft was sewn in place intradurally, and a dural patch was closed in a watertight fashion over the graft. RESULTS Fourteen patients had received HAM grafts to prevent retethering. All patients had at least 6 mo of follow-up (mean follow-up, 14 mo). Retethering was noted in only 1 patient. Surgical re-exploration showed that the retethering occurred caudal to the edge of the HAM graft, with no tethering underneath the original graft. No complications were attributed specifically to the HAM graft placement. CONCLUSION This first-in-human series provides evidence that HAM grafts are a safe and potentially efficacious method for preventing retethering after microsurgical intradural lysis of adhesions. These results lay the groundwork for further prospective controlled trials in patients with this difficult-to-treat pathology.

Spinal Cord Suspension Using Dentate Ligament Hitch Stitches: A Novel Technique for the Repair of Ventral Spinal Cord Herniation

BACKGROUND Idiopathic spinal cord herniation is usually repaired by releasing the spinal cord and inserting a dural patch to close the herniated segment of dura. However, reherniation is a potential limitation of this standard technique. OBJECTIVE To describe early results of a novel technique that utilizes the dentate ligament to hitch the spinal cord and prevent reherniation. METHODS Two patients underwent dural hernia repair and the dentate hitch technique was performed. RESULTS Restored lower limb power and mobility, and satisfactory reduction of spinal cord herniation on magnetic resonance imaging in 2 patients at 6- and 24-mo follow-ups, respectively. CONCLUSION The dentate hitch technique can achieve repair of spinal cord herniation, with satisfactory postoperative results and minimizes the risk of reherniation.

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

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).

Idiopathic Ventral Spinal Cord Herniation: An Increasingly Recognized Cause of Thoracic Myelopathy

Idiopathic spinal cord herniation (ISCH), where a segment of the spinal cord has herniated through a ventral defect in the dura, is a rarely encountered cause of thoracic myelopathy. The purpose of our study was to increase the clinical awareness of this condition by presenting our experience with seven consecutive cases treated in our department since 2005. All the patients developed pronounced spastic paraparesis or Brown-Séquard syndrome for several years (mean, 4.7 years) prior to diagnosis. MRI was consistent with a transdural spinal cord herniation in the mid-thoracic region in all the cases. The patients underwent surgical reduction of the herniated spinal cord and closure of the dural defect using an artificial dural patch. At follow-up, three patients experienced considerable clinical improvement, one had slight improvement, one had transient improvement, and two were unchanged. Two of the four patients with sphincter dysfunction regained sphincter control. MRI showed realignment of the spinal cord in all the patients. ISCH is probably a more common cause of thoracic myelopathy than previously recognized. The patients usually develop progressive myelopathy for several years before the correct diagnosis is made. Early diagnosis is important in order to treat the patients before the myelopathy has become advanced.

Different surgical treatment techniques used by neurosurgeons and orthopedists for syringomyelia caused by Chiari I malformation in Japan

Object Syringomyelia is a rare disease commonly caused by Chiari I malformation. Surgery by neurosurgeons and orthopedists is a critical treatment for symptomatic patients, and surgical techniques are associated with improved symptoms for these patients. The aim of this study was to determine the different surgical techniques used by neurosurgeons and orthopedists in Japan to treat syringomyelia caused by Chiari I malformation. Methods Patients who had undergone a surgical treatment were identified from a 2-stage postal survey conducted in late 2009. The authors compared the type of surgery performed and its association with cavity size reduction, on the basis of whether patients were receiving care in a neurosurgery or orthopedics department. Results A total of 232 patients with syringomyelia caused by Chiari I malformation were included in this study. Two-thirds of patients were treated in a neurosurgery department and the other third in an orthopedics department. Neurosurgeons preferred foramen magnum decompression (FMD) with dural patch grafting, and orthopedists preferred FMD with dural dissection. Foramen magnum decompression with dural patch grafting was associated with better outcomes than was dural dissection with regard to the following: motor impairment (66% vs 39%, p < 0.05), sensory disturbance (60% vs 43%, p = 0.051), pain (67% vs 47%, p < 0.05), and cavity size (74% vs 58%, p < 0.05). Improved motor function was associated more with cavity size reduction than with sensory disturbance and pain. Conclusions Surgical procedures and outcomes differed, depending on whether the patient's care was managed in a neurosurgery or orthopedics department. Outcomes were better after FMD with dural patch grafting.

Spinal duraplasty materials and hydrostasis: a biomechanical study

Object Dural tears are a frequent complication of spinal surgery and contribute to significant morbidity. Occasionally, dural tears cannot be closed primarily and dural patch grafts must be utilized. No data exist on the comparative immediate hydrostatic strength of various patch materials used alone or with a biological adhesive in a spinal dural tear model. Thus, the authors conducted this study to determine the comparative effectiveness of various patch materials used with and without biological adhesive. Methods Twenty-four thoracic spines from calves were prepared with laminectomies and spinal cord evacuation, leaving the dura intact. Foley catheters were inflated on either side of a planned dural defect, and baseline hydrostasis was measured using a fluid column at 30, 60, and 90 cm of H2O. A standard dural defect (1 × 2 cm) was created, and 8 patches of each material (human fascia lata, Duragen, and Preclude) were sutured in place using 5-0 Prolene hemo-seal running sutures. Hydrostasis was again tested at the same pressures. Finally, a hydrogel sealant (Duraseal) was placed over the defect and hydrostasis was again tested. Results were analyzed with repeated measures ANOVA. Results The leakage rate increased significantly at each pressure tested for all conditions. There was no difference in leakage among the 3 patch materials at any of the pressures or for either condition (with or without sealant). All patch materials allowed significantly greater leakage than the intact condition at all pressures. The use of sealant reduced leakage significantly at the 30 and 60 mm Hg pressures to levels similar to the intact condition. At 90 mm Hg, leakage of the sealed construct was greater than at the intact condition but significantly less than without the use of sealant. Conclusions All 3 dural patch materials were of similar hydrostatic strength and allowed greater leakage than at the intact condition. The use of sealant reduced the amount of leakage at all pressures compared with patching alone but allowed more leakage than the intact state at a high hydrostatic pressure (90 mm Hg).