A tight fascial closure can increase the epidural fluid pressure, retard CSF flow and facilitate the dural flaps to adhere. So a tight fascial closure technique is required to avoid CSF leak. When the CSF outflow is beyond the strength of sutured tissue, it will lead to a persistent CSF communication between the intra-dural and outside of the wound. 21Īn epidural CSF pool may be developed secondary to durotomy, which is wrapped up by the incision tissue. When durotomy was used to simulate lumbar subarachnoid drainage, lumbar durotomy plus reposition of the animal to 90°, cervical CSF subarachnoid pressure would be reduced by 46%. The mean lumbar subarachnoid pressure increased by 52%. As inclination increased from 0° (supine position) to 90° (upright), cervical CSF pressure decreased by 29%. 3, 5, 6 To examine the relation between subarachnoid CSF pressure and varying body positions in the cervical and lumbar spine, Gregory set up a dog model, in which two 22-gauge angiocatheters attached to pressure transducers were inserted into the subarachnoid space through laminectomies in the third cervical (C3) and fourth lumbar (L4) regions. In cases of lumbar or thoracic CSF leak, patient should be kept in Trendelenburg or prone position while in cases of cervical CSF leak, opposite of the Trendelenburg position is required. So increasing the height of the dural tear site could decrease the subarachnoid pressure and further reduce the site of CSF leak. In this condition, the pressure is lower at higher position. 20Īs the fluid dynamics of Bernoulli's law demonstrated, the value of (P + ρgh) is constant. 17% of the patients complained of the root irritation pain by catheter placement and headache due to over-drain. 18, 19 But the overall complication rate is up to 44.4% and the most severe complications are over-drain, pneumocephalus and meningitis. The successful rate reported by the literature is 85%–94%. For such cases, diversion of CSF with closed subarachnoid catheter was widely used. 17 For patients with CSF leak, the most challenge is the unrecognized site of the fistula after surgery. After treatment, the CSF leak stopped in all of 28 patients. In a randomized clinical trial, acetazolamide was administrated in the first 48 h with the dose of 25 mg/kg/day. The methods to reduce subarachnoid fluid pressure include inhibiting the formation of CSF, adjusting patient's position, and CSF shunting by subarachnoid catheter. It could revascularize, prevent scar formation, and does not adhere to the neural elements. 15 Autologous fat graft as an excellent water sealant is a good alternative for muscle graft. 14 In Shahrokh'study, the successful rate of watertight closure was 87.5%. Repair with autologous fascia could attenuate neuro-inflammation and help to maintain normal sensory conduction function. The result demonstrated that dural tear could cause a series of inflammatory reaction in the spinal cord and further impair its sensory conduction function. 13 Song established a Sprague–Dawley rat model of dural tear and autologous fascia graft repair. All patients were successfully repaired without reoperation. Joseph reported 144 patients with ossified posterior longitudinal ligament (OPLL) injury undergoing cervical corpectomy, of which 6.3% of dural defect were repaired with an onlay graft of crushed muscle/fascia. 12 There still need more studies to assess its safety.Īugmented closure by means of fat, muscle tissue or fascial graft is indicated when the dural defect is too large to be directly repaired. It showed a significantly higher rate of watertight closure than fibrin glue (98.6% vs. 11 In the year of 2016, a low-swell PEG hydrogel as a modified form was developed. Two cases of cervical cord compression by hydrogel were reported. 10 But there is a warning of potential expansion up to 50% of its size. It was found that the successful rate in watertight closure is 91.2%: 63.6%. 9 Kim compared the efficacy of PEG hydrogel sealant and fibrin glue as an adjuvant repair. Polyethylene Glycol (PEG) is preferred to use as a hydrogel sealant. Many surgeons now preferred direct suture with adjuvant dural closure material. 8 For minimal invasive spine surgery, it is impossible to suture by traditional thread. Suture repair skills are summarized as follows: 1) direct suture being suitable for dural tear or small dural defect 2) continuous suture or 8-figure suture with 4.0–6.0 thread 3) the GORE-TEX suture material only left a very small suture hole 4) <3 mm of the distance between two sutures with each suture apart 1 mm from the margin.
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