Neurosurgical focus最新文献

Objective: This study evaluated the effectiveness of various dural closure and bone reconstruction techniques in preventing CSF leakage following retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors. The goal was to identify whether newer combinations of reconstructive materials offer any advantage in reducing CSF leaks and improving surgical outcomes.

Methods: The authors conducted a retrospective review of 225 patients who underwent a retrosigmoid craniotomy for CPA neoplasms between January 2018 and August 2024. Patient demographics, intraoperative reports, and postoperative complications were analyzed. Various reconstructive methods, including the use of TachoSil, HydroSet, autologous or heterologous dural patches, and bone flap repositioning, were compared. CSF-related complications such as CSF leakage, infections, and postoperative hydrocephalus were systematically evaluated.

Results: CSF leakage occurred in 31% of cases (n = 69), while CSF infections and postoperative hydrocephalus were noted in 6% and 7% of patients, respectively. HydroSet combined with bone flap repositioning significantly reduced CSF leakage (p = 0.008), as did the combination of HydroSet and heterologous dural patches (p = 0.007). TachoSil did not show a significant reduction in CSF leakage. Craniectomy with titanium mesh or heterologous cranioplasty was not associated with any CSF leaks. No other single or combined techniques showed significant associations with CSF leakage.

Conclusions: HydroSet in combination with bone reconstruction and heterologous patches demonstrated superior outcomes in reducing CSF leaks. TachoSil did not significantly affect leakage rates, with less definite results. Refining surgical techniques and selecting appropriate materials for dural and bone reconstruction may help reduce complications and improve patient outcomes in CPA tumor surgeries using the retrosigmoid approach.

Objective: Persistent CSF leakage and symptomatic pseudomeningocele formation are a primary concern following intradural posterior fossa and spinal surgeries, with rates approaching 23.7% and 10%, respectively. These complications occur at a higher rate in cases in which a watertight primary closure cannot be attained. In such cases, various dural substitutes and sealants are at the surgeon's disposal and often require suturing a dural substitute to the existing dura. Herein, the authors describe a novel sutureless inlay-onlay fibrin-coated collagen fleece (TachoSil) "sandwich" closure technique for dural reconstruction and closure.

Methods: The authors retrospectively reviewed posterior fossa and intradural spinal cases performed by the senior author from January 1, 2021, to August 30, 2024, which used the described novel closure technique when primary closure without expansion could not be attained. Primary outcomes were rates of postoperative CSF leakage, symptomatic pseudomeningocele formation, CSF diversion, infection, and revision surgery.

Results: A total of 13 patients (8 craniotomies, 2 craniectomies, and 3 spinal cases) were identified with a mean age of 61.3 ± 14.0 years. Surgical indications included intra-axial and extra-axial tumors, acute cerebellar infarcts, an unruptured aneurysm, and a ruptured arteriovenous malformation. One patient (7.7%) who underwent emergency craniectomy for acute cerebellar infarct developed a postoperative CSF leak and symptomatic pseudomeningocele with suspicion of pseudotumor cerebri, ultimately requiring CSF diversion. There were no complications among patients receiving craniotomy or intradural spinal surgery. No postoperative infections or revision surgeries occurred.

Conclusions: The TachoSil sandwich technique represents an effective means of cranial and spinal dural reconstruction and closure in cases in which watertight primary dural closure cannot be achieved.

Objective: Bifrontal craniotomy often involves the bony opening and mucosal disruption of the frontal sinus (FS), which can lead to cerebrospinal fluid (CSF) leakage and meningitis. These complications are particularly associated with surgical treatments for skull base tumors and anterior cerebral artery aneurysms. The authors initially reported on the basic technique in 2014 with 51 cases. This study presents a detailed description of their technique and postoperative management for sealing the exposed FS during bifrontal craniotomy, including long-term follow-up results and outcomes. To objectively evaluate the effectiveness of suturing FS mucosa in preventing CSF leakage during bilateral frontal craniotomy, the authors focused only on anterior cerebral artery aneurysms. This limitation was necessary as other conditions, like extensive tumors or trauma, might lack intact FS mucosa or require its removal due to infection.

Methods: The records of 34 consecutive patients (median age 62.0 years, mean 60.4 years, range 33-78 years) who underwent bifrontal craniotomy for anterior cerebral artery aneurysms between January 2014 and December 2023 were retrospectively analyzed. All patients had bony opening and mucosal injury of the FS (with exposure to the nasal cavity) that required mucosal suturing. This technique for sealing the exposed FS involves careful dissection of the mucosa from the entire sinus, sterilization with iodine-soaked surgical cotton, and preparation for closure. After the microsurgical procedure is completed, the exposed mucosa is sealed with 6-0 nylon sutures and further secured with fibrin glue-soaked Gelfoam. The bony exposure is covered with an autologous bone flap created from the inner table of the craniotomy bone flap. Finally, the frontal periosteal flap is sutured to the frontal base dura mater. Patients were instructed not to blow their noses for 2 months postoperatively.

Results: Two patients experienced transient non-CSF leakage from the nasal cavity, likely due to irrigation fluid, which resolved within 2 days postoperatively. No recurrence was observed during a mean follow-up period of 52.8 ± 41.7 months (median 49 months, range 3-127 months). No cases of meningitis or other intracranial infections were reported.

Conclusions: The long-term results demonstrate the sustained effectiveness of this technique in preventing postoperative complications related to FS exposure during bifrontal craniotomy.

Objective: A significant complication of spine surgery is persistent postoperative CSF leak secondary to intentional or incidental durotomy. Traditionally, the gold standard for repair of simple durotomy has been primary surgical repair; however, this technique alone may not be possible for more complex durotomy and is often supplemented with sealants or fibrin glues. The authors add to the literature the largest series of spine surgery patients treated with TachoSil, a synthetic collagen patch containing human fibrinogen and human thrombin, for the management of incidental or intentional durotomy.

Methods: The authors identified all patients who underwent a spinal operation and were billed for operative use of TachoSil at their institution between January 1, 2023, and November 3, 2023. Demographic, clinical, and outcome variables were collected and analyzed using standard statistical methods. Categorical variables were reported as number (%), and continuous variables were reported as median (range).

Results: The authors retrieved 55 patients meeting their inclusion criteria. The population consisted of 29 (52.7%) females, had a median age of 52 years, and had a median BMI of 28.3 kg/m2. Of the repaired durotomies, 37 (67.3%) were intentional to the operation and 18 (32.7%) were incidental or secondary to trauma. Abnormal residual fluid collections were appreciated in 1 (1.8%) patient. Wound breakdown was observed in 2 (3.6%) patients. Thirty-day readmission was observed in 6 (10.9%) patients, and 30-day reoperation was necessary in 2 (3.6%) patients. Ninety-day readmission was observed in 7 (12.7%) patients and 90-day reoperation was necessary in 3 (5.5%) patients. One (1.8%) case of 30-day readmission was related to CSF leak, and no cases of 30-day or 90-day reoperation were related to dural closure failure.

Conclusions: This study is a brief examination of the demographic characteristics, surgical variables, and outcomes of durotomy repair in spine surgery with TachoSil and provides encouraging results for the continued use of the material in this context. This study provides the impetus for examination of TachoSil in larger, multi-institutional studies to establish it as a standard of care in spinal dural repair.

Objective: The aim of this study was to review a series of patients who underwent open cranial surgeries to evaluate the incidence of iatrogenic incisional CSF leaks and discuss its prevention and management. The authors also discuss the utility of the "folding technique" used in duraplasty as an alternative to conventional dural reconstruction techniques.

Methods: All patients undergoing open cranial surgery were reviewed, and those with incisional CSF leak were included in this study. CSF leakage was managed using either conservative nonsurgical methods or surgical interventions. When the conservative nonsurgical methods failed to curb the leak, surgical procedures such as lumbar external drainage (LED) using lumbar subarachnoid drainage, external ventricular drainage (EVD), a lumboperitoneal or ventriculoperitoneal shunt (VPS), and reexploration of the surgical site were considered.

Results: Between 2019 and 2024, 2149 patients underwent open cranial surgeries at our hospital for any cranial pathology; 39 (1.8%) of these patients experienced postoperative incisional CSF leakage. The majority of the pathologies requiring surgeries were located in the supratentorial region (76.9%). Patients were classified according to the type of dural closure technique used. Primary stitching, the patient's fascia, or synthetic dura (resorbable, nonresorbable, or both) were used for dural reconstruction. The median interval between the surgery and the start of the leakage was 19 (IQR 1-79) days in patients with no history of radiotherapy; however, this duration was longer in patients who received radiotherapy (median 45 [IQR 10-540] days). The surgical interventions for CSF leakage were classified as wound resuturing (combined with other conservative approaches such as tightened dressing and elevating the head end of the bed), LED or EVD, or surgical reexploration. The folding technique in duraplasty is a simple way to achieve watertight duraplasty even with autograft or synthetic material.

Conclusions: Incisional CSF leakage is a potentially preventable complication with high morbidity. Such cases could be managed via conservative approaches including wound resuturing, LED or EVD, and surgical reexploration. However, the management strategy is beyond any strict algorithm. This folding technique for duraplasty is a worthy replacement for conventional primary suturing for dural repair or reconstruction in cranial and even spinal defects. This study highlights the importance of regaining the watertight nature of the dura in the primary surgery to prevent any further intervention and lower the overall morbidity.

Objective: Through an eyebrow incision, the lateral supraorbital (LSO) keyhole approach provides access to various lesions in the anterior cranial fossa and affords many of the advantages of minimal access and minimally invasive surgery. The LSO approach and other minimal access approaches including various endonasal approaches to the anterior cranial fossa, however, have been associated with nonnegligible rates of CSF leaks postoperatively. The authors report their recent experience using calcium phosphate cement cranioplasty as a method of preventing CSF leakage after LSO keyhole craniectomy.

Methods: A retrospective medical records review was performed for 9 consecutive patients undergoing operations by the senior authors using the LSO keyhole approach with skull defect repair using calcium phosphate cement cranioplasty alone between 2022 and 2024. Review of the medical records included clinic notes, imaging studies, and operative notes as well as details regarding the length of hospital stay, complications, and rate of tumor recurrence.

Results: Eight of 9 patients underwent resection of meningiomas, while 1 underwent resection of a cavernous malformation. The cohort consisted of 7 females (78%) and 2 males (22%) with a mean age of 55.2 years. The mean tumor volume among the 8 meningiomas was 18.09 cm3, and peritumoral edema was present in 8 of the 9 cases (89%). Gross-total resection was achieved in 7 of 8 meningioma cases (87.5%). Among the 9 patients, the mean length of hospital stay was 2.4 days. Two patients (22%) experienced complications. No patients experienced a CSF leak postoperatively. At a mean follow-up of 13.8 months, 1 patient (12.5%) experienced tumor recurrence.

Conclusions: Based on this and prior experience, the use of calcium phosphate cement cranioplasty alone following an LSO keyhole approach to the anterior cranial fossa is a safe alternative to traditional closure techniques, which rely on replacement of bone flap with plates and screws, and it might reduce the rate of postoperative CSF leakage. Larger studies are required to confirm these findings.

Objective: Dural sealant patches (DSPs) are a useful adjunct when closing the dura during cranial or spinal surgery to avoid cerebrospinal fluid (CSF) leakage or infection. Authors of this paper systematically review the outcomes and incidence of CSF leakage and infection with the use of a DSP versus conventional practice.

Methods: The MEDLINE, Embase, Cochrane Library, and Scopus databases were searched, and clinical trials and prospective or retrospective case-control and cohort studies with a low-risk of bias and involving any solid DSP used in adults for cranial or spinal cases were included. Studies that used a DSP in combination with another method of dural sealant closure, used a DSP as a dural substitute rather than an adjunctive closure device, or used hydrogel or polymer gel (i.e., nonsolid) dural sealant "patches" were excluded. A meta-analysis of comparative studies reporting outcomes relating to CSF leakage was performed together with a subgroup analysis for each DSP type. For comparative studies reporting outcomes relating to infection, a separate meta-analysis was conducted.

Results: Across the 7 noncomparative studies included, 669 patients received TachoComb (n = 421, 1 study), TachoSil (n = 8, 1 study), Liqoseal (n = 40, 1 study), TissuePatchDural (n = 144, 2 studies), or Hemopatch (n = 56, 2 studies). Across the 6 comparative studies included, 1013 patients received TachoSil (n = 784, 3 studies), TissuePatchDural (n = 147, 2 studies), or Hemopatch (n = 82, 1 study). When considering the rates of CSF leakage or infection, 2/6 comparative studies found DSPs to be significantly more effective than current practice, while the remaining 4/6 demonstrated noninferiority compared to current practice. All studies considered the DSPs to be safe. A meta-analysis revealed significant improvements in the incidence of CSF leakage with the use of a DSP overall, but the improvements in CSF leak rates for the TachoSil and TissuePatchDural subgroups did not reach statistical significance. The single study evaluating Hemopatch did find statistically significant improvements in CSF leak rates. There were no significant differences in infection between the DSP groups.

Conclusions: There was a significant improvement in the incidence of CSF leaks with the use of DSPs. Comparisons among DSP types and evaluations of outcomes relating to infection should be the focus of further research in this area.

Objective: The goal of this study was to evaluate the efficacy of watertight dural closure (WTDC) in preventing postoperative CSF leakage during extended endoscopic transnasal surgery (ETS) for skull base tumors, while preserving sinonasal quality by omitting the routine use of a nasoseptal flap.

Methods: This retrospective study included 28 patients who underwent ETS and experienced Esposito grade 3 CSF leakage at a single institution between June 2022 and June 2024. WTDC was performed using fascia lata grafts and various suturing techniques. Surgical videos and electronic medical records were reviewed to assess suturing times and postoperative outcomes. The efficacy of WTDC in preventing CSF leakage was evaluated, and the technical aspects of the procedure were analyzed.

Results: Among the 28 patients (14 female, 14 male), WTDC was successfully achieved in 14 cases, with near-watertight closure in the remaining 14. The average suturing time decreased with experience, showing a trend of improved efficiency. No postoperative CSF leaks were observed, and 1 case of postoperative meningitis resolved without sequelae. Despite significant risk factors for CSF leakage, WTDC was effective in all patients without the routine use of lumbar drainage.

Conclusions: WTDC in ETS is a reliable method for preventing postoperative CSF leakage, particularly in complex skull base surgeries with high-risk factors. This technique avoids the complications associated with nasoseptal flap use, preserves sinonasal quality, and reduces the need for lumbar drainage, making it a valuable option for skull base reconstruction.

Objective: CSF leaks are a common complication of spinal surgery, occurring in 3%-16% of elective cases and up to 12% of operatively managed traumatic spinal injuries. They can also occur following lumbar puncture. However, there are limited data on utilization and reimbursement trends within Medicare for CSF leak repairs. Characterizing the economic burden and market of spinal CSF leak repair has implications for optimizing effective management strategies. This study evaluates reimbursement and utilization trends for both surgical repair and epidural blood patch (EBP) management of spinal CSF leaks between the years 2000 and 2021.

Methods: The 2000-2021 provider utilization and payment files from the Centers for Medicare & Medicaid Services was queried to identify all spinal CSF leak repair procedures billed to Medicare part B. For each management strategy, the number of procedures, total charges submitted by providers, and total Medicare reimbursements were extracted. Monetary data were adjusted to 2021 US dollars using changes to the Consumer Price Index. Spearman rank correlation coefficients were used to analyze trends in reimbursement and utilization.

Results: From 2000 to 2021, 62,826 open surgical repairs were reported with $37,082,407 paid in reimbursement (45.9% repaired without additional laminectomy, 28.8% with laminectomy, and 25.3% requiring a spinal dural graft). An additional 63,227 EBPs were reported for CSF leak repair with $7,567,776 in reimbursement. Reimbursement for CSF leak repair without laminectomy totaled $15,707,094; repairs with laminectomy, $12,429,690; and use of spinal dural grafts, $8,945,444. Both a significant 162% increase in the utilization of spinal dural grafts (333 to 872, p < 0.001) and a decrease in reimbursement ($671 to $496, p = 0.02) was observed from 2000 to 2021. There was a significant 31% decrease in reimbursement for EBP ($148 to $102, p < 0.001).

Conclusions: Significant variability exists in the management strategy and rates of utilization and reimbursement for treating spinal durotomy. Despite increasing utilization of spinal dural grafts, reimbursement has declined between the years 2000 and 2021. Further studies are required to optimize both the cost effectiveness and efficacy of spinal durotomy repair techniques.