CT-Guided Percutaneous Fibrin Glue Therapy of Cerebrospinal Fluid Leaks in the Spine After Surgery

Patel, M. D.; Caruso, Paul; Yousuf, Naveed; Rachlin, Jacob

doi:10.2214/ajr.175.2.1750443

Cited by 41 publications

(20 citation statements)

References 9 publications

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“…Other adjuncts in the management of durotomies include fibrin glue, muscle patch, dural patch, 8 subfascial drain, 12,15 subarachnoid drain, 29 CT-guided percutaneous fibrin glue patch, 21 and epidural blood patch. We routinely use an intraoperative Valsalva maneuver to check for watertight closure after primary dural repair.…”

Section: Discussionmentioning

confidence: 99%

Management of intended durotomy in minimally invasive intradural spine surgery

Tan¹,

Takagi²,

Straus³

et al. 2014

SPI

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Object Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. Methods A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Results Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30–74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Conclusions Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.

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Section: Discussionmentioning

confidence: 99%

Management of intended durotomy in minimally invasive intradural spine surgery

Tan¹,

Takagi²,

Straus³

et al. 2014

SPI

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“…1,2,[6][7][8] Although surgical repair is effective, the drawbacks include the generic risks and morbidities associated with reoperating on a recently postoperative spine. CT-guided percutaneous epidural patching targeted to the dural defect offers an alternative to surgery 3,4 and can be performed without general anesthesia and with minimal risk and discomfort to the patient. This article is a case series reporting the Duke neuroradiology experience using targeted CT-guided percutaneous epidural patching to repair incidental durotomies incurred during spinal surgery.…”

mentioning

confidence: 99%

Computed tomography–guided epidural patching of postoperative cerebrospinal fluid leaks

Mihlon¹,

Kranz²,

Gafton³

et al. 2014

SPI

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Object Cerebrospinal fluid leaks due to unrecognized durotomy during spinal surgery are often managed with a second surgery for dural closure. CT-guided percutaneous patching targeted to the dural defect offers an alternative to surgery since it can be performed in a minimally invasive fashion without the need for general anesthesia. This case series describes the authors' experience using targeted CT-guided percutaneous patching to repair incidental durotomies incurred during spinal surgery. Methods This investigation is a retrospective case series involving patients who underwent CT-guided percutaneous patching of surgical incidental durotomies and were referred between January 2007 and June 2013. Their presenting clinical history, myelographic findings, and clinical outcomes, including the need for eventual surgical duraplasty, were reviewed. Results Nine cases were identified, including 7 durotomies incurred during lumbar discectomy, one due to a medial transpedicular screw breach, and one incurred during vertebrectomy for spinal osteosarcoma. All patients who had favorable outcomes with percutaneous intervention alone had 2 common features: dural defect of 4 mm or smaller and absence of a pseudomeningocele. Patients with CSF leaks complicated by pseudomeningocele and those with a dural defect of 6 mm or more all required eventual surgical management. Conclusions The authors' results suggest that findings on CT myelography may help predict which patients with postsurgical durotomy can be treated with percutaneous intervention. In particular, CT-guided patching may be more likely to be successful in those patients with dural defects of less than 5 mm and without pseudomeningocele. In patients with larger dural defects or pseudomeningoceles, percutaneous blood patching alone is unlikely to be successful.

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“…4,21 The largest case series involving percutaneous epidural fibrin glue injection involved 23 patients and reported a 65% success rate. 16 In pediatrics, EBP requires weight-based dosing, and typically between 0.3 and 0.4 ml/kg is used and larger doses (up to 0.8 ml/kg) have been reported for repeat procedures.…”

Section: Discussionmentioning

confidence: 99%

Repair of a traumatic subarachnoid-pleural fistula with the percutaneous injection of fibrin glue in a 2-year-old

Chu¹,

Miller²,

Bazylewicz

et al. 2016

PED

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Subarachnoid-pleural fistulas (SPFs) are rare clinical entities that occur after severe thoracic trauma or iatrogenic injury during anterolateral approaches to the spine. Treatment of these fistulas often entails open repair of the dural defect. The authors present the case of an SPF in a 2-year-old female after a penetrating injury to the chest. The diagnosis of an SPF was suspected given the high chest tube output and was confirmed with a positive β2-transferrin test of the chest tube fluid, as well as visualization of dural defects on MRI. The dural defects were successfully repaired with CT-guided percutaneous epidural injection of fibrin glue alone. This case represents the youngest pediatric patient with a traumatic SPF to be treated percutaneously. This technique can be safely used in pediatric patients, offers several advantages over open surgical repair, and could be considered as an alternative first-line therapy for the obliteration of SPFs.

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CT-Guided Percutaneous Fibrin Glue Therapy of Cerebrospinal Fluid Leaks in the Spine After Surgery

Abstract: Percutaneous CT-guided placement of fibrin glue can provide a treatment option for postoperative cerebrospinal fluid leaks, potentially allowing a major surgical procedure to be avoided. However, the complication of aseptic meningitis may occasionally result from this procedure.

Cited by 41 publications

References 9 publications

Management of intended durotomy in minimally invasive intradural spine surgery

Management of intended durotomy in minimally invasive intradural spine surgery

Computed tomography–guided epidural patching of postoperative cerebrospinal fluid leaks

Repair of a traumatic subarachnoid-pleural fistula with the percutaneous injection of fibrin glue in a 2-year-old

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