A comparison between "sandwich" and conventional methods of repairing spinal dura rupture

Abstract

Objective: To study the therapeutic efficacy of the "sandwich" method (medical glue + gelatin sponge + medical glue) of spinal dural repair for preventing cerebrospinal fluid (CSF) leaks during treatment of subdural tumors.

Methods: Fifty-four patients with spinal subdural tumors treated between April 2007 and June 2011 were retrospectively investigated. The patients were divided into two groups: a conventional group (group A) and a "sandwich" group (group B). The group A patients included 16 males and 7 females with an average tumor course of 11 months (range, 2-34 months). Four of their 23 tumors were in the cervical spine, eight thoracic, and eleven lumbar. The group B patients included 19 males and 12 females with an average tumor course of 12 months (range, 3-36 months). Five of their 31 tumors were in the cervical spines, 10 thoracic, and 16 lumbar. In group A, the dural repairs were performed with interlocking sutures and a gelatin sponge covering the dura; whereas in group B, they were performed with interlocking sutures, painting of medical glue around the dural incision, covering this with a gelatin sponge, and finally covering of the gelatin sponge with medical glue. The total volume of drainage after operation, incidence of CSF leaks, healing of the incision, and recovery of clinical performance were recorded.

Results: Compared to group A patients, group B patients had a significantly smaller total volume of drainage (P < 0.05) on the day of surgery, and the first, second, and third postoperative days. The incidence of CSF leakage in group B was also significantly less than in group A (P < 0.05). Before discharge, three patients in group A developd hydrops, which was successfully treated by aspiration, continuous pressure from sandbags, and the prone position. During the first 3 months of follow-up, five patients developed deep hydrops under their incisions but required no treatment. There were no obvious abnormalities in group B.

Conclusion: After removal of subdural spinal tumors by incising the dura mater, or in related spinal surgery, application of the "sandwich" complex to the damaged spinal dura reduces the volume of drainage postoperatively and reduces the incidence of CSF leakage.

Figure 1

A 37 year‐old male patient with incomplete paralysis. Preoperative MRI showed a 1.6 cm × 2.0 cm × 2.2 cm intradural‐extramedullary spinal neoplasm on the L₁ level that was causing severe spinal cord compression. (a) Axial MRI (b) Sagittal MRI.

Figure 2

Findings on (a) anteroposterior and (b) lateral radiographs in the first week after fenestration and tumor resection.

Figure 3

(a) The tumor was resected by traction on a suture line intraoperatively. (b) The completely resected tumor, which is indeed 1.6 cm × 2.0 cm × 2.2 cm.

Figure 4

The “Sandwich” method procedure. (a) Schematic diagram of the interlocking suture method. (b) The spinal dura has been sutured closely with the interlocking suture method. (c) Medical adhesive has been used to seal the sutured dura. (d) The dura has been covered with gelatin sponge. (e) Medical adhesive has again been used again to cover the gelatin sponge and seal its edges. (f) Schematic diagram of the sandwich method: two layers of medical adhesive with a gelatin sponge between them in addition to interlocking sutures.

Figure 5

MRI (a) in the third month and (b) 18th postoperative month showing that the incision in the spinal dura has healed very well with no complications such as pseudocyst or incision effusion.